Insomnia in older adults
========================

* Anup Katyal

**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.

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## REFERENCES

1.  León-Barriera R, Chaplin MM, Kaur J, 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
    
    [Abstract/FREE Full Text](http://www.ccjm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiY2Nqb20iO3M6NToicmVzaWQiO3M6NzoiOTIvMS80MyI7czo0OiJhdG9tIjtzOjIwOiIvY2Nqb20vOTIvMy8xNDMuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Yeh P, Walters AS, 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
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.1007/s11325-011-0606-x&link_type=DOI) 
    
    [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=22038683&link_type=MED&atom=%2Fccjom%2F92%2F3%2F143.atom) 
    
    [Web of Science](http://www.ccjm.org/lookup/external-ref?access_num=000311301700013&link_type=ISI) 

3.  Winkelman JW, Berkowski JA, 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
    
    [CrossRef](http://www.ccjm.org/lookup/external-ref?access_num=10.5664/jcsm.11390&link_type=DOI) 
    
    [PubMed](http://www.ccjm.org/lookup/external-ref?access_num=39324694&link_type=MED&atom=%2Fccjom%2F92%2F3%2F143.atom)