II. Causes
III. History
- History of Sleepiness
- Comorbid significant medical conditions (e.g. Neurologic Disorders)
- Medications (including non-prescription items, supplements and Herbals)
- Alcohol and other Drugs of Abuse
- Mood and emotional stressors
- Lifestyle, night-time work hours, and sources of sleep deprivation
- Sleep habits (including Insomnia, snoring, and possible Sleep Apnea)
- Restless Leg Syndrome
IV. Screening: Significant Daytime Somnolence indicating additional evaluation
- Falling asleep while driving OR
- Epworth Sleepiness Scale >12
V. Differential Diagnosis
-
Insomnia (Disorder of Initiating and Maintaining Sleep or DIMS)
- Insomnia typically causes paradoxical daytime hyperarousal instead of Sleepiness
- Insomnia with excessive Daytime Sleepiness suggests comorbidity (e.g. Sleep Apnea)
VI. Labs
- Thyroid Function Tests
- Renal Function tests
- Serum Calcium
-
Arterial Blood Gas (ABG)
- Rule-out Hypercapnia
VII. Diagnostics: Sleep Study
- Step 1: Overnight Polysomnography evaluates for Sleep Apnea
- Positive: Treat Sleep Apnea
- Negative: Perform step 2 testing
- Step 2: Polysomnography evaluates Sleep Onset Latency (time to fall asleep)
- Multiple Sleep Latency Test (MSLT)
- Hypersomnolence with early onset REM Sleep diagnoses Narcolepsy without cateplexy
- Maintenance of Wakefullness Test (MWT)
- Assess waking performance in alertness-critical professions (e.g. drivers, pilots)
- Multiple Sleep Latency Test (MSLT)
VIII. Management: General
- Treat underlying cause (e.g. Sleep Deprivation, Sleep Apnea, Restless Legs Syndrome)
- Practice Sleep Hygiene and ensure adequate sleep time
IX. Management: Stimulant Medications
- See Narcolepsy for specific management
- Contraindications
- Untreated Sleep Apnea
- Other secondary causes not fully excluded
- Mild or unproven Hypersomnolence
- Recent vascular event (CVA, MI) or multiple Cardiovascular Risk Factors
- Arrhythmia
- Uncontrolled Hypertension
- Adverse Effects
- Indications
- Excessive Sleepiness despite appropriate Obstructive Sleep Apnea management with CPAP
- Daytime Sleepiness with Shift Work Disorder
- Other moderate to severe excessive Daytime Sleepiness
- First-line agents (controlled substance C-IV Agents)
- Modafinil (Provigil, generic, roughly $90/month in 2020)
- Best safety profile and lowest abuse potential of all stimulant agents
- Czeisler (2005) N Engl J Med 353(5): 476-86 [PubMed]
- Armodafinil (Nuvigil, generic, roughly $90/month in 2020)
- Solriamfetol (Sunosi, expensive at $700/month in 2020)
- Modafinil (Provigil, generic, roughly $90/month in 2020)
- Novel agents (non-controlled)
- Pitolisant (Wakix)
- Released in 2020 for Daytime Somnolence for Narcolepsy
- Active at CNS Histamine receptors and appears to be as effective as Modafinil
- However, very expensive ($11,400 per month) andf many Drug Interactions as well as QT Prolongation
- (2019) presc lett 27(1):6
- Pitolisant (Wakix)
- Other agents (higher risk of abuse or side effects)
- Dextroamphetamine (Dexedrine)
- Methylphenidate (Ritalin)
- Pemoline (Cylert)
- Risk of hepatotoxicity
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Related Studies
Definition (NCI) | The sensation of struggling to remain awake. |
Concepts | Finding (T033) |
MSH | D012894 |
SnomedCT | 206711009, 79519003, 271782001, 284091004, 158122000 |
LNC | LA16352-9 |
English | Drowsiness, Drowsinesses, SLEEPINESS, DROWSINESS, Somnolence, [D]Drowsiness, [D]Drowsiness (context-dependent category), Drowsiness, function, drowsy, drowsiness, drowsy (physical finding), drowsiness (symptom), drowsiness was observed, sleepiness, somnolence, sleepy, somnolent, Mental status, drowsy, Somnolence (sleepiness), Sleepy, [D]Drowsiness (situation), Sleepy (finding), Drowsy, Sleepiness, Drowsiness, function (observable entity), Drowsy (finding), Drowsiness (function) |
Portuguese | SONOLENCIA, Sonolento, Sonolência, LETARGIA |
Dutch | slaperigheid, suf voelen, slaperig, Slaperigheid |
French | Ensommeillé(e), Endormissement, Envie de dormir, ASSOUPISSEMENT, ENVIE EXCESSIVE DE DORMIR, Somnolence, Assoupissement |
German | Verschlafenheit, schlaefrig, Schlaefrigkeit, Schläfrigkeit, DOESIGKEIT, SCHLAEFRIGKEIT, Somnolenz |
Italian | Addormentato, Sonnolenza |
Spanish | Tendencia al sueño, Soñoliento, Adormecimiento, [D]modorra (categoría dependiente del contexto), Somnolencia, ADORMECIMIENTO, MODORRA, [D]modorra, somnoliento, somnoliento (hallazgo), [D]modorra (situación) |
Japanese | 眠気, 眠気状態, 傾眠状態, ネムケ, ケイミンジョウタイ, ネムケジョウタイ |
Czech | Ospalost, Ospalý, ospalost |
Hungarian | Álmosság, Álmos |
Norwegian | Søvnighet |
Ontology: Fatigue (C0015672)
Definition (CCC) | Exhaustion that interferes with physical and mental activities |
Definition (MEDLINEPLUS) |
Everyone feels tired now and then. Sometimes you may just want to stay in bed. But, after a good night's sleep, most people feel refreshed and ready to face a new day. If you continue to feel tired for weeks, it's time to see your doctor. He or she may be able to help you find out what's causing your fatigue and recommend ways to relieve it. Fatigue itself is not a disease. Medical problems, treatments, and personal habits can add to fatigue. These include
One disorder that causes extreme fatigue is chronic fatigue syndrome (CFS). This fatigue is not the kind of tired feeling that goes away after you rest. Instead, it lasts a long time and limits your ability to do ordinary daily activities. NIH: National Institute on Aging |
Definition (NCI) | Overall tiredness and lack of energy.(NICHD) |
Definition (NCI) | A question about whether an individual has or had a lack of energy. |
Definition (NCI_NCI-GLOSS) | A condition marked by extreme tiredness and inability to function due lack of energy. Fatigue may be acute or chronic. |
Definition (NCI_CTCAE) | A disorder characterized by a state of generalized weakness with a pronounced inability to summon sufficient energy to accomplish daily activities. |
Definition (NAN) | An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level |
Definition (MSH) | The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. |
Definition (CSP) | state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. |
Concepts | Sign or Symptom (T184) |
MSH | D005221 |
ICD10 | R53.83 |
SnomedCT | 206767001, 206771003, 158169005, 367392001, 302758002, 139126000, 84229001, 248274002 |
LNC | MTHU013358, LA7542-9 |
French | FATIGUE, Fatigue extrême, Perte d'énergie, Energie diminuée, Ereinté, Lassitude, Sensation de manque total d'énergie, EPUISEMENT, FAIBLESSE, LASSITUDE, Fatigue |
English | FATIGUE EXTREME, TIREDNESS, WEARINESS, [D]Fatigue, [D]Tiredness, [D]Fatigue (context-dependent category), [D]Tiredness (context-dependent category), Extreme fatigue, Decreased energy, decreased energy, fatigue (diagnosis), fatigue, Feeling of total lack of energy, Fatigue extreme, Tired out, Fatigue NOS, Fatigue [Disease/Finding], rndx fatigue (diagnosis), rndx fatigue, lacking energy, fatigues, loss of energy, tired time, tiredness, fatigue extreme, extreme fatigue, weariness, fatigued, tatt, time tired, energy loss, fatiguing, tired all the time, Lacks Energy, [D]Fatigue (situation), [D]Tiredness (situation), Lacking in energy (finding), Tiredness (finding), I have a lack of energy, FATIGUE, Lack Energy, Energy decreased, Tiredness, Lack of energy, Loss of energy, Weariness, Fatigue (finding), Lack of energy (finding), Lacking in energy, Fatigue, Lack of Energy, lack of energy, Lack (of);energy |
Portuguese | FADIGA, Fadiga extrema, Sensação de falta total de energia, Perda de energia, Exausto, Energia diminuída, CANSACO, ESGOTAMENTO, EXAUSTAO, Fadiga |
Spanish | FATIGA, Abatimiento, Sensación de falta absoluta de energía, Pérdida de energía, Fatiga extrema, Cansado, Cansancio, Falta de energía, [D]cansancio (categoría dependiente del contexto), [D]fatiga (categoría dependiente del contexto), ABATIMIENTO, CANSANCIO, FATIGA EXTREMA, [D]cansancio (situación), [D]cansancio, [D]fatiga, faltante de energía, faltante de energía (hallazgo), [D]fatiga (situación), cansancio, falta de energía (hallazgo), falta de energía, fatiga (hallazgo), fatiga, pérdida de energía, Fatiga |
German | ERMUEDUNG, Mangel an Energie, Muedigkeit extrem, Ueberdruss, Energie abgenommen, abgeschlafft, Gefuehl voelligen Energiemangels, Muedigkeit, ABGESCHLAGENHEIT, MUEDIGKEIT STARK, MUEDIGKEIT, Ermuedung, Ermüdung, Müdigkeit |
Italian | Affaticamento, Affaticamento estremo, Esaurito, Sensazione di totale mancanza di energia, Perdita di energia, Energia ridotta, Stanchezza |
Dutch | vermoeid, moeheid, uitzonderlijk moe, verlies van energie, gevoel van energieloosheid, energie afgenomen, vermoeidheid, Moeheid |
Japanese | 活力低下, 活力喪失感, 活力喪失, 疲労困ぱい, 極度の疲労, 疲労, ヒロウコンパイ, カツリョクテイカ, カツリョクソウシツカン, ヒロウ, キョクドノヒロウ, カツリョクソウシツ |
Swedish | Trötthet |
Czech | únava, Utahanost, Extrémní únava, Utahaný, Ztráta energie, Úbytek energie, Únava, Vyčerpanost, Pocit celkového nedostatku energie |
Finnish | Väsymys |
Russian | UTOMLENIE, USTALOST', УСТАЛОСТЬ, УТОМЛЕНИЕ |
Croatian | UMOR |
Polish | Znużenie, Zmęczenie |
Hungarian | Kimerültség, Defatigatio, Kifáradt, Teljes energiahiány érzete, Energia elvesztése, Fáradtság, Kimerültség, extrém, Csökkent energia |
Norwegian | Tretthet, Utmattelse, Trøtthet, Fatigue |
Ontology: Disorders of Excessive Somnolence (C0020524)
Definition (MSH) | Disorders characterized by hypersomnolence during normal waking hours that may impair cognitive functioning. Subtypes include primary hypersomnia disorders (e.g., IDIOPATHIC HYPERSOMNOLENCE; NARCOLEPSY; and KLEINE-LEVIN SYNDROME) and secondary hypersomnia disorders where excessive somnolence can be attributed to a known cause (e.g., drug affect, MENTAL DISORDERS, and SLEEP APNEA SYNDROME). (From J Neurol Sci 1998 Jan 8;153(2):192-202; Thorpy, Principles and Practice of Sleep Medicine, 2nd ed, p320) |
Concepts | Disease or Syndrome (T047) |
MSH | D006970 |
ICD10 | G47.1 |
SnomedCT | 194439006 |
English | Disordrs/excessive somnolence, Disorders of excessive somnolence [hypersomnias], DIS EXCESSIVE SOMNOLENCE, DOES DIS EXCESSIVE SOMNOLENCE, EXCESSIVE SOMNOLENCE DIS, HYPERSOMNOLENCE DIS, DOES (Disorders of Excessive Somnolence), Disorders of Excessive Somnolence, Excessive Somnolence Disorder, Excessive Somnolence Disorders, Somnolence Disorder, Excessive, Somnolence Disorders, Excessive, Hypersomnolence Disorder, Hypersomnolence Disorders, Disorders of Excessive Somnolence [Disease/Finding], DOESs (Disorders of Excessive Somnolence), hypersomnolence disorder, sleep disorder hypersomnolence, hypersomnolence disorder (diagnosis), Disorders of excessive somnolence, Disorder of excessive somnolence, Disorders of excessive somnolence (disorder), hypersomnia type; sleep disorder, sleep disorder; hypersomnia type |
Swedish | Onormalt stort sömnbehov |
Czech | poruchy nadměrné spavosti, nadměrná spavost |
Finnish | Uneliaisuushäiriöt |
Russian | GIPERSOMNIIA, ГИПЕРСОМНИЯ |
German | Krankhaft gesteigertes Schlafbeduerfnis, Störungen durch ekzessive Somnolenz |
Japanese | 過眠症, 睡眠過剰症, 睡眠過剰障害, 過剰睡眠障害, 睡眠過剰, 過剰睡眠 |
Italian | DOES (Disturbi della sonnolenza eccessiva), Disturbi da ipersonnolenza, Disturbi della sonnolenza eccessiva |
Korean | 과다 수면 장애[과면증] |
Polish | Senność wzmożona, Nadmierna senność, Wzmożona senność |
Norwegian | Eksessiv somnolensforstyrrelser, Overtretthetsforstyrrelser, Unormalt stort søvnbehov |
Spanish | Trastornos de Somnolencia Excesiva, Hipersomnia, Trastornos de Excesiva Somnolencia, Hipersomnio, trastornos de somnolencia excesiva (trastorno), trastornos de somnolencia excesiva |
Croatian | Not Translated[Disorders of Excessive Somnolence] |
Portuguese | Transtornos da Sonolência Excessiva, Distúrbios do Sono por Sonolência Excessiva |
Dutch | hypersomnia-type; slaapstoornis, slaapstoornis; hypersomnia-type, Stoornissen met bovenmatige slaperigheid [hypersomnia], Hypersomnie, Slaapzucht |
French | Troubles du sommeil par somnolence diurne excessive, Troubles du sommeil par somnolence excessive |
Ontology: Daytime sleepiness (C0541854)
Concepts | Finding (T033) |
Dutch | slaperigheid overdag |
French | Somnolence diurne |
German | Schlaefrigkeit waehrend des Tages |
Italian | Sonnolenza diurna |
Portuguese | Sonolência diurna |
Spanish | Somnolencia diurna |
Japanese | 日中の眠気, ニッチュウノネムケ |
Czech | Denní ospalost |
English | Daytime sleepiness, sleepiness daytime, daytime sleepiness |
Hungarian | Nappali álmosság |
Ontology: Hypersomnolence (C0751229)
Concepts | Sign or Symptom (T184) |
MSH | D006970 |
Czech | hypersomnolence |
Portuguese | Hipersonolência |
Spanish | Hipersomnolencia |
French | Hypersomnolence |
German | Hypersomnolenz |
English | hypersomnolence, hypersomnolent, Hypersomnolence |
Norwegian | Overtretthet, Hypersomnolens |
Italian | Ipersonnolenza |
Dutch | Hypersomnolentie |
Ontology: Hypersomnia (C0917799)
Definition (NCI_CTCAE) | A disorder characterized by characterized by excessive sleepiness during the daytime. |
Definition (NCI) | A sleep disorder characterized by excessive sleepiness during the daytime. |
Definition (PSY) | Excessive sleepiness. |
Concepts | Sign or Symptom (T184) |
MSH | D006970 |
ICD9 | 780.54 |
ICD10 | G47.10 , G47.1 |
SnomedCT | 309732001, 206751007, 158154009, 270961006, 77692006, 230486000, 158149000, 191998008 |
LNC | LP121711-8, MTHU039892, LA15882-6 |
English | Hypersomnias, [D]Hypersomnia NOS, Sleeping Excessive, [D]Hypersomnia (context-dependent category), [D]Hypersomnia NOS (context-dependent category), [D]Hypersomnia, sleeping too much (symptom), sleeping too much, sleeping too much (hypersomnia), hypersomnia, Sleep excessive, Hypersomnia, unspecified, Hypersomnia NOS, increased sleep, much sleeping too, excessive sleep, excessive sleepiness, sleep too much, too much sleep, much sleep too, excessive sleeping, Primary Hypersomnia, Hypersomnia, [D]Hypersomnia (situation), [D]Hypersomnia NOS (situation), Hypersomnia [D], Hypersomnia (excessive sleeping), Hypersomnia NOS (disorder), Excessive sleeping, Sleep too much, Excessive sleep, Excessive sleepiness, Sleeps too much, Hypersomnia (disorder), Hypersomnia, NOS |
Dutch | slaap overmatig, hypersomnie, Hypersomnia |
French | Sommeil excessif, Hypersomnie |
German | exzessiver Schlaf, Hypersomnie |
Italian | Sonno eccessivo, Ipersomnia, Ipersonnia |
Portuguese | Sono excessivo, Hipersonia, Hipersónia |
Spanish | Sueño excesivo, [D]hipersomnia, SAI (categoría dependiente del contexto), [D]hipersomnia (categoría dependiente del contexto), Hipersomnios, [D]hipersomnia, SAI, [D]hipersomnia (situación), hipersomnia, SAI, [D]hipersomnia, SAI (situación), [D]hipersomnia, hipersomnia, SAI (trastorno), somnolencia excesiva, hipersomnia (trastorno), hipersomnia, Hipersomnia |
Japanese | 睡眠過剰, 過眠症, スイミンカジョウ, カミンショウ |
Czech | hypersomnie, Nadměrný spánek, Hypersomnie |
Hungarian | Hypersomnia, Túlzott mértékő alvás |
Norwegian | Hypersomnia |
Ontology: Daytime somnolence (C2219848)
Concepts | Sign or Symptom (T184) |
SnomedCT | 141000119100 |
English | excessive sleepiness during the day (daytime somnolence), daytime somnolence, excessive sleepiness during day, excessive sleepiness during day (symptom), Daytime somnolence (finding), Daytime somnolence |
Spanish | somnolencia diurna (hallazgo), somnolencia diurna |
Ontology: Daytime hypersomnia (C3662832)
Concepts | Sign or Symptom (T184) |
SnomedCT | 31771000119102 |
English | Daytime hypersomnia (disorder), Daytime hypersomnia |
Spanish | hipersomnia diurna, hipersomnia diurna (trastorno) |