Insomnia
Improve Sleep After 50
Sleep guidelines put CBT-I, a short behavioral therapy, first for insomnia after 50. Tips alone fall short, and many sleep pills carry risks after 65.
Past 50, sleep advice arrives from every direction: cut the coffee, dim the lights, try the gummies, ask about a pill. The drugstore has a whole aisle for it. Humanic Blue follows the research on improving sleep after 50, which points somewhere less shelf-friendly.
For insomnia that has lasted months, the American Academy of Sleep Medicine recommends cognitive behavioral therapy for insomnia (CBT-I) as the treatment to start with. It’s a short course of sleep-habit changes and thinking techniques. A shorter program involving two sessions and two phone calls helped about two-thirds of older adults in one trial. Sleep-hygiene tips on their own aren’t enough, the academy says, and the American Geriatrics Society lists common sleeping pills among the drugs adults 65 and older should avoid. Good sleep is part of living longer and better, and the first step is checking what’s actually waking you.
In This Article
Key Takeaways
- Sleep-medicine and internal-medicine guidelines recommend CBT-I as the first treatment for long-lasting insomnia in adults.
- A four-week program of two sessions and two phone calls helped about two-thirds of older adults in a small trial, compared with a quarter of those given reading material.
- Regular exercise modestly improved self-reported sleep quality in adults over 40 with sleep problems.
- Sleep-hygiene tips alone aren’t recommended as a treatment for chronic insomnia.
- Benzodiazepines, “Z-drugs” and sedating antihistamines are on the American Geriatrics Society’s avoid list for adults 65 and older.
- Nobody has tested whether treating insomnia helps people live longer.
What else could be waking you?
Sleep that gets worse after 50 isn’t always insomnia. Sleep apnea, pain, needing to urinate, menopause symptoms, medications and alcohol can all break up a night. Those causes are covered in Why Sleep Gets Worse With Age and Why Do I Wake Up at 3 AM Every Night?
Snoring, gasping or heavy daytime sleepiness are worth raising with a clinician before trying anything else. They can point to sleep apnea, which is tested for and treated differently.
Sleep doctors put CBT-I first
The American Academy of Sleep Medicine, the professional society for the sleep-medicine field, gave multicomponent CBT-I a strong recommendation in its 2021 guideline for adults with chronic insomnia. CBT-I bundles several techniques over a series of sessions. The academy also backed some of the pieces on their own, more cautiously:
- Stimulus control: using the bed only for sleep, and getting up when sleep won’t come.
- Sleep restriction: limiting time in bed to match the sleep you’re actually getting, then expanding it as sleep improves.
- Relaxation therapy: techniques that ease physical and mental tension.
- Brief therapies: shorter versions of the core techniques.
The academy funded the guideline itself. Several of its authors disclosed research funding from, or an advisory role with, Merck. See every recommendation
The American College of Physicians reached the same conclusion in 2016, recommending CBT-I “as the initial treatment” for all adults with chronic insomnia. Its review found moderate-quality evidence that CBT-I helps older adults specifically. The college’s own rule is that its guidelines lapse five years after publication, so, as of September 25, 2026, the sleep academy’s guidelines are the more recent word.
A 2025 guideline from the U.S. Departments of Veterans Affairs and Defense (VA/DoD) lands in the same place: “For treatment of chronic insomnia disorder, we recommend treatment with CBT-I,” a “Strong for” recommendation.
CBT-I asks something of you. The academy says its main downsides are daytime tiredness and sleepiness, irritability and trouble concentrating, mostly early in treatment and typically gone by the end. Sleep restriction can be hard to stick with. The academy flags it as possibly unsuitable for people who drive or operate heavy machinery for work, and for people with poorly controlled seizures, a tendency toward mania or excessive daytime sleepiness. It also notes that some older adults find it hard to fill the extra time out of bed.
Can a brief treatment help older adults?
Full CBT-I can be hard to find. Daniel Buysse, a professor of psychiatry at the University of Pittsburgh, led a 2011 trial of something shorter, published in the Archives of Internal Medicine.
The trial enrolled about 80 older adults, average age about 72, with long-standing insomnia and the usual mix of other health conditions. A nurse delivered the brief behavioral treatment in two sessions and two phone calls. The comparison group got printed reading material. After four weeks, about two-thirds of the treated group responded, against a quarter of the comparison group. More than half of the treated group no longer had insomnia, against about one in eight. The National Institutes of Health paid for the study.
It’s one small trial with a four-week main result. The improvements showed up in sleep diaries, questionnaires and wrist-worn activity monitors, but not in overnight lab sleep studies. Only people who responded were followed to six months, and most still showed either a meaningful improvement or no longer met the trial’s criteria for insomnia. The American College of Physicians’ evidence review, drawing on several trials, found low- to moderate-quality evidence that brief behavioral therapy improves sleep in older adults. How the trial worked
Which outcomes would make a brief insomnia treatment meaningfully comparable with full CBT-I?
Exercise helps a little, alongside
Researchers at National Taiwan University combined small trials of adults over 40 who had sleep problems in a 2012 review in the Journal of Physiotherapy. Moderate aerobic exercise or high-intensity strength training, mostly for 10 to 16 weeks, improved self-reported sleep quality and helped people fall asleep faster. The review did not find clear differences in how long people slept, the share of time in bed spent asleep, or daytime functioning.
The authors described the effects as moderately positive and suggested exercise could serve as an alternative or complement to other treatments. Nearly four in five participants were women. The review’s numbers
Why sleep-hygiene tips fall short on their own
Sleep-hygiene tips are everywhere: limit caffeine, keep a regular schedule, keep the room dark and cool. The 2025 VA/DoD guideline says, “we suggest against sleep hygiene education as a stand-alone treatment.”
The sleep academy’s 2021 guideline reached the same conclusion, suggesting that clinicians not use sleep hygiene as the only treatment for chronic insomnia.
That isn’t a finding that the tips do harm. They just weren’t enough on their own in the evidence the academy reviewed, so they work as a baseline rather than the whole plan.
How does sleep-hygiene education differ from the treatment tested in insomnia trials?
What are the risks of sleeping pills after 65?
For people in whom CBT-I alone didn’t work, the American College of Physicians recommended that adding medication be a shared decision, “including a discussion of the benefits, harms, and costs of short-term use.”
Starting both at once is a different question. In a 2026 guideline, also led by Buysse, the sleep academy generally favors CBT-I alone over starting CBT-I and medication together. If the alternative is medication alone, it favors adding CBT-I. Both recommendations are conditional: the evidence is uncertain, and individual circumstances can change the decision. In the academy’s announcement, Buysse said the team’s analysis pointed to CBT-I alone as the most effective first treatment for insomnia. Buysse and several co-authors disclosed consulting for companies including Eisai and Idorsia Pharmaceuticals. The American Geriatrics Society affirmed the value of the guideline.
The VA/DoD guideline also favors behavioral treatment over pills as a starting point, suggesting “CBT-I over pharmacotherapy as first-line treatment.”
After 65, the American Geriatrics Society’s 2023 Beers Criteria, its list of medications older adults should generally avoid and still the current edition as of September 25, 2026, name three common kinds of sleep aid:
- Benzodiazepines, such as temazepam, triazolam and lorazepam. The society says they raise the risk of memory and thinking problems, delirium, falls, fractures and car crashes in older adults.
- “Z-drugs,” such as zolpidem, eszopiclone and zaleplon. They carry similar risks, the society says, with only minimal improvement in how fast people fall asleep or how long they sleep.
- First-generation antihistamines, such as diphenhydramine and doxylamine. The society lists confusion, dry mouth and constipation among their risks. It also says people develop tolerance when using them for sleep, meaning the same drug has less effect over time.
Diphenhydramine and doxylamine are sold over the counter as sleep aids, so a drugstore purchase can land on this list. The society also notes that continued benzodiazepine use can lead to physical dependence. Stopping a prescribed sleep medication is something to plan with the prescriber, not do suddenly. What the Beers Criteria say
What’s Interesting
Sleep medicine’s headline treatments mostly take things away. Stimulus control and sleep restriction cut time in bed, time lying awake and time staring at the clock. That runs against the instinct to spend more time in bed when sleep gets harder.
And it doesn’t have to be elaborate. In the Pittsburgh trial, a nurse, two sessions and two phone calls were enough for more than half of the participants to stop meeting the criteria for insomnia. Those volunteers averaged about 72, and 70% were women. People differ, and an average result from a small trial cannot forecast how one person will respond.
What This Means in Practice
For living longer and better, the guidelines point to behavioral treatment first and caution with pills.
- Ask about sleep apnea if you snore, gasp or feel very sleepy during the day.
- For adults with chronic insomnia, the AASM strongly recommends CBT-I and conditionally supports brief behavioral therapies. A clinician can assess whether the approach fits the person.
- Expect some early tiredness if sleep restriction is part of it; the academy says it typically resolves by the end of treatment.
- Exercise may complement other treatment, according to the National Taiwan University review; its sleep benefits were modest.
- Sleep-hygiene education alone is not the treatment the AASM recommends for chronic insomnia. Its guideline distinguishes general bedtime habits from structured therapy.
- Review sleep aids with a clinician or pharmacist, especially after 65, including over-the-counter products.
A primary care clinician can screen for sleep disorders and refer you. Behavioral sleep medicine specialists deliver CBT-I, and a pharmacist can review your medications.
Bottom Line
Sleep apnea, pain and medications can disrupt sleep after 50 and need different responses from insomnia. For ongoing insomnia, the American Academy of Sleep Medicine recommends CBT-I first, and a brief nurse-delivered version helped about two-thirds of older adults in one small trial. Exercise helps modestly alongside it. Sleep-hygiene tips alone aren’t recommended as treatment. For adults 65 and older, the American Geriatrics Society advises avoiding benzodiazepines, Z-drugs and sedating antihistamines. Whether better sleep helps people live longer hasn’t been tested; these steps target how you sleep and function now.
A NOTE FROM LONGEVITY365
We read research, consult expert perspectives and work to make complicated health information easier to understand. What you’re reading here reflects how we’ve interpreted and organized that information. It is educational content—not personal medical advice, diagnosis or treatment guidance.
We’re not perfect, and neither is the available research. Evidence changes, new studies emerge and what’s appropriate for one person may not be appropriate for another.
Use this article as a starting point for your own research and conversations with qualified professionals. Always talk with your doctor or another trusted healthcare professional before making decisions that could affect your health, particularly if you take medications, are receiving treatment, have existing health conditions, are pregnant or have other circumstances that could affect what’s appropriate for you.
Reader Questions
A few questions to carry into the comments or your next conversation. Please leave out identifying or personal medical details.
- 01Which part of insomnia care would you like explained further: the full CBT-I program, a shorter behavioral program, or how medication decisions are made?
- 02Which part of the article helped separate a normal age-related change from something worth asking about?
- 03What question would make a sleep conversation more useful than just chasing a better score?
Extra Insights & Sources
For readers who want the details behind each claim above.
What We Know
- CBT-I is recommended as the first treatment for chronic insomnia. Established.
- Brief behavioral treatment helped most older adults in a randomized trial. Supported.
- Exercise modestly improves self-reported sleep quality in midlife and older adults with sleep problems. Supported.
- Several common sleep medications carry fall, fracture and cognitive risks after 65. Established.
What We Don’t Know
- Whether treating insomnia after 50 extends lifespan. Unknown.
- How well app-based or self-guided CBT-I compares with in-person treatment for older adults. Uncertain.
- Which exercise type and timing works best for sleep. Uncertain.
The guidelines in detail
American Academy of Sleep Medicine, 2021. The AASM guideline on behavioral and psychological treatments, first author Jack Edinger, was built on a systematic review graded with the GRADE method. A strong recommendation is one clinicians should follow under most circumstances; a conditional one requires clinicians to use their knowledge and experience and to strongly consider the patient’s values and preferences.
| Technique | What it involves | AASM recommendation |
|---|---|---|
| Multicomponent CBT-I | Combined behavioral and cognitive techniques over several sessions | Strong |
| Brief multicomponent therapy | A shorter version of the core techniques | Conditional |
| Stimulus control | Using the bed only for sleep; getting up if you can’t sleep | Conditional |
| Sleep restriction | Limiting time in bed to match actual sleep, then expanding it | Conditional |
| Relaxation therapy | Techniques to reduce physical and mental tension | Conditional |
| Sleep hygiene alone | General tips on caffeine, light, routine and environment | Suggests not using as the only treatment |
On harms, the full text names daytime fatigue and sleepiness, mood effects such as irritability, and thinking problems such as trouble paying attention during treatment. It says these are mostly limited to the early stages, when the behavioral therapies are introduced, and typically resolve by the end of treatment. On sleep restriction, it notes that some patients, including older adults and people with chronic pain or depression, may struggle to find meaningful activities for the extra time out of bed. It adds that sleep restriction may be contraindicated for people in high-risk jobs, such as heavy-machinery operators or drivers, and for people predisposed to mania or hypomania, with poorly controlled seizure disorders or with excessive daytime sleepiness.
Disclosures: the guideline’s development was funded by the AASM. Jack Edinger received funding from Merck for an insomnia research study. Suzanne Bertisch was a co-investigator on an insomnia research project funded by Merck (ended 2017). Kenneth Lichstein is a member of Merck’s insomnia advisory board, on a topic the paper describes as unrelated to behavioral treatments of insomnia. Michael Sateia gave a 30-minute melatonin consultation for Physicians Seal in 2018, and other authors disclosed device, consulting and nonprofit roles, according to the paper.
American College of Physicians, 2016. The ACP guideline “recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder” (strong recommendation, moderate-quality evidence). Its second recommendation, on adding medication through shared decision-making when CBT-I alone was unsuccessful, is a weak recommendation based on low-quality evidence. For adults over 55, the ACP’s review found moderate-quality evidence that CBT-I improved Insomnia Severity Index and Pittsburgh Sleep Quality Index scores, and low- to moderate-quality evidence that multicomponent behavioral therapy or brief behavioral therapy improved time to fall asleep, time awake after falling asleep, sleep efficiency and sleep quality. It was based on randomized trials published in English from 2004 through September 2015. Financial support came “exclusively from the ACP operating budget.” The guideline states: “All ACP clinical practice guidelines are considered automatically withdrawn or invalid 5 years after publication or once an update has been issued.”
American Academy of Sleep Medicine, 2026. The AASM combination-treatment guideline, first author Daniel Buysse, makes two conditional recommendations on low certainty of evidence: it suggests combination treatment with CBT-I plus insomnia medication over medication alone, and it suggests against combination treatment over CBT-I alone. A remark adds that patients who care more about increasing total sleep time early in treatment, or less about reducing daytime symptoms, may reasonably choose combination treatment over CBT-I alone. In the AASM announcement, Buysse, described there as professor of psychiatry, medicine, and clinical and translational science at the University of Pittsburgh, also said that adding medication to CBT-I may give a modest benefit for some specific outcomes, such as total sleep time, and that the recommendations are meant to support patient-centered decisions rather than a one-size-fits-all approach. The announcement says the American Geriatrics Society and the American Academy of Family Physicians affirmed the value of the guideline.
Disclosures in the paper include Buysse’s consulting for BeHealth, Eisai, Pear Therapeutics, the National Cancer Institute, Idorsia Pharmaceuticals, Sleep Number and Synchronicity Pharma; research support from Sleep Number (2023–2025); and compensation from sleep questionnaires and diaries including the Pittsburgh Sleep Quality Index. Co-author J. Todd Arnedt consulted for Purdue Pharma, Eisai and Idorsia (2021–2022). Co-author Emerson Wickwire is a consultant for Nox Health and ResMed, has consulted for Axsome Therapeutics, Eisai, Ensodata, Idorsia, Merck Sharp & Dohme and Primasun, and receives research support from Merck Sharp & Dohme and the ResMed Foundation.
VA/DoD, 2025. The VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea (version 3.0, 2025) rests on a systematic evidence review and was developed with the Veterans Health Administration and the Defense Health Agency. It rates CBT-I “Strong for” and brief behavioral therapy for insomnia “Weak for,” the latter partly because “there is a much smaller literature base on BBT-I and the evidence on BBT-I evaluates its effect on older adults only.” It gives sleep hygiene education as a stand-alone treatment a “Weak against” and suggests “CBT-I over pharmacotherapy as first-line treatment” (Weak for). Its reviewers found “no significant harms except for transient sleepiness that may result from sleep restriction caused by CBT-I or BBT-I,” and it lists conditions that call for adapting or delaying treatment, including excessive daytime sleepiness, nighttime fall risk, uncontrolled seizure disorder and bipolar disorder. Work group members completed conflict-of-interest disclosure forms under VHA policy; the guideline says its recommendations “are not intended to represent VA or DOD policies.”
The brief-treatment trial in detail
In the trial, 79 older adults (mean age 71.7; 54 women, 70%) with chronic insomnia and common comorbidities were recruited from the community and one primary care clinic. They were randomly assigned to brief behavioral treatment for insomnia (BBTI) or an information control. BBTI’s instructions derive from sleep restriction and stimulus control; time in bed was limited to average self-reported sleep time plus 30 minutes, with a minimum of 6 hours. The control group was asked to read three American Academy of Sleep Medicine publications. A nurse clinician delivered both.
- Responded to treatment (primary outcome, 4 weeks): 67% (26 people) with BBTI vs 25% (10) with information (P < .001)
- No longer had insomnia: 55% (21) vs 13% (5) (P < .001)
- Number needed to treat: 2.4 for each outcome. This means about two to three people received the treatment for one additional person to benefit compared with the reading-material group.
- Subgroups: no differential effects by hypnotic or antidepressant use, sleep apnea or recruitment source
- Measures: BBTI did better on self-reported sleep and health, sleep diaries and movement-monitor estimates (actigraphy), but not overnight clinical sleep recordings (polysomnography)
- Six months: only short-term BBTI responders were recontacted. Follow-up data were available for 25 BBTI participants; 40% met criteria for remission and 44% for response. The authors did not systematically follow up the nonresponders or the information group.
The authors concluded that “BBTI is a simple, efficacious, and durable intervention for chronic insomnia in older adults.” They listed as limitations a control condition not matched for therapist time, a single therapist for both conditions and a limited follow-up interval. A 2019 erratum corrected errors in table headings. The trial was funded by NIH grants, and the sponsors had no role in the study. Buysse disclosed paid consulting or continuing-education compensation indirectly sponsored by 17 companies, including Merck, Eisai, Sanofi-Aventis, Sepracor, Takeda, Purdue Pharma and Pfizer. Co-author Charles Reynolds received pharmaceutical supplies for NIH-sponsored work from Forest Laboratories, Bristol-Myers Squibb, Eli Lilly and Pfizer.
The exercise review in detail
The standardized mean difference (SMD) expresses a difference in scores relative to the variation in those scores. It lets researchers combine studies; it is not a difference in minutes of sleep. A 95% confidence interval (CI) describes uncertainty around the estimate.
The review, first author Pei-Yu Yang of National Taiwan University’s College of Medicine, pooled six randomized trials with 305 participants (241 female). All six measured sleep quality with the self-reported Pittsburgh Sleep Quality Index. Compared with control groups, exercise improved the global score (standardized mean difference 0.47, 95% CI 0.08 to 0.86), shortened time to fall asleep (SMD 0.58, 95% CI 0.08 to 1.08) and reduced sleep-medication use (SMD 0.44, 95% CI 0.14 to 0.74). The groups did not differ significantly in sleep duration, sleep efficiency, sleep disturbance or daytime functioning. The authors concluded that exercise has moderately positive effects on sleep quality in middle-aged and older adults and could be an alternative or complement to existing therapies for sleep problems. (Note 1)
The Beers Criteria in detail
The 2023 Beers Criteria apply to adults 65 and older in all ambulatory, acute and institutional settings except hospice and end-of-life care, and are designed specifically for use in the United States. All three sleep-aid entries carry a recommendation to avoid the drugs, with moderate-quality evidence and a strong recommendation. In the table, delirium means sudden confusion. Anticholinergic describes drugs that block the action of acetylcholine, a chemical that carries nerve signals; the National Cancer Institute explains the drug action and the signaling chemical.
| Drug type | Examples | Rationale given in the Beers Criteria |
|---|---|---|
| Benzodiazepines | Temazepam, triazolam, lorazepam | As a class, they raise the risk of cognitive impairment, delirium, falls, fractures and motor vehicle crashes in older adults. Continued use can also lead to clinically significant physical dependence. |
| “Z-drugs” | Zolpidem, eszopiclone, zaleplon | Adverse events similar to benzodiazepines in older adults, such as delirium, falls, fractures, more emergency room visits and hospitalizations, and motor vehicle crashes, with minimal improvement in time to fall asleep or sleep duration. |
| First-generation antihistamines | Diphenhydramine, doxylamine | Highly anticholinergic; cleared more slowly with advanced age; tolerance develops when used for sleep; risk of confusion, dry mouth, constipation and other anticholinergic effects or toxicity. |
The paper reports no sponsor. Panel disclosures include consulting for LexiComp (Wolters Kluwer), Precision Health Economics and UnitedHealthcare, and deprescribing grant funding from Blue Cross/Blue Shield. MedlinePlus notes that diphenhydramine “is also used to treat insomnia (difficulty falling asleep or staying asleep) in adults,” and the NIH’s DailyMed label database lists over-the-counter doxylamine succinate tablets sold as sleep aids.
Sources
- Edinger JD, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults (AASM guideline), Journal of Clinical Sleep Medicine, 2021: PubMed 33164742
- Qaseem A, et al. Management of chronic insomnia disorder in adults (ACP guideline), Annals of Internal Medicine, 2016: PubMed 27136449
- Buysse DJ, et al. Combination treatment for chronic insomnia disorder in adults (AASM guideline), Journal of Clinical Sleep Medicine, 2026: PubMed 41975142
- U.S. Departments of Veterans Affairs and Defense: VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea, 2025
- American Academy of Sleep Medicine: New guideline provides recommendations on combining treatments for chronic insomnia
- Buysse DJ, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults, Archives of Internal Medicine, 2011: PubMed 21263078
- Yang PY, et al. Exercise training improves sleep quality in middle-aged and older adults with sleep problems, Journal of Physiotherapy, 2012: PubMed 22884182
- 2023 American Geriatrics Society Beers Criteria Update Expert Panel. AGS Beers Criteria, Journal of the American Geriatrics Society, 2023: PubMed 37139824
- MedlinePlus: Diphenhydramine
- DailyMed: Sleep aid (doxylamine succinate tablet) label
Notes
Note 1: Funding and competing interests for the Yang review aren’t listed in its public record.
Related product and service comparisons
The companion comparison explains access to prescription insomnia software, a public web program and provider-led therapy tools.
Leave a Reply