Pharmacological and non-pharmacological interventions of insomnia in geriatrics: A systematic review

Insomnia is the most prevalent sleep disorder in the geriatric population, affecting 30-48% of communitydwelling older adults and higher proportions in residential care settings. Its management is complicated by age-related pharmacokinetic changes, polypharmacy, and disproportionate risks associated with traditionally prescribed hypnotic agents. This systematic review and meta-analysis synthesise contemporary evidence to address two key clinical questions: (1) what pharmacological agents are effective and safe for treating insomnia in older adults; and (2) what non-pharmacological interventions demonstrate efficacy in this population.

Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, 215 records were identified across major health databases including PubMed/MEDLINE, Web of Science, Scopus, and Google Scholar. After removing duplicates (n=62), 153 unique records were screened via title and abstract. Full-text evaluation was conducted on 23 articles, which were appraised using the Cochrane Risk of Bias tool (RoB 2) and AMSTAR-2. Following the explicit exclusion of one clinical guideline document to preserve analytical matrix consistency, 22 unique studies were included in the final qualitative synthesis. Quantitative synthesis employed random-effects models with heterogeneity evaluation via Cochrane's Q and I² statistics.

For pharmacological management, dual orexin receptor antagonists (DORAs) specifically suvorexant, lemborexant, and daridorexant demonstrated the most favorable efficacy-safety balance across evaluated randomised-control trial (RCT) data, yielding a highly consistent effect size for sleep initiation with low heterogeneity (Subjective Time to Sleep Onset (sTSO) Standardized Mean Difference (SMD): -0.28, 95% Confident Interval (CI): -0.41 to -0.15; I²=22%). Benzodiazepines and Zdrugs were associated with significant fall risks (Risk Ratio ~1.47), cognitive decline, and are classified as potentially inappropriate medications. For non-pharmacological management, face-to-face cognitive behavioral therapy for insomnia (CBT-I) demonstrated clinically significant improvements across 14 RCTs, including sleep efficiency (MD +8.36%; 95% CI: 5.96-10.76) and wake after sleep onset (wake after sleep onset (WASO) Mean Difference (MD) -23.44 min; 95% CI: -32.41 to -14.47), though statistical heterogeneity was high (I²=85%), reflecting variations in Sleep Restriction Therapy adaptation. Digital CBT-I, music therapy (SMD-0.79), and structured exercise also demonstrated substantial benefits.

CBT-I remains the evidence-based first-line treatment for geriatric insomnia. DORAs represent the safest pharmacological option when medication is mandatory, while benzodiazepines and Z-drugs must be actively deprescribed. A multimodal, individualized approach integrating behavioral and safe, targeted pharmacological strategies is strongly recommended.