How should I evaluate and manage an otherwise healthy adult with acute fatigue and sleep disturbance?

Evaluation and Management of Acute Fatigue with Sleep Disturbances in Healthy Adults

Begin with a two-step screening process using two specific questions: (1) "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" and (2) "Does the problem with your sleep negatively affect your daytime functioning?" If both answers are yes, proceed immediately to comprehensive assessment and initiate Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment. 1, 2

Initial Screening and Triage

Critical distinction: You must first differentiate between sleepiness (inability to maintain wakefulness with unintended lapses into sleep) versus fatigue (tiredness without sleep attacks), as these require different diagnostic pathways. 3

• Use the two screening questions above to identify clinically significant sleep disturbance 2
• Apply the Epworth Sleepiness Scale to screen for excessive daytime sleepiness and rule out comorbid sleep disorders like obstructive sleep apnea 4, 2
• Utilize the Insomnia Severity Index for case identification and to establish baseline severity 5, 2

Comprehensive Assessment Protocol

Sleep History Documentation (2-Week Minimum)

Obtain a detailed 2-week sleep diary documenting: 5, 4, 2

• Bedtime and wake times
• Sleep onset latency (time to fall asleep)
• Number and duration of nighttime awakenings
• Total sleep time and sleep efficiency (ratio of sleep time to time in bed)
• Nap frequency and duration
• Sleep quality ratings
• Daytime impairment levels

Behavioral and Environmental Assessment

Evaluate specific sleep hygiene factors: 5, 4

• Pre-sleep behaviors and routines
• Bedroom environment (temperature, light, noise)
• Mental state at bedtime
• Evening meal timing
• Daily physical activity and exercise patterns
• Caffeine consumption (timing and amount)
• Alcohol use
• Screen time before bed

Medical and Psychiatric Screening

Screen for conditions that precipitate insomnia: 4, 2

• Depression (patients with depression are 2.5 times more likely to have insomnia) 4
• Generalized anxiety disorder, panic disorder, PTSD 4
• Cardiovascular disease and COPD 4
• Chronic pain conditions (osteoarthritis, fibromyalgia) 4
• Neurological disorders (Parkinson's, Alzheimer's) 4
• Gastrointestinal and endocrine disorders 2

Medication and Substance Review

Identify sleep-disrupting medications and substances: 4, 2

• SSRIs, SNRIs, venlafaxine, MAO inhibitors 4
• Beta-blockers, bronchodilators, corticosteroids 2
• Decongestants and diuretics 2
• Caffeine, alcohol, nicotine use 4
• Over-the-counter sleep aids 2

Screen for Other Sleep Disorders

Ask specific questions to rule out: 4, 2

• Obstructive sleep apnea: witnessed breathing pauses, loud snoring, waking with headaches 4
• Restless legs syndrome: urge to move legs or uncomfortable leg sensations during rest 4
• Circadian rhythm disorders: consider actigraphy for at least 7 days if suspected 2

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

CBT-I is the first-line treatment for chronic insomnia with superior long-term efficacy compared to medications. 1

CBT-I Components (All Should Be Included):

Stimulus Control Therapy: 1

• Go to bed only when sleepy
• Use bed only for sleep and sex
• Leave bedroom if unable to sleep within 15-20 minutes
• Maintain consistent wake time regardless of sleep duration

Sleep Restriction Therapy: 1

• Limit time in bed to match actual sleep time (from sleep diary)
• Gradually increase as sleep efficiency improves to >85%

Cognitive Restructuring: 1

• Address maladaptive beliefs about sleep
• Challenge catastrophic thinking about sleep loss consequences

Sleep Hygiene Education: 5, 1

• Standard component but insufficient as sole intervention

CBT-I Delivery Options:

CBT-I can be delivered through: 1

• Individual therapy (preferred)
• Group therapy
• Telephone-based delivery
• Web-based/digital programs
• Self-help books (for resource-limited settings)

Pharmacotherapy (Only as Adjunct to CBT-I)

Pharmacotherapy should supplement, never replace, CBT-I. 1

When to Consider Medications:

• CBT-I insufficient after 4-6 weeks 1
• Severe symptoms requiring immediate relief 1
• Patient unable to engage in CBT-I initially

First-Line Pharmacological Options:

For combined sleep onset and maintenance insomnia: 1

• Eszopiclone
• Zolpidem
• Temazepam

Important caveat: These recommendations carry weak evidence quality, and medications should be time-limited. 1

Follow-Up and Monitoring

• Reassess sleep diary data after 2-4 weeks of CBT-I 5
• Monitor for improvement in sleep efficiency (target >85%) 5
• Evaluate daytime functioning improvements 5
• Consider polysomnography only if other sleep disorders suspected (not routinely indicated for insomnia alone) 2

Critical Pitfalls to Avoid

Do not: 4

• Fail to obtain bed partner input about snoring, breathing pauses, or limb movements
• Overlook bidirectional relationship between insomnia and depression
• Miss medication side effects or substance use as causes
• Neglect assessment for underlying sleep disorders
• Rely solely on subjective reports without sleep diary data
• Use sleep hygiene education alone as treatment (insufficient evidence for efficacy as single intervention) 5