How is excessive daytime sleepiness managed?

Management of Excessive Daytime Sleepiness

The management of excessive daytime sleepiness requires first identifying and treating underlying causes, followed by behavioral modifications, and then pharmacologic therapy with modafinil as first-line treatment for most cases of central hypersomnias. 1

Diagnostic Approach

Initial Assessment

• Use validated questionnaires like Epworth Sleepiness Scale (ESS) to quantify sleepiness severity 1
• Evaluate for:
  • Sleep deprivation
  • Sedating medications
  • Medical conditions (thyroid disorders, liver dysfunction)
  • Neurologic disorders (Parkinson's, multiple sclerosis, stroke)
  • Psychiatric conditions

Diagnostic Testing

• Overnight polysomnography (PSG) followed by Multiple Sleep Latency Test (MSLT) for suspected central hypersomnias 1
• Mean sleep latency ≤8 minutes with ≥2 REM sleep episodes on MSLT suggests narcolepsy
• Brain MRI if neurologic cause suspected (tumors, MS, stroke) 1
• Laboratory tests: TSH, liver function, CBC, basic chemistry 1

Treatment Algorithm

Step 1: Address Underlying Causes

• Optimize treatment of medical/neurologic/psychiatric disorders
• Withdraw sedating medications when possible
• Ensure adequate opportunity for nighttime sleep 1

Step 2: Behavioral Modifications

• Implement good sleep hygiene:
  • Regular sleep-wake schedule
  • Adequate time for nocturnal sleep
  • Avoid heavy meals and alcohol 1
• Schedule two 15-20 minute naps daily (noon and 4-5 pm) 1
• Increase daytime physical activity
• Reduce environmental disruptions (noise, light)

Step 3: Pharmacologic Treatment

For Narcolepsy with Cataplexy:

1. Sodium oxybate (first-line): 2

   • Treats both excessive sleepiness and cataplexy
   • Administered as liquid in 2 divided doses (bedtime and 2.5-4 hours later)
   • Starting dose: lower in elderly patients
   • Monitor for headaches, nausea, neuropsychiatric effects 1

2. Modafinil:

   • For elderly: start at 100 mg upon awakening
   • Increase weekly as needed to 200-400 mg daily
   • Common side effects: nausea, headaches, nervousness 1

For Hypersomnias without Cataplexy:

1. Modafinil (first-line):

   • Dosing as above
   • Effective for idiopathic hypersomnia and other central hypersomnias 1

2. Traditional stimulants (second-line):

   • Methylphenidate, amphetamines
   • Consider when modafinil is ineffective
   • Higher risk of cardiovascular side effects and dependence 1

Special Considerations

Elderly Patients

• Start medications at lower doses
• More frequent monitoring for side effects
• Consider drug interactions with existing medications 1
• Avoid stimulants in patients with cardiovascular disease

Occupational Concerns

• Advise patients to avoid:
  • Shift work
  • On-call schedules
  • Driving or operating heavy machinery until symptoms controlled
  • Jobs requiring sustained attention without breaks 1

Monitoring and Follow-up

• More frequent follow-up when starting or adjusting medications 1
• Monitor for:
  • Adverse effects (hypertension, palpitations, irritability)
  • Treatment efficacy using ESS
  • Functional ability improvements 1
• Assess need for occupational accommodations

Common Pitfalls

• Failing to identify and treat underlying sleep disorders (especially sleep apnea)
• Inadequate treatment of cataplexy when present
• Overlooking drug interactions with sodium oxybate and CNS depressants 2, 3
• Insufficient monitoring of treatment response and side effects
• Not recognizing medication-induced sexual dysfunction 2

Referral Indications

• Suspected narcolepsy or idiopathic hypersomnia
• Unknown cause of sleepiness
• Complex cases unresponsive to initial therapy 1