This chapter provides a general introduction to the process of medical decision-making regarding insomnia medications in older adults. It provide a general discussion of the evidence for benefit and the risks of adverse effects related to making clinical decisions regarding the pharmacological treatment of insomnia in older adults. A number of different classes of medications are used to treat insomnia in older adults. Insomnia and its treatment with pharmacological therapy are very common in the elderly. Considering the frequent use of these medications in older adults, there is a surprising lack of data on their efficacy and safety in this population. Notable areas where data are lacking include long term treatment and insomnia occurring co-morbidly with medical and psychiatric conditions. The difference in available data between older and younger adults is even greater for insomnia occurring co-morbidly with medical and psychiatric disorders.