Excessive Sleepiness a ‘Serious Health Concern’

A new position statement from the American Academy of Sleep Medicine (AASM) highlights sleepiness as a key symptom of sleep-wake disorders and a range of psychiatric and neurologic disorders and calls for clinicians to prioritize evaluation and management of sleepiness in their patients.

The AASM released the statement because it wanted to highlight sleepiness as an essential patient-centered component that is present as a potential factor in sleep disorders, medical problems, and medication side effects as well as a general indicator of a person’s sleep habits, co-author Indira Gurubhagavatula, MD, director, Sleep Medicine Fellowship, and professor of medicine at Perelman School of Medicine, University of Pennsylvania, Philadelphia, told Medscape Medical News.

“We wanted to raise awareness for everyone, so that sleepiness is given due consideration in the practice of medicine or in the evaluation of research findings,” she said.

The statement was published online on April 14 in the Journal of Clinical Sleep Medicine.

Far-Reaching Health Effects

Excessive sleepiness during the day is a hallmark feature of hypersomnolence disorders like narcolepsy and idiopathic hypersomnia and is a key symptom associated with obstructive sleep apnea, chronic insomnia disorder, restless legs syndrome, and shift work disorder.

Other conditions associated with sleepiness include infections, inflammatory conditions, structural issues impacting the brain such as a stroke or traumatic brain injury, hypothyroidism, and other diseases affecting the endocrine system, neurodegenerative diseases, psychiatric conditions, and behavioral disorders.

Prescription and over-the-counter drugs can have sleepiness as a side effect as well, and clinicians should consider the potential for sleepiness when selecting a medication for their patient, particularly for older adults or patients with more than one medical condition, Gurubhagavatula and colleagues wrote.

Specific drug classes that may cause sleepiness include benzodiazepines, nonbenzodiazepine hypnotics, anticonvulsants, antipsychotics, anticholinergics, antidepressants, and antihistamines.

Sleepiness also contributes to worse response times, attention lapses, and worse performance at work or in school.

People may also have trouble distinguishing between sleepiness and being tired or fatigued. “While interrelated, sleepiness and fatigue, which refers to physical exhaustion, are distinct phenomena,” the authors wrote.

“Sleepiness is a serious health concern with wide-reaching consequences,” Eric J. Olson, MD, president of the AASM, stated in a press release. “From drowsy driving crashes to workplace errors and long-term health risks, the effects of excessive daytime sleepiness impact individuals and society every day. With one third of US adults reporting they experience excessive sleepiness, the importance of identifying interventions that recognize, assess, and treat it cannot be understated.”

While the public tends to be more aware of insomnia and its link to poor health, people are less aware of the health problems excessive sleepiness can cause, 

Ruth Benca, MD, professor of psychiatry and behavioral medicine at Wake Forest University School of Medicine, Winston-Salem, North Carolina, who was not involved with the statement, told Medscape Medical News.

“I think as a society, we’re chronically sleep deprived. We have been for decades now. Not sleeping is a badge of honor, and we’ve got a workforce that is getting chronically sleep deprived,” Benca said.

“The fact is that the health risks of sleeping too much or feeling excessively sleepy because you don’t sleep enough are probably just as great as the problems of not being able to sleep,” she said.

A Red Flag

It can be challenging to determine the root cause of sleepiness in the clinic. When a patient tells a clinician they are sleepy, it should be a red flag and “really an indication that you need to figure out what’s wrong,” Benca said.

The first step is to consider whether a person reporting excessive sleepiness is getting enough sleep at night, and then move on to other factors such as a potential sleep disorder, medication side effect, abuse of a substance, or another cause.

However, one issue is that a sleep study to confirm excessive sleepiness is a day-long test, Benca noted. “[T]he vast majority of people who are sleepy, which is a big chunk of the population, we don’t have great measures, easily administered objective tests, to look at that,” she said.

The authors of the position statement acknowledged this research gap, noting that there is a need for “objectively measured and reliable biomarkers of excessive sleepiness, including blood biomarkers, other physiologic markers, and metrics derived from the analysis of electroencephalogram recordings obtained during wakefulness and sleep.” 

They also called for greater use of sleepiness as an outcome for clinical trials of potential treatments for sleep-wake disorders, and for research in more diverse populations of patients.

“The future directions are research and better treatments, but I think also education and education of the public of the importance of sleep, and the risks of not getting sufficient sleep,” Benca said.

The authors reported financial relationships in the form of employment, consultancies, research and education grants, and advisory positions for the AASM, Apnimed, Axsome Therapeutics, Eisai, EnsoData, Idorsia, Merck, Nox Health, Primasun, and ResMed. Benca reported being a consultant to Alkermes, Biogen, Eisai, Haleon, and Idorsia, and having received grant support from Eisai and the National Institutes of Health.