Disorders with excessive daytime sleepiness

Disorders with excessive daytime sleepiness

  • Idiopathic hypersomnia 
    • Like narcolepsy, patient complains of excessive sleep
      • 10 or more hours of nighttime sleep plus daytime naps (total sleep time typically does not exceed 12 hours on weekdays, but may be as long as 19 hours on weekends or holidays) 
    • Differentiate from narcolepsy by:
      • Lack of restive naps during the day
      • Prolonged sleep
      • Diagnosis established through a series of sleep studies
        • Epworth sleepiness scale 
          • For a diagnosis of idiopathic hypersomnia, symptoms have to be present for 3 months or longer 
        • Overnight polysomnogram
          • Differentiates idiopathic hypersomnia from narcolepsy and other sleep disturbances (eg, obstructive sleep apnea, periodic leg movement disorder)
        • Multiple sleep latency test 
          • Less than 2 sleep-onset rapid eye movement periods 
          • Mean sleep latency of 8 minutes or less
  • Sleep apnea
    • 1 or more pauses in breathing or shallow breaths during sleep
      • Breathing pauses can last from a few seconds to minutes and may occur 30 times or more per hour 
      • Typically, normal breathing resumes, sometimes with a loud snort or choking sound
      • Sleep quality is poor, which results in excessive daytime sleepiness with frequent episodes of falling asleep, similar to narcolepsy
    • Differentiate from narcolepsy by history of pause in breathing during sleep, detected by polysomnography with apnea-hypopnea index of 5 or more (ie, number of apnea or hypopnea episodes per hour) 
  • Advanced sleep phase syndrome
    • Circadian rhythm disorder defined by a stable sleep schedule that is several hours earlier than the desired sleep schedule, to the degree that the patient experiences significant difficulty keeping to a desired sleep schedule
    • Patients with advanced sleep phase syndrome are sleepy; they retire to bed early in the evening and wake up early in the morning. Sleep attacks are not reported
    • Differentiate by history of very early awakening associated with early bedtime and, if needed, polysomnography to exclude narcolepsy 
  • Delayed sleep phase syndrome
    • Most prevalent circadian rhythm disorder; defined by delayed onset of sleep beyond the conventional bedtime, associated with difficulty in awakening at the desired time
    • Results in daytime sleepiness due to sleep deprivation; sleep attacks are not reported
    • Differentiate by history of late bedtime associated with difficulty arising at a desired (typically more conventional) time and, if needed, polysomnography to exclude narcolepsy
  • Depression with excessive daytime sleepiness (Related: Major depressive disorder)
    • Disruption or irregularity in the circadian sleep-wake cycle resulting in excessive sleepiness or wakefulness at inappropriate times of day or night
    • Sleep attacks are not reported
    • Occurs in patients with depressive disorders and usually responds well to treatment of depression
    • Differentiate by history of depression and response to treatment of depression; if needed, perform multiple sleep latency test to exclude narcolepsy 
  • Restless leg syndrome or periodic limb movement during sleep with subsequent excessive sleepiness
    • Irresistible urge to move the legs to avoid uncomfortable sensations, resulting in sleep disruption
    • Most patients with restless leg syndrome also have periodic limb movement during sleep, which results in nighttime awakening and daytime sleepiness
    • Sleep attacks are not reported
    • Differentiate from narcolepsy by history of restless legs when trying to sleep or periodic limb movements that disrupt sleep and multiple sleep latency test to exclude narcolepsy 
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