How should I evaluate and manage a female patient with chronic insomnia, daytime fatigue, nocturnal knee and hip pain, cognitive fog and memory complaints, a history of knee reconstruction in 2018, and prior shift‑work exposure?

Systematic Evaluation and Management of Chronic Insomnia with Nocturnal Pain and Cognitive Complaints

Begin with a structured evaluation to identify underlying causes—particularly screening for primary sleep disorders (obstructive sleep apnea, periodic limb movements), psychiatric comorbidities (depression/anxiety), and medication/substance contributors—before attributing symptoms to chronic insomnia disorder alone. 1, 2

Initial Diagnostic Priorities

Distinguish Fatigue from True Sleepiness

• Fatigue (low energy, tiredness, weariness) is the expected consequence of chronic insomnia, whereas true sleepiness (involuntary tendency to fall asleep) is uncommon in insomnia and signals an alternative sleep disorder like obstructive sleep apnea, narcolepsy, or periodic limb movement disorder 1
• Specifically ask about involuntary sleep episodes during the day, as this patient's "tiredness" needs clarification—if she's falling asleep unintentionally, polysomnography is warranted immediately 1, 2
• Document the frequency, duration, and timing of any naps (voluntary versus involuntary) 1

Evaluate for High-Probability Comorbidities

• Patients with chronic pain have insomnia rates of 50-75%, requiring bidirectional evaluation—her nocturnal knee and hip pain may be both causing and perpetuating her sleep disturbance 1
• Screen for depression and anxiety disorders, as depressed patients are 2.5 times more likely to report insomnia, and her "brain fog, poor memory, and general life struggles" raise concern for mood disorders 2
• The cognitive complaints (brain fog, poor memory) beyond typical insomnia symptoms can indicate cognitive and mood deterioration that requires psychiatric evaluation 1

Address Shift Work History

• Her prior shift work exposure is relevant—shift work creates conflict between circadian physiology and sleep-wake requirements, leading to both nighttime sleepiness and daytime insomnia that can persist even after stopping shift work 3
• Assess whether she has ongoing circadian rhythm disruption or phase intolerance 3

Comprehensive Medical and Medication Review

Screen for Medical Contributors

• Cardiac and pulmonary diseases are among the most common medical contributors to insomnia, with sleep complaints increasing as the number of medical conditions increases 2
• Evaluate for conditions causing nocturnal symptoms: nocturia from any cause, gastroesophageal reflux, restless legs syndrome, or sleep-disordered breathing 2
• Consider thyroid disorders (check TSH), as these are common medical causes that must be ruled out 2

Conduct Thorough Medication and Substance Review

• Medication review is essential in every insomnia evaluation 2
• Specifically assess for:
  • Stimulants (caffeine intake, any prescribed stimulants) 1
  • Antidepressants (SSRIs, SNRIs, MAO inhibitors) 1
  • Cardiovascular agents (β-blockers, α-receptor agents, diuretics causing nocturia) 1, 2
  • Narcotic analgesics for her pain (oxycodone, codeine) which can fragment sleep 1
• Evaluate alcohol and nicotine use, as both contribute to insomnia through direct effects and withdrawal mechanisms 2

Targeted Laboratory and Sleep Studies

When to Order Polysomnography

• If she reports true sleepiness (involuntary sleep episodes), order overnight polysomnography to evaluate for obstructive sleep apnea or periodic limb movement disorder 1, 4
• Obstructive sleep apnea commonly presents with insomnia symptoms rather than classic daytime sleepiness 2

Selective Laboratory Testing

• Check TSH in all patients with chronic insomnia 2
• Vitamin deficiency screening (vitamin D, B12, folate) should be reserved for patients with restricted diets, malabsorption conditions, or refractory insomnia despite appropriate treatment—not routinely indicated at initial evaluation 5
• Do not delay standard insomnia treatment while awaiting vitamin testing 5

Treatment Algorithm

First-Line: Cognitive Behavioral Therapy for Insomnia (CBT-I)

• CBT-I is the preferred treatment approach because of its efficacy, safety, and durability of benefit, providing superior long-term outcomes 2, 6
• Key components include:
  • Stimulus control therapy 2, 7
  • Sleep restriction therapy 2, 7
  • Sleep hygiene education 2, 7
  • Relaxation techniques 2, 7
• Initiate CBT-I regardless of whether you identify underlying causes or add pharmacotherapy 2

Address Pain Management

• Her nocturnal knee and hip pain requires optimization—inadequately treated pain perpetuates insomnia 1
• Opiates are valuable in pain-associated insomnia, but consider non-opioid alternatives first given their sleep-fragmenting effects 1, 8
• Evaluate whether physical therapy, anti-inflammatory agents, or other pain interventions can reduce nocturnal pain 8

Pharmacotherapy Considerations

• Hypnotics should generally be prescribed for short periods only, with frequency and duration customized to individual circumstances 8
• Newer-generation nonbenzodiazepines (zolpidem, zaleplon, eszopiclone) have better safety profiles for long-term treatment compared to benzodiazepines 8
• Discourage routine use of over-the-counter antihistamines 8
• Never recommend alcohol as a sleep aid due to abuse potential 8

Critical Pitfalls to Avoid

• Do not attribute all symptoms to "just insomnia" without screening for primary sleep disorders—missing obstructive sleep apnea or periodic limb movements leads to treatment failure 1, 2
• Do not overlook psychiatric comorbidities—sleep complaints may herald the onset of mood disorders or exacerbation of existing conditions 1
• Do not delay CBT-I while pursuing extensive workup—initiate behavioral therapy immediately as it provides the foundation for all insomnia treatment 2, 5
• Recognize that polypharmacy with multiple sleep-disrupting agents can create additive or synergistic effects 1