Letters to the editor

Insomnia in older adults

Anup Katyal, MD
Cleveland Clinic Journal of Medicine March 2025, 92 (3) 143-144; DOI: https://doi.org/10.3949/ccjm.92c.03004

To the Editor: I read with great interest the review on insomnia in older adults by Dr. León-Barriera and colleagues1 in the January issue. The authors mention that up to 50% of older adults may have difficulty initiating or maintaining sleep, and that secondary causes of insomnia, such as sleep apnea, should be excluded. One of the important secondary causes of sleep-onset insomnia in adults is restless legs syndrome (RLS). Note that RLS is a misnomer, however, because the disorder can involve the upper extremity; restless limb syndrome is a more appropriate term. The prevalence of RLS increases with advancing age.2 It is a clinical diagnosis made by asking patients if they have a creepy, crawling sensation in the legs or arms with an urge to move; if symptoms occur in the evening or night; if they have onset of symptoms at rest; and if the symptoms improve with movement.

León-Barriera et al1 list mirtazapine, amitriptyline, and the over-the-counter antihistamine diphenhydramine among the agents that have been used for treatment of insomnia. However, these 3 drugs are important secondary causes of RLS, and prescribing them without excluding the diagnosis of RLS has the potential of making sleep-onset insomnia worse.

Recently updated guidelines3 by the American Academy of Sleep Medicine have changed the recommendations for treatment of RLS, now favoring alpha-2-delta ligands like gabapentin and pregabalin as first-line drugs over dopamine agonists.

REFERENCES

    1. León-Barriera R,
    2. Chaplin MM,
    3. Kaur J,
    4. Modesto-Lowe V
    . Insomnia in older adults: a review of treatment options. Cleve Clin J Med 2025; 92(1):43–50. doi:10.3949/ccjm.92a.24073
    1. Yeh P,
    2. Walters AS,
    3. Tsuang JW
    . Restless legs syndrome: a comprehensive overview on its epidemiology, risk factors, and treatment. Sleep Breath 2012; 16(4):987–1007. doi:10.1007/s11325-011-0606-x
    1. Winkelman JW,
    2. Berkowski JA,
    3. DelRosso LM, et al
    . Treatment of restless legs syndrome and periodic limb movement disorder: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2025; 21(1):137–152. doi:10.5664/jcsm.11390