evaluation of sleepy patients

7/27/2019 Evaluation of Sleepy Patients

1/4

clinical

Evaluation of the sleepy patient

Mohammad Torabi Nami

respdets reprted teir priar psicia ad

ever asked w we te sept.2

I a cpreesive surve, 16% f

respdets reprted seepig t uc (priar

persia), 30% swed seep eaviurs a

da, 15% ad igt tie awakeigs fwed

EDS ad 2.5% experieced pres wit wrk.3

Excessive datie seepiess caused

cric seep deprivati as ee ipicated i

ajr catastrpes, icudig te Exx Vadez i

spi ad te space sutte Caeger expsi.4

Seep apea, cric isia ad

parasias a affect cardivascuar,

eurgica ad psciatric status f sufferers,

eadig t icreased ridit ad eve rtait

i severe afficted patiets.5

Excessive datie seepiess is t a

persa eat issue ut as a puic safet

ccer, eaig tat it is iprtat t e

ae t accurate scree ad idetif EDS ad

prvide prper treatet.

C causes f EDS icude seep

reated reatig disrder, isufficiet seep

tie, circadia rt disrder ad siftwrk,

psciatric disrders, restess eg sdre,

edicati effect, arceps, idipatic

persia (wit r witut g seep tie)

ad varius reated edica cditis.6,7

I cparis wit arceps, wic is

caracterised a ara prpesit t fa

aseep, idipatic persia wit g seep

tie ca e viewed as a iaiit t teriate

seep. Idipatic persia witut g

seep tie cud eg t te spectru farceps.

Clinical evaluation

History taking

Te st iprtat step i evauatig EDS is a

detaied istr fr te patiet ad teir fai

eers. Srig, witessed apea, excessive

sweatig, gasp arusas, cturia ad ckig

Daytime sleepiness is defined as the

inability to stay awake and alert during

the major waking episodes of the day,

resulting in unintended lapses into

drowsiness or sleep.1 Sleepiness may

vary in severity and is more likely to occur

in boring, monotonous situations that

require no active participation.

Excessive datie seepiess (EDS) is a c

presetati t geera practitiers ad seep

psicias. Excessive datie seepiess caadverse affect quait f ife ad as ipair

d, persa reatisips ad fuctia

status. Atug a c presetati, EDS

a e uder recgised. I te 2000 Seep

Fudati Gaup Surve cducted i te Uited

States, 20% f respdets reprted tat datie

seepiess iterfered wit teir dai activities,

8% fe aseep at wrk ad 19% ade errrs

at wrk ecause f seepiess, et 61% f te

Background

Inefficient sleep leading to excessive daytime sleepiness is a common complaint

encountered by GPs and sleep physicians. Common causes of excessive daytime

sleepiness include circadian rhythm disorder/shiftwork, sleep apnoea syndrome,

psychiatric disorders, restless leg syndrome, medication effect, narcolepsy and

idiopathic hypersomnia.

Objective

This short review discusses the available objective and subjective testing measures

in office evaluation of sleepy patients, predominantly in the primary care setting.

DiscussionBeyond affecting patients quality of life, mood and functionality, excessive

sleepiness can become a public health concern when affecting critical job holders.

Therefore, a clear understanding of its importance and applying current standards

in evaluating patients with such a complaint are of great necessity. Apart from the

clinical assessments, including a thorough history taking and physical examination,

measures to assess sleepiness and ability to maintain wakefulness are available.

Keywords

disorders of excessive somnolence; sleep apnoea syndromes; general practice

Reprited f AUSTRAlIAn FAmIly PhySICIAn Vol. 41, no. 10, oCTobER 2012 787


2/4

Evaluation of the sleepy patientclinical

r cugig wie aseep are suggestive f seep

reated reatig disrder.

Te istr sud icude tta seep tie

durig te week das ad catcig up seep

weekeds. Te use f te sze fucti

aar ccks ca e idicative f seep iertia

ad isufficiet seep.

Patiets w d siftwrk ad tse w

frequet trave i differet tie zes (jet

ag effect) experiece seepiess as a ra

psigica respse t te tie f da. ma

siftwrkers devep cric partia seep

restricti ad a experiece sece

eve we te are a datie scedue.

Csider te patiets wrk scedue, icudig

wrkig urs per da ad fixed versus rtatig

scedues. If te ave a rtatig scedue,

ascertai weter te rtatis are week r

t, ad frward versus ackward.A g cute t wrk ca sigificat

srte seep durati ad ca cause cric

partia seep deprivati. Te use f tactics

wie drivig t sta awake, suc as rig te

widws dw, paig ud usic, sackig ad

eve sappig esef, are a idicative f EDS.

Restess eg sdre ca e diagsed

te istr ae. Restess eg sdre is

caracterised disagreeae eg sesatis tat

usua ccur efre seep set, a irresistie

urge t ve te is, ad partia r cpete

reief fr discfrt up eg veets.

Tese spts ca ead t sigificat reduced

seep tie, eadig t datie seepiess.

Adverse effects f a edicatis ca

as resut i EDS. Suc edicatis icude

aagesics, atidepressats, ezdiazepies,

atipsctics ad eta-ckers. I additi,

c ver-te-cuter drugs suc as

atiistaies ca ave te sae effect. Te

curret r past use f recreatia drugs, icudig

ac, sud e discussed. Sudde witdrawa

fr stiuats suc as ccaie r apetaiesca as cause sigificat seepiess.

Ask aut seep parasis, catapex,

pggic auciatis ad seep attacks

(irresistie desire t seep). I additi,

te istr sud icude askig aut te

irresistie eed fr aps trugut te da

ad weter te aps are refresig r t. A

diagsis f arceps sud e csidered i

seep patiets wit a cear istr f catapex.

I patiets wit idipatic persia, aps

are t refresig; wereas i arceptics, srt

aps ca e effective.

Physical examination

Te psica exaiati f a patiet sud

icude easureet f d ass idex ad

eck circuferece. Exaie te ra cavit fr

tgue size ad te te presece f a arrw

arced paate, tsiar pertrp, retrgatia,

icrgatia ad crwded ra parx. nasa

septu deviati, aergies, swe turiates

ad asa pps are risk factrs fr seep reated

reatig disrder. Te maapati cassificati

is ver epfu i evauatig airwa size.8 It as

ee sw tat a ig maapati scre ad

asa structi are risk factrs fr structive

seep apea (Figure 1).9,10

Measures of sleepiness

It is ver ard t quatif seepiess, eiter

sujective r jective, wever se

etds ave ee deveped t attept t

deterie te severit f a patiets seepiess.

Ater iitig factr is te fact tat seepiess

is t we defied. It is difficut t differetiate

cric fatigue fr excessive seepiess. Tere

are se sujective ad jective assessets f

prpesit t fa aseep r aiit t sta awake.

Subjective

Epworth Sleepiness Scale

First descried Js i 1991, te Epwrt

Seepiess Scae (ESS) is e f te st

frequet used ts t assess seepiess.11 Te

questiaire descries eigt situatis:

sittig ad readig

watcig teevisi

sittig iactive i a puic pace

as a passeger i a car ridig fr a ur

witut a reak ig dw t rest i te after we

circustaces perit

sittig ad takig wit see

sittig quiet after uc witut ac

eig i a car wie stpped fr a few iutes

i traffic.

Te patiet wi scre eac situati a scae

f 03 (0 = wud ever dze; 1 = sigt cace

f dzig; 2 = derate cace f dzig ad 3 =

ig cace f dzig). A tta scre f 11 r re is

suggestive f EDS.

beig sujective, tis istruet as a wide

argi f errr ad patiets tivati sud

e csidered we aasig te resuts: fr

exape, is te patiet trig t get teir drivers

icece reistated?

Wie te ESS a t crreate we wit

jective easureets, it is sti wide used ad

as prve t e a effective screeig t.11

nte tat ESS resuts d t awas accurate

refect severit f te uderig cditi ad

sud e fwed up wit jective tests.12

Stanford Sleepiness Scale

Wie te Epwrt Seepiess Scae easures

vera prpesit t fa aseep durig varius

udae activities, te Stafrd Seepiess

Scae easures te curret state f seepiess. Itcsists f te fwig seve stateets:

Feelingactive,vital,alertorwideawake

Functioningathighlevels,butnotatpeaks;able

t ccetrate

Awake,butrelaxed;responsivebutnotfully

aert

Somewhatfoggy,letdown

Foggy;losinginterestinremainingawake;

swed dw

Sleepy,woozy,fightingsleep;prefertoliedown

Nolongerfightingsleep,sleeponsetsoon;

avig drea-ike tugts.13

Te patiet cses te stateet tat st

accurate descries teir curret state f

seepiess. Te advatage f te Stafrd

Seepiess Scae is tat it ca e adiistered

utipe ties durig te da; wever te

disadvatage is tat it cat differetiate

etwee acute seep deprivati ad a uderig

seep disrder.

Karolinska Sleepiness Scale

Ater istruet, wic is ver siiar t teStafrd Seepiess Scae, is te Kariska

Seepiess Scae. Tis questiaire requires

te patiet t cse e stateet tat est

descries is r er curret state f aertess.

Te detrieta states f aertess are cassified

as: extree aert, ver aert, aert, rater aert,

eiter aert r seep, se sigs f seepiess,

seep/ effrt t sta awake, ver seep/great

effrt t keep awake/figtig seep.14

788 Reprited f AUSTRAlIAn FAmIly PhySICIAn Vol. 41, no. 10, oCTobER 2012


3/4

clinicalEvaluation of the sleepy patient

Kariska ad Stafrd seepiess scaes

are easures f state (iediate) seepiess.

Te are pra ess usefu we adiistered

wie te patiet is at te ciic; a easure

wud e re usefu if it refected seepiess

wie drivig r pred a re geera trait, ike

degree f seepiess.

Sleep diary

A patiets seep diar ca give isigt it te

cause f te patiets seepiess. Te patiet is

asked t aitai tis g fr 2 weeks, recrdig

edtie, wake tie, uer f arusas, tie it

takes t retur t seep after a arusa, te use

f a seep aid, ad a ter reevat spts.

It is particuar epfu fr idetifig seep

fragetati, isufficiet seep tie, circadia

rt seep disrder ad isia.

Objective measures ofsleepiness

Polysomnogram

A psgra (PSG) is perfred t rue

ut structive seep apea as te cause

f seepiess. Te PSG tpica icudes a

eectrecepagra (EEG), eectr-cugra,

eectrgra, eectrcardigra, respiratr

caes ad xge saturati. A Apea-

hppea Idex (AhI) f re ta 15 per ur f

seep is diagstic fr a seep reated reatig

disrder. Atug t idicated fr restess eg

sdre, te PSG ca ep idetif peridic i

veets as a cause f seep disrupti. A

PSG is as de a igt efre a mutipe Seep

latec Test t esure te patiet acieved a

adequate aut f seep.

Multiple Sleep Latency Test

A mutipe Seep latec Test (mSlT) is priari

idicated fr evauati f arceps ad

idipatic persia. Te mSlT assesses

te patiets prpesit t fa aseep. Te test

csists f five 20 iute ap pprtuities. A

verigt PSG, perfred te igt efre, is

required t esure te patiet attaied adequate

seep. Te first ap is 1.53 urs after te PSG,

wit eac susequet ap take 2 urs apart.

Seep atec is cacuated averagig te tie

fr igts ut t seep set durig eac ap

perid. I additi, te ccurrece f rapid ee

veet (REm) seep durig te 20 iute ap

perid (seep set REm perid, r SoREmP)sud as e ted. Seep atec greater ta

11 iutes is csidered ra. Seep atec f

ess ta 8 iutes ca e see i patiets wit

idipatic persia. hwever, a ea seep

atec f ess ta 8 iutes wit te presece

f tw r re SoREmPS is ig idicative f

arceps. Te treds fr seep prpesit appear

t e idetica i arceptic patiets wit r

witut catapex.15,16

Objective measures ofwakefulness

Maintenance of Wakefulness

Test

Wereas te mSlT tests te prpesit t fa

aseep, te maiteace f Wakefuess Test

(mWT) assesses te aiit f a idividua

t sta awake. It is fte de t verif te

effectiveess f terap i wic seepiess

ca e a sigificat puic eat risk, suc as

i te airie ad truckig idustries. Te mWT

prtc csists f fur 40 iute ap perids,

cducted 2 urs apart. Perfrig a PSG a

igt efre te test is t required. Te patiet

sits i a sei-recied psiti i a di, quiet

r ad is asked t sta awake; a ea seep

atec f ess ta 8 iutes is csidered

ara. A mWT vaue etwee 8 ad 40iutes is iccusive ad is f ucertai

sigificace.13,1517

The steer clear reaction time

I tis test a tw ae street is sw

te cputer scree. Te patiet is asked t

press a utt t avid staces tat appear

rad i eiter ae durig te 30 iute

test perid. Istead f easurig reacti tie,

te uer f its are cuted ad preseted

as a percetage f a staces ecutered.18

Pupillometry

Te size f es pupi is ctred iputs

fr te paraspatetic ad spatetic

ervus sstes. I a state f drwsiess te

paraspatetic te prediates, resutig

i isis, wie i a state f arusa tere is

icreased spatetic te. A we-rested

pers is ae t aitai a stae pupi size

witut uc sciati i 15 iutes f tta

darkess. Pupi size ad staiit are iverse

reated t te degree f seepiess. Preset,pupietr is t used wide i ciica

practice. beig a prtae, rief ad jective

easure, tis test sud t e udervaued

ad furter researc is ecessar t deterie

te re f pupietr i te assesset f

seepiess f varius rigis.18,19 oter cuar

ased easures f seepiess suc as tse

easurig eeid drpig are eig appied

st i researc settigs.

Figure 1. Mallampati classifcation o upper airway

Adapted rom Huang H, et al. BMC Gastroenterology 2011, 11:12 doi:10.1186/1471-

230X-11-12, under the terms o the creative commons attribution license

Class I Class II

Class IVClass III

Reprited f AUSTRAlIAn FAmIly PhySICIAn Vol. 41, no. 10, oCTobER 2012 789


4/4

Evaluation of the sleepy patientclinical

Oxford Sleep Resistance Test

Te oxfrd Seep Resistace Test ca e used as

a surrgate fr te mWT. beaviura eeets

are used i ieu f a EEG t deterie seep

set. Te suject is asked t respd t a fas

f igt astig 1 secd, wic igts up ever

3 secds. Seep set is defied as te faiure

t respd t te igt fr seve csecutive

iuiatis.18,20 Te test is perfred i fur 40

iute sessis ed 2 urs apart.

Summary

Excessive seepiess is a c cditi tat

as a sigificat puic safet risk. Isufficiet

seep ad cric seep deprivati secdar t

seep reated reatig disrder are te tw st

c causes f persia.

Pepe wit tigt siftwrk scedues,

itetia cric seep restricti, witessedseep apea r sef reprted refresig

seep wit sujective datie seepiess a e

patiets w are at a icreased risk f tr

veice accidets ad wrk reated ijuries, as we

as sigificat cardivascuar diseases ad d

disrders. Patiets suspected t ave tis icreased

risk sud e carefu evauated geera

practitiers ad te, if deeed eeded, referred

fr furter assesset.

Sujective easures t assess seepiess

are gd fr screeig. hwever, te sud

t repace a detaied istr ad psica

exaiati. Se screeig ts ca e

used fr seep patiets i priar care, suc

as te seep diar; te Epwrt, Kariska ad

Stafrd Seepiess scaes; ad te oxfrd Seep

Resistace Test. Te oxfrd Seep Resistace Test,

fr istace, ca e used as a surrgate fr te

mWT, wic wi reduce te urde veraded

seep aratries.

It fte eces adatr t cduct

evauati i a seep aratr (eg. usig PSG,

mSlT ad mWT) t tai a accurate diagsisad apprpriate terapeutic iterveti.

Author

maad Trai nai mD, PD, is lecturer,

Departet f neursciece, Sc f Advaced

medica Sciece ad Tecgies, Siraz

Uiversit f medica Scieces, Siraz, Ira.

[email protected].

Cfict f iterest: e decared.

References1. Aerica Acade f Seep medicie. Te itera-

tia cassificati f seep disrders: diagstic adcdig aua, secd editi. Westcester, Iiis:Aerica Acade f Seep medicie, 2005.

2. natia Seep Fudati. 2000 oius Seepi Aerica P. Wasigt, DC: natia SeepFudati, 2000.

3. yug Tb. Epideig f datie seepiess:defiitis, sptatg, ad prevaece. J CiPsciatr 2004;65(16 Supp):126.

4. legaut G. Seep ad eat reated cages i te cg-itive perfrace f udergrud iers: a pssieeat ad safet ccer. mieras 2011;1:4972.

5. Aredt JT, Cr DA, Pser DA, Aia mS.Evauati f te isia patiet. Seep med Ci2006;1:31932.

6. Krger mh, Rt T, Deet W.C. Pricipes adpractice f seep edicie, fift editi. Piadepia:Sauders/Esevier Sciece, 2011.

7. Trp mJ, biiard m, editrs. Seepiess: causes,csequeces ad treatet. Caridge: CaridgeUiversit Press, 2011.

8. maapati SR, Gatt SP, Gugi lD, et a. A ciicasig t predict difficut tracea ituati: a prspec-

tive stud. Ca Aaest Sc J 1985;32:42934.9. liistr G, Raux P, bege C, et a. hig maapatiscre ad asa structi are assciated riskfactrs fr structive seep apea. Eur Respir J2003;21:24852.

10. Gzaes J, marsa S, Russia C. Te reatisipetwee te maapati Scrig Sste, te beriQuestiaire, ad te Epwrt Seepiess Scae.Te Iteret Jura f Aied heat Scieces adPractice 2011;9:3.

11. Js m. A ew wa f easurig datieseepiess: te Epwrt Seepiess Scae. Seep1991;14:5405.

12. Cervi RD, Adric mS. Te Epwrt seepiessscae a t refect jective easures f seepi-ess r seep apea. neurg 1999;52:12531.

13. hddes E, Zarce V, Ste h, Piips R, DeetWC. Quatificati f seepiess: a ew apprac.Pscpsig 1973;10:4316.

14. Kaida K, Takaasi m, Akerstedt T, et a. Vaidati fte Kariska seepiess scae agaist perfracead EEG variaes. Ci neurpsi 2006;117:157481.

15. Takei y, Kada y, naa K, et a. Differeces ifidigs f ctura psgrap ad utipeseep atec test etwee arceps ad idipaticpersia. Ci neurpsi 2012;123:13741.

16. Akerstedt T, Gierg m. Sujective ad jectiveseepiess i te active idividua. It J neursci1990;52:2937.

17. litter mR, Kusida C, Wise m, et a. Practice para-eters f te ciica use f te utipe seep atec

test ad te aiteace f wakefuess test. Seep2005;28:11321.

18. matis J, hess CW. Seepiess ad vigiace tests.Swiss med Wk 2009;139:2149.

19. lwestei o, Fieerg R, lwefed I. Pupiarveets durig acute ad cric fatigue: a ewrest fr te jective evauati f tiredess. Ivestopta 1963;2:13857.

20. beett lS, Stradig JR, Davies RJ. A eaviuratest t assess datie seepiess i structive seepapea. J Seep Res 1997;6:1425.

790 Reprited f AUSTRAlIAn FAmIly PhySICIAn Vol. 41, no. 10, oCTobER 2012

evaluation of sleepy patients

Documents