How should I evaluate daytime sleepiness in an 88‑year‑old woman with GERD, osteoarthritis, COPD, constipation, hyperlipidemia, chronic kidney disease, prior stroke, urinary incontinence, abdominal aortic aneurysm status post bilateral lower‑extremity revascularizations, atrial fibrillation on diltiazem, anticoagulated with rivaroxaban, and taking albuterol, Trelegy Ellipta (fluticasone furoate/umeclidinium/vilanterol), midodrine, fluticasone nasal spray, Bactrim (trimethoprim‑sulfamethoxazole), nitrofurantoin, ciprofloxacin, cetirizine, montelukast, and other medications?

Evaluation of Daytime Sleepiness in an 88-Year-Old Woman with Multiple Comorbidities

Begin with a comprehensive medication review focusing on sedating agents, as polypharmacy with multiple sleep-disrupting medications is the most likely culprit in this complex patient, followed by systematic evaluation for primary sleep disorders and undertreated medical conditions.

Immediate Medication Assessment

Your first priority is identifying and addressing medication-induced sleepiness, as this patient is on multiple agents known to cause daytime sedation:

• Cetirizine (antihistamine) is a sedating medication that can cause significant daytime drowsiness and should be discontinued or switched to a non-sedating alternative 1
• Diltiazem (beta-blocker alternative, but still a cardiovascular agent) can contribute to sleepiness and fatigue 2, 3
• Montelukast and fluticasone nasal spray may have sedating effects in some patients 1
• Nitrofurantoin and ciprofloxacin (concurrent use raises concern for polypharmacy and potential CNS effects) should be reviewed for necessity 1
• Bactrim DS chronic use may indicate recurrent infections that could contribute to fatigue 1

The combination of multiple medications with sedating properties creates additive or synergistic effects that significantly worsen daytime sleepiness 2

Critical Distinction: Sleepiness vs. Fatigue

Determine whether the patient has true sleepiness (involuntary tendency to fall asleep) or fatigue (low energy, tiredness, weariness):

• True sleepiness with involuntary sleep episodes suggests obstructive sleep apnea, narcolepsy, or periodic limb movement disorder and requires immediate sleep specialist referral 2, 1
• Fatigue without involuntary sleep is more consistent with medication effects, undertreated medical conditions, or depression 2
• Ask specifically about falling asleep during conversations, while eating, or during activities—this indicates pathologic sleepiness requiring urgent evaluation 1

Structured History Taking

Obtain history from both patient AND caregiver, as cognitive impairment from prior stroke may limit reliability 1:

Sleep-Wake Pattern Assessment

• Duration of nighttime sleep and total time in bed (distinguish insufficient sleep from hypersomnia) 1
• Frequency, duration, and timing of naps—both voluntary and involuntary episodes 2
• Presence of snoring, witnessed apneas, or gasping (COPD and heart failure increase OSA risk) 3
• Nocturia frequency (likely given age, medications, and urinary incontinence) 1, 3

Symptom Characterization

• Onset, frequency, and duration of sleepiness 1
• Response to napping (refreshing vs. non-refreshing) 1
• Presence of cataplexy, sleep paralysis, hypnagogic hallucinations, or automatic behaviors (narcolepsy features, though rare at this age) 1
• Restless legs symptoms or leg jerking during sleep (common in elderly, worsened by iron deficiency) 4

Red Flag Assessment

• Cognitive decline beyond baseline post-stroke (sleepiness predicts dementia progression) 5
• Severe irritability, depression, or social withdrawal disproportionate to sleep complaints 2, 3
• New or worsening cardiovascular symptoms (excessive daytime sleepiness independently predicts cardiovascular mortality with HR 2.55-2.85) 6, 7

Physical Examination Priorities

• Neurologic assessment focusing on post-stroke deficits, Parkinson's features (associated with hypersomnia), and cognitive status using standardized tool 1
• Cardiovascular examination for heart failure exacerbation (orthopnea, edema, elevated JVP) 1, 3
• Respiratory assessment for COPD control (wheezing, prolonged expiration, accessory muscle use) 1, 3
• Body mass index and neck circumference (OSA risk factors) 1

Objective Assessment Tools

Administer the Epworth Sleepiness Scale (ESS) immediately—this validated tool quantifies subjective sleepiness and predicts mortality in elderly nursing home residents 1, 8:

• ESS >10 indicates excessive daytime sleepiness and predicts 1.63-fold increased mortality risk at 12 months 8
• ESS >10 also triggers need for polysomnography evaluation 1

Implement a 2-week sleep diary or actigraphy to distinguish insufficient sleep syndrome from true hypersomnia 4

Laboratory Evaluation

Order targeted laboratory tests to identify reversible medical causes 1:

• Thyroid-stimulating hormone (TSH) (hypothyroidism causes hypersomnia) 1, 3
• Complete blood count (anemia contributes to fatigue) 1
• Comprehensive metabolic panel (renal function given CKD, hepatic function, electrolytes) 1
• Iron studies, B12, folate, vitamin D (deficiencies worsen sleep quality and cause restless legs) 4

Polysomnography Indications

Refer for overnight polysomnography followed by Multiple Sleep Latency Test (MSLT) if 1:

• ESS >10 with true involuntary sleepiness 1, 2
• Suspected obstructive sleep apnea (snoring, witnessed apneas, COPD, heart failure) 3
• Suspected periodic limb movement disorder or restless legs syndrome 1
• Sleepiness persists after medication optimization and treatment of medical conditions 1

Note: Common medications in elderly patients (including those this patient takes) may complicate MSLT interpretation and should be reviewed with sleep specialist before testing 1

Comorbidity-Specific Considerations

Post-Stroke Hypersomnia

• Stroke is a recognized cause of hypersomnia due to neurologic injury 1
• Brain MRI may identify additional vascular lesions contributing to sleepiness 1

COPD and Cardiovascular Disease

• Shortness of breath from COPD or heart failure directly disrupts sleep 1, 3
• Patients with respiratory symptoms are 40% more likely to report insomnia, which paradoxically can present as daytime sleepiness 3
• Optimize COPD management—ensure Trelegy Ellipta is taken consistently (currently "only when remembered") 1

Depression Screening

• Depression is 2.5 times more likely in patients with insomnia and causes fatigue mimicking sleepiness 1, 3
• Prior stroke significantly increases depression risk 1

Atrial Fibrillation

• Uncontrolled atrial fibrillation causes fatigue and reduced cardiac output 1
• Verify rate control adequacy with diltiazem 1

Immediate Management Steps

Medication Optimization (First-Line Intervention)

1. Discontinue cetirizine immediately or switch to non-sedating antihistamine (fexofenadine, loratadine) 1
2. Review necessity of chronic antibiotics (nitrofurantoin, Bactrim, ciprofloxacin)—chronic UTI prophylaxis may not be indicated 1
3. Consider switching diltiazem to ACE inhibitor or calcium channel blocker with less CNS penetration if blood pressure and rate control allow 2
4. Ensure Trelegy Ellipta adherence (poor COPD control worsens sleep) 1

Sleep Hygiene and Behavioral Interventions

• Establish fixed wake time 7 days/week (critical for circadian stability in elderly) 4
• Increase morning bright light exposure for 30-60 minutes 4
• Eliminate daytime napping if present (napping increases fall risk and disrupts nighttime sleep in elderly) 4, 3
• Optimize bedroom environment: cool (65-68°F), dark, quiet 4

Medical Optimization

• Optimize COPD management to reduce nocturnal dyspnea 1, 3
• Address nocturia (review diuretic timing, consider midodrine timing adjustment) 1, 3
• Treat constipation (can cause discomfort disrupting sleep) 1

Specialist Referral Criteria

Refer to sleep specialist when 1:

• Narcolepsy or idiopathic hypersomnia suspected 1
• Cause of sleepiness remains unknown after initial evaluation 1
• Patient unresponsive to initial medication optimization and behavioral interventions 1
• ESS >10 with true involuntary sleepiness 2, 8

Critical Prognostic Information

Excessive daytime sleepiness in this 88-year-old predicts significantly increased mortality risk:

• 2.55-2.85 times increased cardiovascular mortality risk 6, 7
• 1.63 times increased all-cause mortality at 12 months in nursing home residents 8
• Independent predictor of cognitive decline and dementia progression 5

This makes evaluation and treatment urgent, not optional 6, 7, 8

Common Pitfalls to Avoid

• Do not assume sleepiness is "normal aging"—it indicates pathology requiring evaluation 5
• Do not add sedating medications (benzodiazepines) without first addressing underlying causes—this worsens outcomes in elderly 4
• Do not overlook medication-induced sleepiness in polypharmacy patients—this is the most common reversible cause 1, 2
• Do not confuse fatigue with true sleepiness—the distinction determines diagnostic pathway 2
• Do not delay sleep specialist referral if initial interventions fail—complex elderly patients benefit from specialist expertise 1