What is drowsiness

Drowsiness is a sensation of sleepiness, normally occurring at night as you are falling asleep, weaving its way into your waking consciousness in varying degrees. This feeling can range from a vague drowsiness which is merely annoying to an overwhelming, irresistible sensation of fighting to remain awake. Feeling drowsy during the day is a sensation which you’ll have after a night of poor sleep. Excessive drowsiness is also a common feature of many psychiatric conditions. The terms excessive daytime sleepiness or hypersomnia are also often used to refer to daytime drowsiness. Excessive daytime drowsiness is defined by having an increased pressure to fall asleep during typical wake hours. It is a common complaint of many adults and children. Excessive daytime drowsiness is the most common symptoms of people with sleep disorders, however, one of the most common cause is sleep apnea, affecting approximately 4% of the population. Excessive daytime drowsiness is a leading cause of fatalities from motor vehicle accident.

• Primary sleepiness include diagnoses of sleep disorders like narcolepsy, sleep apnea, restless leg syndrome, and insomnia. Primary sleepiness is less common than secondary sleepiness, affecting less than 1% of the population and usually associated with a more widely known diagnosis.
• Secondary sleepiness is much more prevalent. The excessive sleepiness can be a result of other conditions such as depression, obesity, epilepsy, or multiple sclerosis. It is common in those with upper airway resistance syndrome, restless leg syndrome, sleep deprivation, and substance abuse. Some people may be genetically predisposed to the condition as well.
  • Psychiatric disorders:
    • Mood disorders (e.g., major depressive disorder, atypical depression, seasonal affective disorder)
    • Psychosis (e.g., schizophrenia)
  • Drowsiness may be due to the following:
    • Long-term (chronic) pain
    • Diabetes
    • Having to work long hours or different shifts (nights, weekends)
    • Long-term insomnia and other problems falling or staying asleep
    • Changes in blood sodium levels (hyponatremia or hypernatremia)
    • Medicines (tranquilizers, sleeping pills, antihistamines)
    • Not sleeping long enough
    • Too much calcium in your blood (hypercalcemia)
    • Underactive thyroid (hypothyroidism)

Excessive daytime drowsiness is a non-specific symptom. There are several potential causes of excessive daytime drowsiness. Excessive daytime drowsiness is difficult to assess objectively. There are several questionnaires available to assess excessive daytime drowsiness. One of the most popular questionnaires is the Epworth Sleepiness Scale (see Figure 1). This scale uses eight questions composed of eight scenarios. The user rates the likelihood of falling asleep from 0-3 points per scenario. The total is tallied up to a highest sleepiness score of 24.

If the sensation of drowsiness becomes overwhelming, you might actually fall asleep during the day at times when it is crucial to remain awake and alert. You may even “wake up” during the day without realizing you have fallen asleep. Drowsiness which invades your waking life at the wrong times can create a multitude of undesirable and possibly dangerous consequences.

For most of people, feeling a little drowsy at times is not of great concern. However, when drowsiness begins to interfere with your ability to remain awake at work or school, driving a car, reading, attending church, watching television, or in other quiet circumstances, fighting drowsiness can begin to control your life. When drowsiness intrudes into life to this extent, you should consider the reasons for this drowsiness.

The most basic purpose of sleeping well at night is to keep you alert and functioning at your best during the day. Good quality sleep and adequate amounts of sleep are essential for good daytime functioning. When drowsiness begins to interfere with waking, it is possible that some aspect of your nighttime sleep is disturbed or that there is another problem. Drowsiness may be caused by a straightforward, simple issue such as having a busy schedule and not getting enough sleep at night. However, there may also be medical problems or serious sleep disorders such as sleep apnea present.

After a night of sleep you should feel refreshed when you wake up. If you require a stimulant like caffeine which is present in coffee, tea, soft drinks, energy drinks, and chocolate to stay awake, it is likely that you are not getting enough sleep or that your nighttime sleep is not of good quality. Furthermore, if you drink caffeine in the evening, this may cause your sleep that night to be even more disturbed. It is true that physical movement may also allow you to feel more alert, but continuous movement is not a realistic means of keeping awake.

Figure 1. Epworth Sleepiness Scale Questionnaire

How to counteract drowsiness from medication?

Some medications can cause drowsiness and the only way to counteract drowsiness from medication is discuss it with to your medication prescriber. Your doctor may alter the dosage or find alternative non-drowsy medicine for you.

Sometimes when I am at school or in a meeting at work, I seem to “zone out”. Does this mean that I am drowsy during the day?

Although losing focus in these situations is not necessarily a sign of sleepiness, it could mean that you are momentarily drifting into sleep, sometimes for fractions of a second, without even being aware of doing so. The term microsleeps is one which is often applied to these very brief sleep periods. If you find that you repeatedly have a problem with concentration or fogginess in your thinking, microsleeps may be affecting you.

Aren’t some people just naturally sleepy?

There are some sleep disorders for example, narcolepsy, periodic limb movements, sleep walking, and sleep apnea, which are known to have either a genetic basis or to run in families. Of particular note is that older persons often seem to be “naturally” sleepy during the day. However, older people are more vulnerable to irregular sleep schedules and may not obtain enough sleep at night. In addition, the incidence of sleep disorders increases with advancing age.

What causes drowsiness

There are many different causes for daytime drowsiness. In general, anything which delays, interrupts, or shortens your sleep has the potential to cause drowsiness during the day. These same factors also apply to shift workers who work at night and sleep during the day. Here are some of the most common causes associated with daytime drowsiness.

Your sleeping environment may be disturbing you

If you are drowsy during the day, your bedroom environment may be contributing to poor quality nighttime sleep. Some of these factors may seem relatively unimportant or trivial. However, nothing is unimportant if it bothers you when you are trying to sleep. Consider whether the following aspects of your sleeping environment may be bothering you.

• Your bed is not comfortable
• Your pillows are too lumpy or too flat
• Your bedcovers feel too heavy
• Your pajamas or bed clothes are not comfortable
• The curtains let in light from the outside
• The temperature in the room frequently seems too hot or too cold
• There are noises in the house, such as appliances or heating and air conditioning units going on and off, which wake you
• Your cat or dog comes in and out of your room at night or your pet sleeps in your bed
• Sometimes you don’t feel secure or safe in your bedroom
• The LED displays on your alarm clock and other electronics in the room are bright
• Your bed partner snores loudly
• Your bed partner thrashes and moves during sleep
• Your bed partner has a different time of going to bed from you
• Other people, including babies and children, in your house wake you up during the night
• You leave the television on when you’re in bed trying to sleep
• You leave your cell phone on when you sleep or you sleep with your cell phone in bed with you so that you can answer calls and reply to texts during the night
• Outside noises such as garbage trucks or traffic wake you up
• There are other noises or disruptions unique to your sleeping environment

Shift workers who work at night and sleep during the day may face even more challenges in eliminating these disturbing elements from their sleeping environment.

Not getting enough sleep at night

It may seem obvious, but if you do not get enough sleep at night, you will invariably feel drowsy during the day. Americans are a very sleep deprived society, and most adults do not regularly obtain sufficient sleep. There is a myth that sleep is a waste of time, and you often hear reports that public and business figures can function effectively on three or four hours of sleep per night. However, there is a great deal of research which suggests that not enough sleep can be associated with serious medical conditions such as high blood pressure or diabetes. There is also evidence to suggest that insufficient amounts of sleep may even affect how long you live.

So what is the ideal amount of sleep that you should obtain at night? It is recommended that at least seven hours of sleep per night for adults is optimal. Even children and teenagers may not obtain an ideal amount of sleep. Guidelines from the American Academy of Sleep Medicine published last year suggest the following sleep amounts per 24 hours (including daytime naps) to promote good health for the following age groups.

• Infants (4-12 months) 12 – 16 hours
• Children (1-2 years) 11 – 14 hours
• Children (3-5 years) 10 – 13 hours
• Children (6-12 years) 9 – 12 hours
• Teenagers (13-18 years) 8 – 10 hours

Your schedule of sleep and waking times may not be regular

It is very important to have an adequate number of sleeping hours each night to keep yourself from becoming drowsy during the day. Besides the amount of sleep you should obtain, there is a second important factor in determining how refreshed you feel during the day. This second factor is the regular timing of sleep during each 24 hour period. This is referred to as the circadian timing of sleep during each 24 period of day and night.

Besides a normal amount of sleep each night, you must also maintain a regular schedule of going to bed each night and getting up each morning during each 24 hour period. There are significant changes in body temperature and hormone secretions that vary according to circadian cycles of sleep and waking. For example, it is well known that there is a decline in body temperature in the evening hours anticipating the time of sleep onset and a rise in body temperature which occurs in anticipation of waking.

Keeping a regular sleep-wake schedule is crucial for good sleep. Most of people usually keep a fairly regular schedule of sleeping and waking times during the work week. But then the weekend comes. You often feel on weekends as though you are finally free to go to bed and get up whenever you want, without paying much attention to your schedule. Nothing could be further from your biology in keeping your sleep on track.

Since you often do not have a pressing need to wake up early on a Saturday morning for work, you may stay up much later than usual on a Friday night. As a result you may stay asleep longer and wake up later on a Saturday morning. This pattern is often repeated again from Saturday night to Sunday morning. By altering your time of going to bed later and then getting up several hours later, even for just a weekend, you send your sleep-wake cycle confusing messages about when you should sleep and wake. Then, on Sunday night, it may be very difficult to fall asleep at your normal work week time and very difficult, if not impossible, to wake up on time for work on Monday morning. You should also be aware that taking prolonged daytime naps lasting more than 30 minutes or so can result in producing irregularity in your sleep schedule.

Not having a regular bedtime routine

Everyone has had the experience of a stressful day and then having trouble falling asleep. To help yourself fall asleep when you finally do get into bed, plan on mentally and physically relaxing to prepare yourself for sleep. Taking a few minutes to sort out problems from the day, eating a small snack, or reading before you turn out the lights can help you fall asleep. Besides mental relaxation, mild stretching exercises or deep breathing exercises can help you physically relax. A relaxed mind and a relaxed body will help ease your transition to sleep so that you to obtain your usual amount of sleep and do not feel drowsy the next day.

Drinking caffeine or eating heavy meals too close to bedtime

Caffeine is a stimulant, and it is contained in beverages such as coffee, tea, soda, and energy drinks. Chocolate also contains caffeine. Caffeine can result in nighttime sleep disruption and then drowsiness may be increased the next day.

Your favorite heavy or spicy meal may cause an upset stomach and prevent you from falling asleep. A light snack before bed, however, may be of help in falling asleep.

Exercise too close to bedtime

In addition to good quality sleep and a balanced diet, regular exercise is one of the foundations for good health. Studies have shown that exercise can improve sleep quality. However, the timing of exercise is important so that it does not interfere with your sleep. Often in your busy lives it is difficult to schedule exercise during the day. If you cannot fit exercise in during the day, then exercise in the evening hours may be your only option. However, following exercise, you may feel more awake immediately afterwards due to elevations in heart rate or blood pressure. If you then try to sleep immediately after exercise, you may have trouble falling asleep. You should allow a cool down period lasting a couple of hours before trying to sleep.

Alcohol

Alcohol can result in falling asleep more quickly at the beginning of the night, and there is a myth that alcohol is beneficial for sleep. Many people do use alcohol as a temporary “sleeping pill”. However, studies have shown that even though alcohol can speed up the process of falling asleep, alcohol invariably causes frequent brief awakenings and restless sleep, resulting in daytime drowsiness.

Alcohol consumption alters the normal sequence of sleep stages during the night and most notably suppresses rapid eye movement sleep (REM) sleep or dreaming sleep. Additionally, alcohol can suppress breathing during sleep. The volume and frequency of snoring can increase, indicating a partial blockage of the airway. The airway can also become completely obstructed resulting in the appearance of actual episodes of stopping breathing during sleep. The duration of these episodes ranges from 10 seconds or so to over a minute. Only a few of these nonbreathing episodes may appear, but it is not uncommon for several hundred episodes to occur during sleep Significant changes in heart rate, blood pressure, and oxygen levels typically occur. Each time that breathing stops and then begins again, there is a brief arousal from sleep.

You can see that using alcohol for sleep is not only decreases sleep quality, but also that there are potentially dangerous effects on the functioning of your body.

Medications or chronic illness

Many prescription medications and over the counter sleep aids like melatonin can disturb nighttime sleep resulting in sleepiness during the day. Prescription medications can also cause drowsiness the day. Some long acting sleeping pills which may improve your ability to fall asleep at night can also “hang over” effects the next day, causing you to feel drowsy. Most of the newer sleeping pills do not have these kinds of daytime effects due to their shorter action. However, do not take a sleeping pill of any kind during the middle of the night in order to fall back asleep since the effects of the sleeping pill may extend to your daytime hours.

If you notice that you seem to feel drowsier than usual during the day after taking a medication, talk to your doctor about the possible contribution of these medications in disturbing sleep at night or in causing you to feel sleepy during the day.

Medical illnesses, hospitalizations, and chronic pain are frequently associated with disruption of nighttime sleep and subsequent sleepiness during the day. Once again it is important to talk to your physician about your symptoms.

Sleep disorder

If your daytime drowsiness is persistent despite your best efforts, it is important to discuss this issue with your physician about your problem. He or she may perform various tests to determine if another medical problem is causing your drowsiness. You may also be referred to a Sleep Center for an overnight sleep test. During this test, your brain and muscle activity along with your breathing, heart rate, and oxygen levels are continuously recorded and then analyzed. Sometimes a daytime nap test, the Multiple Sleep Latency Test (MSLT), is also performed to evaluate the degree of daytime sleepiness. Both of these tests can determine if you have a disorder which is specific to your sleep that cannot be detected during the day.

Some sleep disorders which are associated with the symptom of daytime drowsiness include the following:

Sleep apnea

Sleep apnea is a disorder in which loud snoring, breath holding episodes accompanied by oxygen decreases, and restlessness occurs during sleep. A brief arousal from sleep occurs following breath holding episodes when breathing begins again, resulting in a very brief arousal. Hundreds of these episodes are often present, severely disturbing sleep. During the day, drowsiness related to sleep apnea can be extreme with patients often actually falling asleep driving a car or in other dangerous situations. Middle-aged males who are overweight and who have with a large neck, a crowded throat often with tonsils present, and high blood pressure appear to be most likely to have sleep apnea. However, sleep apnea can affect both males and females of all ages from babies to the elderly

Restless legs syndrome

Restless legs are a creeping, crawling, uncomfortable, unpleasant sensations in the legs which occurs sitting quietly during the day, but which becomes most disruptive as someone is trying to fall asleep. The only relief of these sensations is to walk or move your legs, but then the sensation returns requiring further movement. It is not hard to imagine how this disorder could prevent you from falling asleep or waking up during the night.

Periodic limb movements

Periodic limb movements frequently accompany restless legs. These leg movements are repetitive, rhythmic jerking movements most often of your legs, but which can also occur in the arms, during sleep. Periodic limb movements are often completely unknown to the sleeper, but a bed partner is able to observe these rhythmic movements. Hundreds of these jerking movements during sleep result in brief arousals and awakenings and then sleepiness during the day. If a person with restless legs is finally able to fall asleep at night, they often have periodic limb movements during sleep.

Narcolepsy

Narcolepsy is associated with extreme sleepiness during the day, and it is thought to be a less common sleep disorder than sleep apnea or restless legs/periodic limb movements. Narcolepsy is associated with an abnormality in the timing of REM sleep (rapid eye movement) or dreaming sleep. Symptoms of narcolepsy can include cataplexy (loss of muscle tone during the day with strong emotions), sleep paralysis (an inability to move upon falling asleep or waking up), and hypnagogic hallucinations (vivid, dreamlike experiences which occur during waking before sleep onset).

Circadian rhythm disturbances

Circadian rhythm disturbances are a misalignment between a desired schedule of sleeping and waking times and the times that you actually feel like sleeping and waking. In advanced sleep phase syndrome if your desired sleep times are between 10 pm and 6 am, you may feel, for example, ready to sleep at 7 pm and then wake up early at 3 am. In delayed sleep phase syndrome, you may not feel sleepy, for example, until 1 am and then wake up late at 9 am. In both of these situations you can feel drowsy during the day at times when you want to remain alert.

Other sleep disorders

Sleep walking, sleep talking, night terrors, nightmares, enuresis (bed wetting), bruxism (tooth grinding), and REM behavior disorder are all disorders which can disturb sleep and cause sleepiness during the day. Some of these disorders such as sleep walking, enuresis, and night terrors (awakenings during the night with screaming or crying but the sleeper has no memory of the event) are most common in children. In adults, REM behavior disorder is associated with vigorous and sometime injurious behavior to themselves and their bed partner. This disorder occurs during REM sleep, a sleep stage in which there is normally muscle paralysis and an inability to move.

These are some of the most common sleep disorders which can disturb sleep and which can result in drowsiness during the day. There are also other sleep disorders which are associated with daytime sleepiness that can be diagnosed with overnight sleep studies. If you are aware of unusual behavior during sleep or others sleeping around you report that you have these symptoms, talk to your physician. A comprehensive evaluation of these sleep problems can be obtained in Sleep Clinics.

Drowsiness symptoms

Drowsiness is a sensation of sleepiness, normally occurring at night as you are falling asleep, weaving its way into your waking consciousness in varying degrees. This feeling can range from a vague drowsiness which is merely annoying to an overwhelming, irresistible sensation of fighting to remain awake.

Drowsiness diagnosis

Clinical assessment

A focused physical examination is important because obesity and systemic hypertension are associated with sleep-disordered breathing ¹. Obesity increases the risk of developing obstructive sleep apnea from 2 to 4 percent in the general adult population to 20 to 40 percent in individuals with a body mass index (BMI) above 30 ¹. Factors predictive of obstructive sleep apnea in the severely obese include observed apneas, male sex, higher BMI, older age, increased fasting insulin, and glycosylated hemoglobin A1c levels ¹. Obstructive sleep apnea has long been associated with hypertension, and there is growing evidence that the relationship may be causal ². Even patients with mild to moderate obstructive sleep apnea have an elevated risk of high blood pressure and associated comorbidities (e.g., cardiovascular disease, stroke, decreased quality of life).

In addition, an upper airway examination (i.e., assessment of the posterior airspace, lower jaw structure, neck circumference) should be part of the physical examination ³. Many upper airway variables shown to be associated with obstructive sleep apnea have been incorporated into complex predictive models, but unfortunately these models are not practical in community office practices. However, Nuckton and colleagues have found that the Mallampati score, which is used to identify individuals who may be at risk for a difficult tracheal intubation, is predictive of the presence and the severity of obstructive sleep apnea ⁴. The simplicity of this method of assessing the upper airway makes it a fast and convenient tool in clinical settings. Another commonly used staging system for sleep-disordered breathing is the Friedman scale ⁵.

Although many sleep disorders can be diagnosed using history alone, overnight polysomnography may be useful to assess for disorders such as obstructive sleep apnea (OSA). Polysomnography monitors brain wave activity (electroencephalogram), eye movements (electro-oculogram), muscle activity (electromyogram), heart rate and rhythm (electrocardiogram), and respiration (via nasal pressure transducer and oronasal thermistor, and oxygen saturation using pulse oximetry).

Validated self-administered questionnaires have been used in research studies and in the clinical setting to determine sleep habits and assess the effects of sleep-inducing and wake-promoting medications. Such questionnaires may be incorporated into clinical practice settings to supplement the clinical interview. Sleep studies, such as the polysomnogram (PSG), the multiple sleep latency test (MSLT), and the maintenance of wakefulness test (MWT), must be performed in a sleep laboratory, and although more labor intensive, may also be helpful in evaluating diminished alertness and excessive sleepiness.

The most commonly used questionnaire to assess excessive sleepiness is the Epworth Sleepiness Scale (ESS) (see Figure 1). The Epworth Sleepiness Scale is a simple self-administered questionnaire that offers a subjective measurement of a patient’s level of excessive sleepiness, defined as the average sleep propensity ⁶. The patient assesses his or her likelihood of falling asleep in eight situations. Ratings on the Epworth Sleepiness Scale range from 0 (would never doze or sleep) to 3 (high chance of dozing or sleeping). As with any subjective instrument, the Epworth Sleepiness Scale may be influenced by patient motivation, recall bias, and fatigue. Some researchers have questioned whether the Epworth Sleepiness Scale is a valid surrogate for objective tests, such as the multiple sleep latency test (MSLT) ⁷.

Polysomnography

A polysomnography is the primary objective test to look for sleep disordered breathing or to investigate abnormal movements during sleep ⁸. Usually performed overnight, a polysomnography monitors multiple neurophysiologic and cardiorespiratory variables to assess sleep stages, limb movements, airflow, respiratory effort, heart rate and rhythm, oxygenation, and body position. Although it is common for physicians to diagnose a sleep disorder on the basis of a single night study, multiple recordings may provide more reliable information ⁹. Unfamiliar surroundings may disturb the sleep architecture and result in inaccurate test results. On the other hand, a controlled testing environment may remove environmental factors in the home that can interfere with sleep, potentially biasing results.

The American Academy of Sleep Medicine recommends the use of polysomnography for the diagnosis of a number of sleep-wake disturbances ¹⁰, including sleep-related breathing disorders, narcolepsy (the night before a multiple sleep latency test [MSLT]), sleep-related behaviors that may result in injury to the patient or others ¹¹ and atypical or unusual parasomnias.

Polysomnography is not routinely needed to diagnose or treat restless legs syndrome, circadian rhythm disorders, uncomplicated parasomnias, or depression.

Figure 2. Sleep Log –  to assess sleep behaviors over a period of time.

Multiple sleep latency test

The multiple sleep latency test, an objective measure of excessive sleepiness, is considered to be the gold standard measure of somnolence.41 The test was developed to assess excessive sleepiness and to determine the presence of sleep-onset rapid eye movement periods (SOREMP) ¹². The multiple sleep latency test is used to diagnose narcolepsy ¹³ and idiopathic hypersomnia ¹⁴, as well as to monitor treatment effects ¹⁵.

The multiple sleep latency test measures an individual’s physiologic sleep tendency when potential alerting cues are controlled. These cues may be environmental (e.g., light, sound, temperature) or internal (e.g., circadian and homeostatic rhythms) ¹⁵. Sleep latency is assessed over five daytime nap trials of 20 minutes each, at two-hour intervals ¹⁶. A two-week sleep log and nocturnal sleep polysomnography should always precede an multiple sleep latency test to exclude other possible causes of a short Multiple Sleep Latency and multiple SOREMPs, such as obstructive sleep apnea, sleep deprivation, and delayed-phase sleep syndrome. Patients should be advised not to take stimulant medications or REM-suppressing medications for two weeks before the test ¹⁶. Drug discontinuation may be impractical for some patients; however, multiple sleep latency test results are more difficult to interpret if the medications are not discontinued. In many cases, it may be reasonable to do a urine drug screen before the patient starts the multiple sleep latency test.

Several physiologic factors influencing multiple sleep latency test have been reported; they include age, circadian rhythms, prior total sleep times, current medications, and sleep structure disruption due to a comorbid condition. For example, prepubescent children have the longest sleep latencies and young adults have the shortest ¹⁵. For shift workers and individuals with delayed sleep phase syndrome, the timing of the test is critical, because variations in circadian phases may alter sleep latency times and sleep-onset rapid eye movement periods (SOREMPs) ¹⁷.

Maintenance of wakefulness test

The maintenance of wakefulness test (MWT) determines an individual’s ability to maintain a state of wakefulness ¹⁸. A large study of 258 consecutive patients undergoing evaluation for excessive sleepiness found that although the multiple sleep latency test and the maintenance of wakefulness test measure different things (tendency to fall asleep and ability to stay awake, respectively), there is a low but significant correlation between the test results ¹⁹.

In summary, the multiple sleep latency test is a reliable objective test to assess excessive daytime sleepiness, and the maintenance of wakefulness test is a reliable objective test to assess the ability to maintain wakefulness. Nevertheless, the variability in Multiple Sleep Latency due to protocol differences and potential confounding factors (e.g., prior activity, caffeine use, age), coupled with the nonspecificity of sleep-onset rapid eye movement periods (SOREMPs), led a task force of the American Academy of Sleep Medicine to recommend caution in making a diagnosis of excessive sleepiness based solely on multiple sleep latency test or maintenance of wakefulness test findings ¹⁵. These test results, along with patient history and other medical data, should be incorporated into the diagnosis, since excessive sleepiness due to an intrinsic sleep disorder may have a marked effect on job status, quality of life, and safety.

How to get rid of drowsiness

Here are some suggestions to improve your nighttime sleep and decrease daytime drowsiness.

Take an inventory of your bedroom and sleeping environment to identify potential problems

Examine your bedroom and sleeping environment carefully to identify what might be bothering your sleep at night and causing you to feel drowsy during the day.

Some possible remedies for issues which you might discover include the following:

• If your mattress feels uncomfortable and there are obvious lumps or bumps in the mattress, you might consider replacing it. However, there is not a “magic” mattress which will assure that you have a perfect night of sleep. You should pick a mattress that feels comfortable to you. Changing your pillows, bedcovers, and bedclothes may increase your comfort. Examine and if necessary replace your curtains or blinds so that your bedroom is dark and light from street lights or early morning light does not shine in your room. Black out curtains may also be helpful.
• Most people sleep more comfortably in a room which is cool rather than warm. Lowering your thermostat to decrease the temperature during your time in bed may improve your sleep.
• Try to identify sources of noise in your room and house which wake you during the night and eliminate them. A room fan or a “white noise” machine may help mask sounds. You might also consider soft earplugs to muffle noises.
• Pets can be surprisingly disruptive to sleep by jumping off and on the bed or coming in and out of the room at night. Consider training your pet to stay off your bed and to sleep in his/her own dedicated sleeping area away from your bed.
• Feeling secure in your house and bedroom is important for relaxation and sleep. If you have security concerns about your locks or access to your home, address these issues.
• That tiny little light on your alarm clock can be a surprising source of sleep disruption. Turn your clock around so that you cannot see its light or check the time when you should be trying to sleep. Turn off or cover the lights on other electronic equipment in your bedroom.
• The sleep problems of other persons in your household also become your sleep problems if your sleep is disturbed by them. A snoring, thrashing bed partner can be a source of sleep disruption, often forcing one or the other person to sleep in a separate room. If your partner’s sleep has become your sleep problem, observe your partner closely for an interrupted pattern of snoring and if there are breath holding episodes during sleep. Also observe any patterns of jerking or twitching movements during sleep. Consultation with a physician may result in a referral to a Sleep Center for evaluation, diagnosis and treatment of your partner’s sleep problem.

If your child is having difficulty with sleep or he/she is drowsy during the day, follow these same suggestions for making sure that your child’s sleeping environment and sleep habits encourage good sleep. Also be aware that children of all ages, like adults, can have sleep disorders which are diagnosed and treated in a Sleep Center.

• Do not sleep with your television on, even though you may believe that you need the television to sleep. The light and the sound from the television will invariably disturb your sleep. If you feel as though your bedroom is “too quiet” when you get into bed to sleep, a white noise machine when you sleep or relaxing music at a low volume may help.
• Do not take your cell phone to bed with you. Unless you are expecting emergency calls do not plan on answering your cell phone during the night. Do not text on your cell phone when you are trying to sleep. Ideally, your cell phone will be off during the night, but this, of course, is not always possible.

Be sure you are spending enough time in bed each night.

As previously discussed, recent guidelines from the American Academy of Sleep Medicine recommend at least seven hours of sleep per night for adults with more sleep required for children and adolescents. Plan your schedule so that you obtain at least this amount of sleep each night. You may find that you require more than seven hours of sleep to feel fully alert during the day, and you should increase your sleep amounts, if necessary, to feel at your most alert. Remember that at least seven hours of sleep, not the total amount of sleep averaged across several days, is your goal. You cannot “make up” lost sleep, so plan on this amount during both the work week and on weekends.

Keep a regular schedule of going to bed at night and getting up in the morning.

Besides getting enough sleep at night, it is of importance to follow a regular schedule both during the work week and on weekends. This allows your body to establish a regular 24 hour cycle of sleeping and waking times.

It is very helpful to keep a daily diary to track both the amounts and timing of sleep. By recording the time you go to bed and get up in the morning over a period of two to four weeks, you will be able to determine if you are keeping a regular schedule with enough time in bed at night.

Figure 3. Sleep Diary

Limit your consumption of caffeine and meals near bedtime

Do not drink caffeine containing beverages including coffee, tea, or energy drinks in the evening. Chocolate contains caffeine and may also bother your sleep. Do not eat spicy or heavy meals in the evening.

Do not drink alcohol to “improve” your sleep

The myth of alcohol being “good” for sleep is only a myth. However, many people believe that alcohol is beneficial for sleep. In fact alcohol causes fragmented sleep as well as alterations in normal sleep patterns as well as suppression of the respiratory system. Do not drink alcohol before bed.

Put the brakes on your racing mind when you are trying to sleep

You have had a busy day at work or at home with problems, both big and small, popping up like uninvited weeds in a well manicured lawn. At last you are in bed, it is quiet and you have finally have uninterrupted time to think about these problems and try to find solutions. This is probably the worst time to think about your problems since your mind will start to fight sleepiness when you should be sleeping. However, it is easier said than done to make yourself to stop thinking so that you can sleep, and much of the time we are unsuccessful in controlling our thoughts so easily.

If you know that this often happens as you are falling asleep, a relaxing bedtime routine will help. Plan to allot time for thinking about these issues before you get in bed. You can schedule time before getting into bed to think about, devise solutions for, and even write down your thoughts before trying to sleep. Once this scheduled “thinking time” is over, you can devote yourself to falling asleep

Talk to your physician

You may be reluctant to discuss daytime drowsiness with your physician because it may seem to you that sleepiness is a trivial problem in comparison to other serious diseases. Nothing could be further from the truth. There is recognition in the medical community of the serious consequences of sleep disorders. Not only can daytime drowsiness can have significant impact upon our quality of life, but it may be a sign of a serious medical conditions such as sleep apnea. Drowsiness may also be the result of medications or a symptom of some other medical condition not specifically related to sleep.

How to counteract drowsiness with medication

Medications to treat excessive sleepiness include several different chemical classes of wake-promoting medications: 1) direct-acting sympathomimetics (e.g., phenylephrine); 2) indirect-acting sympathomimetics (e.g., methylphenidate, amphetamine); and 3) nonsympathomimetic stimulants (e.g., caffeine, modafinil) (Table 1) ²⁰. In addition, there are numerous activating antidepressants, such as bupropion, protryptyline, and several of the selective serotonin reuptake inhibitors (SSRIs), that may be considered for psychiatric patients who have sedation problems. REM-suppressing antidepressants, including venlafaxine and older tricyclic drugs, may be effective in the treatment of cataplexy, hallucinations, and sleep paralysis.

Table 1. Currently available wake-promoting medications

Footnote:

*Methylphenidate: up to 60mg; dextroamphetamine: up to 60mg; methamphetamine: 5–50mg.

†Regular blood pressure monitoring is recommended.

**Not indicated for patients with pre-existing cardiovascular problems, including hypertension. Regular blood pressure monitoring is essential in all patients.

Sympathomimetic agents

The earliest treatments used for excessive sleepiness, the amphetamines, achieve their alerting effects by directly or indirectly regulating dopaminergic and noradrenergic systems located in the ventral tegmental area and the locus coeruleus, respectively, which project widely throughout the brain. Activation of non–wake-promoting regions, including the striatum and nucleus accumbens, may produce side effects such as tics and abuse liability ²⁰.

As noted by Mitler and O’Malley in a previous review of sympathomimetic alerting agents, the dosing guidelines for traditional stimulants, such as dextroamphetamine and methamphetamine, have not changed significantly since their development nearly 70 years ago ²⁰. In a 1956 study, daily doses of methylphenidate ranging from 20mg to 240mg demonstrated effectiveness in treating excessive sleepiness ²². Treatment often begins with trials of low to moderate doses of amphetamines or methylphenidate, with titration up to 60mg of either drug as necessary to promote alertness. Amphetamine prescriptions above 60mg per day are not recommended ²³. Amphetamines are available in a range of preparations with different half-lives, allowing flexibility in the development of dosing strategies (Table 1).

Dose-dependent adverse events associated with sympathomimetic therapy include headaches, irritability, nervousness, decreased appetite, insomnia, gastrointestinal problems, dyskinesia, and palpitations ²⁰. Nighttime sleep also may be disturbed ²⁴. Pre-existing psychiatric problems may be aggravated, although psychosis and hallucinations rarely are reported in patients taking amphetamines for excessive sleepiness ²⁰. Cognitive, behavioral, and motor problems (e.g., obsessive thought patterns, paranoia, stereotypical movements, perseveration) may develop after sustained use of sympathomimetic therapies at high doses. The frequency of side effects is similar with use of methylphenidate and amphetamine ²⁰.

Although cardiac and vascular complications are infrequent, advanced cardiovascular disease is a contraindication for sympathomimetic drug use. Isolated cases of stroke, cardiomyopathy, and ischemic vascular complications have been reported with chronic use of these medications, especially at high doses ²⁰. However, substantial numbers of patients have taken sympathomimetic drugs for many years without experiencing adverse cardiovascular events. Moreover, normotensive patients typically do not experience clinically significant increases in blood pressure at standard doses ²⁰. Nevertheless, patients receiving sympathomimetic therapy should have regular blood pressure monitoring.

The abuse potential of sympathomimetic drugs is high. Even though most users (more than 90%) do not become addicted, compulsive use may lead to dependence ²⁰. Bingeing may produce a sequence of psychiatric symptoms beginning with euphoria and culminating in psychosis; these may be followed by exhaustion, anxiety, depression, and a strong need for sleep. Amphetamine withdrawal is associated with apathy, anhedonia, and drug cravings, which subside over subsequent weeks ²⁰.

Tolerance to the alerting effects of sympathomimetic therapy may develop with varying frequencies and is most evident in patients taking high doses. It is believed that habituation is true tolerance, rather than a consequence of diminished nocturnal sleep. Tolerance does not appear to be less common with methylphenidate than with dextroamphetamine ²⁰.

Caffeine

Often used as a remedy for sleepiness, caffeine has central nervous system (CNS) effects by antagonizing adenosine receptors in the hypothalamus. Adenosine contributes to the homeostatic sleep regulatory system, and extracellular levels rise during sustained periods of wakefulness ²⁵. By inhibiting A1 adenosine receptors, caffeine prevents sleep onset; this action may produce the side effects often associated with the drug, including gastric stimulation, diarrhea, flushing, sweating, and elevated heart and respiratory rates ²⁰.

The well-known effects of caffeine on alertness and cognitive skills have been demonstrated in numerous clinical studies. Caffeine supplements taken at bedtime can delay sleep onset and disrupt sleep continuity ²⁶. At doses of 2mg/kg, caffeine improved psychomotor performance and vigilance in patients, demonstrating that caffeine is a useful treatment for shift work disorder ²⁷. Slow-release caffeine (300mg) was shown to be effective for a longer period than napping in counteracting drivers’ sleepiness induced by partial sleep deprivation ²⁸. Also, high doses of caffeine (600mg) compared favorably with 200mg and 400mg of modafinil in maintaining alertness and cognitive performance in healthy sleep-deprived young adults ²⁹. The body of evidence shows that caffeine may improve alertness and reduce the risk of accidents and injuries in sleep-deprived individuals. For these reasons, caffeine is used most commonly in acute situations (e.g., while driving) to prolong wakefulness. However, the benefits may be lost if the dose is not adequate, if the timing of administration is incorrect, or if there is a background of severe caffeine dependence ²⁰. Habituation may also pose a problem (Table 1).

In the context of excessive sleepiness, the most important side effect associated with caffeine is disturbed nighttime sleep. This side effect typically is seen in patients with high caffeine sensitivity and often is missed as a cause of abnormal nocturnal sleep in those who have become habituated to the drug. In addition, caffeine may be implicated in sleep fragmentation in the elderly, who have slower metabolic rates. Clinicians should discuss caffeine use whenever addressing a patient’s complaints about sleeplessness. Education may help patients moderate their caffeine consumption if it is identified as a factor in sleep onset and maintenance. Abrupt cessation of caffeine consumption may cause headaches, increased anxiety and depression, reduced vigor, and increased fatigue ³⁰. In general, moderate doses of caffeine are safe in the absence of these side effects.

Modafinil

Modafinil is a novel somnolytic agent approved for the treatment of excessive sleepiness associated with narcolepsy, shift work disorder, and obstructive sleep apnea refractory to mechanical treatments such as nasal continuous positive airway pressure (nCPAP) ³¹. Although the precise mechanism of action remains unclear, the drug does not appear to be a dopaminergic agonist and its regional effects differ from those of sympathomimetic agents. There is evidence that modafinil is active in selected areas of the hypothalamus and the central nucleus of the amygdala; these regions of the brain are thought to be involved in regulating sleep-wake behavior.60,61 It is likely that the drug uses multiple mechanisms to trigger sleep-wake centers in the hypothalamus ²⁰.

The standard dose of modafinil for the treatment of excessive sleepiness is 200mg per day ³¹, although some individuals with severe sleepiness may require up to 600mg per day in divided doses (400mg at 7 AM, 200mg at noon) for symptomatic relief (Table 1) ³².

Modafanil may be preferable to sympathomimetic agents as a treatment option because of its favorable side effect profile. It was well tolerated in clinical trials, with headache the most frequent adverse event ³³. No significant cardiovascular or psychiatric events were reported, although a few patients complained of insomnia or nervousness. These symptoms typically were transient and dose dependent, and habituation to modafinil rarely has been a matter of concern ²⁰. Modafinil at the recommended doses has not been found to increase blood pressure significantly ³⁴; however, regular blood pressure monitoring may be needed during the first few months of therapy.

Initial results from a series of clinical studies suggest that modafinil has the potential to improve symptoms of residual excessive sleepiness in patients with depression ³⁵. Modafinil may augment serotonergic drug therapy in partial responders who experience sleepiness and fatigue. Further research may show that modafinil is a useful adjunctive treatment for the short-term management of patients with depression who experience persistent sleepiness and fatigue.

In addition, modafinil may be effective in mitigating the sedating effects of various antipsychotic ³⁶, antidepressant ³⁷ and mood-stabilizing drugs ²¹. Additional studies are necessary to confirm whether modafinil will play a role in the treatment of psychiatric patients with excessive somnolence.

Sodium oxybate

Sodium oxybate (sodium salt of gamma hydroxybutyric acid) is indicated for treating the sleepiness and cataplexy associated with narcolepsy. By activating gamma-aminobutyric acid b (GABAb) and possibly modulating GABAa and GABAc, sodium oxybate improves sleep architecture by increasing slow-wave sleep duration and delta power and decreasing REM sleep duration ³⁸. The drug, which is effective in treating cataplexy, has been shown to limit nocturnal sleep disruptions and consolidate sleep ²¹. Although sodium oxybate is usually well tolerated at indicated doses, there have been reports of respiratory depression, confusion, and depression and at toxic doses, bradycardia and hypotension ³⁸.

1. Dixon JB, Schachter LM, O’Brien PE. Predicting sleep apnea and excessive day sleepiness in the severely obese: indicators for polysomnography. Chest. 2003;123:1134–41[↩][↩][↩]
2. Goldberg AN, Schwab RJ. Identifying the patient with sleep apnea: upper airway assessment and physical examination. Otolaryngol Clin North Am. 1998;31:919–30.[↩]
3. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep. 2006;29:903–8.[↩]
4. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg. 2002;127:13–21.[↩]
5. Johns MW. Daytime sleepiness, snoring, and obstructive sleep apnea. The Epworth Sleepiness Scale. Chest. 1993;103:30–6.[↩]
6. Chervin RD, Aldrich MS. The Epworth Sleepiness Scale may not reflect objective measures of sleepiness or sleep apnea. Neurology. 1999;52:125–31.[↩]
7. Kushida, et al. Practice parameters for the indications for polysomnography and related procedures: An update for 2005. Sleep. 2005;28(4):499–521.[↩]
8. Institute of Medicine of the National Academies. Committee on Sleep Medicine and Research. In: Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academy of Sciences; 2006.[↩]
9. Wise MS. Objective measures of sleepiness and wakefulness: Application to the real world? J Clin Neurophysiol. 2006;23:39–49.[↩]
10. American Academy of Sleep Medicine. International Classification of Sleep Disorders, Second Edition: Diagnostic and Coding Manual. Westchester, IL: American Academy of Sleep Medicine; 2005 [↩]
11. Chervin RD. Sleepiness, fatigue, tiredness, and lack of energy in obstructive sleep apnea. Chest. 2000;118:377–9.[↩]
12. Richardson GS, Carskadon MA, Flagg W, et al. Excessive daytime sleepiness in man: Multiple sleep latency measurement in narcoleptic and control subjects. Electroencephalogr Clin Neurophysiol. 1978;45:621–7.[↩]
13. van den Hoed J, Kraemer H, Guilleminault C, et al. Disorders of excessive daytime somnolence: Polygraphic and clinical data for 100 patients. Sleep. 1981;4:23–37.[↩]
14. Mitler MM, Gujavarty KS, Browman CP. Maintenance of wakefulness test: a polysomnographic technique for evaluating treatment efficacy in patients with excessive somnolence. Electroencephalogr Clin Neurophysiol. 1982;53:658–61.[↩]
15. Arand D, Bonnet M, Hurwitz T, et al. The clinical use of the MSLT and MWT. Sleep. 2005;28:123–44.[↩][↩][↩][↩]
16. Institute of Medicine of the National Academies. Committee on Sleep Medicine and Research. In: Colten HR, Altevogt BM, editors. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC: National Academy of Sciences; 2006[↩][↩]
17. Richardson GS, Miner JD, Czeisler CA. Impaired driving performance in shiftworkers: The role of the circadian system in a multifactorial model. Alcohol Drugs Driving. 1989;90(5/6):265–73.[↩]
18. Sangal RB, Thomas L, Mitler MM. Maintenance of wakefulness test and multiple sleep latency test. Measurement of different abilities in patients with sleep disorders. Chest. 1992;101:898–902.[↩]
19. Restless Legs Syndrome Fact Sheet. https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Restless-Legs-Syndrome-Fact-Sheet[↩]
20. Daly DD, Yoss RE. The treatment of narcolepsy with methyl phenylpiperidylacetate: A preliminary report. Proc Staff Meet Mayo Clin. 1956;31:620–5.[↩][↩][↩][↩][↩][↩][↩][↩][↩][↩][↩][↩][↩][↩][↩]
21. McWhirter D, Bae C, Budur K. The assessment, diagnosis, and treatment of excessive sleepiness: practical considerations for the psychiatrist. Psychiatry (Edgmont). 2007;4(9):26-35. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2880940/[↩][↩][↩]
22. Guilleminault C. Amphetamines and narcolepsy: Use of the Stanford database. Sleep. 1993;16:199–201.[↩]
23. Mitler MM, Hajdukovic R, Erman MK. Treatment of narcolepsy with methamphetamine. Sleep. 1993;16:306–17.[↩]
24. Porkka-Heiskanen T, Strecker RE, Thakkar M, et al. Adenosine: A mediator of the sleep-inducing effects of prolonged wakefulness. Science. 1997;276:1265–8.[↩]
25. Roehrs T, Merlotti L, Halpin D, et al. Effects of theophylline on nocturnal sleep and daytime sleepiness/alertness. Chest. 1995;108:382–7.[↩]
26. Muehlbach MJ, Walsh JK. The effects of caffeine on simulated night-shift work and subsequent daytime sleep. Sleep. 1995;18:22–9.[↩]
27. De Valck E, De Groot E, Cluydts R. Effects of slow-release caffeine and a nap on driving simulator performance after partial sleep deprivation. Percept Mot Skills. 2003;96:67–78.[↩]
28. Silverman K, Evans SM, Strain EC, Griffiths RR. Withdrawal syndrome after the double-blind cessation of caffeine consumption. N Engl J Med. 1992;327:1109–14.[↩]
29. Wesensten NJ, Belenky G, Kautz MA, et al. Maintaining alertness and performance during sleep deprivation: modafinil versus caffeine. Psychopharmacology (Berl) 2002;159:238–47.[↩]
30. Provigil (modafinil) Full Prescribing Information. West Chester, PA: Cephalon, Inc.; 2004.[↩]
31. Schwartz JR. Modafinil: New indications for wake promotion. Expert Opin Pharmacother. 2005;6:115–29.[↩][↩]
32. US Modafinil in Narcolepsy Multicenter Study Group. Randomized trial of modafinil as a treatment for the excessive daytime somnolence of narcolepsy. Neurology. 2000;54:1166–75.[↩]
33. Czeisler CA, Walsh JK, Roth T, et al. for the US Modafinil in Shift Work Sleep Disorder Study Group. Modafinil for excessive sleepiness associated with shift-work sleep disorder. N Engl J Med. 2005;353:476–86.[↩]
34. DeBattista C, Doghramji K, Menza MA, et al. for the Modafinil in Depression Study Group. Adjunct modafinil for the short-term treatment of fatigue and sleepiness in patients with major depressive disorder: A preliminary double-blind, placebo-controlled study. J Clin Psychiatry. 2003;64:1057–64.[↩]
35. Fava M, Thase ME, DeBattista C. A multicenter, placebo-controlled study of modafinil augmentation in partial responders to selective serotonin reuptake inhibitors with persistent fatigue and sleepiness. J Clin Psychiatry. 2005;66:85–93.[↩]
36. Sevy S, Rosenthal MH, Alvir J, et al. Double-blind, placebo-controlled study of modafinil for fatigue and cognition in schizophrenia patients treated with psychotropic medications. J Clin Psychiatry. 2005;66:839–43.[↩]
37. Berigan T. Modafinil treatment of excessive sedation associated with divalproex sodium [letter] Can J Psychiatry. 2004;49:72–3.[↩]
38. Xyrem (sodium oxybate) Full Prescribing Information. Palo Alto, CA: Jazz Pharmaceuticals, Inc.; 2005.[↩][↩]