Approach to the patient with excessive daytime sleepiness
- Ronald D Chervin, MD, MS
Ronald D Chervin, MD, MS
- Editor-in-Chief — Sleep Medicine
- Section Editor — Pediatric Sleep Medicine
- Professor of Neurology
- University of Michigan
Patients with excessive daytime sleepiness (EDS) have impaired function due to difficulty maintaining wakefulness or alertness at appropriate times during the day. Complaints of EDS, or related terms such as tiredness, fatigue, and lack of energy, constitute some of the most common issues presented to clinicians. EDS is important to recognize because it can signal an undiagnosed sleep disorder or other treatable conditions. In addition, EDS can have a negative impact on a broad range of activities and raise safety risks while driving or operating other machinery.
This topic provides a general overview of the epidemiology, etiology, clinical features, and diagnosis of disorders that cause excessive daytime sleepiness. Classification of sleep disorders, sleep deprivation, and quantification of sleepiness are discussed separately. (See "Classification of sleep disorders" and "Sleep insufficiency: Definition, consequences, and management" and "Quantifying sleepiness".)
Excessive daytime sleepiness — Daytime sleepiness is defined as excessive when it causes a subjective complaint or interferes with function. The American Academy of Sleep Medicine defines EDS as the inability to maintain wakefulness and alertness during the major waking episodes of the day, with sleep occurring unintentionally or at inappropriate times almost daily for at least three months .
Hypersomnia — The term hypersomnia encompasses excessive sleepiness but can also refer to excessive time spent asleep. The label "hypersomnias" refers to a group of specific sleep disorders. (See 'Central disorders of hypersomnolence' below.)
Fatigue — Fatigue refers to a subjective lack of physical or mental energy. Clinical fatigue incorporates three components, present to variable degrees in individual patients: inability to initiate activity (perception of generalized weakness, in the absence of objective findings); reduced capacity to maintain activity (easy fatigability); and difficulty with concentration, memory, and emotional stability (mental fatigue) . (See "Approach to the adult patient with fatigue".)
- International Classification of Sleep Disorders, 3rd ed, American Academy of Sleep Medicine, Darien, IL 2014.
- Markowitz AJ, Rabow MW. Palliative management of fatigue at the close of life: "it feels like my body is just worn out". JAMA 2007; 298:217.
- Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest 2000; 118:372.
- Chotinaiwattarakul W, O'Brien LM, Fan L, Chervin RD. Fatigue, tiredness, and lack of energy improve with treatment for OSA. J Clin Sleep Med 2009; 5:222.
- Young TB. Epidemiology of daytime sleepiness: definitions, symptomatology, and prevalence. J Clin Psychiatry 2004; 65 Suppl 16:12.
- Hublin C, Kaprio J, Partinen M, et al. Daytime sleepiness in an adult, Finnish population. J Intern Med 1996; 239:417.
- Baldwin CM, Kapur VK, Holberg CJ, et al. Associations between gender and measures of daytime somnolence in the Sleep Heart Health Study. Sleep 2004; 27:305.
- Hara C, Lopes Rocha F, Lima-Costa MF. Prevalence of excessive daytime sleepiness and associated factors in a Brazilian community: the Bambuí study. Sleep Med 2004; 5:31.
- Chesson AL Jr, Ferber RA, Fry JM, et al. The indications for polysomnography and related procedures. Sleep 1997; 20:423.
- Chervin RD. Use of clinical tools and tests in sleep medicine. In: Principles and Practice of Sleep Medicine, Kryger MH, Roth T, Dement WC. (Eds), Elsevier Saunders, St Louis 2011. p.666.
- Bodkin CL, Manchanda S. Office evaluation of the "tired" or "sleepy" patient. Semin Neurol 2011; 31:42.
- Carney CE, Buysse DJ, Ancoli-Israel S, et al. The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep 2012; 35:287.
- Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep 1991; 14:540.
- Richardson GS, Carskadon MA, Flagg W, et al. Excessive daytime sleepiness in man: multiple sleep latency measurement in narcoleptic and control subjects. Electroencephalogr Clin Neurophysiol 1978; 45:621.
- Littner MR, Kushida C, Wise M, et al. Practice parameters for clinical use of the multiple sleep latency test and the maintenance of wakefulness test. Sleep 2005; 28:113.
- Excessive daytime sleepiness
- Insufficient sleep
- Sleep disorders
- Central disorders of hypersomnolence
- Medical disorders
- Psychiatric disorders
- Medications and substance abuse
- INITIAL EVALUATION
- Physical examination
- Epworth Sleepiness Scale
- ADDITIONAL TESTING
- Home sleep apnea testing
- Multiple sleep latency test
- WHEN TO REFER TO A SLEEP MEDICINE PHYSICIAN
- SAFETY CONSIDERATIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS