Maria is a 63-year-old white woman with stage II, estrogen receptor–positive, progesterone receptor–positive, human epidermal growth factor receptor 2–negative breast cancer. Following a lumpectomy with sentinel lymph node biopsy, she completed chemotherapy and radiation therapy, and recently started treatment with an aromatase inhibitor (AI). She works part-time as a receptionist. She presents with an irregular sleep schedule; complaints of difficulty falling asleep; and more than six awakenings per night due to AI-related hot flashes, aches, and pains. The results of her physical examination are unremarkable and her physical status is good. She reports severe fatigue (7 on a scale of 0 to 10) and experiences daytime sleepiness that leads to afternoon naps 3 to 5 days per week. She has a history of anxiety and is very worried about cancer recurrence.
APPLICATION OF THE ALGORITHMStep 1: Screen – Yes.Step 2: No.Step 3: Her Insomnia Severity Index (ISI) score is 16 (due to irregular sleep schedule, hot flashes, anxiety, fatigue, and pain).Step 4: Focus on regular sleep schedule; better sleep environment; and management of hot flashes, aches, and pain.Step 5: Exercise program and mindfulness-based stress reduction strategies to reduce anxiety; short-term zolpidem tartrate at 5 mg PRN.Step 6: Repeat assessment at 12 weeks: ISI = 10; patient rates fatigue and anxiety as moderate (5 on a scale of 0 to 10). Continue to assess; sleep medication not renewed.