Daytime Sleepiness

Aka: Daytime Sleepiness, Daytime Somnolence, Daytime Hypersomnia, Sleepiness, Daytime Tiredness, Tiredness, Hypersomnia, Hypersomnolence, Somnolence, Disorder of Excessive Daytime Sleepiness, Disorders of Excessive Somnolence

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II. Causes

  1. Hypersomnolence Causes

III. History

  1. History of Sleepiness
  2. Comorbid significant medical conditions (e.g. Neurologic Disorders)
  3. Medications (including non-prescription items, supplements and Herbals)
  4. Alcohol and other Drugs of Abuse
  5. Mood and emotional stressors
  6. Lifestyle, night-time work hours, and sources of sleep deprivation
  7. Sleep habits (including Insomnia, snoring, and possible Sleep Apnea)
  8. Restless Leg Syndrome

IV. Screening: Significant Daytime Somnolence indicating additional evaluation

  1. Falling asleep while driving OR
  2. Epworth Sleepiness Scale >12

V. Differential Diagnosis

  1. Insomnia (Disorder of Initiating and Maintaining Sleep or DIMS)
    1. Insomnia typically causes paradoxical daytime hyperarousal instead of Sleepiness
    2. Insomnia with excessive Daytime Sleepiness suggests comorbidity (e.g. Sleep Apnea)

VI. Labs

  1. Thyroid Function Tests
  2. Renal Function tests
  3. Serum Calcium
  4. Arterial Blood Gas (ABG)
    1. Rule-out Hypercapnia

VII. Diagnostics: Sleep Study

  1. Step 1: Overnight Polysomnography evaluates for Sleep Apnea
    1. Positive: Treat Sleep Apnea
    2. Negative: Perform step 2 testing
  2. Step 2: Polysomnography evaluates Sleep Onset Latency (time to fall asleep)
    1. Multiple Sleep Latency Test (MSLT)
      1. Hypersomnolence with early onset REM Sleep diagnoses Narcolepsy without cateplexy
    2. Maintenance of Wakefullness Test (MWT)
      1. Assess waking performance in alertness-critical professions (e.g. drivers, pilots)

VIII. Management: General

  1. Treat underlying cause (e.g. Sleep Deprivation, Sleep Apnea, Restless Legs Syndrome)
  2. Practice Sleep Hygiene and ensure adequate sleep time

IX. Management: Stimulant Medications

  1. See Narcolepsy for specific management
  2. Contraindications
    1. Untreated Sleep Apnea
    2. Other secondary causes not fully excluded
    3. Mild or unproven Hypersomnolence
    4. Recent vascular event (CVA, MI) or multiple Cardiovascular Risk Factors
    5. Arrhythmia
    6. Uncontrolled Hypertension
  3. Adverse Effects
    1. Headache
    2. Nausea
    3. Anxiety
  4. Indications
    1. Excessive Sleepiness despite appropriate Obstructive Sleep Apnea management with CPAP
    2. Daytime Sleepiness with Shift Work Disorder
    3. Other moderate to severe excessive Daytime Sleepiness
  5. First-line agents (controlled substance C-IV Agents)
    1. Modafinil (Provigil, generic, roughly $90/month in 2020)
      1. Best safety profile and lowest abuse potential of all stimulant agents
      2. Czeisler (2005) N Engl J Med 353(5): 476-86 [PubMed]
    2. Armodafinil (Nuvigil, generic, roughly $90/month in 2020)
    3. Solriamfetol (Sunosi, expensive at $700/month in 2020)
  6. Novel agents (non-controlled)
    1. Pitolisant (Wakix)
      1. Released in 2020 for Daytime Somnolence for Narcolepsy
      2. Active at CNS Histamine receptors and appears to be as effective as Modafinil
      3. However, very expensive ($11,400 per month) andf many Drug Interactions as well as QT Prolongation
      4. (2019) presc lett 27(1):6
  7. Other agents (higher risk of abuse or side effects)
    1. Dextroamphetamine (Dexedrine)
    2. Methylphenidate (Ritalin)
    3. Pemoline (Cylert)
      1. Risk of hepatotoxicity

X. References

  1. Kreiger (2000) Sleep 23:S95-8 [PubMed]
  2. Pagel (2009) Am Fam Physician 79(5): 391-6 [PubMed]

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