Preamble

Chinese Expert Consensus on Sleep Health and Rehabilitation Management for Community-dwelling Older Adults (2025 Edition)
Community Rehabilitation Working Committee of Chinese Rehabilitation Medical Association

Corresponding author: JIA Jie, Chief Physician/Professor, Huashan Hospital, Fudan University; E-mail: shannonjj@126.com

[Abstract] Poor sleep quality in older adults is closely associated with a range of adverse health outcomes. Strengthening sleep health and rehabilitation management within existing primary healthcare services for older adults can help prevent or delay the onset and progression of many chronic diseases, thereby saving substantial medical resources. However, a comprehensive sleep rehabilitation management system has yet to be established at the primary healthcare level. To address this gap, the Community Rehabilitation Working Committee of the Chinese Rehabilitation Medical Association has developed the Chinese Expert Consensus on Sleep Health and Rehabilitation Management for Community-dwelling Older Adults (2025 Edition), in collaboration with experts from multiple domestic institutions. Grounded in evidence-based research on sleep rehabilitation and informed by multidisciplinary clinical experience, this consensus considers the current availability of community-level rehabilitation resources and future trends in primary healthcare. It offers consensus-based recommendations on age-related changes in sleep physiology, goals and requirements for sleep health management at the primary care level, rehabilitation screening and assessment, management content, and procedural workflows. The publication of this consensus is expected to play a pivotal role in guiding primary healthcare institutions to implement standardized and evidence-based management of sleep rehabilitation in older adults.

[Key words] Sleep; Sleep disorders; Rehabilitation; Aged; Community; Expert consensus

Funding: National Key R&D Program of China (2018YFC2002301); National Natural Science Foundation of China Innovative Research Group Project (82021002); National Natural Science Foundation of China Major Research Plan Integration Project (91948302); Shanghai "Science and Technology Innovation Action Plan" Elderly Care Technology Support Special Project (24YL1900202)

Citation: Community Rehabilitation Working Committee of Chinese Rehabilitation Medical Association. Chinese Expert Consensus on Sleep Health and Rehabilitation Management for Community-dwelling Older Adults (2025 Edition) [J]. Chinese General Practice, 2025. DOI: 10.12114/j.issn.1007-9572.2025.0205. [Epub ahead of print]

1. Consensus Development Methods

This consensus was initiated by the Community Rehabilitation Working Committee of the Chinese Rehabilitation Medical Association in January 2025, with a drafting period of 5 months.

1.1 Target Users

This consensus is intended for general practitioners, rehabilitation physicians, rehabilitation therapists, nurses, and other health service providers engaged in health management and rehabilitation assessment and treatment at primary healthcare institutions. It aims to guide the delivery of sleep health and rehabilitation management services for community-dwelling older adults aged 65 years and above, particularly those with sleep disorders or related health risk factors.

1.2 Consensus Development Working Group

The working group comprised senior experts and frontline practitioners from multiple disciplines, including rehabilitation medicine, clinical medicine, geriatrics, sleep medicine, general practice, nursing, psychiatry, evidence-based medicine, and public health. The group was divided into a guidance expert panel and a drafting expert panel, with all members selected and confirmed by the Community Rehabilitation Working Committee of the Chinese Rehabilitation Medical Association. Drafting experts were selected based on holding associate senior professional titles or above, with research directions or clinical expertise in the aforementioned fields. Guidance experts were selected based on their leadership or core participation in the development of national standards, group standards, expert consensus documents, or clinical guidelines, or their high academic authority and extensive clinical experience in sleep-related fields.

1.3 Consensus Registration

This consensus has been registered with the International Practice Guideline Registration and Transparency Platform (PREPARE, https://www.guidelines-registry.org/) under registration number PREPARE-2025CN774.

1.4 Literature Search

The consensus development team conducted systematic literature searches using keywords including "sleep," "sleep disorders," "sleep quality," "sleep disturbance," "aged," "older adults," "rehabilitation," "assessment," "therapy," "primary healthcare," "睡眠," "睡眠障碍," "老年人," "康复评估," "康复治疗," and "基层卫生" in PubMed, Web of Science, Cochrane Library, CNKI, Wanfang Data, VIP, and other Chinese and English databases, as well as professional websites such as the UK's National Institute for Health and Care Excellence (NICE) and the American Academy of Sleep Medicine. The search timeframe spanned from database inception to April 30, 2025.

Inclusion criteria: (1) Studies on screening, assessment, and management of sleep quality or sleep disorders in older adults (age ≥ 60 years); (2) Studies involving primary healthcare, community rehabilitation service models, and management processes for sleep health; (3) High-level evidence literature including expert consensus, clinical practice guidelines, meta-analyses, systematic reviews, randomized controlled trials (RCTs), and observational studies; (4) Priority given to Chinese and English literature from the past 10 years, with high-quality earlier studies included when necessary.

Exclusion criteria: (1) Studies not involving sleep assessment, intervention, or long-term management; (2) Low-quality studies such as case reports, conference abstracts, and non-peer-reviewed literature; (3) Non-Chinese or non-English literature.

1.5 Consensus Development Process

Based on the retrieved evidence and considering China's clinical realities, rehabilitation resources, and primary healthcare practices, the drafting team prepared the initial draft. Given that this consensus primarily aims to propose management processes and guide grassroots practice, it does not adopt the GRADE system for rating recommendation strength and evidence quality. Some recommendations were based on existing systematic reviews or clinical trials and are referenced accordingly, while others were formulated through multi-round expert discussions. Between March and May 2025, the Community Rehabilitation Working Committee organized three plenary sessions where the drafting experts conducted repeated discussions and revisions of the draft. Evidence-based medicine experts reviewed the methodology, and the guidance expert panel was responsible for final review and approval. During the consensus development process, contentious issues were thoroughly discussed and consulted upon by the working group; consensus was considered reached when over 75% of experts agreed. Content that failed to reach consensus after revision and re-evaluation was excluded from the final version.

1.6 Publication, Dissemination, and Update

To promote dissemination and clinical application, the consensus will be published in professional journals and subsequently disseminated nationwide through academic conferences, training workshops, and online lectures. The consensus development working group will conduct regular literature searches, evidence updates, and evaluations, with plans to revise the consensus every 5 years.

2. Definitions

2.1 Sleep-Wake Cycle

Sleep consists of two physiological states: non-rapid eye movement (NREM) sleep and rapid eye movement (REM) sleep. NREM sleep is further divided into three stages based on electroencephalographic characteristics: N1, N2, and N3. The N1 stage represents the transition from wakefulness to sleep, typically lasting a few minutes. The N2 stage is characterized by slowing heart rate and breathing, decreasing body temperature, and brain activity dominated by sleep spindles and K-complexes, lasting several tens of minutes. The N3 stage, also known as slow-wave sleep (SWS), features the lowest heart rate, breathing, and blood pressure of the day, with brain activity dominated by delta waves, marking deep sleep [8]. REM sleep is a complex neurophysiological state currently considered the deepest stage of sleep. Normal sleep consists of periodically alternating NREM and REM cycles, with each cycle lasting approximately 90 minutes and comprising 4-5 cycles throughout the night [9].

2.2 Sleep Health

Sleep health is a positive, comprehensive framework encompassing multiple sleep characteristics, including regularity, daytime functioning, duration, continuity, efficiency, satisfaction, and quality. It extends beyond individual sleep symptoms and disorders and can be viewed as a continuous indicator measuring sleep status across populations, facilitating nuanced understanding and evaluation of individual sleep patterns and providing personalized guidance and interventions for sleep improvement [10-11].

2.3 Sleep Quality

Sleep quality represents one dimension of sleep health. The National Sleep Foundation identifies 11 indicators for assessing good sleep quality across three dimensions: (1) Sleep continuity indicators: sleep onset latency, number of nighttime awakenings (each >5 minutes), wake-time after sleep onset (WASO), and sleep efficiency; (2) Sleep architecture indicators: proportions of REM, N1, N2, and N3 sleep; (3) Napping-related indicators: number of naps within 24 hours, duration of each nap, and weekly nap frequency [12]. Reference ranges for these indicators vary across age groups (see Table 1 [TABLE:1]). Generally, shorter sleep onset latency and WASO, fewer nighttime awakenings, and higher sleep efficiency are considered core manifestations of good sleep quality.

2.4 Sleep Disorders

Based on the harmful dysfunction analytical framework, sleep disorders are defined as syndromes in which clinically significant disturbances in sleep quality, quantity, rhythm, or the sleep-wake cycle result from dysregulation of the brain's dynamic functional sleep-wake control mechanisms or abnormalities in other physiological, developmental, and behavioral regulatory systems during sleep [13]. According to the International Classification of Sleep Disorders (Third Edition), sleep disorders comprise seven core categories: insomnia, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep-wake disorders, sleep-related movement disorders, parasomnias, and other sleep disorders, each containing specific diseases or symptom clusters [14]. The National Patriotic Health Campaign Office's Core Information and Interpretation on Sleep Health identifies three major categories of sleep disorders—"difficulty falling asleep," "difficulty staying awake," and "poor sleep quality"—encompassing over 90 specific conditions [15].

2.5 Sleep Rehabilitation

Currently, no unified, authoritative definition of "sleep rehabilitation" exists in domestic or international literature and guidelines. Based on the whole-cycle rehabilitation concept, this consensus proposes the following definition: Sleep rehabilitation is a process of whole-cycle rehabilitation management for sleep health across the entire population, with sleep function as the core target and non-pharmacological therapies as the primary intervention approach, supplemented by specialized treatment when necessary. It aims to maintain and improve sleep function, promote overall health, delay functional decline, and enhance individual quality of life. Unlike previous concepts of sleep disorder treatment, sleep rehabilitation emphasizes continuous management of sleep as a health function, with management targets including not only individuals diagnosed with sleep disorders but also those with declining sleep function and those without apparent sleep problems but with relevant risk factors.

3. Physiological Changes in Sleep Among Older Adults

Sleep problems in older adults are not entirely natural consequences of aging; therefore, it is necessary to distinguish between normal and abnormal sleep changes. With natural aging, sleep undergoes a series of physiological changes that, while not entirely pathological, may lead to decreased sleep quality and affect daily functioning and health status. Common physiological changes in older adults' sleep include [16]:

3.1 Sleep Duration

Meta-analyses show that for every 10-year increase in age, total sleep duration decreases by 10.1 minutes in healthy adults. This decline in total sleep duration is more pronounced in young and middle-aged populations and stabilizes after age 60 [17].

3.2 Sleep Patterns

Changes in sleep patterns among older adults include advanced sleep phase, reduced ability to initiate and maintain sleep, shortened nocturnal sleep duration, increased frequency of daytime naps, and more frequent and prolonged nighttime awakenings.

3.3 Sleep Architecture

Age-related changes in sleep architecture primarily manifest as prolonged sleep onset latency, decreased sleep efficiency, reduced proportions of SWS and REM sleep, increased proportions of N1 and N2 sleep, lowered sleep arousal threshold, and sleep fragmentation due to multiple awakenings.

3.4 Circadian Rhythm Changes

With aging, the stability of circadian rhythms declines, affecting sleep quality and regularity. Specific changes include advanced sleep-wake cycle phase, earlier secretion timing of key hormones such as melatonin and cortisol, reduced amplitude of circadian-regulated physiological processes, and diminished capacity to adapt to phase changes—requiring more time to recover stable rhythms after transmeridian travel or shift work [18].

3.5 Endocrine Changes

Aging brings significant changes in the secretion of multiple hormones involved in sleep regulation, affecting sleep architecture and quality. These include: (1) Growth hormone: Reduced nocturnal growth hormone secretion in older adults may directly or indirectly lead to decreased SWS proportion; (2) Cortisol: Older adults are prone to elevated nocturnal cortisol levels and advanced rhythm phase, potentially causing reduced SWS and frequent nighttime awakenings; (3) Prolactin: Normally increases after sleep onset, but reduced SWS or sleep fragmentation limits its nocturnal secretion, with older adults showing significantly lower nocturnal prolactin levels than younger individuals; (4) Thyroid-stimulating hormone: Total secretion decreases in older adults, though circadian rhythm characteristics remain largely unchanged; (5) Melatonin: Nocturnal melatonin secretion significantly decreases in older adults while daytime baseline levels remain unchanged; (6) Sex hormones: Male testosterone levels continuously decline after age 30, with older men potentially losing its circadian rhythm, and sleep fragmentation further suppressing testosterone secretion. In postmenopausal women, estradiol decreases significantly with elevated follicle-stimulating hormone, potentially causing difficulty falling asleep and sleep maintenance problems. Reduced progesterone may also increase the risk of sleep-disordered breathing in postmenopausal women [19-20].

4. Goals and Basic Requirements for Sleep Health and Rehabilitation Management of Community-Dwelling Older Adults

[Recommendation 1] Primary healthcare institutions should include all older adults receiving health management services in the scope of sleep health and rehabilitation management. Family doctor contract teams should serve as the core unit for establishing older adult sleep rehabilitation management teams. These teams should be staffed with relevant medical personnel according to actual conditions; ideally, they should include general practitioners, rehabilitation physicians, traditional Chinese medicine physicians, psychiatrists, endocrinologists, orthopedic surgeons, nutritionists, rehabilitation therapists, psychotherapists, and nurses, while establishing a complete "two-way referral" mechanism to effectively improve sleep problems among community-dwelling older adults.

4.1 Management Target Population

Older adults aged 65 years and above receiving health management services at primary healthcare institutions.

4.2 Management Goals

Primary healthcare institutions provide health services for more than half of China's older adult population and possess unique advantages in geriatric sleep rehabilitation management, enabling earlier and more timely identification of older adults with sleep problems and intervention during early stages to reduce risks of various physical and mental health complications derived from sleep disorders. Therefore, management goals should include: (1) Regular screening and follow-up for sleep disorders; (2) Sleep health education to improve older adults' awareness and knowledge of maintaining sleep health; (3) Expanded psychosocial support for older adults with sleep disorders; (4) Identification and effective management of major physical diseases and depression that may affect sleep; (5) Provision of rehabilitation therapy to improve sleep disorders when conditions permit; (6) Referral to psychiatrists and sleep specialists when necessary [21].

4.3 Responsibilities of the Sleep Rehabilitation Management Team

Sleep disorders in older adults involve not only sleep itself but also multiple factors including pain, medical conditions, psychiatric disorders, medication effects, social participation, and lifestyle/environmental changes, requiring multidisciplinary team collaboration and multi-level intervention based on preventive healthcare [22].

[Recommendation 2] General practitioners should systematically collect basic sleep-related information during initial assessments, including subjective sleep symptoms, medical history, mental health status, physical examination findings, and medication use, to preliminarily differentiate primary from secondary sleep disorders and inform subsequent intervention decisions, graded management, and necessary referrals.

4.3.1 Family Doctor/General Practitioner

Family doctors should serve as the primary responsible parties for sleep rehabilitation management, coordinating with chronic disease health management. They are mainly responsible for screening, assessment, and graded management of older adults' sleep status; identifying potential risk factors for sleep disorders; developing preliminary intervention plans based on individual conditions; referring to higher-level hospitals when necessary; and participating in follow-up and evaluation of intervention outcomes.

4.3.2 Nurses

Nurses are responsible for individualized sleep health education and daily follow-up for older adults, assisting in sleep health screening and health record management, and cooperating in follow-up and home guidance.

4.3.3 Rehabilitation Therapists

Rehabilitation therapists conduct detailed sleep health assessments, provide safe and appropriate exercise intervention guidance, muscle relaxation training, respiratory training, and non-pharmacological interventions such as neuromodulation, regularly evaluate sleep improvement, and timely adjust rehabilitation content.

4.3.4 Psychotherapists

Psychotherapists provide psychological support and counseling for older adults with anxiety, depression, loneliness, and other psychological problems, offer cognitive behavioral therapy (CBT) or other psychological treatments when necessary, assist in screening for severe psychological disorders, and guide referral processes.

5. Screening and Assessment

5.1 Basic Information Collection

[Recommendation 3] Primary healthcare providers may use simple, feasible scale tools to assess older adults' sleep status, covering sleep quality evaluation, sleep disorder screening, sleep health level, sleep hygiene behaviors, and related psychological states. For older adults with cognitive impairment or those unable to cooperate with assessment due to other factors, information can be obtained by asking family members or caregivers.

5.1.1 Sleep History

Inquire with older adults or their caregivers about sleep disorder-related symptoms and triggers, daytime functional impairment, sleep habits, sleep duration, sleep quality, sleep environment, history of mental illness or cognitive dysfunction, and assess the impact of environmental noise, light, sleep schedule changes, and nighttime thirst on sleep [23].

5.1.2 Physical Examination

Combine basic physical examination and common chronic disease assessment to preliminarily determine whether older adults have comorbidities related to sleep disorders, with particular focus on evaluating the impact of treatment and care for hypertension, diabetes, respiratory diseases (e.g., chronic obstructive pulmonary disease), cardiovascular disease, and neurological diseases on sleep.

5.1.3 Medication Use

Understand older adults' medication use, particularly drugs that may affect sleep, such as diuretics, glucocorticoids, sedative-hypnotics, antidepressants, and antipsychotics.

5.2 Subjective Assessment

5.2.1 Sleep Quality Assessment

The Pittsburgh Sleep Quality Index (PSQI) is recommended for assessing overall sleep quality in older adults. The PSQI is a reliable and valid tool for evaluating subjective sleep quality in older adults, comprising 7 dimensions: subjective sleep quality, sleep latency, sleep duration, sleep efficiency, daytime dysfunction, sleep disturbances, and use of sleep medication, with 9 items total. Assessment requires 5-10 minutes, with total scores ranging from 0-21 [24]. Corresponding interventions should be provided based on PSQI scores (Table 2 [TABLE:2]).

5.2.2 Sleep Disorder Screening

For older adults with suspected or confirmed sleep disorders, appropriate scales should be selected for screening or severity assessment. The Insomnia Severity Index can be used for insomnia evaluation; the STOP-BANG scale, Berlin Questionnaire, or OSA-50 screening questionnaire can be used for obstructive sleep apnea (OSA) risk screening; the Epworth Sleepiness Scale can be used for daytime sleepiness assessment, though it presents certain difficulties for older adults (particularly those with cognitive impairment) and its reliability and validity require further research; the Sleep Functional Outcomes Questionnaire can assess the impact of daytime sleepiness on daily activities and quality of life; and the International Restless Legs Syndrome Scale can evaluate symptom intensity and frequency, sleep problems, and impact on mood and daily life in restless legs syndrome (RLS) [25].

5.2.3 Sleep Health Assessment

The Regularity, Satisfaction, Alertness, Timing, Efficiency, and Duration (RU-SATED) scale can be used for sleep health assessment. This scale comprises 6 items using a 0-2 Likert 3-point scoring system, with total scores of 12 points; higher scores indicate better sleep health status. The scale has been translated, cross-culturally adapted, and validated in Chinese, demonstrating good reliability, with assessment requiring 1-2 minutes [26].

5.2.4 Sleep Hygiene Assessment

The Sleep Hygiene Awareness and Practice Scale (SHAPS) can objectively assess the degree to which environment and personal behaviors affect sleep, helping identify poor sleep hygiene habits. The Chinese version of SHAPS demonstrates high test-retest reliability with a Cronbach's α coefficient of 0.71 [27]. Although no large-scale studies have investigated the reliability and validity of SHAPS in older adults, primary healthcare providers are recommended to use this scale to assess sleep hygiene in older adults and provide behavioral guidance based on assessment results.

5.2.5 Psychological Assessment

The Geriatric Depression Scale and Geriatric Anxiety Scale can be used to assess older adults' mental health status.

5.3 Objective Assessment

[Recommendation 4] Primary healthcare institutions with available resources should prioritize equipping and using convenient, accessible tools such as wrist actigraphy, clinically validated millimeter-wave radar sleep monitors/mattresses, and other wearable sleep monitoring devices for objective sleep assessment in older adults. Portable polysomnography (PSG) may be combined for further diagnosis when necessary.

Objective sleep monitoring primarily includes PSG, portable PSG, wrist actigraphy, multiple sleep latency testing, and wearable/non-contact sleep monitoring devices. Different objective assessment methods have distinct advantages in indications, accuracy, and accessibility (Table 3 [TABLE:3]) and should be reasonably selected based on assessment purposes, individual circumstances, and resource conditions.

6. Sleep Rehabilitation Management Content

6.1 Health Records

[Recommendation 5] It is recommended to add sleep-related content to older adults' health records based on the existing National Basic Public Health Service Standards, including sleep history, sleep disorder assessment results, medication use, psychological status, comorbidities, and use of sleep assistive devices and activities of daily living.

6.2 Sleep Rehabilitation Management Principles

[Recommendation 6] Primary healthcare institutions should develop differentiated sleep rehabilitation management strategies based on older adults' sleep status and health risks. For those without apparent sleep disorders, the focus should be on promoting healthy sleep and preventive interventions. For those preliminarily identified with primary sleep disorders, initial rehabilitation management should primarily involve non-pharmacological interventions. For secondary sleep disorders, priority should be given to identifying and intervening in related underlying diseases, medications, and psychological factors, with referral to higher-level medical institutions when necessary.

6.3 Sleep Health Education

[Recommendation 7] All older adults should receive sleep health education to inform them about normal age-related sleep physiological changes, avoid excessive worry, assist in creating a good sleep environment, establish regular sleep-wake schedules, ensure adequate natural light exposure and daytime physical activity, and provide pre-sleep behavioral guidance.

Currently, no unified standard exists for sleep health education content, with definitions and components varying across studies. Based on existing research, it can be defined as a comprehensive management strategy that promotes healthy sleep through establishing regular schedules, optimizing sleep environments, and adjusting daily behavioral habits. Its core components include three dimensions: (1) Behavioral regulation, including management of caffeine and alcohol intake, timing of exercise/physical activity, maintaining sleep duration/regularity, napping, smoking, pre-sleep relaxation, stimulus control, eating, sleep restriction, and rational use of sleep medications and other substances; (2) Environmental optimization, including adjustment of lighting, noise control, temperature regulation, and comfortable bedding; (3) Regulation of stress and other psychological factors affecting sleep [28].

6.4 Psychotherapy

[Recommendation 8] Primary healthcare institutions with available resources may provide psychotherapy services including CBT, mindfulness therapy, group psychotherapy, and digital intervention methods to improve sleep quality in older adults.

Multiple meta-analyses and RCTs have demonstrated that psychotherapy effectively improves sleep quality and insomnia symptoms in older adults. CBT is the first-line treatment for chronic insomnia, with RCTs and pre-post studies showing it most significantly reduces insomnia severity in older adults while improving sleep efficiency, shortening sleep onset latency, reducing WASO, and decreasing hypnotic medication use [29-30]. Digital CBT can serve as an effective alternative when primary healthcare resources are limited, providing efficient, remote insomnia intervention for older adults. Meta-analyses show digital CBT, as a scalable and widely accessible treatment, effectively improves insomnia, anxiety, and depression symptoms in adults aged 65 and older [31-32]. Mindfulness therapy is an intervention that enhances sleep experience and reduces sleep maintenance difficulties through meditation and mindfulness practices. An RCT involving 127 older adults showed that mindfulness therapy, compared to traditional sleep hygiene combined with exercise intervention, effectively reduced PSQI and Insomnia Severity Index scores and improved objective sleep measures including sleep onset latency and WASO [33].

6.5 Rehabilitation Therapy

[Recommendation 9] Primary healthcare institutions may employ multiple rehabilitation interventions to improve sleep problems based on resource availability and older adults' specific conditions. Priority should be given to safe, evidence-based interventions such as individualized exercise therapy, music therapy, and light therapy. With professional equipment and personnel, emerging technologies such as repetitive transcranial magnetic stimulation (rTMS), transcutaneous auricular vagal nerve stimulation (ta-VNS), and virtual reality (VR) therapy may be implemented.

6.5.1 Exercise Therapy

A meta-analysis including 3,937 older adults showed that exercise interventions positively affect sleep quality in older adults, significantly improving sleep quality, reducing insomnia severity, increasing sleep efficiency, and decreasing WASO, though without significant effects on daytime sleepiness, sleep onset latency, or number of nighttime awakenings [34]. Among exercise types, aerobic exercise is most effective for improving PSQI total scores, while yoga shows good effects on improving sleep disturbances, sleep efficiency, sleep duration, and daytime dysfunction [35-36].

6.5.2 rTMS

Systematic reviews indicate that rTMS stimulation of bilateral dorsolateral prefrontal cortex (DLPFC), right parietal cortex, and dominant primary motor cortex (M1) can treat primary insomnia, while stimulation of bilateral M1 leg areas, left primary somatosensory cortex, and left M1 can improve subjective symptoms and severity of RLS, with effects lasting several weeks. However, no therapeutic effects were observed for OSA or narcolepsy (Table 4 [TABLE:4]) [37]. RCT studies show that for older adults with mild cognitive impairment and comorbid sleep disorders, 1 Hz rTMS applied to the right DLPFC can enhance the effect of Tai Chi in improving PSQI scores [38].

6.5.3 Transcranial Direct Current Stimulation (tDCS)

An RCT including 14 older adults with chronic pain and subjective sleep problems showed that tDCS improved pain scores compared to sham stimulation but did not improve sleep [39]. A study of patients with depression comorbid with insomnia showed that tDCS improved sleep efficiency and PSQI total scores [40]. Additionally, research indicates that tDCS applied to the sensorimotor area had no significant effect on drug-naïve RLS patients [41]. Therefore, the efficacy of tDCS for improving sleep disorders in older adults requires further investigation.

6.5.4 ta-VNS

RCT studies show that a 2-week course of ta-VNS can improve PSQI scores in community residents [42]. Other studies indicate that ta-VNS significantly improves sleep quality and relieves anxiety in older healthcare workers while reducing symptom severity in patients with severe drug-resistant RLS [43-44].

6.5.5 VR Therapy

An RCT involving 63 patients with chronic insomnia showed that VR therapy improved sleep quality, reduced depression and anxiety symptoms, and simultaneously improved cognitive and autonomic nervous function [45].

6.5.6 Music Therapy

Meta-analyses show that listening to soft or sedative music can effectively improve sleep quality in older adults without cognitive impairment or hearing loss, with sedative music (characterized by slow tempo of 60-80 beats per minute and smooth melody) showing better effects than rhythmic music, and interventions lasting more than 4 weeks being more effective than shorter durations, though study quality is variable and evidence is limited [24, 46].

6.5.7 Light Therapy

A meta-analysis showed that light therapy effectively improved sleep efficiency (from 73% to 86%) and sleep-wake cycles in older adults living long-term in care facilities, though its efficacy may be influenced by light exposure duration, intensity, and equipment, requiring further research to optimize treatment parameters [47]. Light therapy can be delivered through morning bright light exposure, evening or nighttime dim light exposure, natural light exposure, wearable light therapy devices, and light environment modification. Common parameters include exposure between 7:00-12:00, duration of 30-120 minutes, intervention lasting 1 week to several months, and intensity typically ranging from 2,500-10,000 lux. Based on exposure intensity and duration, strategies can be categorized as short-term (30-60 minutes) high-intensity exposure (≥10,000 lux), relatively long-term (1-2 hours) moderate-intensity exposure (2,500-10,000 lux), and long-term (1-4 hours or all-day) low-intensity exposure (≤2,500 lux). All these strategies have been reported to improve sleep efficiency and subjective sleep measures in older adults.

6.6 Traditional Chinese Medicine Healthcare

[Recommendation 10] Primary healthcare institutions should expand the application of traditional Chinese medicine in older adults' sleep health management according to local TCM resources and service capabilities, employing approaches such as acupuncture, herbal medicine, traditional exercise practices, and auricular therapy.

Traditional Chinese medicine demonstrates certain efficacy in treating sleep disorders, enjoys broad public acceptance, and is feasible for application in primary healthcare institutions. Given the extensive content of TCM interventions, variable evidence levels, and need for standardized clinical pathways, this consensus does not focus on TCM interventions but lists some commonly used methods for clinical reference.

6.6.1 Acupuncture

Data mining studies exploring acupuncture point selection patterns for treating sleep disorders in older adults indicate that such disorders can be differentiated into patterns including heart-spleen deficiency, liver depression transforming into fire, heart-kidney non-interaction, stomach qi disharmony, heart-gallbladder qi deficiency, and yin deficiency with fire effulgence. Acupuncture treatment should follow principles of harmonizing yin-yang and calming the heart to tranquilize the spirit, emphasizing regulation of spirit and qi, with core acupoint combinations including Shenmen (HT7), Baihui (GV20), Sanyinjiao (SP6), Neiguan (PC6), and Sishencong (EX-HN1), with pattern-based point selection in clinical practice [48].

6.6.2 Herbal Medicine

According to the Clinical Practice Guidelines for Integrated Traditional Chinese and Western Medicine Rehabilitation of Insomnia, insomnia patients may be treated with Chinese patent medicines such as Zaoren Anshen Capsule, Shumian Capsule, Wuling Capsule, and Tianmeng Oral Liquid to relieve corresponding symptoms based on pattern differentiation, or with herbal formulas such as Suanzaoren Decoction and Chaihu Longgu Muli Decoction combined with conventional Western medicine [49]. However, when combining Chinese and Western medicine for sleep disorders in older adults, special attention must be paid to drug interactions, individual pharmacokinetic characteristics, and effects of comorbidities. Family doctors should conduct regular medication reviews and strengthen monitoring of sleep, blood pressure, blood glucose, falls, and other indicators after medication use.

6.6.3 Traditional Exercise Practices

Meta-analyses show that traditional exercise training ≥3 times per week and aerobic exercise both significantly improve overall sleep quality in older adults, with traditional exercises showing greater advantages, and qigong demonstrating larger intervention effects than Tai Chi [50]. Another meta-analysis showed that 12+ weeks of Baduanjin can improve insomnia severity in older adults as an effective complementary therapy [51].

6.6.4 Auricular Therapy

RCT studies show that compared to using vaccaria seeds, magnetic bead auricular point pressing at seven ear points—Shenmen, Heart, Kidney, Liver, Spleen, Occiput, and Subcortex—for 3 weeks can further improve sleep quality in older adults and maintain long-term effects [52-53].

7. Sleep Rehabilitation Management Workflow for Community-Dwelling Older Adults

[Recommendation 11] Primary healthcare institutions may develop older adult sleep rehabilitation management workflows suitable for their jurisdictions based on the workflow diagram provided in this consensus (Figure 1 [FIGURE:1]), which should include key stages of initial screening and record establishment, assessment and graded management, and dynamic follow-up with effectiveness evaluation.

7.1 Initial Screening and Record Establishment

7.1.1

Obtain subjective sleep status information by asking older adults or their caregivers, and use the PSQI for preliminary assessment of those with sleep complaints or previous sleep disorder histories.

7.1.2

Older adults with PSQI total scores ≥5 points, or self-reported insomnia ≥3 times per week for ≥3 months, should be included in the community sleep health key management population. Detailed sleep history, physical examination findings, comorbidities, and medication history should be further collected to establish health records.

7.2 Assessment and Graded Management

7.2.1 Preliminary Sleep Disorder Type Determination and Assessment Methods

Combine chief complaints and comorbidities to preliminarily determine sleep disorder type, including primary insomnia, OSA, circadian rhythm sleep-wake disorders, and insomnia comorbid with chronic diseases or mood disorders. Corresponding standardized assessment scales (e.g., Insomnia Severity Index, OSA-50) should be used to evaluate severity. Primary healthcare institutions with available resources may combine objective assessment methods such as wrist actigraphy, portable PSG, or intelligent sleep monitoring devices. Individualized graded management plans should be developed based on comprehensive assessment results.

7.2.2 Intervention Measures and Referral Recommendations

For older adults assessed with mild sleep disorders, non-pharmacological interventions should be prioritized, including sleep health education, aerobic exercise intervention, CBT, transcranial magnetic stimulation, and traditional Chinese medicine healthcare, with an initial intervention cycle of 4-8 weeks. Studies show that community-based 1-year non-pharmacological interventions can significantly improve sleep disorders in older adults [54]. For those with severe symptoms, suspected severe OSA, or complex physical/psychiatric comorbidities, timely referral to sleep specialists or relevant departments at higher-level medical institutions is recommended, with follow-up and management maintained. Pharmacological intervention may be used under professional guidance when necessary, following principles of low dose, short course, and individualized medication to ensure safety and effectiveness.

7.3 Dynamic Follow-up and Effectiveness Evaluation

For older adults with good sleep quality and no apparent sleep disorder symptoms, routine follow-up every 6 months is recommended. For key sleep health management populations, follow-up every 1-3 months is recommended based on individual conditions. Follow-up content includes patient feedback, subjective scale assessments, and wearable device monitoring data. For those with good follow-up outcomes, original plans may be continued or intervention frequency reduced until complete recovery; for those with poor follow-up outcomes or worsening symptoms, intervention methods should be adjusted and referral to higher-level medical institutions for further assessment and treatment should be considered when necessary.

8. Limitations and Future Directions

As China's population structure gradually moves toward deep aging, sleep problems in older adults have become increasingly prominent, representing an important public health issue affecting their quality of life and health outcomes. Primary healthcare institutions, as the first line of defense in older adult health management, should play a crucial role in sleep health and rehabilitation management. This consensus, based on current domestic and international evidence and clinical practice experience, considers community feasibility and provides specific recommendations on key aspects including sleep rehabilitation management requirements, screening and assessment, graded interventions, and follow-up management, emphasizing a comprehensive management strategy primarily based on non-pharmacological interventions supplemented by pharmacological interventions, and advocating the concept of "whole-cycle rehabilitation."

The innovations of this consensus mainly include: (1) For the first time within China's older adult health management framework, it explicitly proposes the concept and connotation of "sleep rehabilitation," emphasizing function-oriented and long-term management; (2) Unlike previous sleep disorder guidelines focusing on clinical diagnosis and treatment, this consensus is practice-oriented for primary care, using PSQI as the core tool to construct an operational screening-intervention-follow-up pathway and providing a community-applicable workflow diagram.

However, this consensus also has certain limitations: (1) Recommendations are based on expert experience and existing evidence, with some content still lacking high-quality, multi-center RCT support, and the evidence level needs improvement. Future work should also refine evidence levels and recommendation grading; (2) China's primary healthcare resource allocation shows significant regional and urban-rural differences. The management workflow proposed in this consensus represents an ideal framework under optimal conditions, primarily targeting primary healthcare institutions with preliminary rehabilitation capabilities and relatively complete older adult health service systems. Specific implementation should be advanced according to local resources, staffing, and older adult characteristics, avoiding mechanical copying. In summary, this consensus is applicable as practical guidance for primary healthcare institutions in China to implement sleep health and rehabilitation management for older adults, suitable for managing mild-to-moderate sleep disorders and at-risk populations. For individuals with severe symptoms or complex comorbidities, timely referral should follow the workflow, avoiding direct equivalence of this consensus content with specialized diagnosis and treatment pathways. Future efforts should continue high-quality community intervention research, refine graded management strategies and assessment tool systems, enhance professional capabilities of primary healthcare providers, and jointly promote the standardized and systematic development of geriatric sleep rehabilitation services in China.

Consensus Development Group

Group Leader: JIA Jie (Huashan Hospital, Fudan University)

Writers: LIN Yifang (Huashan Hospital, Fudan University), ZHANG Yan (Jiaozuo People's Hospital), HE Zhijie (Huashan Hospital, Fudan University)

Guidance Expert Panel (in alphabetical order by surname): YAN Tiebin (Sun Yat-sen Memorial Hospital, Sun Yat-sen University), ZHENG Jiejiao (Huadong Hospital, Fudan University), ZHENG Xianzhao (Jiaozuo People's Hospital)

Drafting Expert Panel (in alphabetical order by surname): BAI Rui (Affiliated Hospital of Yan'an University), CHEN Wanqiang (First Hospital of Lanzhou University), CHEN Yao (Shanghai Third Rehabilitation Hospital), CHENG Zicui (Tai'an Traditional Chinese Medicine Hospital), CHU Yanli (Dawukou Hospital, Ningxia Hui Autonomous Region Fifth People's Hospital), DENG Jiafu (Shamming Sha County District Traditional Chinese Medicine Hospital), DENG Xiaolei (Laizhou People's Hospital), ZHAI Hongwei (Xuzhou Central Hospital), DU Aiqing (Jinhua Gulian Jinfan Rehabilitation Hospital), GAO Chong (Tianjin Binhai New Area Haibin People's Hospital), GE Junsheng (Shenzhen Dapeng New District Nan'ao People's Hospital), Gulidana·Anasihan (Altay Prefecture Traditional Chinese Medicine Hospital), GUO Shushan (Beijing Fengtai District Huaxiang Street Baotai Village Community Health Service Station), HE Wen (Shanghai Fourth Rehabilitation Hospital), HU Bin (Second Affiliated Hospital of Qiqihar Medical College), JI Wanxiang (Suzhou Science and Technology City Community Health Service Center), JIANG Baoyin (Hunan Provincial Finance and Trade Hospital), LI Feizhou (Shougang Shuigang Hospital), LI Hui (Fujian Changcai Hospital), LI Jingquan (Eye, Ear, Nose and Throat Hospital of Fudan University), LI Lin (Chongqing Shapingba District Chenjiaqiao Hospital), LI Pici (Cangnan County Traditional Chinese Medicine Hospital), LI Shuwei (Shaanxi Provincial Rehabilitation Hospital), LI Sumei (Second Affiliated Hospital of Baotou Medical College), LIU Jiangbo (Yuncheng People's Hospital), LIU Qiang (Guangxi Zhuang Autonomous Region People's Hospital), LIU Yuqi (Second Affiliated Hospital of Fujian Medical University), LIU Yuanbiao (Second Affiliated Hospital of Nanjing Medical University), LU Qingwu (Yichang Wujiagang District People's Hospital), LUO Lun (Chengdu Second People's Hospital), Lü Haidong (Jiaozuo People's Hospital), MOU Yang (Fuling Hospital Affiliated to Chongqing University), SHAO Sen (Hangzhou Xixi Hospital), SONG Zhenhua (Haikou People's Hospital), SU Guoqiang (Ruian People's Hospital Red Cross Branch), SU Hongmin (Chongqing Nan'an District Traditional Chinese Medicine Hospital), SUN Qingyin (Tongliao Second People's Hospital), SUN Yi (Urumqi Friendship Hospital), TAN Xuemei (Changzhou De'an Hospital), TIAN Maolin (Tongren People's Hospital), TU Mei (Mianyang Central Hospital), WANG Jialin (Dongfang Hospital, Beijing University of Chinese Medicine), WANG Jinyu (Liuzhou Traditional Chinese Medicine Hospital), WANG Jingxin (Zhengzhou Central Hospital), WANG Juan (Hubei Provincial Integrated Traditional Chinese and Western Medicine Hospital), WANG Jun (Shanghai Changning District Xianxia Street Community Health Service Center), WANG Kaijie (Tangshan Workers' Hospital), WANG Shunda (Shaanxi Provincial People's Hospital), WEI Xinping (Shanghai Minhang District Meilong Community Health Service Center), WU Ge (Guoyang County People's Hospital), WU Xiaogang (Lanzhou Petrochemical General Hospital), WU Yumei (Shenzhen Pingle Orthopedic Hospital), XIA Jing (Shanghai Putuo District People's Hospital), XIANG Tao (Chengdu Jinniu District People's Hospital), XIE Li (Yuncheng People's Hospital), XIE Long (Zibo Radio and Television Hospital), XING Hongxia (Third Affiliated Hospital of Xinxiang Medical College), XU Hong (Liuzhou Traditional Chinese Medicine Hospital), XU Yanzhong (Far East Horizon Medical Group), XU Sheng (Jinhua Second Hospital), XUE Fen (Nanyang First People's Hospital), YAN Yin (First Affiliated Hospital of Nanchang University), YAN Lin (Tacheng People's Hospital), YAN Wen (Foshan Fifth People's Hospital), YANG Fang (Zhejiang University of Chinese Medicine), YANG Nenggang (Chongqing Shapingba District Shuangbei Community Health Service Center), YANG Ying (Suzhou High-tech Zone People's Hospital), YAO Dongpo (Beijing Chaoyang Integrated Traditional Chinese and Western Medicine Emergency Rescue Hospital), YAO Liqing (Second Affiliated Hospital of Kunming Medical University), YE Liang (Hangzhou Linping District Integrated Traditional Chinese and Western Medicine Hospital), YIN Qing (Second Affiliated Hospital, Army Medical University, Department of Pain and Rehabilitation), YU Huixian (Capital Medical University Affiliated Beijing Tiantan Hospital), ZHANG Ge (Luoyang Central Hospital), ZHANG Jianping (Shanghai Putuo District Liqun Hospital), ZHANG Kunhua (Shandong First Rehabilitation Hospital), ZHANG Min (Gansu Provincial People's Hospital), ZHANG Renzhi (Songzi City Weishui Town Health Center), ZHANG Weimin (Third Clinical Hospital Affiliated to Changchun University of Chinese Medicine), ZHANG Xiduo (Shenzhen Ping An), ZHAO Shenghui (Chongqing Shapingba District Chenjiaqiao Hospital)

Conflict of Interest: All authors declare no conflicts of interest.

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Received: June 10, 2025; Revised: July 10, 2025
(Edited by MAO Yamin)