What is the appropriate evaluation and management for a 55‑year‑old woman presenting with fatigue and insomnia?

Management of Fatigue and Insomnia in a 55-Year-Old Woman

Begin with Cognitive Behavioral Therapy for Insomnia (CBT-I) immediately as first-line treatment, while simultaneously conducting a focused evaluation for underlying causes—particularly perimenopause, depression, anxiety, medications, and medical comorbidities—since fatigue with insomnia in this demographic most commonly reflects either primary insomnia with daytime consequences or an underlying psychiatric/medical disorder that requires specific treatment. 1, 2

Initial Diagnostic Evaluation

Essential Sleep Assessment

• Complete a 2-week sleep diary documenting bedtime, wake times, sleep latency, number of awakenings, total sleep time, and daytime naps 2
• Administer the Epworth Sleepiness Scale to screen for other sleep disorders; note that true sleepiness (tendency to fall asleep) is uncommon in primary insomnia, whereas fatigue (low energy, physical tiredness) is the predominant complaint 1, 2
• Document the specific insomnia pattern: difficulty falling asleep, staying asleep, or early-morning awakening 2

Critical History Components

Pre-sleep conditions and behaviors that perpetuate insomnia 1:

• Bedroom environment: light exposure, noise, temperature, TV/screen use
• Maladaptive behaviors: excessive time in bed trying to "catch up" on sleep, clock-watching, phone use, eating in bed
• Mental state at bedtime: anxious and hyperalert versus relaxed

Daytime dysfunction assessment 1:

• Mood disturbances: irritability, loss of interest, mild depression, anxiety
• Cognitive difficulties: memory problems, difficulty focusing, mental inefficiency
• Quality of life impact: interpersonal difficulties, avoidance of social activities, work impairment

Screen for Comorbid Conditions

Psychiatric disorders account for 40-50% of chronic insomnia cases 1, 3:

• Depression and anxiety are the most common; the relationship between insomnia and psychiatric disorders is bidirectional 1
• Insomnia may herald the onset of mood disorders or represent residual symptoms during antidepressant treatment 1, 3

Medical conditions to evaluate 1:

• Cardiovascular disease, chronic pain, GERD, asthma/COPD, neurological disorders, hyperthyroidism
• In a 55-year-old woman, specifically assess for perimenopausal symptoms (hot flashes, night sweats)
• Anemia and nutritional deficiencies 1

Medication and substance review 1:

• SSRIs/SNRIs (fluoxetine, paroxetine, sertraline, venlafaxine) commonly cause insomnia
• Stimulants, decongestants, β-blockers, theophylline, albuterol
• Caffeine timing and quantity, alcohol use (causes sleep fragmentation), nicotine

When polysomnography IS indicated 2:

• Suspected obstructive sleep apnea, periodic limb movement disorder, or narcolepsy
• Treatment-resistant insomnia after appropriate therapy
• Excessive daytime sleepiness (uncommon in primary insomnia and suggests another sleep disorder) 1, 2

Treatment Algorithm

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

Initiate CBT-I immediately for all patients with chronic insomnia (≥3 nights/week for ≥3 months); it demonstrates superior long-term efficacy compared to medications and maintains benefits after discontinuation 2, 4

Core CBT-I components 2, 5:

• Stimulus control therapy: go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 20 minutes
• Sleep restriction therapy: limit time in bed to actual sleep time, then gradually increase
• Cognitive restructuring: address maladaptive beliefs about sleep and catastrophic thinking
• Relaxation techniques: progressive muscle relaxation, meditation, breathing exercises
• Sleep hygiene education: avoid caffeine/alcohol in evening, maintain consistent sleep-wake times, limit daytime naps to 30 minutes before 2 PM, ensure dark/quiet/comfortable bedroom 1, 2

Second-Line: Add Pharmacotherapy if CBT-I Insufficient After 2-4 Weeks

Continue CBT-I while adding medication; never use pharmacotherapy as monotherapy 2

For Sleep-Onset Insomnia

First choice: Ramelteon 8 mg at bedtime 2:

• Zero addiction potential, non-DEA scheduled
• Particularly suitable for patients with substance use history
• No next-day cognitive or motor impairment

Alternative: Short-acting BzRAs 2:

• Zolpidem 5-10 mg (use 5 mg in women due to slower metabolism) 6
• Zaleplon 5-10 mg (very short half-life, minimal residual sedation)

For Sleep-Maintenance Insomnia

First choice: Low-dose doxepin 3-6 mg 2:

• Reduces wake-after-sleep-onset by 22-23 minutes
• Minimal anticholinergic effects at low doses
• No abuse potential
• No weight gain

Alternative: Eszopiclone 2-3 mg 2

Medications to AVOID as First-Line

Medication	Reason to Avoid	Citation
OTC antihistamines (diphenhydramine, doxylamine)	No proven efficacy; anticholinergic effects; tolerance in 3-4 days	[2]
Traditional benzodiazepines (lorazepam, temazepam)	Higher dependency risk, falls, cognitive impairment, respiratory depression	[2]
Trazodone	Insufficient efficacy data for primary insomnia; no difference vs. placebo in sleep efficiency	[2]
Atypical antipsychotics (quetiapine, olanzapine)	Insufficient evidence; significant metabolic side effects (weight gain, metabolic syndrome)	[2]
Melatonin supplements	Insufficient efficacy data for chronic insomnia in adults	[2]

Third-Line: Sedating Antidepressants

Reserve for patients with comorbid depression/anxiety or when first-line agents fail 2, 3:

• Trazodone 50-150 mg (commonly prescribed but limited published data) 3
• Mirtazapine (sedating, may cause weight gain)
• Low-dose tricyclic antidepressants (amitriptyline, doxepin at antidepressant doses)

Critical Safety Considerations

Before prescribing any hypnotic 2, 6:

• Educate about complex sleep behaviors (sleep-driving, sleep-walking, sleep-eating); discontinue immediately if these occur 6
• Warn about next-day impairment, especially with driving; requires 7-8 hours of sleep time 6
• Avoid alcohol and other CNS depressants 6
• Use lowest effective dose for shortest duration 2

Reassess every 2-4 weeks initially 2:

• Evaluate effectiveness on sleep latency, maintenance, and daytime functioning
• Monitor for adverse effects: daytime sedation, falls (especially in elderly), cognitive changes
• Screen for complex sleep behaviors
• Decide on continuation versus tapering

For patients with depression 6:

• Worsening depression and suicidal ideation have been reported with sedative-hypnotics
• Prescribe the smallest feasible quantity at one time
• Monitor closely for mood changes

Common Pitfalls to Avoid

• Do not prescribe hypnotics without attempting CBT-I first; medications alone have inferior long-term outcomes 2
• Do not overlook comorbid psychiatric conditions; depression and anxiety have 50-75% insomnia prevalence and must be treated to resolve insomnia 2, 3
• Do not continue ineffective medications; if no improvement after 1-2 weeks at therapeutic doses, switch agents rather than increase dose 2
• Do not ignore excessive daytime sleepiness; this is uncommon in primary insomnia and suggests OSA, narcolepsy, or other disorders requiring polysomnography 1, 2
• Do not use benzodiazepines as first-line; they have higher dependency risk, cognitive impairment, and fall risk compared to non-benzodiazepine alternatives 2, 4

Special Considerations for This Patient Population

For a 55-year-old woman specifically 2:

• Assess for perimenopausal symptoms that may disrupt sleep
• If using zolpidem, prescribe 5 mg (not 10 mg) due to slower metabolism in women
• Consider ramelteon or low-dose doxepin 3 mg as safest choices due to minimal fall risk
• Screen for depression, which commonly presents with fatigue and insomnia in this age group 1