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Saturday, August 23, 2025

Excessive daytime sleepiness (hypersomnia)


Introduction

Excessive daytime sleepiness (EDS), also known as hypersomnia, refers to a persistent inability to stay awake and alert during the day, leading to unintended lapses into drowsiness or sleep. Unlike fatigue (a feeling of low energy), hypersomnia specifically reflects a pathologic drive to sleep.

It is a major public health problem, affecting up to 10–20% of the population at some point, and is associated with impaired productivity, reduced quality of life, and increased risk of motor vehicle accidents and occupational injuries.

Physiology of Wakefulness and Sleep Regulation

  • Wakefulness and sleep are regulated by a balance of circadian rhythm (suprachiasmatic nucleus, melatonin release) and homeostatic sleep drive (adenosine accumulation).

  • Key neurotransmitters promoting wakefulness: dopamine, norepinephrine, histamine, orexin (hypocretin).

  • Disruption of these pathways leads to hypersomnia.

Causes of Excessive Daytime Sleepiness

1. Sleep Deprivation (Most Common)

  • Lifestyle-related: insufficient sleep (<6–7 hours per night).

  • Shift work disorder.

2. Sleep Disorders

  • Obstructive sleep apnea (OSA): Intermittent airway collapse during sleep → fragmented sleep.

  • Narcolepsy: Autoimmune loss of orexin-producing neurons in hypothalamus.

  • Idiopathic hypersomnia: Excessive sleep not explained by other disorders.

  • Restless legs syndrome/Periodic limb movement disorder.

  • Circadian rhythm disorders.

3. Medical/Neurological Causes

  • Parkinson’s disease, multiple sclerosis, traumatic brain injury.

  • Post-infectious hypersomnia (encephalitis, viral illness).

  • Endocrine disorders (hypothyroidism, diabetes).

4. Psychiatric Causes

  • Depression, anxiety, bipolar disorder.

5. Medications/Substances

  • Sedatives (benzodiazepines, opioids, antihistamines).

  • Alcohol, cannabis.

  • Withdrawal from stimulants.

6. Rare Causes

  • Tumors affecting hypothalamus.

  • Genetic syndromes (Kleine–Levin syndrome).

Clinical Features

  • Persistent sleepiness during the day, despite adequate opportunity for sleep.

  • Unintentional dozing, especially in quiet environments (meetings, reading, watching TV).

  • Poor concentration, memory impairment.

  • Irritability, depression.

  • Risk of accidents (falling asleep while driving).

Associated features depending on cause:

  • Loud snoring, witnessed apneas → OSA.

  • Cataplexy (sudden muscle weakness triggered by emotion) → narcolepsy.

  • Prolonged night sleep, difficulty waking → idiopathic hypersomnia.

Differential Diagnosis

  • Sleep deprivation vs. pathologic hypersomnia.

  • Depression-related fatigue.

  • Medication-induced drowsiness.

  • Neurological vs. psychiatric causes.

Diagnostic Evaluation

1. Clinical History

  • Sleep schedule, sleep hygiene, occupational/lifestyle factors.

  • Snoring, witnessed apneas, nocturnal choking.

  • Cataplexy, sleep paralysis, hallucinations.

  • Drug/alcohol use, medication history.

2. Physical Examination

  • BMI, neck circumference (OSA risk).

  • Neurological exam.

  • Psychiatric assessment.

3. Sleep Studies

  • Polysomnography (PSG): Gold standard for OSA and other sleep disorders.

  • Multiple Sleep Latency Test (MSLT): Measures tendency to fall asleep; diagnostic for narcolepsy.

4. Laboratory Tests

  • Thyroid function tests.

  • CBC, glucose, electrolytes.

  • Consider MRI brain if tumor/structural lesion suspected.

Management and Treatment

Treatment depends on the underlying cause.

A. General Lifestyle and Sleep Hygiene

  • Ensure 7–9 hours of quality sleep nightly.

  • Maintain regular sleep–wake schedule.

  • Limit caffeine, alcohol, sedatives.

  • Optimize sleep environment (quiet, dark, cool).

B. Obstructive Sleep Apnea (OSA)

  • Continuous Positive Airway Pressure (CPAP): Gold standard.

  • Weight loss, avoidance of alcohol/sedatives.

  • Oral appliances, surgery in selected cases.

Medications (for residual sleepiness in treated OSA):

  • Modafinil: 200 mg orally each morning (max 400 mg/day).

  • Armodafinil: 150–250 mg orally each morning.

  • Solriamfetol: 75–150 mg orally once daily.

C. Narcolepsy

  • Stimulants:

    • Modafinil: 200 mg orally in the morning.

    • Methylphenidate: 10–20 mg orally two to three times daily (max 60 mg/day).

    • Amphetamine salts: 10–30 mg orally daily, divided doses.

  • Cataplexy management:

    • Sodium oxybate: 4.5–9 g orally at night in divided doses.

    • Venlafaxine (SNRI): 75–150 mg orally daily.

    • Fluoxetine (SSRI): 20–40 mg orally daily.

D. Idiopathic Hypersomnia

  • Modafinil 200–400 mg orally daily.

  • Methylphenidate or amphetamine derivatives if refractory.

E. Depression or Psychiatric Disorders

  • Treat underlying condition:

    • SSRIs (e.g., Sertraline 50–100 mg orally daily).

    • Cognitive-behavioral therapy (CBT).

  • Avoid sedating medications when possible.

F. Endocrine/Neurological Disorders

  • Hypothyroidism: Levothyroxine replacement (start 25–50 mcg orally daily, titrate).

  • Parkinson’s disease: Dopaminergic therapy may reduce hypersomnia but sometimes worsens it (monitor).

  • Address metabolic derangements (glucose, electrolytes).

G. Medication- or Substance-Induced Sleepiness

  • Review current medications.

  • Switch or taper sedating agents (benzodiazepines, opioids, antihistamines).

  • Counsel regarding alcohol/cannabis impact.

Complications

  • Impaired academic/work performance.

  • Accidents (road traffic, workplace).

  • Relationship/psychological difficulties.

  • Long-term untreated OSA: cardiovascular disease, stroke, cognitive decline.

Prognosis

  • Sleep deprivation: Excellent, resolves with improved sleep hygiene.

  • OSA: Very good with CPAP adherence.

  • Narcolepsy/idiopathic hypersomnia: Lifelong, managed with stimulants and lifestyle adaptation.

  • Psychiatric/endocrine causes: Prognosis depends on underlying condition.

Patient Education

  • Differentiate between fatigue and true sleepiness.

  • Maintain regular sleep schedule.

  • Avoid drowsy driving.

  • Adherence to CPAP (if OSA) dramatically improves outcomes.

  • Medication compliance and monitoring for side effects.




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