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Evaluation of the Sleepy Patient (Pdf 762KB) CLINICAL Evaluation of the sleepy patient Mohammad Torabi Nami respondents reported their primary physician had Background never asked how well they slept.2 Inefficient sleep leading to excessive daytime sleepiness is a common complaint In a comprehensive survey, 16% of encountered by GPs and sleep physicians. Common causes of excessive daytime respondents reported sleeping too much (primary sleepiness include circadian rhythm disorder/shiftwork, sleep apnoea syndrome, hypersomnia), 30% showed sleepy behaviours all psychiatric disorders, restless leg syndrome, medication effect, narcolepsy and day, 15% had night time awakenings followed by idiopathic hypersomnia. EDS and 2.5% experienced problems with work.3 Objective Excessive daytime sleepiness caused by This short review discusses the available objective and subjective testing measures chronic sleep deprivation has been implicated in in office evaluation of sleepy patients, predominantly in the primary care setting. major catastrophes, including the Exxon Valdez oil Discussion spill and the space shuttle Challenger explosion.4 Beyond affecting patients’ quality of life, mood and functionality, excessive Sleep apnoea, chronic insomnia and sleepiness can become a public health concern when affecting critical job holders. parasomnias may affect cardiovascular, Therefore, a clear understanding of its importance and applying current standards neurological and psychiatric status of sufferers, in evaluating patients with such a complaint are of great necessity. Apart from the leading to increased morbidity and even mortality clinical assessments, including a thorough history taking and physical examination, in severely afflicted patients.5 measures to assess sleepiness and ability to maintain wakefulness are available. Excessive daytime sleepiness is not only a Keywords personal health issue but also a public safety disorders of excessive somnolence; sleep apnoea syndromes; general practice concern, meaning that it is important to be able to accurately screen and identify EDS and provide proper treatment. Common causes of EDS include sleep Daytime sleepiness is defined as the related breathing disorder, insufficient sleep ‘inability to stay awake and alert during time, circadian rhythm disorder and shiftwork, the major waking episodes of the day, psychiatric disorders, restless leg syndrome, resulting in unintended lapses into medication effect, narcolepsy, idiopathic drowsiness or sleep’.1 Sleepiness may hypersomnia (with or without long sleep time) vary in severity and is more likely to occur and various related medical conditions.6,7 in boring, monotonous situations that In comparison with narcolepsy, which is require no active participation. characterised by an abnormal propensity to fall asleep, idiopathic hypersomnia with long sleep Excessive daytime sleepiness (EDS) is a common time can be viewed as an inability to terminate presentation to general practitioners and sleep sleep. Idiopathic hypersomnia without long physicians. Excessive daytime sleepiness can sleep time could belong to the spectrum of adversely affect quality of life and also impair narcolepsy. mood, personal relationships and functional status. Although a common presentation, EDS Clinical evaluation may be under recognised. In the 2000 Sleep History taking Foundation Gallup Survey conducted in the United States, 20% of respondents reported that daytime The most important step in evaluating EDS is a sleepiness interfered with their daily activities, detailed history from the patient and their family 8% fell asleep at work and 19% made errors members. Snoring, witnessed apnoea, excessive at work because of sleepiness, yet 61% of the sweating, gasp arousals, nocturia and choking Reprinted fom AUSTRALIAN FAMILY PHYSICIAN VOL. 41, NO. 10, OCTOBER 2012 787 CLINICAL Evaluation of the sleepy patient or coughing while asleep are suggestive of sleep In patients with idiopathic hypersomnia, naps high chance of dozing). A total score of 11 or more is related breathing disorder. are not refreshing; whereas in narcoleptics, short suggestive of EDS. The history should include total sleep time naps can be effective. Being subjective, this instrument has a wide during the week days and ‘catching up on sleep’ margin of error and patients’ motivation should Physical examination on weekends. The use of the snooze function on be considered when analysing the results: for alarm clocks can be indicative of sleep inertia The physical examination of a patient should example, is the patient trying to get their driver’s and insufficient sleep. include measurement of body mass index and licence reinstated? Patients who do shiftwork and those who neck circumference. Examine the oral cavity for While the ESS may not correlate well with frequently travel in different time zones (jet tongue size and note the presence of a narrow objective measurements, it is still widely used and lag effect) experience sleepiness as a normal arched palate, tonsillar hypertrophy, retrognathia, has proven to be an effective screening tool.11 physiological response to the time of day. Many micrognathia and crowded oral pharynx. Nasal Note that ESS results do not always accurately shiftworkers develop chronic partial sleep septum deviation, allergies, swollen turbinates reflect severity of the underlying condition and restriction and may experience somnolence and nasal polyps are risk factors for sleep related should be followed up with objective tests.12 even when they are on a daytime schedule. breathing disorder. The Mallampati classification Stanford Sleepiness Scale Consider the patient’s work schedule, including is very helpful in evaluating airway size.8 It has working hours per day and fixed versus rotating been shown that a high Mallampati score and While the Epworth Sleepiness Scale measures schedules. If they have a rotating schedule, nasal obstruction are risk factors for obstructive overall propensity to fall asleep during various ascertain whether the rotations are weekly or sleep apnoea (Figure 1).9,10 mundane activities, the Stanford Sleepiness monthly, and forward versus backward. Scale measures the current state of sleepiness. It A long commute to work can significantly Measures of sleepiness consists of the following seven statements: shorten sleep duration and can cause chronic It is very hard to quantify sleepiness, either • Feeling active, vital, alert or wide awake partial sleep deprivation. The use of tactics subjectively or objectively, however some • Functioning at high levels, but not at peaks; able while driving to stay awake, such as rolling the methods have been developed to attempt to to concentrate windows down, playing loud music, snacking and determine the severity of a patient’s sleepiness. • Awake, but relaxed; responsive but not fully even slapping oneself, are all indicative of EDS. Another limiting factor is the fact that sleepiness alert Restless leg syndrome can be diagnosed is not well defined. It is difficult to differentiate • Somewhat foggy, let down by the history alone. Restless leg syndrome is chronic fatigue from excessive sleepiness. There • Foggy; losing interest in remaining awake; characterised by disagreeable leg sensations that are some subjective and objective assessments of slowed down usually occur before sleep onset, an irresistible propensity to fall asleep or ability to stay awake. • Sleepy, woozy, fighting sleep; prefer to lie down urge to move the limbs, and partial or complete • No longer fighting sleep, sleep onset soon; Subjective relief from discomfort upon leg movements. having dream-like thoughts.13 These symptoms can lead to significantly reduced Epworth Sleepiness Scale The patient chooses the statement that most sleep time, leading to daytime sleepiness. accurately describes their current state of Adverse effects of many medications can First described by Johns in 1991, the Epworth sleepiness. The advantage of the Stanford also result in EDS. Such medications include Sleepiness Scale (ESS) is one of the most Sleepiness Scale is that it can be administered analgesics, antidepressants, benzodiazepines, frequently used tools to assess sleepiness.11 The multiple times during the day; however the antipsychotics and beta-blockers. In addition, questionnaire describes eight situations: disadvantage is that it cannot differentiate common over-the-counter drugs such as • sitting and reading between acute sleep deprivation and an underlying antihistamines can have the same effect. The • watching television sleep disorder. current or past use of recreational drugs, including • sitting inactive in a public place Karolinska Sleepiness Scale alcohol, should be discussed. Sudden withdrawal • as a passenger in a car riding for an hour from stimulants such as cocaine or amphetamines without a break Another instrument, which is very similar to the can also cause significant sleepiness. • lying down to rest in the afternoon when Stanford Sleepiness Scale, is the Karolinska Ask about sleep paralysis, cataplexy, circumstances permit Sleepiness Scale. This questionnaire requires hypnogogic hallucinations and sleep attacks • sitting and talking with someone the patient to choose one statement that best (irresistible desire to sleep). In addition, • sitting quietly after lunch without alcohol describes his or her current state of alertness. the history should include asking about the • being in a car while stopped for a few minutes The detrimental states of alertness are classified irresistible need for
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