Co-author: Louise Organista is an Advanced Clinical Pharmacist in the Frail Elderly Assessment team at the University Hospitals of Derby and Burton NHS Foundation Trust. She is also co-chair of the BGS Pharmacy Professionals Group. Louise posts on X via @Louise1401.
Co-author: Ian Wood is a GP in Buckinghamshire and UK Medical Director at Big Health, makers of Sleepio. He posts on Bluesky: @DrIanWood.bsky.social.
World Sleep Day on 15th March calls us to celebrate sleep but also to act on important issues in relation to it. In this article, we discuss why denying older people the right treatment for insomnia is putting their health at risk – and what needs to change.
Working in geriatrics, we see firsthand the significant toll that insomnia can take on older people.
Insomnia is the persistent difficulty in getting to sleep, maintaining sleep, or quality of sleep, resulting in impaired daytime functioning. It’s the plight of many and actually the most common mental health condition there is: between 6-10% of adults experience insomnia symptoms on at least three nights per week for three months or more.
Older adults are especially vulnerable: approximately 40% of people aged 65 and over experience insomnia regularly, with up to 75% suffering from some form of sleep disturbance.
Insomnia’s effects go far beyond fatigue. It’s a highly debilitating condition, impacting both mental and physical health and overall well-being - with persistent lack of sleep linked to increased risks of cardiovascular disease, diabetes, depression, anxiety and cognitive decline. It doesn’t just impact health either: older adults with insomnia spend significantly more time and money on medical visits and prescription medications compared to those without sleep disorders.
How should we treat it?
The National Institute for Health and Care Excellence (NICE) recommends cognitive behavioural therapy for insomnia (CBTi) as the first-line treatment.
CBTi tackles the root cause of the problem, addressing the cognitive and behavioural factors that cause insomnia. It’s backed by decades of robust evidence that demonstrates its safety, efficacy, and clinical effectiveness.
However, this proven treatment – which NICE recommends can be provided face-to-face or digitally - remains out of reach for the vast majority of people across England. That’s because face-to-face CBTi has long been largely unavailable due to a gross shortage of specialist trained therapists, and NHS England has still not made NICE-recommended digital CBTi available nationwide.
Sleeping tablets: a potential nightmare?
As a result of the lack of access to NICE-recommended digital CBTi, we clinicians are left with very few options for our patients. While sleep hygiene has sensible principles, it has not proven particularly effective for treating insomnia alone. Sleeping tablets (benzodiazepines and z-drugs) have been the de facto treatment for decades, yet their use is not recommended. NICE guidance clearly states that they should be avoided when possible due to significant adverse effects, including dependence, cognitive impairment, falls and fractures.
However, an analysis of NHS prescribing data suggests older people are one of the three groups most likely to be prescribed sleeping tablets. This is concerning given their increased susceptibility to the sedating and depressant effects of these medicines, as well as their heightened risk of serious injury and mortality following any fall. In addition, many in this age group contend with multiple comorbidities and medications, further underscoring the need to avoid sleeping tablets where possible.
CBT at scale - can digital be the answer?
Insomnia is one of the few conditions for which patients cannot reliably access guideline care - a situation that needs to change. We know CBTi is safe and effective and that it’s the first-line treatment; the question is how to make it widely available to those who need it.
Face-to-face CBTi is scarcely available, and this is unlikely to change. However, NICE-recommended digital CBTi offers a proven, viable solution.
Sleepio, which uses evidence-based cognitive and behavioural techniques to address the root causes of insomnia, became the first-ever digital treatment to be recommended by NICE in May 2022 and is currently the only digital CBTi-based treatment recommended by NICE. NICE validated Sleepio’s effective treatment outcomes and recognised its potential to expand access to CBTi nationwide. Importantly for our patients, evidence suggests that the benefits of using Sleepio may be even greater for those over 65 years of age.
However, while NICE-recommended digital CBTi has been funded nationally across Scotland with Sleepio since 2021, it is still not routinely available to patients in England, Wales and Northern Ireland.
How can it be that, 30 months after it was recommended by NICE, this first-line digital CBTi treatment is not available, whereas a new drug for insomnia was made available to patients in 2023, just two months after it secured a NICE recommendation as a second-line treatment behind CBTi?
Given the risks associated with overreliance on sleeping tablets, polypharmacy, and multiple morbidities - particularly among older people - it’s time to rethink our approach to treating insomnia. NICE-recommended digital treatments like Sleepio offer clinically proven, non-pharmacological alternatives with a robust evidence base. They deserve the same level of availability and access in clinical care as traditional drug treatments. This shift would help reduce overreliance on medicines while delivering clinical benefit for patients.
If the NHS is serious about addressing mental health and improving care for older people, giving patients and clinicians up and down the country the option of NICE-recommended digital CBTi is a sensible decision.
What can be done now?
On April 2nd 2025, key stakeholders from Government, NHS England, the third sector and academia, people with lived experience of insomnia, NHS primary care professionals and BGS will meet to discuss the serious concerns around the overprescribing of sleeping pills for insomnia and devise a unified strategy for change.
Until such times as CBTi is available as a non-pharmacological option for management of insomnia, please continue to have open conversations with your patients about sleep. If you don't already, consider incorporating this into your Comprehensive Geriatric Assessment.
Practical points such as completing a medication review, addressing poorly managed pain, discussing a patient's daily routine and providing good sleep hygiene advice accordingly can help. Don't forget the effects of alcohol and caffeine too! It's these conversations that may have potentially life-changing impact for older patients who are struggling to sleep and help avoid a future prescription.
If you're a BGS member and interested to be involved in the insomnia discussion and input into the upcoming summit, please contact louise.organista@nhs.net.
