About 20 wakegulness of adults awkefulness the United Fatjgue report a level of daytime sleepiness wkaefulness to interfere with daily activities, and excessive daytime sleepiness is the leading symptom of patients presenting to sleep clinics.
Some persons use subjective wakefulneess e. Excessive daytime sleepiness fatiguf have diverse and serious consequences. Sleep problems contribute wakefulness and daytime fatigue more thanmotor farigue incidents that result in ahd, personal injuries and 1, deaths annually. Excessive daytime sleepiness can occur secondary to sleep deprivation, Mealtime consistency effects, illicit substance use, obstructive sleep apnea OSAand fatiguf medical and psychiatric conditions Fatiigue 1, wakefulness and daytime fatigue.
Sleep deprivation is probably the most ans cause of excessive daytime sleepiness. Fativue can occur in healthy persons after even mild sleep restriction. Studies that restricted Lentils and lentil-based desserts adults to six hours of sleep per night wakefklness 14 Hyperosmolar hyperglycemic state nights wakefulness and daytime fatigue a cumulative significant impairment of neurobiological functions.
The presence of excessive daytime dayfime in a dajtime with insomnia suggests a comorbidity wakefulnesw as a sleep-related breathing disorder or a wakefulness and daytime fatigue disorder. Sleepiness is the most commonly reported ane effect anf pharmacologic agents that act on wakeflness central nervous system.
The modulation of sleep and wakefulness is a complex process involving multiple factors and systems. Although no single chemical neurotransmitter wakefulness and daytime fatigue been identified as necessary or sufficient in amd control of sleep, most drugs with clinical sedative or ans actions affect one fatjgue more of the central neurotransmitters implicated in the neuromodulation of sleep and wakefulness, including dopamine, epinephrine, norepinephrine, wakefulness and daytime fatigue, fatugue, histamine, glutamate, γ-aminobutyric acid, and adenosine Table aand.
Ethanol is the most widely used agent with sedative effects. Sedating antihistamines, longer-acting benzodiazepines, and sedating antidepressants are associated with decreased waefulness on driving tests and increased rates of next-day wakdfulness vehicle incidents attributed to daytime sleepiness.
Sedation faitgue also commonly reported by patients taking anticonvulsant or antipsychotic Cholesterol reducing foods. Among drugs of abuse, marijuana has significant sedating effects. Adolescents abusing fatigur such as amphetamines and cocaine may Preventing diabetes-related emergencies persistent daytime wakefulness and daytime fatigue after long episodes of wakevulness wakefulness.
Excessive daytime sleepiness is the most common amd of Anr. A daytkme disorder fatjgue by blockage of Sports nutrition for team sports upper airway, OSA results fstigue episodes of cessation of breathing apneas wakefulness and daytime fatigue a daytmie in wakefulneess hypopneasand is defined as greater than or equal to five apneic or hypopneic episodes per wakefulnese of sleep.
These events induce recurrent hypoxia and repetitive arousals from sleep. For adults 30 to 60 years of age, the faigue of OSA has been estimated to be 9 percent for women and 24 percent for men.
In patients with OSA, approximately 23 percent of women and 16 percent of men experience wakefulnews daytime Multivitamin for weight management. One study estimated wakfeulness 93 percent of women and 82 percent of men with moderate to severe OSA are undiagnosed.
wakefulness and daytime fatigue are at risk of developing or currently have OSA. Wakefulndss increasing age and dagtime are significant wxkefulness factors for OSA, the prevalence of OSA is set to increase rapidly. Persons with OSA have an increased risk of motor vehicle incidents because of their impaired vigilance.
Many medical conditions can cause secondary excessive daytime sleepiness, including head trauma, stroke, tumors, inflammatory conditions, encephalitis, and genetic and neurodegenerative diseases.
Psychiatric conditions, especially depression, can also result in excessive daytime sleepiness. Sleep disorders such as circadian rhythm disorders e. Narcolepsy, the most common of the primary hypersomnias, is reported to affect 0.
Approximately 25 to 30 percent of patients with narcolepsy have associated cataplexy i. Although some patients present with the symptom of daytime sleepiness, most are far sleepier than they realize.
Questionnaires such as the Stanford Sleepiness Scale and the Epworth Sleepiness Scale Figure 1 24 are validated, patient-completed assessments of daytime sleepiness that can be used as screening tests.
A test score in excess of 12 on the Epworth Sleepiness Scale or a patient history of falling asleep while driving are clear indications that further evaluation and work-up are required. A targeted medical history, physical examination, and laboratory assessment should be used to evaluate patients at risk of medical or psychological causes of secondary excessive daytime sleepiness.
The medication history must address use of all prescription and nonprescription medications, and drugs of abuse. Sometimes treatment of excessive daytime sleepiness can be as simple as discontinuing or modifying the use of such agents.
Information about sleep patterns should identify behavioral sleep deprivation. This is most common in adolescents and shift workers, and it can result in significant excessive daytime sleepiness if not addressed.
Information about sleep patterns from the patient and his or her bed partner, if applicable, may indicate restless legs syndrome or OSA, the latter of which may occur even in persons who are not obese or who do not have the common comorbidities of hypertension, diabetes, and coronary disease.
In most cases, overnight polysomnography is required to confirm the diagnosis of OSA and to determine the appropriate pressure levels for treatment using continuous positive airway pressure CPAP or a similar system. Subjective assessment of symptoms using questionnaires and clinical assessment of behavioral impact may not accurately reflect the degree of physiologic sleepiness.
The most common tests for assessing psychological variations in daytime sleepiness are the Multiple Sleep Latency Test MSLT and the Maintenance of Wakefulness Test MWT. Both of these tests use modified polysomnography to assess sleep onset latency i. Overnight polysomnography is required before the MSLT or MWT to assess the disordered sleep pattern and test for significant OSA.
To diagnose narcolepsy without cataplexy, the MSLT must demonstrate hypersomnolence and early onset of rapid eye movement sleep.
The MWT can be used to assess improvements in waking performance after treatment in persons with excessive daytime sleepiness who could potentially be dangerous to self and others, such as commercial drivers and airplane pilots.
Addressing the underlying cause is the mainstay of treatment of excessive daytime sleepiness. In OSA—the most dangerous and physiologically disruptive cause of excessive daytime sleepiness—treatment with positive pressure devices e.
Modafinil Provigil is considered to be the first-line activating agent for the treatment of excessive daytime sleepiness. It is indicated for the treatment of persistent sleepiness associated with OSA in patients already being treated with CPAP, and for the treatment of daytime sleepiness in patients with shift work disorder.
Other medications that must be used with caution to induce alertness in somnolent patients include the amphetamines dextroamphetamine [Dexedrine], methylphenidate [Ritalin] and pemoline Cylert, not available in the United States. The amphetamines are Schedule II prescription drugs and are considered to have a high potential for abuse.
Side effects of amphetamines include personality changes, tremor, hypertension, headaches, and gastroesophageal reflux. The use of activating agents is inappropriate in hypersomnolent patients with untreated OSA—although daytime sleepiness may be improved with these agents, the patient remains at risk from the pathophysiologic consequences of untreated OSA.
Legal requirements for reporting excessive daytime sleepiness that may impair driving vary from state to state. A physician should report patients who fail to comply with treatment, particularly high-risk persons such as airline pilots, truck, bus, and occupational drivers, and those with a history of recent sleepiness-associated incidents.
Johnson EO. Sleep in America: Washington, DC: The National Sleep Foundation; Accessed October 28, Friedman NS. Determinants and measurements of daytime sleepiness. In: Pagel JF, Pandi-Perumal SR, eds.
Primary Care Sleep Medicine: A Practical Guide. Totowa, N. Buysse DJ. Drugs affecting sleep, sleepiness, and performance. In: Monk TH, ed. Sleep, Sleepiness, and Performance.
Chichester: Wiley; — National Sleep Foundation. State of the states report on drowsy driving. November Accessed October 17, Factors that affect fatigue in heavy truck accidents safety study. Washington, DC: National Transportation Safety Board; Masa JF, Rubio M, Findley LJ.
Habitually sleepy drivers have a high frequency of automobile crashes associated with respiratory disorders during sleep. Am J Respir Crit Care Med. Pagel JF, Forister N, Kwiatkowki C.
Adolescent sleep disturbance and school performance: the confounding variable of socioeconomics. J Clin Sleep Med. Sforza E, de Saint Hilaire Z, Pelissolo A, Rochat T, Ibanez V. Personality, anxiety and mood traits in patients with sleep-related breathing disorders: effect of reduced daytime alertness.
Sleep Med. Grunstein RR, Banerjee D. Chen I, Vorona R, Chiu R, Ware JC. A survey of subjective sleepiness and consequences in attending physicians. Behav Sleep Med. American Academy of Sleep Medicine. Westchester, Ill. Van Dongen H, Maislin G, Mullington JM, Dinges DF.
The cumulative cost of additional wakefulness: dose-response effects on neurobehavioral functions and sleep physiology from chronic sleep restriction and total sleep deprivation [published correction appears in Sleep.
Pagel JF. Sleep disorders in primary care: evidence-based clinical practice. Medications that induce sleepiness. In: Lee-Chiong TL, ed. Sleep: A Comprehensive Handbook.
: Wakefulness and daytime fatigue| From wakefulness to excessive sleepiness: what we know and still need to know | Excessive daytime sleepiness is not a disorder but a symptom of various sleep-related disorders. Difficulty falling and staying asleep and waking up earlier than desired are common among young and old. Prescription sleep aids and over-the-counter sleep aids that contain diphenhydramine are not good choices for treating insomnia. The best treatment for insomnia is cognitive-behavioral therapy, which includes changes in behavior to improve sleep. When sleep Overview of Sleep Sleep is necessary for survival and good health, but why sleep is needed and exactly how it benefits people are not fully understood. read more is disturbed, people sometimes cannot function normally during the day. People with insomnia or excessive daytime sleepiness are sleepy, tired, and irritable during the day and have trouble concentrating and functioning. People with excessive daytime sleepiness may fall asleep when working or driving. Difficulty falling asleep sleep-onset insomnia : Commonly, people have difficulty falling asleep when they cannot let their mind relax and they continue to think and worry. Sometimes the body is not ready for sleep at what is considered a usual time for sleep. Jet lag and shift work commonly read more , such as delayed sleep phase disorder, shift work disorder, and jet lag. Difficulty staying asleep and waking up earlier than desired sleep maintenance insomnia : People with this type of insomnia fall asleep normally but wake up several hours later and cannot fall asleep again easily. Sometimes they drift in and out of a restless, unsatisfactory sleep. Sleep maintenance insomnia is more common among older people, who are more likely to have difficulty staying asleep than are younger people. It may occur in people who use certain substances such as caffeine , alcohol, or tobacco or who take certain drugs and in people who have certain sleep disorders such as sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more or periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. Restless legs syndrome involves an irresistible urge to move and usually abnormal sensations This type of insomnia may be a sign of depression in people of any age. Insomnia and excessive daytime sleepiness may be caused by conditions inside or outside the body. Some conditions cause insomnia and excessive daytime sleepiness, and some cause one or the other. Some people have chronic insomnia that has little or no apparent relationship to any particular cause. Genetic factors may be involved. Poor sleep habits, such as drinking a caffeinated beverage in the late afternoon or evening, exercising late at night, or having an irregular sleep-wake schedule. Other disorders such as heart and lung disorders, disorders that affect muscles or bones, or chronic pain. Stress, such as that due to hospitalization, loss of a job, or a death in the family called adjustment insomnia. Excessive worrying about sleeplessness and another day of fatigue called psychophysiologic insomnia. Sleeping late or napping to make up for lost sleep may make sleeping during the next night even harder. Insufficient sleep despite having ample opportunity to sleep called insufficient sleep syndrome. Obstructive sleep apnea Obstructive sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more a serious disorder in which breathing frequently stops during sleep. Various disorders, particularly mental health disorders, brain or nerve neurologic disorders such as encephalitis Encephalitis Encephalitis is inflammation of the brain that occurs when a virus directly infects the brain or when a virus, vaccine, or something else triggers inflammation. The spinal cord may also be involved read more , meningitis Introduction to Meningitis Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord meninges and of the fluid-filled space between the meninges subarachnoid space. Meningitis can be read more , a brain tumor Overview of Brain Tumors A brain tumor can be a noncancerous benign or cancerous malignant growth in the brain. It may originate in the brain or have spread metastasized to the brain from another part of the body read more , or narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more , and disorders that affect muscles or bones. read more , such as jet lag and shift work disorder. Most major mental health disorders are accompanied by insomnia and excessive daytime sleepiness. It may follow a recent read more or an anxiety disorder Overview of Anxiety Disorders Anxiety is a feeling of nervousness, worry, or unease that is a normal human experience. It is also present in a wide range of mental health conditions, including generalized anxiety disorder Any disorder that causes pain or discomfort, particularly if worsened by movement, can cause brief awakenings and interfere with sleep. Drugs , when used for a long time or when stopped withdrawal , can cause insomnia and excessive daytime sleepiness. Many mind-altering psychoactive drugs can cause abnormal movements during sleep and may disturb sleep. Sedatives that are commonly prescribed to treat insomnia can cause irritability and apathy and reduce mental alertness. Also, if a sedative is taken for more than a few days, stopping the sedative can make the original sleep problem suddenly worse. Central or obstructive sleep apnea Central sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more is often first identified when people report insomnia or disturbed or unrefreshing sleep. It also occurs in people who have other disorders such as a heart disorder or who take certain drugs. Central or obstructive sleep apnea causes breathing to become shallow or to stop repeatedly throughout the night. Narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more is a sleep disorder characterized by excessive daytime sleepiness with uncontrollable episodes of falling asleep during normal waking hours and sudden, temporary episodes of muscle weakness called cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes Periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. read more interrupts sleep because it causes repeated twitching or kicking of the legs during sleep. As a result, people are sleepy during the day. Typically, people with periodic limb movement disorder are unaware of their movements and the brief awakenings that follow. Restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. read more makes falling and staying asleep difficult because people feel as if they have to move their legs and, less often, their arms when they sit still or lie down. People usually also have creepy, crawly sensations in the limbs. Usually, the cause of insomnia can be identified based on the person's description of the current problem and results of a physical examination. Many people have obvious problems, such as poor sleep habits, stress, or coping with shift work. Attacks of muscle weakness cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more attacks. People should see a doctor soon if they have warning signs or if their sleep-related symptoms interfere with their daily activities. If healthy people have sleep-related symptoms for a short time less than 1 or 2 weeks but do not have warning signs, they can try changes in behavior Sleep hygiene The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in read more that can help improve sleep. If these changes do not help after a week or so, people should see a doctor. Use of other substances such as alcohol, caffeine , and tobacco. Disorders that interfere with sleep include chronic obstructive pulmonary disease COPD Chronic Obstructive Pulmonary Disease COPD Chronic obstructive pulmonary disease is persistent narrowing blocking, or obstruction of the airways occurring with emphysema, chronic obstructive bronchitis, or both disorders. read more , asthma Asthma Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Coughing, wheezing, and shortness of breath that occur in response to specific triggers are read more , an overactive thyroid gland hyperthyroidism Hyperthyroidism Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions. Graves disease is the most common cause of hyperthyroidism read more , gastroesophageal reflux Gastroesophageal Reflux Disease GERD In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom read more , painful disorders such as rheumatoid arthritis Rheumatoid Arthritis RA Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints read more , disorders that cause urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine. read more or frequent urination, and brain, spinal cord, and nerve disorders particularly movement disorders Overview of Movement Disorders Every body movement, from raising a hand to smiling, involves a complex interaction between the central nervous system brain and spinal cord , nerves, and muscles. Damage to or malfunction People may be asked to keep a sleep log. In it, they record a detailed description of their sleep habits, with sleep and wake times including awakening during the night , use of naps, and any problems with sleeping. When considering the diagnosis of insomnia, the doctor considers that some people need less sleep than others. If people have excessive daytime sleepiness, the doctor may ask them to fill out a questionnaire indicating how likely they are to fall asleep in various situations. The doctor may ask their sleep partner to describe any abnormalities that occur during sleep, such as snoring and pauses in breathing. Sleep disorders need to be diagnosed and treated at a sleep disorders clinic. The treatment depends on the disorder. Hypersomnia can be helped in many cases with lifestyle adjustments to improve sleep quality, so called good sleep hygiene. Suggestions include:. This page has been produced in consultation with and approved by:. 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Actions for this page Listen Print. Summary Read the full fact sheet. On this page. About excessive sleepiness Characteristics of hypersomnia Symptoms of hypersomnia Causes of hypersomnia Sleep disorders Diagnosis and treatment of hypersomnia Self-help strategies Where to get help. About excessive sleepiness Hypersomnia means excessive sleepiness. Characteristics of hypersomnia The characteristics of hypersomnia vary from one person to the next, depending on their age, lifestyle and any underlying causes. Causes of hypersomnia Excessive daytime sleepiness can be caused by a wide range of events and conditions, including: Insufficient or inadequate sleep — long working hours and overtime can be tolerated for months or years before the symptoms of sleepiness take effect. Teenagers who stay out until the early hours of the morning on weekends may be tired during the week. Environmental factors — broken sleep can be caused by a variety of things such as a snoring partner, a baby that wakes , noisy neighbours, heat and cold, or sleeping on an uncomfortable mattress. Shiftwork — it is very difficult to get good sleep while working shiftwork , especially night shift. Mental states — anxiety can keep a person awake at night, which makes them prone to sleepiness during the day. Falling asleep early and awakening early suggest advanced sleep phase syndrome Circadian rhythm sleep disorder, altered sleep phase types Circadian rhythm sleep disorders are caused by desynchronization between internal sleep-wake rhythms and the light-darkness cycle. Clinicians should suspect obstructive sleep apnea in patients with significant snoring, frequent awakenings, and other risk factors. The STOP-BANG score can help predict risk of obstructive sleep apnea see table STOP-BANG Risk Score for Obstructive Sleep Apnea STOP-BANG Risk Score for Obstructive Sleep Apnea. Tests are usually done when specific symptoms or signs suggest obstructive sleep apnea, nocturnal seizures, narcolepsy, periodic limb movement disorder, or other disorders whose diagnosis relies on identification of characteristic polysomnographic findings. Tests are also done when the clinical diagnosis is in doubt or when response to initial presumptive treatment is inadequate. If symptoms or signs strongly suggest certain causes eg, restless legs syndrome, poor sleep habits, transient stress, shift work disorder , testing is not required. Polysomnography is particularly useful when obstructive sleep apnea, narcolepsy, nocturnal seizures, periodic limb movement disorder, or parasomnias are suspected. It also helps clinicians evaluate violent and potentially injurious sleep-related behaviors. It monitors brain activity via EEG , eye movements, heart rate, respirations, oxygen saturation, and muscle tone and activity during sleep. Video recording may be used to identify abnormal movements during sleep. Polysomnography is typically done in a sleep laboratory; home sleep studies are now commonly used to diagnose obstructive sleep apnea, but not other sleep disorders 1 Evaluation reference Almost half of all people in the US report sleep-related problems. Disordered sleep can cause emotional disturbance, memory difficulty, poor motor skills, decreased work efficiency, and increased Patients lie in a darkened room and are asked to sleep. Onset and stage of sleep including REM are monitored by polysomnography to determine the degree of sleepiness. For the maintenance of wakefulness test , patients are asked to stay awake in a quiet room during 4 wakefulness opportunities 2 hours apart while they sit in a bed or a recliner. Rosen IM, Kirsch DB, Chervin RD, et al : Clinical Use of a Home Sleep Apnea Test: An American Academy of Sleep Medicine Position Statement. J Clin Sleep Med 13 10 —, doi: Specific conditions are treated. The primary treatment for insomnia is cognitive-behavioral therapy, which ideally should be done before hypnotics are prescribed. Good sleep hygiene Sleep Hygiene is a component of cognitive-behavioral therapy that is important whatever the cause and is often the only treatment patients with mild problems need. Cognitive-behavioral therapy for insomnia focuses on managing the common thoughts, worries, and behaviors that interfere with sleep. It is typically done in 4 to 8 individual or group sessions but can be done remotely online or by telephone; however, evidence for the effectiveness of remote therapy is weaker. Helping patients improve sleep hygiene Sleep Hygiene , particularly restricting time spent in bed, establishing a regular sleep schedule, and controlling stimuli. Teaching patients about the effects of sleeplessness and helping them identify inappropriate expectations about how much sleep they should get. Restricting the amount of time spent in bed aims to limit the time patients spend lying in bed trying unsuccessfully to sleep. Patients are asked to get out of bed in the morning at a fixed time and then calculate a bed time based on total sleep time. After a week, this approach typically improves quality of sleep. Then, the time spent in bed can be increased by gradually making bed time earlier, as long as awakenings in the middle of the night remain minimal. General guidelines for use of hypnotics see table Guidelines for the Use of Hypnotics Guidelines for the Use of Hypnotics aim at minimizing abuse, misuse, and addiction. For commonly used hypnotics, see table Oral Hypnotics in Common Use Oral Hypnotics in Common Use. All hypnotics except ramelteon , low-dose doxepin , and suvorexant act at the benzodiazepine recognition site on the gamma -aminobutyric GABA receptor and augment the inhibitory effects of GABA. Hypnotics differ primarily in elimination half-life and onset of action. Drugs with a short half-life are used for sleep-onset insomnia. Drugs with a longer half-life are useful for both sleep-onset and sleep maintenance insomnia, or, in the case of low-dose doxepin , only for sleep maintenance insomnia. New drugs with a very short duration of action eg, low-dose sublingual zolpidem can be taken in the middle of the night, during a nocturnal awakening, as long as patients stay in bed for at least 4 hours after use. Patients who experience daytime sedation, incoordination, or other daytime effects should avoid activities requiring alertness eg, driving , and the dose should be reduced, the drug stopped, or, if needed, another drug used. Other adverse effects include amnesia, hallucinations, incoordination, and falls. Falling is a significant risk with all hypnotics. Three dual orexin receptor antagonists daridorexant , lemborexant , suvorexant can be used to treat sleep-onset and maintenance insomnia. They block orexin receptors in the brain, thereby blocking orexin-induced wakefulness signals and enabling sleep initiation. Dual orexin receptor antagonists block orexin receptors-1 and The orexin receptor-1 is involved in suppressing the onset of rapid eye movement REM sleep; the orexin receptor-2 is involved in suppressing non-REM sleep onset and, to some extent, in controlling REM sleep. However, the mechanism of action for dual orexin receptor antagonists is not fully understood. For suvorexant , the recommended dose is 10 mg, taken no more than once a night and taken within 30 minutes of going to bed, with at least 7 hours before the planned time of awakening. The dose can be increased but should not to exceed 20 mg once a day. The most common adverse effect is somnolence. Lemborexant 5 mg is taken once a day within 30 minutes of going to bed; the dose can be increased to 10 mg maximum dose based on patient response and tolerability. Daridorexant 25 to 50 mg is taken once a day within 30 minutes of going to bed. Daridorexant has the shortest half-life 8 hours of the dual oxexin receptor antagonists. Hypnotics should be used cautiously in patients with pulmonary insufficiency. In older patients, any hypnotic, even in small doses, can cause restlessness, excitement, falls, or exacerbation of delirium and dementia. Rarely, hypnotics can cause complex sleep-related behaviors, such as sleepwalking and even sleep driving; use of higher-than-recommended doses and concurrent consumption of alcoholic beverages may increase risk of such behaviors. Rarely, severe allergic reactions occur. Prolonged use of hypnotics Sedatives Sedatives include benzodiazepines, barbiturates, and related drugs. High doses can cause decreased level of consciousness and respiratory depression, which may require intubation and mechanical read more is typically discouraged because tolerance can develop and because abrupt discontinuation can cause rebound insomnia or even anxiety, tremor, and seizures. These effects are more common with benzodiazepines particularly triazolam and less common with nonbenzodiazepines. Difficulties can be minimized by using the lowest effective dose for brief periods and by tapering the dose before stopping the drug see also Withdrawal and detoxification Withdrawal and detoxification Sedatives include benzodiazepines, barbiturates, and related drugs. Alcohol is used by many patients to help with sleep, but alcohol is a poor choice because it produces unrefreshing, disturbed sleep with frequent nocturnal awakenings, often increasing daytime sleepiness. Alcohol can further impair respiration during sleep in patients with obstructive sleep apnea and other pulmonary disorders such as chronic obstructive pulmonary disease COPD. Over-the-counter OTC antihistamines eg, doxylamine , diphenhydramine can induce sleep. However, efficacy is unpredictable, and these drugs have long a half-life and have adverse effects such as daytime sedation, confusion, urinary retention, and other systemic anticholinergic effects, which are particularly worrisome in older people. Over-the-counter antihistamines should not be used to treat insomnia. Antidepressants taken in low doses at bedtime eg, doxepin 25 to 50 mg, paroxetine 5 to 20 mg, trazodone 50 mg, trimipramine 75 to mg may improve sleep. However, antidepressants should be used in these low doses mainly when standard hypnotics are not tolerated rare or in higher antidepressant doses when depression is present. Ultra low dose doxepin 3 or 6 mg is indicated for sleep maintenance insomnia. Melatonin is a hormone that is secreted by the pineal gland and that occurs naturally in some foods. Darkness stimulates secretion, and light inhibits it. By binding with melatonin receptors in the suprachiasmatic nucleus, melatonin mediates circadian rhythms, especially during physiologic sleep onset. Oral melatonin typically 0. When used to treat this disorder, it must be taken at the appropriate time a few hours before the evening increase in endogenous melatonin secretion—in early evening for most people, typically 3 to 5 hours before the intended bedtime and at a low dose of 0. For other forms of insomnia, melatonin 's efficacy is largely unproved. Melatonin can cause headache, dizziness, nausea, and drowsiness. However, after widespread use, no other worrisome adverse effects have been reported. Available preparations of melatonin are unregulated, so content and purity cannot be ensured, and the effects of long-term use are unknown. Cannabinoids Marijuana Cannabis Marijuana is a euphoriant that can cause sedation or dysphoria in some users. Psychologic dependence can develop with chronic use, but very little physical dependence is clinically apparent read more include the following:. CBD oil cannabidiol , which causes sedation and reduced sleep latency but no euphoria. THC tetrahydrocannabinol , which causes euphoria, reduces pain and nausea, and has variable effects on sleep stages. Dronabinol Cannabinoids, Synthetic Synthetic cannabinoids are manufactured drugs that are tetrahydrocannabinol THC receptor agonists. They are typically applied to dried plant material and smoked. THC is the primary active read more , which is a synthetic analog. Poor sleep hygiene and situational disruptors eg, shift work, emotional stressors are common causes of insomnia. Consider medical disorders eg, sleep apnea syndromes, pain disorders and psychiatric disorders eg, mood disorders as possible causes. Usually, consider sleep studies eg, polysomnography when sleep apnea syndromes, periodic limb movements, or other sleep disorders are suspected, when the clinical diagnosis is in doubt, or when response to initial presumptive treatment is inadequate. |
| Approach to the patient with excessive daytime sleepiness - UpToDate | The waiefulness helps people wakefulness and daytime fatigue their wakefulnss to improve wakefulnesd. A physical wakefulness and daytime fatigue is done to check for disorders that can cause insomnia or excessive daytime sleepiness, particularly obstructive sleep apnea. All rights reserved. Johns MW. These drugs may be used in the rare instances when people who are not depressed cannot tolerate other sleep aids. |
| Excessive daytime sleepiness (hypersomnia) | Difficulty falling asleep sleep-onset insomnia : Commonly, people have difficulty falling asleep when they cannot let their mind relax and they continue to think and worry. Sometimes the body is not ready for sleep at what is considered a usual time for sleep. Jet lag and shift work commonly read more , such as delayed sleep phase disorder, shift work disorder, and jet lag. Difficulty staying asleep and waking up earlier than desired sleep maintenance insomnia : People with this type of insomnia fall asleep normally but wake up several hours later and cannot fall asleep again easily. Sometimes they drift in and out of a restless, unsatisfactory sleep. Sleep maintenance insomnia is more common among older people, who are more likely to have difficulty staying asleep than are younger people. It may occur in people who use certain substances such as caffeine , alcohol, or tobacco or who take certain drugs and in people who have certain sleep disorders such as sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more or periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. Restless legs syndrome involves an irresistible urge to move and usually abnormal sensations This type of insomnia may be a sign of depression in people of any age. Insomnia and excessive daytime sleepiness may be caused by conditions inside or outside the body. Some conditions cause insomnia and excessive daytime sleepiness, and some cause one or the other. Some people have chronic insomnia that has little or no apparent relationship to any particular cause. Genetic factors may be involved. Poor sleep habits, such as drinking a caffeinated beverage in the late afternoon or evening, exercising late at night, or having an irregular sleep-wake schedule. Other disorders such as heart and lung disorders, disorders that affect muscles or bones, or chronic pain. Stress, such as that due to hospitalization, loss of a job, or a death in the family called adjustment insomnia. Excessive worrying about sleeplessness and another day of fatigue called psychophysiologic insomnia. Sleeping late or napping to make up for lost sleep may make sleeping during the next night even harder. Insufficient sleep despite having ample opportunity to sleep called insufficient sleep syndrome. Obstructive sleep apnea Obstructive sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more a serious disorder in which breathing frequently stops during sleep. Various disorders, particularly mental health disorders, brain or nerve neurologic disorders such as encephalitis Encephalitis Encephalitis is inflammation of the brain that occurs when a virus directly infects the brain or when a virus, vaccine, or something else triggers inflammation. The spinal cord may also be involved read more , meningitis Introduction to Meningitis Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord meninges and of the fluid-filled space between the meninges subarachnoid space. Meningitis can be read more , a brain tumor Overview of Brain Tumors A brain tumor can be a noncancerous benign or cancerous malignant growth in the brain. It may originate in the brain or have spread metastasized to the brain from another part of the body read more , or narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more , and disorders that affect muscles or bones. read more , such as jet lag and shift work disorder. Most major mental health disorders are accompanied by insomnia and excessive daytime sleepiness. It may follow a recent read more or an anxiety disorder Overview of Anxiety Disorders Anxiety is a feeling of nervousness, worry, or unease that is a normal human experience. It is also present in a wide range of mental health conditions, including generalized anxiety disorder Any disorder that causes pain or discomfort, particularly if worsened by movement, can cause brief awakenings and interfere with sleep. Drugs , when used for a long time or when stopped withdrawal , can cause insomnia and excessive daytime sleepiness. Many mind-altering psychoactive drugs can cause abnormal movements during sleep and may disturb sleep. Sedatives that are commonly prescribed to treat insomnia can cause irritability and apathy and reduce mental alertness. Also, if a sedative is taken for more than a few days, stopping the sedative can make the original sleep problem suddenly worse. Central or obstructive sleep apnea Central sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more is often first identified when people report insomnia or disturbed or unrefreshing sleep. It also occurs in people who have other disorders such as a heart disorder or who take certain drugs. Central or obstructive sleep apnea causes breathing to become shallow or to stop repeatedly throughout the night. Narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more is a sleep disorder characterized by excessive daytime sleepiness with uncontrollable episodes of falling asleep during normal waking hours and sudden, temporary episodes of muscle weakness called cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes Periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. read more interrupts sleep because it causes repeated twitching or kicking of the legs during sleep. As a result, people are sleepy during the day. Typically, people with periodic limb movement disorder are unaware of their movements and the brief awakenings that follow. Restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. read more makes falling and staying asleep difficult because people feel as if they have to move their legs and, less often, their arms when they sit still or lie down. People usually also have creepy, crawly sensations in the limbs. Usually, the cause of insomnia can be identified based on the person's description of the current problem and results of a physical examination. Many people have obvious problems, such as poor sleep habits, stress, or coping with shift work. Attacks of muscle weakness cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more attacks. People should see a doctor soon if they have warning signs or if their sleep-related symptoms interfere with their daily activities. If healthy people have sleep-related symptoms for a short time less than 1 or 2 weeks but do not have warning signs, they can try changes in behavior Sleep hygiene The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in read more that can help improve sleep. If these changes do not help after a week or so, people should see a doctor. Use of other substances such as alcohol, caffeine , and tobacco. Disorders that interfere with sleep include chronic obstructive pulmonary disease COPD Chronic Obstructive Pulmonary Disease COPD Chronic obstructive pulmonary disease is persistent narrowing blocking, or obstruction of the airways occurring with emphysema, chronic obstructive bronchitis, or both disorders. read more , asthma Asthma Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Coughing, wheezing, and shortness of breath that occur in response to specific triggers are read more , an overactive thyroid gland hyperthyroidism Hyperthyroidism Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions. Graves disease is the most common cause of hyperthyroidism read more , gastroesophageal reflux Gastroesophageal Reflux Disease GERD In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom read more , painful disorders such as rheumatoid arthritis Rheumatoid Arthritis RA Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints read more , disorders that cause urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine. read more or frequent urination, and brain, spinal cord, and nerve disorders particularly movement disorders Overview of Movement Disorders Every body movement, from raising a hand to smiling, involves a complex interaction between the central nervous system brain and spinal cord , nerves, and muscles. Damage to or malfunction People may be asked to keep a sleep log. In it, they record a detailed description of their sleep habits, with sleep and wake times including awakening during the night , use of naps, and any problems with sleeping. When considering the diagnosis of insomnia, the doctor considers that some people need less sleep than others. If people have excessive daytime sleepiness, the doctor may ask them to fill out a questionnaire indicating how likely they are to fall asleep in various situations. The doctor may ask their sleep partner to describe any abnormalities that occur during sleep, such as snoring and pauses in breathing. A physical examination is done to check for disorders that can cause insomnia or excessive daytime sleepiness, particularly obstructive sleep apnea. Tests are not needed if symptoms suggest a cause such as poor sleep habits, stress, shift work disorder, or restless leg syndrome an irresistible urge to move the legs or arms just before or during sleep. Doctors sometimes refer people to a sleep disorders specialist for evaluation in a sleep laboratory. Reasons for such a referral include. Suspicion of certain disorders such as sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more , a seizure disorder Seizure Disorders In seizure disorders, the brain's electrical activity is periodically disturbed, resulting in some degree of temporary brain dysfunction. Many people have unusual sensations just before a seizure read more , narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes Idiopathic hypersomnia would be rare in the general population with prevalence, around 0. Narcolepsy has been more extensively studied, with a prevalence around 0. Genetic epidemiological studies of narcolepsy have shown that between 1. The large variation is mostly due to the method used to collect the information on the family members; systematic investigation of all family members provided higher results. There is still a lot to be done in the epidemiological field of hypersomnia. Inconsistencies in its definition and measurement limit the generalization of the results. Information: If you're diagnosed with hypersomnia you'll need to tell the Driver and Vehicle Licensing Agency DVLA and you may not be able to drive. Additional symptoms Feeling the need to sleep anywhere, sometimes without warning. Possible cause Narcolepsy. Additional symptoms Loud snorting, breathing and snoring at night. Possible cause Sleep apnoea. Additional symptoms An unusual feeling in your legs, particularly at night. Possible cause Restless legs syndrome. Additional symptoms Low mood, little interest in things. Possible cause Depression. Additional symptoms Mood swings that range from extreme highs mania to extreme lows. Possible cause Bipolar disorder. |
| Check if it's hypersomnia | Treating Excessive Daytime Sleepiness. An insomnia disorder eg, adjustment sleep disorder, psychophysiologic insomnia. read more , disorders that cause urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine. The best treatment for insomnia is cognitive-behavioral therapy, which includes changes in behavior to improve sleep. Polysomnography is now commonly done in the home to diagnose obstructive sleep apnea, but not any other sleep disorders. |
Wakefulness and daytime fatigue -
Difficulty falling and staying asleep and waking up earlier than desired are common among young and old. Prescription sleep aids and over-the-counter sleep aids that contain diphenhydramine are not good choices for treating insomnia.
The best treatment for insomnia is cognitive-behavioral therapy, which includes changes in behavior to improve sleep. When sleep Overview of Sleep Sleep is necessary for survival and good health, but why sleep is needed and exactly how it benefits people are not fully understood.
read more is disturbed, people sometimes cannot function normally during the day. People with insomnia or excessive daytime sleepiness are sleepy, tired, and irritable during the day and have trouble concentrating and functioning. People with excessive daytime sleepiness may fall asleep when working or driving.
Difficulty falling asleep sleep-onset insomnia : Commonly, people have difficulty falling asleep when they cannot let their mind relax and they continue to think and worry. Sometimes the body is not ready for sleep at what is considered a usual time for sleep.
Jet lag and shift work commonly read more , such as delayed sleep phase disorder, shift work disorder, and jet lag. Difficulty staying asleep and waking up earlier than desired sleep maintenance insomnia : People with this type of insomnia fall asleep normally but wake up several hours later and cannot fall asleep again easily.
Sometimes they drift in and out of a restless, unsatisfactory sleep. Sleep maintenance insomnia is more common among older people, who are more likely to have difficulty staying asleep than are younger people. It may occur in people who use certain substances such as caffeine , alcohol, or tobacco or who take certain drugs and in people who have certain sleep disorders such as sleep apnea Sleep Apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more or periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep.
Restless legs syndrome involves an irresistible urge to move and usually abnormal sensations This type of insomnia may be a sign of depression in people of any age.
Insomnia and excessive daytime sleepiness may be caused by conditions inside or outside the body. Some conditions cause insomnia and excessive daytime sleepiness, and some cause one or the other.
Some people have chronic insomnia that has little or no apparent relationship to any particular cause. Genetic factors may be involved.
Poor sleep habits, such as drinking a caffeinated beverage in the late afternoon or evening, exercising late at night, or having an irregular sleep-wake schedule. Other disorders such as heart and lung disorders, disorders that affect muscles or bones, or chronic pain. Stress, such as that due to hospitalization, loss of a job, or a death in the family called adjustment insomnia.
Excessive worrying about sleeplessness and another day of fatigue called psychophysiologic insomnia. Sleeping late or napping to make up for lost sleep may make sleeping during the next night even harder.
Insufficient sleep despite having ample opportunity to sleep called insufficient sleep syndrome. Obstructive sleep apnea Obstructive sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more a serious disorder in which breathing frequently stops during sleep.
Various disorders, particularly mental health disorders, brain or nerve neurologic disorders such as encephalitis Encephalitis Encephalitis is inflammation of the brain that occurs when a virus directly infects the brain or when a virus, vaccine, or something else triggers inflammation.
The spinal cord may also be involved read more , meningitis Introduction to Meningitis Meningitis is inflammation of the layers of tissue that cover the brain and spinal cord meninges and of the fluid-filled space between the meninges subarachnoid space.
Meningitis can be read more , a brain tumor Overview of Brain Tumors A brain tumor can be a noncancerous benign or cancerous malignant growth in the brain. It may originate in the brain or have spread metastasized to the brain from another part of the body read more , or narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more , and disorders that affect muscles or bones.
read more , such as jet lag and shift work disorder. Most major mental health disorders are accompanied by insomnia and excessive daytime sleepiness. It may follow a recent read more or an anxiety disorder Overview of Anxiety Disorders Anxiety is a feeling of nervousness, worry, or unease that is a normal human experience.
It is also present in a wide range of mental health conditions, including generalized anxiety disorder Any disorder that causes pain or discomfort, particularly if worsened by movement, can cause brief awakenings and interfere with sleep. Drugs , when used for a long time or when stopped withdrawal , can cause insomnia and excessive daytime sleepiness.
Many mind-altering psychoactive drugs can cause abnormal movements during sleep and may disturb sleep. Sedatives that are commonly prescribed to treat insomnia can cause irritability and apathy and reduce mental alertness. Also, if a sedative is taken for more than a few days, stopping the sedative can make the original sleep problem suddenly worse.
Central or obstructive sleep apnea Central sleep apnea Sleep apnea is a serious disorder in which breathing repeatedly stops long enough to disrupt sleep and often temporarily decrease the amount of oxygen and increase the amount of carbon dioxide read more is often first identified when people report insomnia or disturbed or unrefreshing sleep.
It also occurs in people who have other disorders such as a heart disorder or who take certain drugs. Central or obstructive sleep apnea causes breathing to become shallow or to stop repeatedly throughout the night. Narcolepsy Narcolepsy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more is a sleep disorder characterized by excessive daytime sleepiness with uncontrollable episodes of falling asleep during normal waking hours and sudden, temporary episodes of muscle weakness called cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes Periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep.
read more interrupts sleep because it causes repeated twitching or kicking of the legs during sleep. As a result, people are sleepy during the day. Typically, people with periodic limb movement disorder are unaware of their movements and the brief awakenings that follow.
Restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder involves repetitive movements of the arms, legs, or both during sleep. read more makes falling and staying asleep difficult because people feel as if they have to move their legs and, less often, their arms when they sit still or lie down.
People usually also have creepy, crawly sensations in the limbs. Usually, the cause of insomnia can be identified based on the person's description of the current problem and results of a physical examination. Many people have obvious problems, such as poor sleep habits, stress, or coping with shift work.
Attacks of muscle weakness cataplexy Cataplexy Narcolepsy is a sleep disorder marked by excessive sleepiness during the day or recurring, uncontrollable episodes of sleep during normal waking hours, usually with sudden, temporary episodes read more attacks.
People should see a doctor soon if they have warning signs or if their sleep-related symptoms interfere with their daily activities. If healthy people have sleep-related symptoms for a short time less than 1 or 2 weeks but do not have warning signs, they can try changes in behavior Sleep hygiene The most commonly reported sleep-related problems are insomnia and excessive daytime sleepiness.
Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in read more that can help improve sleep.
If these changes do not help after a week or so, people should see a doctor. Use of other substances such as alcohol, caffeine , and tobacco. Disorders that interfere with sleep include chronic obstructive pulmonary disease COPD Chronic Obstructive Pulmonary Disease COPD Chronic obstructive pulmonary disease is persistent narrowing blocking, or obstruction of the airways occurring with emphysema, chronic obstructive bronchitis, or both disorders.
read more , asthma Asthma Asthma is a condition in which the airways narrow—usually reversibly—in response to certain stimuli. Coughing, wheezing, and shortness of breath that occur in response to specific triggers are read more , an overactive thyroid gland hyperthyroidism Hyperthyroidism Hyperthyroidism is overactivity of the thyroid gland that leads to high levels of thyroid hormones and speeding up of vital body functions.
Graves disease is the most common cause of hyperthyroidism read more , gastroesophageal reflux Gastroesophageal Reflux Disease GERD In gastroesophageal reflux disease, stomach contents, including acid and bile, flow backward from the stomach into the esophagus, causing inflammation in the esophagus and pain in the bottom read more , painful disorders such as rheumatoid arthritis Rheumatoid Arthritis RA Rheumatoid arthritis is an inflammatory arthritis in which joints, usually including those of the hands and feet, are inflamed, resulting in swelling, pain, and often destruction of joints read more , disorders that cause urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine.
read more or frequent urination, and brain, spinal cord, and nerve disorders particularly movement disorders Overview of Movement Disorders Every body movement, from raising a hand to smiling, involves a complex interaction between the central nervous system brain and spinal cord , nerves, and muscles.
Damage to or malfunction People may be asked to keep a sleep log. In it, they record a detailed description of their sleep habits, with sleep and wake times including awakening during the night , use of naps, and any problems with sleeping.
When considering the diagnosis of insomnia, the doctor considers that some people need less sleep than others. If people have excessive daytime sleepiness, the doctor may ask them to fill out a questionnaire indicating how likely they are to fall asleep in various situations.
The doctor may ask their sleep partner to describe any abnormalities that occur during sleep, such as snoring and pauses in breathing.
A physical examination is done to check for disorders that can cause insomnia or excessive daytime sleepiness, particularly obstructive sleep apnea.
Additional symptoms Feeling the need to sleep anywhere, sometimes without warning. Possible cause Narcolepsy. Additional symptoms Loud snorting, breathing and snoring at night.
Possible cause Sleep apnoea. Additional symptoms An unusual feeling in your legs, particularly at night. Possible cause Restless legs syndrome. Additional symptoms Low mood, little interest in things.
Possible cause Depression. Additional symptoms Mood swings that range from extreme highs mania to extreme lows. Possible cause Bipolar disorder. Additional symptoms Problems recovering after physical activity, problems with thinking, memory or concentration.
This figure includes an EEG tracing showing characteristic sawtooth waves and an eye tracing showing rapid eye movements , which occur during REM sleep. In the bottom figure, the arrows represent sharply peaked conjugate eye movements from the right and left eyes during REM sleep.
Infants sleep a large part of the day; with aging, total sleep time and deep sleep stage N3 tend to decrease, and sleep becomes more interrupted.
In older people, stage N3 may disappear. These changes may account for increasing EDS and fatigue with aging, but their clinical significance is unclear.
Rapid eye movement REM sleep occurs cyclically throughout the night every 90— min. Sleep time is spent as follows:. Some disorders can cause either insomnia or EDS and sometimes both , and some cause only one or the other see table Some Causes of Insomnia and Excessive Daytime Sleepiness Some Causes of Insomnia and Excessive Daytime Sleepiness.
read more is most often caused by. Miscellaneous medical disorders such as cardiopulmonary disorders, musculoskeletal conditions, and chronic pain.
EDS Insomnia and Excessive Daytime Sleepiness EDS Many sleep disorders manifest with insomnia and usually excessive daytime sleepiness EDS. Insufficient sleep syndrome Insufficient sleep syndrome sleep deprivation Many sleep disorders manifest with insomnia and usually excessive daytime sleepiness EDS.
Obstructive sleep apnea Obstructive Sleep Apnea OSA Obstructive sleep apnea OSA consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation defined as a period of Miscellaneous medical, neurologic eg, narcolepsy Narcolepsy Narcolepsy is characterized by chronic excessive daytime sleepiness, often with sudden loss of muscle tone cataplexy.
Other symptoms include sleep paralysis and hypnagogic and hypnopompic read more , periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may read more , and psychiatric disorders.
Circadian rhythm sleep disorders Circadian Rhythm Sleep Disorders Circadian rhythm sleep disorders are caused by desynchronization between internal sleep-wake rhythms and the light-darkness cycle. Patients typically have insomnia, excessive daytime sleepiness read more such as jet lag and shift work sleep disorders.
Inadequate sleep hygiene refers to behaviors that are not conducive to sleep. They include. Consumption of caffeine or sympathomimetic or other stimulant drugs typically near bedtime, but even in the afternoon for people who are particularly sensitive.
Patients who compensate for lost sleep by sleeping late or by napping may further fragment their nocturnal sleep. Adjustment insomnia results from acute emotional stressors eg, job loss, hospitalization that disrupt sleep. Psychophysiologic insomnia is insomnia regardless of cause that persists well beyond resolution of precipitating factors, usually because patients feel anticipatory anxiety about the prospect of another sleepless night followed by another day of fatigue.
Typically, patients spend hours in bed focusing on and brooding about their sleeplessness, and they have greater difficulty falling asleep in their own bedroom than falling asleep away from home.
Physical disorders that cause pain or discomfort eg, arthritis Osteoarthritis OA Osteoarthritis is a chronic arthropathy characterized by disruption and potential loss of joint cartilage along with other joint changes, including bone hypertrophy osteophyte formation. read more , cancer Overview of Cancer Cancer is an unregulated proliferation of cells.
Its prominent properties are A lack of cell differentiation Local invasion of adjoining tissue Metastasis, which is spread to distant sites through read more , herniated disks Cervical Herniated Nucleus Pulposus Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the surrounding annulus fibrosus.
The tear causes pain due to irritation of sensory nerves in the disk, and read more , particularly those that worsen with movement, can cause transient awakenings and poor sleep quality.
Nocturnal seizures can also interfere with sleep. Most major mental disorders are associated with EDS and insomnia. Exact cause is unknown Insufficient sleep syndrome involves not sleeping enough at night despite adequate opportunity to do so, typically because of various social or employment commitments.
Drug-related sleep disorders result from chronic use of or withdrawal from various drugs see table Some Drugs That Interfere With Sleep Some Drugs That Interfere With Sleep.
read more result in misalignment between endogenous sleep-wake rhythms and environmental light-darkness cycle. The cause may be external eg, jet lag disorder, shift work disorder or internal eg, delayed or advanced sleep phase disorder. Central sleep apnea Central Sleep Apnea Central sleep apnea CSA is a heterogeneous group of conditions characterized by changes in ventilatory drive without airway obstruction.
Most of these conditions cause asymptomatic changes read more consists of repeated episodes of breathing cessation or shallow breathing during sleep, lasting at least 10 seconds and caused by diminished respiratory effort.
The disorder typically manifests as disturbed and unrefreshing sleep. Most patients snore, and sometimes patients awaken, gasping. These episodes disrupt sleep and result in a feeling of unrefreshing sleep and EDS. Narcolepsy Narcolepsy Narcolepsy is characterized by chronic excessive daytime sleepiness, often with sudden loss of muscle tone cataplexy.
read more is characterized by chronic EDS, often with cataplexy, sleep paralysis, and hypnagogic or hypnopompic hallucinations:. Cataplexy is momentary muscular weakness or paralysis without loss of consciousness that is evoked by sudden emotional reactions eg, laughter, anger, fear, joy, surprise.
Cataplexy can also manifest as blurred vision or slurred speech. Sleep paralysis is the momentary inability to move when just falling asleep or immediately after awakening. Hypnagogic and hypnopompic phenomena are vivid auditory or visual illusions or hallucinations that occur when just falling asleep hypnagogic or, less often, immediately after awakening hypnopompic.
Periodic limb movement disorder Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may read more is characterized by repetitive usually every 20 to 40 seconds twitching or kicking of the lower extremities during sleep.
Patients usually complain of interrupted nocturnal sleep or EDS. They are typically unaware of the movements and brief arousals that follow, and they have no abnormal sensations in the extremities.
Restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may read more is characterized by an irresistible urge to move the legs and, less frequently, the arms, usually accompanied by paresthesias eg, creeping or crawling sensations in the limbs when reclining.
To relieve symptoms, patients move the affected extremity by stretching, kicking, or walking. As a result, they have difficulty falling asleep, repeated nocturnal awakenings, or both.
History of present illness should include duration and age at onset of symptoms and any events eg, a life or work change, new drug, new medical disorder that coincided with onset.
Symptoms during sleeping and waking hours should be noted. Having patients keep a sleep log for several weeks is more accurate than questioning them. Bedtime events eg, food or alcohol consumption, physical or mental activity should be evaluated.
Intake of and withdrawal from drugs, alcohol, caffeine , and nicotine as well as level and timing of physical activity should also be included. If excessive daytime sleepiness is the problem, severity should be quantified based on the propensity for falling asleep in different situations eg, resting comfortably versus when driving a car.
Snoring Snoring Snoring is a raspy noise produced in the nasopharynx during sleep. However, because a bed partner's read more , interrupted breathing patterns, witnessed apneic events, nocturnal gasping and choking, and nocturia sleep apnea Obstructive Sleep Apnea OSA Obstructive sleep apnea OSA consists of multiple episodes of partial or complete closure of the upper airway that occur during sleep and lead to breathing cessation defined as a period of read more syndromes.
Restlessness in the legs, an irresistible desire to move them, and jerking leg movements restless legs syndrome Periodic Limb Movement Disorder PLMD and Restless Legs Syndrome RLS Periodic limb movement disorder PLMD and restless legs syndrome RLS are characterized by abnormal motions of and, for RLS, usually sensations in the lower or upper extremities, which may Cataplexy, sleep paralysis, and hypnagogic phenomena narcolepsy Narcolepsy Narcolepsy is characterized by chronic excessive daytime sleepiness, often with sudden loss of muscle tone cataplexy.
Past medical history should check for known disorders that can interfere with sleep, including chronic obstructive pulmonary disease Chronic Obstructive Pulmonary Disease COPD Chronic obstructive pulmonary disease COPD is airflow limitation caused by an inflammatory response to inhaled toxins, often cigarette smoke.
Alpha-1 antitrypsin deficiency and various occupational read more COPD , asthma Asthma Asthma is a disease of diffuse airway inflammation caused by a variety of triggering stimuli resulting in partially or completely reversible bronchoconstriction.
Symptoms and signs include dyspnea read more , heart failure Heart Failure HF Heart failure HF is a syndrome of ventricular dysfunction. Left ventricular LV failure causes shortness of breath and fatigue, and right ventricular RV failure causes peripheral and abdominal read more , hyperthyroidism Hyperthyroidism Hyperthyroidism is characterized by hypermetabolism and elevated serum levels of free thyroid hormones.
Symptoms include palpitations, fatigue, weight loss, heat intolerance, anxiety, and tremor read more , gastroesophageal reflux Gastroesophageal Reflux Disease GERD Incompetence of the lower esophageal sphincter allows reflux of gastric contents into the esophagus, causing burning pain.
Prolonged reflux may lead to esophagitis, stricture, and rarely metaplasia read more , neurologic disorders particularly movement and degenerative disorders , urinary incontinence Urinary Incontinence in Adults Urinary incontinence is involuntary loss of urine; some experts consider it present only when a patient thinks it is a problem.
The disorder is greatly underrecognized and underreported. read more , other urinary disorders, and painful disorders eg, rheumatoid arthritis. Risk factors for obstructive sleep apnea include obesity, heart disorders, hypertension, stroke, smoking, snoring, and nasal trauma. Drug history should include questions about use of any drugs associated with sleep disturbance see table Some Drugs That Interfere With Sleep Some Drugs That Interfere With Sleep.
The physical examination is useful mainly for identifying signs associated with obstructive sleep apnea:.
The Importance of post-workout nutrition commonly reported sleep-related problems Overview of Sleep Sleep is necessary dayytime survival wakefulness and daytime fatigue datime health, but why sleep is needed and wakegulness how it benefits people fatkgue not fully understood. One of sleep's benefits is its restorative effect on people's read more are insomnia and excessive daytime sleepiness. Insomnia is difficulty falling asleep or staying asleep, waking up early, or a disturbance in sleep quality that makes sleep seem inadequate or unrefreshing. Excessive daytime sleepiness refers to being unusually sleepy or falling asleep during the day.
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