Unmet Needs in the Management of Insomnia in Older Adults and the Role of Lemborexant: A Real-World Perspective

This narrative review integrates available evidence with expert opinion to explore the challenges and unmet needs in insomnia care for older adults and the role of lemborexant in this milieu. A panel of nine clinicians with extensive experience in managing sleep disorders met in February 2025 and discussed the challenges and barriers they face when managing insomnia in older adults, and their experience with lemborexant in this population. The assessment and diagnosis of insomnia in older adults is complicated by age-related sleep changes, comorbidities, polypharmacy, and cognitive decline, and requires a systematic approach that considers comprehensive sleep history alongside medical, cognitive, pharmacological, and psychosocial contributors to sleep disturbances. Sedative-hypnotic agents are associated with risks in older adults, including falls, cognitive impairment, residual sedation, and poor motor coordination; prolonged use may lead to tolerance, dependence, and rebound insomnia upon discontinuation. Lemborexant, a dual orexin receptor antagonist approved for the treatment of insomnia in adults, shows sustained efficacy in older adults by improving sleep onset and maintenance through 12 months with a favorable safety profile and low risk of next-morning sedation, dependency, or withdrawal. Long-term real-world studies will confirm the safety and effectiveness of lemborexant in older adults with insomnia. Insomnia in older adults is underdiagnosed and undertreated, with available treatments constrained by risks including dependency, falls, residual sedation and cognitive impairment. Lemborexant, with demonstrated efficacy in improving sleep onset and maintenance, a favorable safety profile, and low dependency and withdrawal risks, may be a valuable alternative to sedative-hypnotics.