Assessment and Management of Insomnia and Poor Appetite
The best next step for a patient with insomnia and poor appetite is to conduct a focused assessment to identify underlying causes, followed by implementing cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment while addressing nutritional concerns with appropriate dietary interventions. 1, 2
Initial Assessment
Sleep Evaluation
Screen with two key questions 1:
- Do you have problems with sleep on average for three or more nights a week?
- Does the sleep problem negatively affect your daytime functioning?
Complete a focused sleep assessment 1:
- Sleep patterns (bedtime, wake time, sleep latency, number/duration of awakenings)
- Pre-sleep behaviors and environment
- Daytime consequences (fatigue, mood changes, cognitive difficulties)
- Use of a 2-week sleep diary to document patterns
Appetite Evaluation
- Assess for:
- Pattern of poor eating (timing, quantity, food preferences)
- Weight changes
- Associated symptoms (nausea, early satiety, taste changes)
- Impact on energy levels and daily functioning
Medication Review
- Evaluate current medications that may contribute to insomnia or poor appetite 1:
- Antidepressants (SSRIs, venlafaxine)
- Stimulants and decongestants
- Cardiovascular medications (β-blockers, diuretics)
- Narcotic analgesics
Medical/Psychiatric Comorbidity Assessment
- Screen for underlying conditions that commonly cause both symptoms:
- Depression and anxiety disorders
- Chronic pain conditions
- Gastrointestinal disorders
- Cancer or other chronic illnesses 3
- Substance use disorders
Treatment Approach
First-Line Treatment for Insomnia
- Implement Cognitive Behavioral Therapy for Insomnia (CBT-I) 1, 2:
- Sleep restriction therapy (limiting time in bed to actual sleep time)
- Stimulus control (using bed only for sleep and sex)
- Sleep hygiene education
- Relaxation techniques
- Cognitive restructuring for sleep-related thoughts
Addressing Poor Appetite
- Implement nutritional interventions:
- Small, frequent meals rather than three large meals
- Nutrient-dense foods when appetite is better
- Liquid nutritional supplements between meals
- Schedule meals at consistent times
Pharmacological Considerations
If depression is suspected and contributing to both symptoms, consider mirtazapine (7.5-15mg) which has both sleep-promoting and appetite-stimulating properties 2
For short-term insomnia management (if non-pharmacological approaches insufficient):
Follow-up and Monitoring
- Schedule follow-up within 7-10 days of initiating treatment 2
- Use standardized measures like the Insomnia Severity Index to track progress
- Reassess both insomnia and appetite symptoms after 4-6 weeks
- Monitor for medication side effects and adjust as needed
Important Considerations and Pitfalls
Avoid common pitfalls:
- Don't treat insomnia without investigating poor appetite (or vice versa) as they may share a common cause
- Avoid long-term use of sedative-hypnotics due to risks of dependence, tolerance, and adverse effects 4
- Don't overlook the possibility of serious underlying medical conditions presenting with these symptoms
- Avoid trazodone in elderly patients due to limited efficacy and unfavorable side effect profile 2
Special considerations:
- In elderly patients, use lower doses of medications and prioritize non-pharmacological approaches 2
- Be cautious with sedative-hypnotics due to increased risk of falls, cognitive impairment, and complex sleep behaviors 4
- Poor appetite and insomnia together may signal depression requiring specific treatment 3
By systematically evaluating both symptoms and implementing appropriate behavioral interventions first, followed by judicious use of pharmacotherapy when necessary, most patients with insomnia and poor appetite can achieve significant improvement in both conditions.