Insomnia in Older Adults: Causes, Risks, and Treatment

Author: Angela Bogdanova · Published: October 10, 2026 · Editorial Policy

Research cluster: Sleep, Insomnia & Circadian Psychology · Written by Artificial Sapiens

Insomnia in older adults is a persistent difficulty falling asleep, staying asleep, or returning to sleep after waking that becomes clinically important when it causes distress or problems during the day. Age-related changes in sleep timing and structure can make nighttime awakenings more common, but chronic insomnia deserves assessment and effective treatment at any age. Older adults generally continue to need about seven to nine hours of sleep, although individual needs vary. The National Institute on Aging emphasizes that aging does not eliminate the need for restorative sleep.

The most effective starting point for chronic insomnia is usually cognitive behavioral therapy for insomnia (CBT-I), adapted to a person's health, mobility, cognition, and daily routine. Evaluation should also look for obstructive sleep apnea, pain, nocturia, restless legs symptoms, depression, medication effects, and circadian timing changes. Sleeping pills require particular care because several common sedatives increase fall, confusion, and other risks in later life. The recommendations below integrate the American Academy of Sleep Medicine (AASM) behavioral treatment guideline, the 2025 VA/DoD insomnia and sleep apnea guideline, and the American Geriatrics Society (AGS) Beers Criteria.

For a broader clinical discussion of insomnia and its management, see Insomnia: Symptoms, Causes, Diagnosis, and Treatment.

What counts as insomnia in an older adult?

Insomnia is defined by sleep difficulty together with significant distress or impaired daytime functioning, despite adequate opportunity and circumstances for sleep. A person may take a long time to fall asleep, wake repeatedly, awaken too early and be unable to resume sleep, or experience a combination of these problems. Daytime consequences can include fatigue, irritability, reduced concentration, worry about sleep, and impairment in everyday activities. Feeling sleepy and unintentionally dozing during the day, however, should also raise the possibility of inadequate sleep or another sleep disorder.

Chronic insomnia disorder generally involves sleep difficulties at least three nights per week for at least three months, with associated daytime consequences and sufficient opportunity to sleep. Shorter episodes can occur after illness, grief, travel, hospitalization, a change in routine, or acute stress. The clinical classification comes from the AASM's International Classification of Sleep Disorders, Third Edition, Text Revision (ICSD-3-TR). The frequency and duration thresholds are a guide to clinical classification; a problem deserves attention before it reaches three months if distress, functional impairment, or safety concerns are substantial.

Time awake in bed by itself does not establish a disorder. An older person who naturally falls asleep at 8:30 p.m. and wakes refreshed at 4:30 a.m. may have an earlier biological sleep phase rather than insomnia. Someone who wakes briefly and then goes back to sleep without difficulty may be experiencing normal sleep fragmentation. Conversely, an older adult who spends ten hours in bed, sleeps intermittently, dreads nighttime, and struggles with concentration the next day may have a treatable insomnia disorder even if a wearable device reports an acceptable sleep score.

How sleep changes with age

Aging commonly changes sleep architecture, sleep continuity, and circadian timing. Slow-wave or deep sleep tends to decline, and awakenings may become more frequent. Many older adults feel sleepy earlier in the evening and wake earlier in the morning. Health conditions, medication use, environmental interruptions, reduced daytime activity, and changes in social schedules can add to these biological patterns. The National Institute on Aging explains these changes while maintaining that older adults still need adequate sleep.

Sleep need, sleep opportunity, and sleep obtained are separate questions. Being retired can allow someone to remain in bed much longer than their individual sleep requirement. That mismatch may increase time spent awake in bed and reinforce frustration. For others, caregiving, illness, noisy housing, or early medical appointments shorten the opportunity for sleep. Clinicians interpret both situations in context rather than using age or total time in bed as a diagnosis.

Daytime napping also requires context. A short, planned nap may be helpful for some people, while long or late naps may diminish sleep pressure before bedtime and complicate nighttime insomnia. Excessive, irresistible naps or repeated unintended dozing suggest a reason to assess sleep quantity, medication effects, breathing disorders, or a central hypersomnolence condition rather than simply banning naps.

Why insomnia is common in later life

Medical conditions and physical symptoms

Persistent or poorly controlled pain can interrupt sleep and increase nighttime vigilance. Osteoarthritis, neuropathic discomfort, reflux, chronic cough, heart or lung symptoms, and urinary urgency can all contribute. Nocturia may be associated with urinary conditions, fluid timing, diuretics, sleep apnea, or other illnesses, so repeatedly waking to urinate deserves its own assessment. Menopausal symptoms and uncomfortable nighttime temperature changes can also play a role. Treating the underlying symptom often improves sleep opportunity, although insomnia may remain as an independent learned or behavioral problem even after the original trigger improves.

Sleep apnea is a particularly important differential. Snoring, gasping, witnessed pauses in breathing, morning headaches, unrefreshing sleep, and daytime sleepiness may suggest obstructive sleep apnea, but some older adults primarily report insomnia or fatigue. Clinical evaluation determines whether home sleep apnea testing or laboratory polysomnography is appropriate. An insomnia diagnosis and sleep apnea can coexist. The AASM's diagnostic testing guideline explains when objective testing is indicated and why a home test cannot rule out every sleep disorder.

Restless legs syndrome produces an urge to move the legs, usually accompanied by uncomfortable sensations that arise during rest, worsen in the evening or at night, and improve with movement. It may make falling asleep difficult. Periodic limb movements, cramps, arthritis, neuropathy, and nighttime restlessness are different clinical findings and require different reasoning. The updated AASM restless legs and periodic limb movement guideline addresses evaluation and management, including the relevance of iron status.

Medication and substance effects

A medication review is central to older-adult sleep assessment. Some stimulants, corticosteroids, selected antidepressants, activating medications, and drugs whose timing increases nocturia can interfere with sleep. Sedating medicines may create next-day drowsiness or disturb cognition and mobility. Alcohol can make sleep onset feel easier while worsening later sleep continuity, and caffeine may have effects well into the evening. Nicotine and certain over-the-counter combinations can be stimulating. People should bring an actual list of prescription drugs, nonprescription medications, supplements, and use times to their clinician or pharmacist. Medication changes and tapering plans should be supervised, especially when dependence or withdrawal is possible.

Depression, anxiety, grief, and cognitive conditions

Depressive symptoms, anxiety, prolonged stress, bereavement, and isolation often occur alongside sleep complaints. Their relationships with insomnia can be bidirectional: distress disrupts sleep, and poor sleep can intensify distress or impair coping. An older adult who wakes very early with low mood, loses interest in normal activities, or experiences persistent anxiety warrants assessment of the broader presentation. Sleep complaints alone do not diagnose depression or dementia.

Cognitive impairment or dementia can make sleep timing less stable and complicate nighttime routines, agitation, or communication of pain. In these circumstances, clinicians also assess caregivers' observations, the physical environment, medication burden, and possible delirium when a sudden change occurs. A new, abrupt disturbance accompanied by confusion or acute illness needs prompt medical assessment rather than routine sleep coaching. The National Institute on Aging's sleep resources provide additional condition-specific information for families.

Changes in habits, environment, and the sleep–wake schedule

Less outdoor light, lower physical activity, reduced social contact, irregular wake times, lengthy time in bed, nighttime television, and repeated clock-checking may contribute to the persistence of insomnia. Hospitalization, retirement, a partner's death, and changes in caregiving can disrupt familiar routines. Some people move bedtime earlier to compensate for a bad night, then spend additional hours awake; others sleep late after poor nights and progressively weaken a stable wake-time signal.

Circadian phase advancement should be considered when someone repeatedly becomes sleepy early in the evening and wakes very early after an otherwise satisfactory sleep period. It differs from the distressing early awakening of insomnia. Delayed sleep phase, irregular sleep–wake timing, and other circadian disorders require separate diagnostic evaluation. Light exposure and melatonin depend on the specific timing problem; the AASM circadian rhythm guideline does not support one universal timing prescription for every older adult.

Hyperarousal and learned insomnia

Insomnia can persist through a cycle of conditioned arousal. An unpleasant night leads to increased monitoring of sleep, fear of tomorrow's consequences, earlier bedtimes, longer periods spent in bed, and stronger association of the bedroom with wakefulness. Physiological arousal, intrusive thoughts, clock-watching, and sleep-related expectations can reinforce each other. These processes help explain why treating pain or acute stress sometimes does not fully resolve chronic insomnia. CBT-I targets these maintaining mechanisms rather than focusing only on relaxation or a perfect nighttime environment. The AASM psychological treatment guideline summarizes the treatment evidence.

Risks and consequences of persistent insomnia

Insomnia is associated with poorer quality of life, fatigue, depressed mood, reduced attention, lower daytime functioning, and increased distress. In older adults, nighttime walking while groggy, sedating medication exposure, and poor balance can contribute to fall risk. Sleep deprivation may also impair driving and other activities that demand sustained attention. Someone who is dangerously sleepy should avoid driving until the problem has been assessed.

Research also links sleep disturbances to long-term cardiometabolic and cognitive outcomes. These associations require careful interpretation because pain, cardiovascular disease, depression, medications, and early neurological changes can affect both sleep and subsequent health. A systematic review of insomnia and dementia risk found an association but substantial heterogeneity; it does not prove that insomnia causes dementia or that insomnia treatment prevents it. Insomnia should be treated for its established effects on well-being and function without promising prevention of dementia.

There is more direct evidence for some mental-health outcomes. A randomized trial in older adults examined whether treating insomnia with CBT-I could reduce subsequent major depression compared with sleep education. Its findings are promising for this particular population and intervention; they should not be extrapolated to all older adults, all depression mechanisms, or dementia prevention.

When an older adult should seek medical care

Arrange clinical assessment when sleep difficulty persists, causes distress, reduces daytime independence, disrupts relationships or caregiving, or leads to frequent reliance on sleep medication or alcohol. Earlier assessment is appropriate when pain, frequent urination, suspected sleep apnea, uncomfortable leg sensations, newly emerging psychiatric symptoms, or a recent medication change accompanies the problem.

Urgent attention is needed for severe or sudden confusion, fainting, chest pain, severe breathing difficulty, significant injury during sleep, or rapidly worsening health. Loud snoring with witnessed apneas, gasping, or substantial daytime sleepiness warrants timely sleep-medicine evaluation; do not assume that insomnia alone explains it. Dangerous sleepiness when driving requires immediate safety changes and a clinical assessment. Sudden nighttime behavioral changes in a person with cognitive impairment may indicate delirium or another acute medical problem.

A primary care clinician can begin evaluation and coordinate sleep medicine, behavioral sleep medicine, geriatrics, mental health, neurology, or other specialists depending on the findings. A family member or caregiver can help describe patterns while respecting the older person's autonomy and wishes.

How clinicians evaluate insomnia in older adults

An evaluation begins with a detailed history of typical bedtime, estimated time to fall asleep, awakenings, final wake time, time out of bed, naps, and daytime symptoms. The clinician asks about duration, recent triggers, sleep opportunity, work or caregiver duties, snoring and breathing symptoms, leg discomfort, mood, pain, urinary frequency, medication timing, alcohol and caffeine, and any previous treatments. The goal is to identify the clinical sleep problem and the factors that maintain it.

A sleep diary kept for about one to two weeks often provides more useful information than a single recollection of a difficult night. It can document when someone goes to bed, when they attempt sleep, when they get up, naps, and relevant events. A diary reflects reported experience; it does not measure brain-defined sleep stages. The Insomnia Severity Index or other questionnaires may quantify symptoms and monitor change, but a screening score is neither a diagnosis nor a substitute for a clinician's assessment.

Polysomnography is not routinely necessary for straightforward chronic insomnia. Testing becomes more relevant when a different sleep disorder is suspected, symptoms are atypical, treatment fails for unclear reasons, or sleep-related breathing, movements, or complex behaviors need investigation. Wrist actigraphy may assist selected circadian or sleep-pattern evaluations; consumer wearables cannot diagnose insomnia or reliably exclude sleep apnea. The AASM sleep apnea testing guideline and 2025 VA/DoD guideline support targeted testing driven by the clinical question.

A thoughtful assessment also checks mobility, cognition, vision, hearing, fall history, living situation, and ability to follow a treatment schedule. Older adults are diverse: a healthy 68-year-old, an 84-year-old with multiple medications, and a person living with dementia may need substantially different implementation even when all three report poor sleep.

First-line treatment: cognitive behavioral therapy for insomnia

CBT-I is a structured psychological and behavioral treatment for chronic insomnia. It aims to reduce unhelpful sleep-related arousal and improve the fit between sleep opportunity, sleep drive, routines, and the bedroom environment. It commonly involves several coordinated components over a defined treatment course with follow-up and adjustments. The AASM gives multicomponent CBT-I a strong recommendation. The American College of Physicians recommends CBT-I as initial treatment for chronic insomnia in adults, including older adults.

What CBT-I usually includes

• Sleep education explains how sleep drive, circadian timing, awakenings, and expectations affect nights and daytime function.

• Stimulus control strengthens the association between bed and sleep by reducing prolonged frustrated wakefulness in bed, within mobility and safety constraints.

• Sleep scheduling or sleep compression adjusts time in bed based on clinical assessment and monitored response. In some protocols, carefully supervised sleep restriction is used.

• Cognitive techniques address catastrophic predictions about lost sleep, rigid sleep rules, repeated monitoring, and bedtime rumination.

• Relaxation approaches reduce arousal and can complement the other components.

• Sleep-supportive habits address light, wake time, activity, caffeine, alcohol, and environmental factors as part of a complete plan.

Sleep restriction must be individualized. In a frail older adult, someone with unstable bipolar disorder, seizure risk, significant daytime sleepiness, a high fall risk, or certain untreated sleep disorders, abrupt unsupervised sleep restriction can be unsafe. A clinician may use gentler sleep compression or another adapted schedule and monitor daytime function closely. This article intentionally provides no fixed number of hours or do-it-yourself restriction formula.

Does CBT-I work for older adults?

Yes. Evidence comes from clinical guidelines, randomized trials, and reviews focused on later life. A meta-analysis of 14 studies reported improvement in diary-based sleep efficiency, time to fall asleep, and wakefulness after sleep onset. Substantial between-study variability means these are average results rather than a guaranteed individual response. A systematic review of behavioral components found improvements particularly in subjective sleep measures, while objective actigraphy or polysomnography often showed smaller or less consistent changes.

A randomized study of telephone-delivered CBT-I enrolled older adults with insomnia and osteoarthritis pain and found sustained benefits for insomnia severity and fatigue compared with sleep education. Among participants with available 12-month follow-up data, 56.3% of the CBT-I group and 25.8% of the control group met the trial's remission definition. These results show that therapy can work when medical comorbidity is present, and that telephone delivery can improve access.

An earlier randomized trial comparing CBT with zopiclone also favored behavioral treatment for several sleep outcomes over follow-up, although it was a small study and should not be treated as the single definitive comparison of all medicines. A 2024 systematic review of insomnia treatments in adults aged 55 and older supports the continuing role of nonpharmacological interventions and highlights gaps in medication and complementary-treatment evidence.

CBT-I can be delivered in individual appointments, groups, telephone-based care, and appropriately designed digital programs. Clinical complexity, sensory or cognitive accessibility, adherence difficulties, and coexisting conditions may make clinician-supported care preferable. Digital delivery is a format for structured treatment; a general chatbot, generic sleep app, or wearable score should not be described as equivalent to a validated CBT-I program.

What if sleep hygiene has not helped?

Regular daytime light exposure, a tolerable exercise routine, consistent waking, a comfortable sleep environment, and a review of late caffeine or alcohol can support sleep. They are reasonable preventive and supportive measures, but they do not constitute an adequate stand-alone treatment for chronic insomnia. The AASM explicitly suggests against sleep hygiene as the sole treatment. When bedtime habits are already reasonable and distress persists, the next step is clinical evaluation and evidence-based insomnia treatment, not a longer list of bedtime rules.

Treating conditions that contribute to nighttime waking

Improving insomnia often involves treating more than one problem. A clinician may address pain management, urinary symptoms, reflux, breathing disorders, depression, anxiety, medication timing, mobility needs, and environmental accessibility alongside CBT-I. This integrated approach recognizes that a coexisting illness can trigger insomnia while learned sleep-related patterns can keep it going.

For suspected obstructive sleep apnea, assessment and indicated treatment take priority; sedative decisions require particular caution. For restless legs syndrome, clinicians clarify symptom criteria and may assess iron indices as recommended by current guidance. For a clearly advanced sleep phase, clinicians evaluate circadian timing and may consider carefully timed interventions. For depression, anxiety, or grief, appropriate psychological or medical care is coordinated without assuming that a single intervention will treat every condition.

Fall prevention can be practical: clear paths to the bathroom, accessible lighting, supportive footwear where needed, and a review of orthostatic symptoms or sedating medications. Some people need assistance rising from bed or moving at night. Maintaining daytime activity, social connection, and outdoor light where safe can also help anchor the sleep–wake cycle.

Sleep medications in later life: benefits and special risks

Insomnia medication decisions in older adults require more than asking which pill acts fastest. Clinicians weigh the type and duration of insomnia, severity of daytime impairment, fall or fracture history, cognitive status, breathing problems, kidney and liver function, drug interactions, previous response, patient preferences, and whether CBT-I is available or has been tried.

The 2023 AGS Beers Criteria recommend avoiding benzodiazepines for most older adults because of risks including cognitive impairment, delirium, falls, fractures, dependence, and motor vehicle crashes. The criteria also recommend avoiding Z-drugs such as zolpidem, zaleplon, and eszopiclone because their adverse effects resemble those of benzodiazepines while average sleep improvements may be modest. These recommendations are criteria for individualized prescribing, with recognized exceptions; they should not be interpreted as instructions to abruptly stop a medicine.

First-generation sedating antihistamines such as diphenhydramine and doxylamine are also problematic in later life because of anticholinergic effects, confusion, dry mouth, constipation, urinary retention, and next-day sedation. Some off-label sedating antidepressants or antipsychotics introduce their own risks and should not automatically become default insomnia treatments. The AGS's 2025 alternatives guidance prioritizes assessing contributors and using CBT-I, while recommending shared decision-making if short-term medication is considered after CBT-I has proved insufficient.

Other prescription medication classes, including melatonin-receptor agonists, low-dose doxepin, and dual orexin receptor antagonists, may be considered for selected patients based on symptoms, approved indications, clinical history, interactions, adverse effects, and access. Evidence differs by agent and by older-adult subgroup. Newer does not automatically mean risk-free, and a drug's effects in healthy trial participants may not generalize to frail individuals with complex medical needs. The 2025 VA/DoD guideline is a contemporary resource for treatment selection.

Melatonin supplements should not be treated as a universal cure for insomnia. Evidence depends on the specific problem and product, and timing matters most when a circadian disorder is present. Quality and content can vary among supplement products. The risks of sedation, falls, and interactions still warrant medication review. Do not combine sleep aids, alcohol, and sedating prescriptions or change long-standing benzodiazepine treatment without a clinician-supervised plan.

Adjusting treatment for frailty, dementia, and caregiving

For an older adult living with cognitive impairment, insomnia assessment should consider pain that is difficult to communicate, anxiety, medication side effects, nighttime light and noise, long daytime naps, changes in supervision, and disrupted routines. Clinicians may use caregiver observations alongside the person's own account. Treatment can emphasize daytime activity and light, a predictable schedule, a comfortable environment, and carefully adapted behavioral measures. Decisions should take capacity, comfort, preferences, and caregiver burden into account.

CBT-I depends partly on understanding and practicing strategies, but adaptation may still be possible with a caregiver's help or simplified approaches. The evidence for standard protocols in people with significant dementia is more limited than in cognitively intact older adults; it is inappropriate to assume that every person can or should follow the same procedure. Sedative use raises additional concern when confusion, falls, breathing disorders, or nighttime wandering occur.

Caregivers benefit from identifying specific needs before labeling all nighttime wakefulness as insomnia. Someone may awaken because of pain, hunger, a need to use the bathroom, discomfort, or disorientation. Sudden changes require evaluation for acute illness or delirium. Treatment should support both safety and dignity rather than relying on sedation for convenience.

Practical steps while arranging an evaluation

• Write down sleep timing, awakenings, naps, and daytime symptoms for one to two weeks, including whether nights were interrupted by pain, breathing, urination, worries, or noise.

• Make a full medication and supplement list with times taken, and ask a pharmacist or clinician to review possible sleep disruption, sedating effects, and interactions.

• Keep a reasonably consistent wake time and get daytime light and activity as health and mobility allow; adjust the plan to the person's actual schedule.

• Keep the route between bedroom and bathroom safely lit and unobstructed, especially if there have been falls or nighttime dizziness.

• Discuss persistent insomnia and possible sleep apnea, leg symptoms, depressed mood, or cognitive changes with a healthcare professional; ask specifically about access to CBT-I.

• Judge improvement by distress, daytime function, awakenings, and sustainable sleep patterns rather than by a wearable score alone.

These steps can clarify patterns and reduce preventable disruptions, but they do not replace clinical treatment of chronic insomnia or medical assessment of warning signs.

Frequently asked questions

Is insomnia a normal part of aging?

Age-related changes in lighter sleep, more awakenings, and earlier sleep timing are common. Persistent difficulty sleeping with daytime impairment is a clinical problem worth assessing. Older adults remain capable of meaningful sleep improvement, and chronic insomnia has evidence-based treatments.

How many hours should a 70- or 80-year-old sleep?

The National Institute on Aging reports that older adults generally need about seven to nine hours of sleep. Individual needs vary, and a person's full-day pattern, functioning, health, and sleep opportunity are more informative than one isolated night or a rigid numerical target.

Why do older adults wake up at 3 or 4 a.m.?

Possible explanations include earlier circadian timing, bedtime that is too early for the person's sleep need, depression, pain, nocturia, sleep apnea, medication effects, environmental noise, or sleep-maintenance insomnia. Whether the person wakes refreshed or distressed, and whether they can return to sleep, helps distinguish possibilities.

What is the best treatment for chronic insomnia in older adults?

Multicomponent CBT-I is the recommended first-line treatment for most adults with chronic insomnia, with appropriate individualization. Clinicians should simultaneously evaluate and address contributing illnesses, medications, and other sleep disorders. AASM guidance and AGS alternatives guidance support this approach.

Is it safe for older adults to use sleeping pills every night?

Long-term use of several common sedative classes creates important risks, especially for people vulnerable to falls, confusion, cognitive effects, or dependence. The answer depends on the exact drug and individual situation. A clinician should review ongoing benefit, adverse effects, alternatives, and any supervised taper. Abrupt discontinuation of some medicines can cause withdrawal and may be dangerous.

Is melatonin safer than prescription medication?

Its effects and risks depend on what is being treated, the dose and timing chosen by a clinician, the product, other medication use, and the person's health. Melatonin is particularly sensitive to circadian timing and is not equivalent to CBT-I for chronic insomnia. Natural origin alone does not establish superior safety or effectiveness.

Does insomnia mean a person has dementia?

No. Insomnia is not a dementia diagnosis. Sleep problems and cognitive changes may coexist, and observational studies report associations with later cognitive outcomes without proving a single cause. New or progressive memory and functioning concerns need their own clinical assessment.

Can sleep apnea look like insomnia in older adults?

Yes. Some patients report fragmented or unrefreshing sleep without describing classic daytime sleepiness. Snoring, witnessed breathing pauses, gasping, or cardiovascular risk can strengthen suspicion. A clinician determines whether diagnostic sleep testing is needed; a consumer tracker cannot exclude apnea.

Do naps make insomnia worse?

Long or late naps can decrease sleep pressure at bedtime for some people, but naps have different causes and benefits. Repeated unintended sleep episodes need evaluation rather than automatic restriction. An individualized plan considers sleepiness, safety, frailty, and daily function.

What if CBT-I is difficult because of limited mobility or memory problems?

Treatment can sometimes be adapted through gentler sleep scheduling, remote delivery, simplified instructions, caregiver involvement, and safety-conscious stimulus control. Some protocols are unsuitable in particular medical or cognitive situations. A trained clinician can select and monitor a feasible approach instead of relying on an unsupervised app.

When should someone see a sleep specialist?

Consider referral if chronic symptoms persist after appropriate evaluation and treatment, if sleep apnea or a movement disorder is suspected, if the sleep schedule suggests a circadian disorder, or if unusual nighttime behaviors, dangerous sleepiness, or complex medication issues arise. Primary care can coordinate the referral.

Related Articles

• Insomnia: Symptoms, Causes, Diagnosis, and Treatment — the broader clinical overview and distinction between insomnia symptoms and disorder.

• Cognitive Behavioral Therapy for Insomnia (CBT-I): How It Works — treatment principles and how behavioral therapy is delivered.

• Insomnia Assessment: Sleep Diaries, Clinical Questions, and Tests — evaluation and the role of sleep records and clinical testing.

Waking Up Too Early: Causes and What to Do

Sleep Apnea: Symptoms, Testing, and Treatment Options

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