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Clinical Assessment of Sleepiness

Assessing the clinical significance of a patient’s complaint of excessive sleepiness can be complex
for an inexperienced clinician. The assessment depends on two important factors: chronicity and
reversibility. Chronicity can be explained simply. Although a healthy normal individual and
unremitting. As to reversibility, unlike the healthy normal person, increased sleep time may not
completely or consistently ameliorate a patient’s sleepiness. Patients with excessive sleepiness may
not complain of sleepiness per se, but rather its consequences: loss of energy, fatigue, lethargy,
weariness, lack of initiative, memory lapses, or difficulty concentrating.

To clarify the patient complaint, it is important to focus on soporific situations in which
physiological sleepiness is more likely to be manifest, as was discussed earlier. Such situations might
include watching television, reading, riding in a car, listening to a lecturer, or sitting in a warm room.
Table 4-1 presents the commonly reported “sleep including “ situations for a large sample of patients
with sleep apnea syndrome. After clarifying the complaint, one should ask the patient about the entire
day: morning, midday, and evening. In the next section, it will become clear that most adults
experience sleepiness over the midday. However, patients experience sleepiness at other times of the
day as well, and often throughout the day. Whenever possible, objective documentation of sleepiness
and its severity should be sought. As indicated earlier, the standard and accepted method to document
sleepiness objectively is the MSLT.

Guidelines for interpreting the result of the MSLT are available (see Fig 4-1). “A number of
case series of patients with disorders of excessive sleepiness have been published with accompanying
MSLT data for each diagnostic classification. These data provide the clinician with guidelines for
evaluating the clinical significance of a given patient’s MSLT results. Although these data cannot be
considered norms, a scheme for a ranking MSLT scores to indicate degree of pathology has been
suggested. An average daily MSLT score of 5 minutes of fewer suggests pathological sleepiness, a
score of more than 5 minutes but fewer than 10 minutes is considered a diagnostic gray area, and a
score of more than 10 minutes is considered to be in the normal range (see Fig 4-1 for MSLT results
in the general population). The MSLT is also useful in identifying sleep-onset REM periods
(SOREMPs), which are common in patients with narcolepsy. The American Academy of Sleep
Medicine Standards of Practice Committee has concluded that the MSLT is indicated in the evaluation
of patients with suspected narcolepsy. MSLT results, however, must also be evaluated with respect
to the conditions under which the testing was conducted. Standards have been published for
administering the MSLT, which must be followed to obtain a valid, interpretable result.

Reduced sleep time explains the excessive sleepiness of several patient and non-patient groups.e.e. and report about 2 hours more sleep on each weekend day than each weekday. “normal” nocturnal sleep with unusually high sleep efficiency (time asleep-time in bed). the set point around which the sleep homeostat regulates daily sleep time. Regularizing bedtime and increasing time in bed produces a resolution of their symptoms and normalized MSLT results. 4-1) However. modest nightly sleep restriction accumulates over nights to progressively increase daytime sleepiness and performance lapses (see Fig. partial or total sleep deprivation in healthy normal subjects is followed by increased daytime sleepiness the following day. As to sleepiness. The basal differences may reflect insufficient nightly sleep relative to ones’ sleep need.DETERMINANTS OF SLEEPINESS Quantity of Sleep The degree of daytime sleepiness is directly related to the amount of nocturnal sleep. that is how large a sleep deficit the system can tolerate and how robustly the sleep homeostat produces sleep when detecting deficiency.. A difference in the basal level of sleepiness at the start of a sleep time manipulation is quite possible given the range of sleepiness in the general population (see Fig. their sleepiness is reduced to a level resembling the general population mean. which then increases the duration of the subsequent recovery process. as studies have shown adaptation to a slow accumulation of 1 to 2 hours nightly occurs. have long been hypothesized and one study has suggested a gene polymorphism may mediate vulnerability to sleep loss. Further. There also may be differences in the sensitivity and responsivity of the sleep homeostat to sleep loss. The increased sleepiness of healthy young adults also can be attributed to insufficient nocturnal sleep. Increased sleep time in healthy. . Therefore. Individual differences in tolerability to sleep loss have been reported. genetic differences in sleep need.. The performance effects of acute and chronic sleep deprivation are discussed in Chapters 5 and 6. These all are fertile areas for research. a subgroup of sleep clinic patients has been identified whose excessive daytime sleepiness can be attributed to chronic insufficient sleep. For example. the speed at which sleep loss is accumulated is critical. When the sleepiest 25% of a sample of as long as 5 to 14 consecutive nights. 4-1). reduction in sleepiness). the pharmacological extension of sleep time by an increase in mean sleep latency on the MSLT (i. These patients show objectively documented excessive sleepiness. Finally. but sleepy. These differences can be attributed to a number of possible factors. young adults by extending bedtime beyond the usual 7 to 8 hours per night produces an increase in alertness (i. increased alertness).