Evidenced-Based Review and Evaluation of Clinical Significance: Nonpharmacological and Pharmacological Treatment of Insomnia in the Elderly

•We provided an expanded evidenced-based review of all available pharmacotherapies and non-pharmacotherapies in the treatment of insomnia in the elderly. We also evaluated the safety of pharmacotherapies within the context of the 2019 Beers Criteria for Potentially Inappropriate Medications in the Elderly.•We found no studies limited to the elderly on treatments not contraindicated by Beers criteria with clinically significant results We found four studies, two on relaxation training, one on sleep restriction, and one on stimulus control limited to the elderly with positive results.•The challenge of determining which non-pharmacological and pharmacological treatment truly improve insomnia sleep to a clinically relevant degree remains paramount in the field of insomnia research. Further investigation with comprehensive meta-analyses and systematic reviews would add rigor to our understanding of the effectiveness of these options. Insomnia in the elderly is a prevalent condition that poses treatment challenges to practitioners across medical fields. There are many behavioral and other nonpharmacological therapies, 18 Food and Drug Administration-approved pharmacotherapies, and numerous off-label, over the counter and alternative treatments. Most reviews on this subject focus either on pharmacological treatments or behavioral treatments. The authors provide a combined review of available pharmacological and nonpharmacological treatments. The authors narratively reviewed each treatment from our literature search, tabled results with the highest level of available evidence on 5 major sleep outcomes and evaluated these results for clinical significance. The authors also evaluated the safety of pharmacotherapies within the context of the 2019 Beers Criteria for Potentially Inappropriate Medications in the Elderly. The authors found the most rigorous evidence supporting Cognitive Behavioral Therapy for Insomnia as a first-line treatment option, with longer lasting therapeutic effects than treatment with pharmacologic agents alone. The authors also found evidence of similar outcomes from other behavioral interventions, such as Brief Behavioral Therapy for Insomnia and relaxation training. The authors found 4 studies, 2 on relaxation training, 1 on sleep restriction, and 1 on stimulus control limited to the elderly with clinically significant results. The authors found no pharmacological studies limited to the elderly on treatments not contraindicated by Beers crite