Sleep

How Is Excessive Sleepiness Treated?

Behavioral and medical interventions can help with excessive sleepiness.

Posted Mar 31, 2020

"Yin and Yang" by Klem - This vector image was created with Inkscape by Klem, and then manually edited by Mnmazur.. Licensed under Public Domain via Wikimedia Commons
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Source: "Yin and Yang" by Klem - This vector image was created with Inkscape by Klem, and then manually edited by Mnmazur.. Licensed under Public Domain via Wikimedia Commons

In recent blog posts, I have focused on the importance of getting good sleep during these stressful times. Poor sleep affects our mental and physical health while good sleep helps us function effectively and protects our health.

For many people, a primary problem is staying awake during the day. Everyone has experienced daytime sleepiness. It is common to have drowsiness after lunch during the circadian low of the day and after getting a poor night of sleep. These periods of sleepiness tend to be brief and can be “treated” with a nap, a cup of coffee, or best of all, getting a good night’s sleep. Sometimes daytime sleepiness is, however, so intense that it is nearly disabling.

This intense kind of sleepiness is relentless and plagues the person throughout the day. Thoughts of sleep are never far from the mind of the person dealing with hypersomnia. 

Sleepiness is not to be confused with fatigue, which is being overtired and exhausted. It is characterized by a lack of energy and low motivation. Sleepiness is the feeling of needing to sleep and is characterized by uncontrollable eye closing and head bobbing.

One way to think about it is, generally speaking, it is usually not dangerous to drive when fatigued. It is unpleasant and errors can be made but it is usually possible to push on and keep going with short breaks from time to time. Drowsy driving, on the other hand, cannot be done safely and is a significant cause of motor vehicle accidents. With sleepiness, there are brief periods of unconsciousness that can become extended if the person fully falls asleep. It is during these periods of sleepiness that people lose control of their vehicles and accidents occur. 

Distinguishing between fatigue and excessive sleepiness is not always easy and ambiguity remains in the scientific literature on this issue. While efforts have been made to better define and measure fatigue and excessive sleepiness (Pigeon, Sateia, & Ferguson, 2003) more work needs to be done. When I meet with patients who have complaints that can be difficult to distinguish between fatigue and sleepiness, I inquire carefully and in detail about their problems to make clear the actual nature of the complaint.

Sometimes, as with disorders like sleep apnea and insomnia, significant fatigue can continue even after successful treatment. This is discouraging to patients. I explain that fatigue is a complex problem and has many causes including lifestyle factors such as insufficient sleep, lack of exercise, and excessive activity as when working long hours. Medical causes such as fibromyalgia, cancer, and heart disease can also be a factor. While most fatigue is probably related to lack of adequate rest and overworking, persistent and unexplained fatigue should be evaluated medically.

Excessive daytime sleepiness is defined as “the inability to stay alert and awake during the major waking episodes of the day, typically resulting in unintended lapses into sleep” (Sateia & Thorpy, 2017, p. 623).  It is an extremely common complaint and is estimated to affect up to 20% of the population (Pagel, 2009). It is associated with poorer health as well as with motor vehicle and industrial accidents. It is therefore not an insignificant health and safety issue and is a major cause of decreased quality of life for afflicted individuals.

The first step in treating excessive daytime sleepiness is to determine its cause. A thorough evaluation by a physician is important to determine possible causes and to rule that which is not relevant. 

Excessive sleepiness, or hypersomnia, is a symptom that may be attributable to behaviorally induced sleep deprivation, which is referred to as insufficient sleep syndrome, to a medical condition, or to substance use or psychiatric disorder. In these cases, treating the underlying sleep, medical, substance, or psychiatric disorder is the best approach and has a high probability of success. It is also possible that some people are long sleepers and need more than 10 hours of sleep a night to function effectively. This is not, in and of itself, a sleep disorder as the sleep itself is normal and the person will be able to function effectively if they can get sufficient time for sleep. Problems arise when social or work obligations result in schedules that do not provide sufficient time for this amount of sleep. This needs to be addressed by adjustments to work and social schedules.

When the problem is another sleep disorder such as insomnia or sleep apnea, the underlying cause must be evaluated and treated. For acute insomnia, standard sleep hygiene techniques and sleeping medications may be helpful. For chronic insomnia cognitive behavioral therapy, perhaps augmented with sleeping medications, can be beneficial. Insufficient sleep must be addressed by increasing sleep time. If the primary cause is sleep apnea, a sleep study and treatment with an intervention such as continuous positive airway pressure (CPAP) therapy is indicated. 

If the sleepiness is related to poor sleep associated with a psychological disorder such as depression or anxiety, the sleep problem itself may be addressed with cognitive behavioral therapy and possibly sleeping medication, while the individual also receives psychotherapy and/or medication for the psychological disorder.

Some excessive sleepiness may be related to medical problems such as head trauma that need to be managed medically. Excessive sleepiness may be caused by sedating drugs. A patient may be unaware that a medication they have been prescribed for another medical problem may be causing their sleepiness. Discussing the excessive sleepiness with the prescribing provider is an important first step in this case. Many drugs used recreationally or addictively, such as heroin and alcohol, may be the root of the problem and substance abuse treatment may be required. 

Central disorders of hypersomnolence are not attributable to another sleep or medical disorder and have excessive sleepiness as their primary symptom (see Sateia & Thorpy, 2017). These are narcolepsy, idiopathic hypersomnia, and Klein-Levine syndrome. Narcolepsy is characterized by overwhelming sleepiness and sudden sleep attacks. It may be accompanied by other symptoms such as cataplexy (a sudden loss of muscle tone) and sleep paralysis. Idiopathic hypersomnia is characterized by excessive sleepiness that is not relieved by napping. It is considered to be objectively demonstrated by falling asleep in less than an average of eight minutes during multiple nap opportunities during the day. This is called the multiple sleep latency test, which is used to measure sleepiness and diagnose narcolepsy and hypersomnia. Kleine-Levin syndrome is an unusual and uncommon sleep disorder characterized by recurrent periods of several days to weeks of hypersomnia accompanied by other symptoms such as overeating and uninhibited sexual behavior. 

The mainstay medical treatment of hypersomnia in narcolepsy is stimulant medication. A number of medications are used by sleep physicians including modafinil (Provigil), armodafinil (Nuvigil), dextroamphetamine (Dexedrine), and methylphenidate (Ritalin). Modafinil and armodafinil are considered to have less abuse potential than amphetamine and may be preferred for this reason. These medications work on the central nervous system causing increased alertness that can counteract the sleep drive that afflicts patients with hypersomnolence.

Behavioral interventions have also been used, typically in conjunction with medications, in the treatment of narcolepsy. These include providing patient education on such topics as symptoms, effects, time course, lifestyle factors, and pharmacological interventions; sleep hygiene to help improve the quality of nighttime sleep; taking planned, brief naps; and cognitive behavioral therapy to help manage symptoms such as low mood and anxiety, addressing negative cognitions that may arise, and supporting adherence to a program of medication management (Bhattarai & Sumerall, 2017). 

While excessive daytime sleepiness remains a challenge for those who suffer from it, we are fortunate that progress is being made in understanding its causes and in developing more effective treatments for it. 

References

Agudelo, H.A.M.,  Correa, U.J.,  Sierra, J.C., Pandi-Perumal, S.R., & Schenck, C.H. (2014). Cognitive behavioral treatment for narcolepsy: can it complement pharmacotherapy? Sleep Science 7, 30–42. 

Bhattarai, J. & Sumerall , S. (2017). Current and Future Treatment Options for Narcolepsy: A Review. Sleep Science, 10(1), 19-27. 

Pagel, J.F. (2009).  Excessive Daytime Sleepiness. American Family Physician, 79(5):391-396. 

Pigeon, W.R., Sateia, M.J., & Ferguson, R.J. (2003). Distinguishing between excessive daytime sleepiness and fatigue: Toward improved detection and treatment. Journal of Psychosomatic Research, 54 (1), 61 – 69, doi.org/10.1016/S0022-3999(02)00542-1

Sateia, M.J. & Thorpy, M.J. (2017). Classification of sleep disorders, in Kryger, M, Roth, T, & Dement, W.C. (Eds.), (2017). Principles and Practice of Sleep Medicine sixth edition, Philadelphia: Elsevier, Inc.