Daytime Sleepiness – Finding the Cause
Do you feel tired all the time no matter
how much sleep you get?
Daytime sleepiness has a significant impact on quality of life. People with daytime sleepiness struggle with social, academic and work demands,they are at risk of motor vehicle and workplace
accidents and generally have poorer health than comparable adults.
Accurate diagnosis is important, not only because of the negative impacts of sleepiness and its root causes on health
and social function but because excessive sleepiness is generally remediable with appropriate treatment . The list of possible causes of excessive daytime sleepiness spans virtually every major area of medicine, neurology and psychiatry. A clear, detailed history is invaluable in negotiating these numerous diagnostic considerations .
To assist patients and doctors when considering the cause of daytime sleepiness we have compiled a list of known causes and routine tests. Please note: there are numerous possible causes, this is by no means a complete list. It is only intended as a guide to assist you and your doctor find the cause of your excessive daytime sleepiness.
Behavioural sleep deprivation The most common cause of daytime sleepiness is insufficient sleep/poor sleep hygiene. Sleep-related breathing disorders
Sleep apnea. Residual sleepiness in treated obstructive sleep apnea. Upper Airway Resistance Syndrome.
Other sleep disorders
Includes circadian rhythm sleep disorders (Delayed Sleep Phase Syndrome, shift work disorder), REM Sleep Behaviour Disorder and other Parasomnias, Post-traumatic hypersomnia (following head trauma or illness) Insomnia, Narcolepsy. Also sleep-related movement disorders (Periodic Limb Movement Disorder, Restless Legs Syndrome).
Mental health conditions Including Depression, Anxiety, Bipolar Disorder.
Includes prescription, non-prescription, and drugs of abuse. *refer to list of medications below.
Including head trauma, stroke, cancer, inflammatory conditions, encephalitis, neurodegenerative conditions (eg: Parkinson Disease, myotonic dystrophy etc), Chronic Fatigue Syndrome, Fibromyalgia, Hypothyroidism (Hashimotos), Ehlers-Danlos Syndrome, Arnold-Chiari Malformation, Multiple Sclerosis. Other medical conditions that are associated with sleep fragmentation can result in daytime sleepiness, including: arthritis, spondylosis, chronic pain of any nature, nocturnal angina, epilepsy, asthma, chronic obstructive pulmonary disease, alcoholism, urinary dysfunction and gastrointestinal disorders (e.g. peptic ulcer disease), gastro-oesophageal refux and irritable bowel syndrome
Hypersomnia that develops after a viral infection including mononucleosis (glandular fever/mono), or Guillain-Barre syndrome. Patients may experience fatigue and hypersomnolence and can sleep most of the 24-hour day. The outcome tends to be favourable; however, the resolution may take months or even years .
Long sleepers, also called "healthy hypersomniacs," are people who require more sleep at night than normal. They may be misdiagnosed with idiopathic hypersomnia because of extremely long sleep episodes at night. These subjects are normally alert, however, once they have obtained their required amount of sleep .
Medication Classes Commonly Associated with Daytime Sleepiness
Alpha-adrenergic blocking agents
Anticonvulsants (e.g., hydantoins, succinimides)
Antidepressants (monoamine oxidase inhibitors, tricyclics, selective serotonin reuptake inhibitors)
Antimuscarinics and antispasmodics
Benzodiazepines, other γ-aminobutyric acid affecting agents, and other anxiolytics
Beta-adrenergic blocking agents
Genitourinary smooth muscle relaxants
Opiate agonists and partial opiate agonists
Skeletal muscle relaxants
Routine tests to consider for causes of daytime sleepiness
Thyroid tests should include: TSH, Free T3 (FT3), Free T4 (FT4), Reverse T3 (rT3), and thyroid antibodies for Hashimoto's Thyroiditis
Nutrient deficiencies including vitamin D (25-Hydroxy), B12 and serum folate, magnesium, zinc, iodine and selenium
Iron studies: Iron, TIBC, %Sat, Ferritin
Carnitine panel: free, total, esterified, esterified/free
Complete Blood Count
Complete Metabolic Panel (glucose, sodium, creatinine, etc)
Cortisol (preferably 8 am spot cortisol or 24-hr urinary cortisol)
Excessive daytime sleepiness affects at least 20% of the population and identifying the underlying cause can often prove difficult. While it may be tempting for a doctor to diagnose Idiopathic Hypersomnia in cases of excessive daytime sleepiness of unknown cause this does a gross disservice to the many patients that in fact do not meet the clinical definition of Idiopathic Hypersomnia.
Idiopathic Hypersomnia is a neurological disorder diagnosed by identifying key clinical features and by a thorough exclusion process. Unfortunately, a lack of awareness and proper understanding of what these key clinical features are and a less than thorough exclusion process results in misdiagnosis and unnecessary prescription of stimulant medications. It also results in the underlying cause remaining unidentified and untreated.
"Idiopathic hypersomnia is probably one of the most frequently overdiagnosed sleep disorders because there is a tendency to classify in this category all hypersomnias that do not fit the criteria of either narcolepsy or the sleep apnea syndrome. Indeed, the difficulty does not stem from disorders of excessive daytime sleepiness, such as narcolepsy or the obstructive sleep apnea syndrome, which are identified easily by their clinical and polysomnographic features; instead, it comes from other disorders associated with excessive daytime sleepiness that require more sophisticated investigation or that still are delineated insufficiently both clinically and polysomnographically.”– Professor Michel Billiard 5
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1, 2. http://brain.oxfordjournals.org/content/124/8/1482.long 3, 4, 5. http://www.beatcfsandfms.org/references/IdiopathicHypersomnia.html First published on Hypersomnolence Australia's website in July 2015