Recognizing Problem Sleepiness in Your Patients

American Family Physician,  Feb 15, 1999  

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NATIONAL CENTER ON SLEEP DISORDERS RESEARCH WORKING GROUP, Bethesda, Maryland

Normal sleep is required for optimal functioning. Normal wakefulness should be effortless and free of unintended sleep episodes. Problem sleepiness is common and occurs when the quantity of sleep is inadequate because of primary sleep disorders, other medical conditions or lifestyle factors. Medications and substances that disturb sleep, such as caffeine and nicotine, or those that have sedating side effects, may also cause problem sleepiness. This condition can lead to impairment in attention, performance problems at work and school, and potentially dangerous situations when the patient is driving or undertaking other safety- sensitive tasks. However, problem sleepiness is generally correctable when it is recognized. Asking a patient and his or her bed partner about the likelihood of drowsiness or of falling asleep during specific activities, as well as questions that uncover factors contributing to the sleepiness, helps the physician to recognize the disorder. Accurate diagnosis of specific sleep disorders may require evaluation by a specialist. The primary care physician is in an ideal position to identify signs and symptoms of problem sleepiness and initiate appropriate care of the patient, including educating the patient about the dangers of functioning while impaired by sleepiness.

Patients who are frequently sleepy at inappropriate times may have "problem sleepiness" and not realize it. Problem sleepiness occurs when patients don't get enough sleep because of primary sleep disorders (such as obstructive sleep apnea, insomnia, restless legs syndrome or narcolepsy), other medical conditions (such as chronic bronchitis or congestive heart failure) or lifestyle factors (such as shift work).1 Sleepy persons exhibit levels of impairment that range from poor functioning at home, school or work, to potentially life-threatening automobile crashes and industrial accidents.

Performance impairment caused by sleepiness is comparable to that caused by alcohol intoxication.2 Patients with problem sleepiness may complain of having difficulty with concentration, fatigue and emotional lability. The primary care physician has a central role in the detection and correction of problem sleepiness. Incorporating sleep-related questions into the history-taking process will aid in the initial assessment. The physician also should educate patients about the signs and dangers of problem sleepiness, the possible underlying causes and the importance of obtaining adequate sleep for optimal functioning.

Consequences of Problem Sleepiness

automobile crashes

The National Highway Traffic Safety Administration estimates that approximately 56,000 crashes per year are the result when drivers fall asleep "at the wheel."3 Persons with untreated sleep disorders such as sleep apnea, narcolepsy or insomnia have higher rates of automobile crashes than do other drivers.4,5 In a survey of drivers in New York state,6 approximately 25 percent reported they had fallen asleep at the wheel at some time. Fall-asleep crashes are especially common in young male drivers.7

adolescent development and school performance

In addition to placing young people at high risk for automobile crashes, problem sleepiness can impair learning, perceptual skills and memory,8,9 which may lead to poor school performance and grades. Mood, attention and behavior deteriorate in adolescents and young adults when they have not had adequate amounts of sleep.10 These changes may interfere with a teenager's ability to cope with daily stressors.

work-related accidents

Sleepiness in the workplace contributes significantly to performance errors and increases the risk of accidents. Sleepiness has contributed to serious incidents in industrial operations, nuclear power plants and all modes of transportation.11

Causes of Problem Sleepiness

In all people, sleepiness is regulated by two primary processes: the body's circadian rhythm, which causes an increase in sleepiness twice during a 24-hour period (in general, during the hours between midnight and 7 a.m. and for a brief period in the midafternoon, between 1 p.m. and 4 p.m.); and the physiologic need for sleep, which is increased by sleep loss and sleep disruption.

The need for sleep and the circadian rhythm interact to determine a person's levels of sleepiness and alertness.12 People with disturbances of either of these sleep-regulating mechanisms can exhibit problem sleepiness, with the most common causes being primary sleep disorders, other medical conditions that disrupt sleep, drugs and lifestyle.

primary sleep disorders

Obstructive Sleep Apnea. Obstructive sleep apnea, a potentially life- threatening disorder, is produced by a narrowing or collapsing of the upper airway during sleep that restricts or prevents breathing.13 Repeated episodes of airway collapse throughout the night disrupt and fragment sleep, and may produce hypoxemia and other cardiovascular stress. Sleep apnea has been suspected of contributing to myocardial ischemia and myocardial infarction in patients with coronary artery disease.14