With the acceleration of global population aging, the incidence of age-related neurodegenerative diseases continues to increase. Alzheimer’s disease has become a global public health issue, and mild cognitive impairment (MCI), at its preclinical stage, has attracted significant attention from many researchers. According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (1), MCI is defined as a clinical state characterized by progressive decline in one or more cognitive domains without impairing daily living abilities and does not meet the criteria for dementia diagnosis. A recent study indicated that the global prevalence of MCI among community-dwelling adults is 15.56%, highlighting that this condition has become a significant global public health issue (2). Furthermore, the prevalence of MCI is relatively high in the elderly population in China. Epidemiological surveys indicate that approximately 38.77 million individuals aged 60 years and above in China are affected by MCI, with a prevalence rate as high as 15.5% (3). It should be noted that approximately 10–15% of patients progress to dementia annually, with a conversion rate to dementia exceeding one-third within five years (4).

However, cognitive impairment in patients with MCI not only affects multiple cognitive domains such as memory, language, attention, executive function, visuospatial function, and social cognition, but may also impair non-cognitive domains such as mental behavior, mood, sleep, activities of daily living, and frailty (5). Studies have shown that the prevalence of sleep disorders among community-dwelling older adults with MCI ranges from 57.52% to 70%, which is significantly higher than that among older adults with normal cognitive function (6, 7). Insomnia is the most common type of sleep disorder and often presents as a noncognitive symptom of mild cognitive impairment (8), the prevalence of insomnia in patients with MCI is as high as 50% (9). According to the International Classification of Sleep Disorders, Third Edition (ICSD-3) (10), insomnia primarily manifests as difficulty falling asleep, difficulty in maintaining sleep, early awakening, reduced sleep quality, and decreased total sleep time, often accompanied by daytime functional impairments. Cognitive function in patients with MCI is closely associated with insomnia, which not only reduces sleep quality but also accelerates cognitive decline and psychiatric or behavioral impairments in patients with MCI. Many studies have found that the sleep characteristics of older adults with MCI exhibit significant abnormal changes, primarily related to insomnia, including reduced total sleep time, decreased sleep efficiency, prolonged sleep latency, and increased frequency and duration of awakenings (11, 12), These changes are closely associated with further cognitive decline (13–16). Furthermore, numerous studies have found that insufficient sleep may contribute to neurodegeneration through mechanisms such as beta-amyloid deposition, increased tau protein levels, inflammation, and impaired clearance of interstitial fluid from the cerebrospinal fluid into the interstitial spaces (17–19). Therefore, adequate and high-quality sleep is crucial to reduce cognitive decline. Currently, international evidence-based prevention guidelines for AD (20) have explicitly identified sleep disorders, such as insomnia, as modifiable risk factors for cognitive impairment and have incorporated sleep management into primary prevention, emphasizing the importance of sleep issues in the prevention and treatment of cognitive impairment.

Currently, the “3P” model of insomnia proposed by Spielman et al. (21) in 1986 is widely used to explain the causes of the onset, development, and maintenance of insomnia. This model conceptualizes the etiology of insomnia into three categories: predisposing, precipitating, and perpetuating factors. The presence of perpetuating factors is the primary reason for the persistence of insomnia symptoms. Among these, the inappropriate behavioral coping mechanisms developed by patients with insomnia to compensate for sleep deprivation are an important factor contributing to the persistence of insomnia (22). Studies have indicated that many individuals with insomnia often adopt various inappropriate behaviors to cope with sleep difficulties, such as going to bed early to compensate for perceived sleep loss, delaying morning rise times, or taking frequent daytime naps. During nighttime awakenings, they may either remain in bed in an attempt to force sleep or get up and engage in activities such as using smartphones or watching television to self-induce sleep (23). These behaviors not only fail to alleviate insomnia but may also contribute to its persistence. Several studies have elucidated the underlying mechanisms from different perspectives. For example, prolonged daytime napping can disrupt circadian rhythm and diminish nocturnal sleep drive, thereby hindering the improvement of insomnia (24–26). Going to bed early to extend sleep opportunities may actually increase nighttime awakenings, leading to more fragmented sleep and trapping individuals in a vicious cycle of excessive effort to sleep, which may also increase anxiety, further exacerbating the condition (27, 28). In summary, inappropriate coping behaviors can undermine sleep capacity, both physiologically and cognitively, thereby contributing to the chronicity of insomnia.

Although previous studies have confirmed that inappropriate coping strategies are a major factor in maintaining insomnia, most current research relies on patients’ self-reported sleep diaries to better understand their coping strategies. This approach often limits the understanding of sleep behavior to descriptions in these diaries, which are insufficiently in-depth and comprehensive. Few studies have employed qualitative research methods to thoroughly explore patients’ coping strategies, and even fewer have examined the unique coping strategies of individuals with insomnia who also have cognitive impairments, such as MCI. Therefore, this study aims to gain a deeper understanding of the coping strategies of community-dwelling older adults with MCI and insomnia through semi-structured interviews to provide a reference basis for the development of insomnia intervention and treatment methods tailored to this population.

In this study, data saturation was achieved after interviewing 17 participants, a total of 17 participants were ultimately included (coded P1-P17). The participants’ age ranged from 60 to 86 years, with a mean age of 71.24 ± 8.04 (mean ± SD). Among them, 7 were male (41.18%) and 10 were female (58.82%). The basic characteristics of participants are shown in Table 1. After analyzing the study results, we extracted three themes and ten subthemes, as shown in Table 2.

This study found that community MCI older adults with insomnia present a complex insomnia coping state with negative, positive, and ambivalent attitudes. This attitudinal differentiation is closely related to the lack of knowledge about insomnia treatment and insufficient knowledge about insomnia in older adults with MCI, which is similar to the results of Ting Ding’s previous study, which found that a lack of knowledge about insomnia is closely related to the patients’ poor attitudes when coping with insomnia, and the attitudes of inattention and negligence further lead to the patients’ failure to intervene actively in the problem of insomnia, which then leads to a decline in their ability to cope with insomnia (31). In addition, a qualitative study by Zhou et al. found that MCI patients generally lacked correct perception of disease symptoms, and most believed that the appearance of the corresponding symptoms was caused by normal aging (32), suggesting that compared with older adults with normal cognitive function, older adults with MCI tend to have a lower ability to perceive disease. At present, research on chronic diseases in the elderly predominantly emphasizes targeted interventions for diagnosed common conditions, such as hypertension and diabetes. In contrast, insomnia has received relatively limited attention in the field of geriatric health, resulting in insufficient public education regarding insomnia awareness among older adults. Consequently, many community-dwelling older adults with MCI and insomnia fail to acquire relevant knowledge in a timely manner, leading to an inadequate understanding of insomnia, often causing them to underestimate their multifaceted impact on health, adopt a passive attitude toward management, and develop a negative and ambivalent perception of the condition. However, there is a close association between insomnia and cognitive decline, and many studies have shown that insomnia is a high risk factor for further cognitive decline in patients with MCI (13–15), and if older adults with MCI negatively cope with insomnia due to insufficient knowledge of insomnia, it may accelerate the further decline of cognitive function and increase the risk of transition to dementia. It should be noted that the American College of Physicians (33), American Academy of Sleep Medicine (34), European Sleep Society (35), and British Association of Psychopharmacology (36) have pointed out that cognitive behavioral therapy for insomnia (CBT-I) is preferred as the first choice of non-pharmacological therapy for insomnia in adult insomnia patients, especially in older adults. Furthermore, the Chinese Sleep Research Society (37) also pointed out that non-pharmacological treatment should be preferred for elderly patients with insomnia, with a particular emphasis on CBT-I. However, because of the relatively limited methods of diagnosis and treatment of insomnia and the lack of professional implementers in primary healthcare institutions, such as community health service centers in China, non-pharmacological treatments, such as CBT-I, have not been widely used, and traditional sedative-hypnotic and traditional Chinese medicine treatments are still dominant (38). Moreover, many older adults in the community suffer from potential inappropriate medication (PIM) due to issues such as frailty and multimorbidity (39), and the use of hypnotic agents is often associated with a high incidence of adverse reactions and concerns regarding drug dependence (40), leading to treatment discontinuation and suboptimal outcomes. These factors collectively diminish older adults’ willingness to seek medical care, resulting in a generally passive and ambivalent attitude toward managing insomnia. It is well known that for the elderly in the community, the primary medical institutions represented by community health service centers are often the most convenient choice for medical consultation, and previous studies have shown that the training of primary health care doctors in CBT-I components can bring clinically meaningful and continuous improvement of insomnia symptoms for patients in the community (41). Therefore, in the future, community health centers should actively organize relevant medical personnel to conduct cognitive behavioral therapy training for insomnia, strengthen the publicity of non-pharmacological treatment of insomnia represented by CBT-I, and break the single mode of only using medication, so as to provide increasingly lasting non-pharmacological treatment of insomnia in elderly people with insomnia who are suffering from MCI in the community, and then improve their willingness to be treated and change their attitude of coping with insomnia. Meanwhile, relevant medical staff of community health centers should also actively carry out insomnia knowledge popularization activities for older adults with MCI and their families, such as carrying out group lectures and distributing insomnia treatment manuals, which can raise the importance of insomnia and correct cognitive bias so as to encourage them to change their attitudes and actively cope with insomnia. Furthermore, community medical personnel can use digital resources such as the Internet to publicize insomnia treatment by combining online and offline methods, such as setting up WeChat groups to facilitate communication and regularly pushing popular science articles and short videos to expand publicity channels to improve the convenience of popularizing science.

In addition, this study showed that most older adults cope poorly with insomnia. First, regarding coping with insomnia symptoms, most older adults tend to adopt a series of wrong behaviors, which tend to further contribute to the persistence of their insomnia. Previous studies have found that patients with insomnia, due to insufficient nighttime sleep as well as the lack of correct cognition of insomnia, which is often accompanied by the daytime compensatory rest phenomenon, often take excessive sleep, such as daytime frequent and prolonged naps and other undesirable behaviors, which may reduce the nighttime sleep drive, thus further disrupting the circadian rhythm and leading to the persistence of insomnia (25, 42). Therefore, the relevant medical personnel of community health service centers should pay attention to the symptomatic coping of older adults with MCI and insomnia and guide them to improve their attention to the behavioral habits of sleep, thus motivating them to correct their wrong behaviors and develop a correct way of coping with insomnia. Second, regarding active intervention for insomnia, older adults with MCI and insomnia indicated that behavioral therapy is the most effective way to avoid daytime naps, refraining from drinking strong tea in the afternoon, reducing mobile phone use before sleep, and going to bed only when feeling sleepy significantly improved their sleep quality. This observation aligns closely with the therapeutic principles of CBT-I, which mainly consist of sleep hygiene education, stimulus control therapy, sleep restriction therapy, relaxation therapy, and cognitive therapy etc. (34). As a multicomponent intervention, CBT-I is designed to rectify patients’ maladaptive beliefs about insomnia and dysfunctional sleep-related behaviors through a series of cognitive restructuring and behavioral modification techniques, thereby helping them develop appropriate coping strategies for insomnia. This highlights the importance of community healthcare professionals in prioritizing the management of sleep-related behaviors in older adults with MCI and insomnia. This can be achieved by conducting regular assessments via interviews to identify the presence of poor sleep habits, followed by the implementation of a range of behavioral interventions for insomnia, such as sleep hygiene education, stimulus control therapy, and sleep restriction therapy, which can promptly address and correct these inappropriate sleep behaviors. Finally, it is well noted that older adults with MCI and insomnia often face additional cognitive challenges when managing sleep disturbances due to cognitive decline, which complicates insomnia treatment in this population. Consistent with previous research findings, these individuals exhibit reduced learning and memory capacities compared to their previous abilities, making it difficult for them to acquire and master conventional insomnia interventions. It is necessary to construct a scientific, feasible, and applicable sleep intervention program for the cognitive characteristics of older adults (43); therefore, subsequent interventions should consider the cognitive characteristics of older adults with MCI and adopt cognitive-friendly approaches in the treatment of insomnia, in order to reduce cognitive load and help older adults with MCI improve cognitive memory ability, which can enhance the feasibility of the treatment and make them more cooperative with the treatment. This can be achieved by increasing reminders through the use of social chat platforms online or paper reminder slips offline to strengthen the memory of older adults with MCI, and at the same time simplifying the steps of behavioral interventions so that they are easy to understand, which can help reduce the difficulty of implementation for older adults with MCI.

The results also demonstrated that community-dwelling older adults with MCI and insomnia have multiple needs for insomnia management. These needs reflect expectations for coping with sleep disturbances and provide guidance for the development of tailored insomnia interventions suited to this population in future research. First, treatment needs focused on the use of non-pharmacological, side-effect-free alternative therapies, consistent with the findings of a previous qualitative study exploring the experiences of patients with chronic insomnia, which showed that insomnia patients disliked sleeping pills and preferred other gentle, non-pharmacological alternatives such as Traditional Chinese Medicine (TCM), Acupuncture, Acupressure, or dietary changes (44). Meanwhile, a previous study investigating insomnia patients’ views on insomnia behavioral treatment in primary care also showed that most insomnia patients tend to learn behavioral skills to improve their sleep first, and prefer non-pharmacological behavioral treatments to pharmacological treatments (45), suggesting that community health service centers should consider non-pharmacological behavioral treatments, such as CBT-I, to minimize insomnia medications in their treatment choices of insomnia in elderly patients, th MCI and reduce the impact of adverse drug reactions on the cognition and other aspects of health of elderly people with MCI, and motivate them to actively treat insomnia from the perspective of correcting their poor sleep behaviors, in order to delay the decline of cognitive function. Second, knowledge demand manifests as older adults’ desire to obtain professional insomnia improvement guidance and to increase insomnia-related knowledge. Previous studies have found that sleep hygiene education can allow patients to learn more about the knowledge and principles of sleep, effectively improve the cognition of normal sleep, and help them understand the persistence factors that lead to insomnia, so as to enhance their self-confidence and motivation in the treatment (46, 47). This highlights the importance of community health service centers proactively providing older adults with insomnia with accessible guidance on sleep improvement knowledge, such as sleep hygiene education, as well as regularly organizing health promotion activities within the community to raise awareness about insomnia treatment. These efforts can enhance illness awareness among older adults with MCI, enabling them to recognize the detrimental effects of insomnia, and thereby manage insomnia appropriately under professional guidance. A key finding of this study is that the special needs of older adults with MCI for insomnia treatment are cognitive needs, which require insomnia treatment methods that are easy to remember, simple, and repeatable. This suggests that conventional non-pharmacological treatments, such as verbal explanations by doctors, have limited effects on older adults with MCI. A previous study by Zhang Ruifen et al. indicated that conventional non-pharmacological interventions for patients with MCI primarily relied on unimodal cognitive training, which often fails to stimulate patients’ initiative and engagement. In contrast, multimodal nursing interventions that integrate verbal, visual, and auditory stimuli can engage multiple sensory channels such as vision, touch, and hearing. This approach facilitates a more comprehensive understanding and retention of information, while also offering flexibility and interactivity, thereby enhancing patient acceptance and adherence (48), This suggests that multimodal information delivery methods could be considered to reduce cognitive load in older adults with MCI. For example, treatment manuals can be designed with text and images for easy memorization, or animated demonstrations of the implementation steps can be created with voiceovers. Finally, demand for support is manifested in the expectations of family care and community services. Some older adults reflected that their family members did not support them in treating insomnia, which may be due to the lack of family members’ knowledge of insomnia and their lack of concern for older adults with MCI. Family care is the closest social support system, which can provide patients with realistic care, companionship, and emotional communication, and good family functioning can improve patients’ sleep quality (49). Furthermore, most studies have pointed out that the support and understanding of family members can help alleviate the symptoms of insomnia (50–52). Therefore, community health service centers should emphasize the role of family support in the treatment of insomnia and consider involving family members to help them correctly understand insomnia, thereby guiding them to support and encourage older adults with MCI to actively accept treatment. At the same time, family members can also play a supervisory role to ensure that interventions are implemented on a regular basis. In addition, the elderly with MCI also reflected a lack of support services related to insomnia treatment in community health service centers, such as insufficient popularization of insomnia and insufficient publicity of treatment, leading to a lack of knowledge related to insomnia prevention and treatment. Previous research by Wang et al. pointed out that there is insufficient knowledge of sleep disorders among older adults in the community in China and that community health workers should follow the physiological-psychosocial-social medical model to educate older adults and their caregivers about sleep health-related knowledge, such as conducting community lectures and door-to-door knowledge dissemination (53). Therefore, community health service centers should consider leveraging the existing chronic disease management frameworks to integrate sleep management for older adults with MCI and insomnia into essential community services. By consolidating community resources and regularly organizing health education activities such as insomnia awareness lectures, corresponding sleep support services can be provided. These efforts would further establish a stepped home-community medical support system, thereby maximizing therapeutic support for this vulnerable population.

While this study explored the current situation of insomnia among older adults with MCI and insomnia in the community, it is important to recognize that there are some limitations. The study was conducted in only one community health center in Fuzhou City, Fujian Province, which may limit the generalizability of the findings to scenarios such as other communities or rural healthcare institutions. Future studies should be replicated in different geographic areas to ensure broader applicability of the findings. In addition, the small sample size of this interview may not fully reflect the diversity of the current status of insomnia coping among older adults with mild cognitive impairment and insomnia in the community. Future studies should expand the sample size to include participants of different ages, socioeconomic backgrounds, and cultural backgrounds to enhance the persuasiveness of the findings.

Moreover, because the coping styles of insomnia are affected by coping attitudes, interviewing only patients may cause too much bias owing to the inclusion of subjective personal emotions. Future studies can further interview doctors in community health service centers, and interview the wrong coping styles of insomnia patients who come to the clinic from the doctors’ perspective, in order to establish a patient-doctor dyadic perspective to obtain more comprehensive insights into the coping status of insomnia among older adults with MCI and insomnia.

It is worth noting that although this study emphasized the importance of developing correct insomnia coping attitudes and styles in older adults with MCI and insomnia, insomnia interventions that are appropriate for the cognitive level of older adults with MCI still need to be further explored in subsequent studies. Future studies should attempt to construct cognitively adapted, non-pharmacological insomnia intervention protocols for older adults with MCI, in order to more effectively help older adults with MCI to improve their insomnia, which will in turn have a positive impact on cognitive function.

Finally, this study only interviewed older adults with MCI comorbid with insomnia, and the insomnia coping status of patients with other comorbid insomnia has not yet been investigated, which may have different coping styles and needs due to the different effects of the disease. In the future, we will continue to conduct qualitative research to explore the current insomnia coping status of the insomnia group with different disease comorbidities to provide targeted guidance for the treatment of insomnia in this group of people.

In this study, we explored the insomnia coping status of older adults with MCI through semi-structured interviews, and found that older adults with MCI had more negative attitudes toward insomnia, more incorrect ways of coping with insomnia, and more diverse needs for coping with insomnia. This finding suggests that nonpharmacological insomnia interventions for older adults with MCI and insomnia are of great value. Therefore, it is suggested that primary medical institutions, such as community health centers, should pay attention to the insomnia problem of older adults with MCI and formulate targeted and cognitively friendly non-pharmacological intervention strategies, strengthen professional training on non-pharmacological treatment of insomnia for relevant medical personnel in the primary community, and improve the ability of early identification of insomnia and behavioral interventions for older adults with MCI in the community. At the same time, they should carry out targeted sleep hygiene education as early as possible to help older adults with MCI establish correct sleep hygiene cognition. In the future, we will focus on providing behavioral interventions to improve insomnia by correcting erroneous sleep behavioral habits from the perspective of eliminating factors that maintain insomnia.