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

Shalihin, Mohd Shaiful Ehsan and Sharin, Shazrin Iman and Abdul Aziz, Muhammad Amirul Najmi (2026) Pharmacological and non-pharmacological interventions of insomnia in geriatrics: a systematic review. Medical Journal of Malaysia, 81 (5). pp. 787-794. ISSN 0300-5283

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Abstract

ABSTRACT Introduction: 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. Materials and Methods: 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. Results: 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. Conclusion: 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.

Item Type:	Article (Journal)
Uncontrolled Keywords:	Insomnia, Geriatrics, Cognitive behavioral therapy (CBT-I), Dual Orexin Receptor Antagonists (DORAs)
Subjects:	R Medicine > R Medicine (General) R Medicine > RA Public aspects of medicine R Medicine > RC Internal medicine R Medicine > RT Nursing
Kulliyyahs/Centres/Divisions/Institutes (Can select more than one option. Press CONTROL button):	Kulliyyah of Medicine Kulliyyah of Medicine > Department of Family Medicine (Effective: 1st January 2011)
Depositing User:	Dr Mohd Shaiful Ehsan Shalihin
Date Deposited:	06 Oct 2026 00:44
Last Update:	06 Oct 2026 00:44
Queue Number:	2026-09-Q5441
URI:	http://irep.iium.edu.my/id/eprint/131719
Indexed In:	MyCite

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