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Managing chronic insomnia in an older patient

This is a fictional case study, based on a typical patient you may encounter in clinical practice.

Image is of a model

Steve, 73 – Retired mechanic

Sleep history
Reports that he’s “never been a good sleeper” but quality and length of sleep have deteriorated significantly over the last 2 years.
Has tried OTC remedies with no success.
Was prescribed a 13-week course of melatonin – initially improved sleep somewhat, but no lasting effect.

Medical history
Type 2 diabetes (5 years, metformin, SGLT2i).
Previous TIA; hypertension; stage 3 CKD (clopidogrel, ACE inhibitor; calcium channel blocker).
BMI 30 kg/m2.

Family and social history
Smoker (25 pack‑years; has recently decreased number of cigarettes per day); 10‑15 units of alcohol per week.
Father died following a myocardial infarction.
Lives alone.

Current consideration
Steve reports he is currently getting 3-4 hours’ sleep per night, and that this has been going on for about 6 months. He wakes up often in the night and sometimes gets up to urinate. He has episodes of forgetfulness and is feeling lethargic in the daytime. He says he struggles to find the energy to go out, so spends a lot of time indoors and has quite a solitary existence.

Sleep in older adults

Although older people may report sleeping less than before, it is a common misconception that they actually require less sleep than their younger counterparts.1 However, sleep patterns and quality can change with advancing age:

7+ hours1,2
  • The recommended amount of sleep per night does not change for older adults
Falling asleep earlier1,3
  • Sleep patterns often change in older adults, in part due to changes in circadian rhythms4
More naps than younger adults1,3
  • 25% of older adults take daytime naps which may affect night‑time sleep onset
Average 1 hour outdoors1
  • Many older adults have insufficient exposure to daylight, which may affect sleep
Effect of comorbidities1,4
  • The higher the number of comorbidities, the greater the probability of a sleep disorder
Different lifestyle1
  • Less structured days, loss of independence and isolation can lead to stress and anxiety, which can affect sleep

Difficulty in sleeping for older adults can be due to a combination of changes in sleep physiology, lifestyle and comorbidities.1,3 Comorbidities associated with sleeping difficulty include, but are not limited to, obstructive sleep apnoea, depression, cardiovascular disease, diabetes and inflammatory conditions.1 Nocturia is also very common in the older adult men; estimates vary, but rates may be as high as 62% in men aged 55-74 years and 80% in men aged 80 years and over.5

Ready for the next step?

Initial management

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ACE: angiotensin-converting enzyme; CBTi: cognitive behavioural therapy for insomnia; CKD: chronic kidney disease; CPAP: continuous positive airway pressure; OTC: over‑the‑counter; SGLT2i: sodium glucose cotransporter‑2 inhibitor; TIA: transient ischaemic attack

QUVIVIQ™ is indicated for the treatment of adult patients with insomnia characterised by symptoms present for at least 3 months and considerable impact on daytime functioning.18

This information is intended for UK healthcare professionals.

▼This medicine is subject to additional monitoring.

Adverse events must be reported. Healthcare professionals are asked to report any suspected adverse reactions via www.mhra.gov.uk/yellowcard or search for MHRA Yellow Card in Google Play or Apple App Store. Adverse events should also be reported to ds.safety.uk@idorsia.com

References

  1. Sleep Foundation. Aging and sleep, 19 September 2023. Available at: sleepfoundation.org. Accessed August 2025
  2. National Institutes of Health (NIH): National Institute on Aging. A good night’s sleep. Available at: nia.nih.gov. Accessed August 2025
  3. Patel D, Steinberg J, Patel P. Insomnia in the elderly: a review. J Clin Sleep Med 2018;14(6):1017-1024
  4. Cohen Z L, Eigenberger P M et al. Insomnia and other sleep disorders in older adults. Psychiatr Clin North Am 2022;45(4):717-734
  5. Duffy J F, Scheuermaier K, Loughlin K R. Age-related sleep disruption and reduction in the circadian rhythm of urine output: contribution to nocturia? Curr Aging Sci 2016;9(1):34-43
  6. Riemann D, Espie C A et al. The European Insomnia Guideline: an update on the diagnosis and treatment of insomnia 2023. J Sleep Res 2023;32(6):e14035
  7. Wilson S, Anderson K et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: an update. J Psychopharmacol 2019;33(8):923-947
  8. National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Insomnia. Scenario: managing long-term insomnia (more than 3 months duration), May 2025. Available at: cks.nice.org.uk. Accessed August 2025
  9. National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Stroke and TIA. Scenario: secondary prevention following stroke and TIA, May 2025. Available at: cks.nice.org.uk. Accessed August 2025
  10. Morin C M, Belleville G et al. The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep 2011;34(5):601-608
  11. Solikhah F K, Nursalam N, Ulfiana E. The effect of sleep hygiene on the sleep quality in elderly. Proceedings of the 8th International Nursing Conference on Education, Practice and Research Development in Nursing (INC 2017) 2017;doi: 10.2991/inc-17.2017.26
  12. National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Obstructive sleep apnoea syndrome. Scenario: management of sleep apnoea, May 2025. Available at: cks.nice.org.uk. Accessed August 2025
  13. Prolonged-release melatonin Summary of Product Characteristics
  14. National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Insomnia. Scenario: managing short-term insomnia (less than 3 months duration), May 2025. Available at: cks.nice.org.uk. Accessed August 2025
  15. Zolpidem Summary of Product Characteristics
  16. Zopiclone Summary of Product Characteristics
  17. National Institute for Health and Care Excellence (NICE). Clinical knowledge summary. Insomnia. Prescribing information: Z-drugs, May 2025. Available at: cks.nice.org.uk. Accessed August 2025
  18. QUVIVIQ™ Idorsia Pharmaceuticals Ltd, Summary of Product Characteristics

© NICE 2023 Daridorexant for treating long-term insomnia. Available from www.nice.org.uk/guidance/ta922. All rights reserved. Subject to Notice of rights.

NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/ publication.

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UK-DA-00657 | Date of preparation: September 2025

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