Excessive Daytime Sleepiness: A Clinical Review

Excessive daytime sleepiness (EDS) is a highly prevalent condition that is associated with significant morbidity. The causes of EDS are varied, and include inadequate sleep, sleep disordered breathing, circadian rhythm sleep-wake disorders, and central disorders of hypersomnolence (narcolepsy, idiopathic hypersomnia, and Kleine-Levin syndrome). Additionally, EDS could represent a symptom of an underlying medical or psychiatric disorder. Assessment of EDS includes a thorough sleep, medical, and psychiatric history, targeted clinical examination, and appropriate use of actigraphy to measure sleep duration and sleep-wake patterns, polysomnography to assess for associated conditions such as sleep-related breathing disorders or other factors that might disrupt nighttime sleep, multiple sleep latency testing to ascertain objective sleepiness and diagnose central disorders of hypersomnolence, and measurement of cerebrospinal fluid hypocretin-1 concentration. Treatment of EDS secondary to central disorders of hypersomnolence is primarily pharmacologic with wakefulness-promoting agents such as modafinil, stimulants such as methylphenidate and amphetamines, and newer agents specifically designed to improve wakefulness; behavioral interventions can provide a useful adjunct to pharmacologic treatment. When excessive sleepiness is secondary to other conditions, the treatment should focus on targeting the primary disorder. This review discusses current epidemiology, provides guidance on clinical assessments and testing, and discusses the latest treatment options. For this review, we collated the latest evidence using the search terms excessive sleepiness, hypersomnia, hypersomnolence, treatment from PubMed and MEDLINE and the latest practice parameters from the American Academy of Sleep Medicine.     

睡眠监测技术对日间过度思睡患者病因诊断的研究

目的:探讨睡眠监测技术对日间过度思睡(Excessive Daytime Sleepiness,EDS)的病因学诊断价值.方法:选取2017年6月至2019年6月安徽医科大学附属巢湖医院收治的EDS患者115例作为研究对象,行整夜多导睡眠监测及次日的多次睡眠潜伏期试验(Multiple Sleep Latency Te...     

A case-control study on excessive daytime sleepiness in episodic migraine

Migraine patients often complain of sleepiness, a problem that manifests both during and outside an attack, may impair the quality of life and can lead to potentially harmful situations. Findings from an uncontrolled study suggest that a high percentage of migraineurs experience excessive daytime sleepiness (EDS). We investigated EDS in a case-control study on 100 patients with episodic migraine and 100 age- and sex-matched healthy controls and also assessed sleep quality, anxiety and depression. Although it was found that EDS was more frequent in migraineurs than in controls (14% vs. 5%; odds ratio 3.1; 95% confidence interval 1.1-8.9), the frequency was lower than previously reported. EDS correlated with migraine disability, sleep problems and anxiety. EDS in patients with migraine probably stems from the full constellation of headache-sleep-affective symptoms resulting from the complex clinical burden of the disease.     

Disorders of excessive daytime sleepiness

The complaint of excessive daytime sleepiness (EDS) is associated with a number of disorders. The frequently disabling symptoms of EDS are just beginning to be addressed. This article offers nurse practitioners background information to help in evaluating EDS symptoms. Disorders related to the physiological need for sleep and the response to disrupted sleep or the effect of psychobiological sleep disruption are presented. Differential diagnoses are reviewed and keys to case management are offered. The management of sleep disorders may involve a collaborative role with other health professionals in order to provide optimal patient care. To assist the NP in referring the patient to specialized care, referral services are described.     

Narcolepsy

Narcolepsy is a chronic disorder of EDS. All patients experience EDS. Other symptoms include cataplexy, sleep paralysis, hypnagogic hallucinations, and disrupted nocturnal sleep. Treatment, usually with stimulants and low-doses of antidepressant medications, can dramatically improve the patient's quality of life. Although only advanced practice nurses may be actively involved in the diagnosis and treatment of this disorder, all nurses can encourage their patients who complain of EDS to consult a specialist in sleep disorders medicine, provide emotional support after diagnosis, and educate patients and their families about narcolepsy and its treatment.     

Restless legs syndrome and quality of sleep in type 2 diabetes

OBJECTIVE: To investigate the presence of restless legs syndrome (RLS) and the quality of sleep in a population of type 2 diabetic patients. RESEARCH DESIGN AND METHODS: The study population was composed of 100 consecutive patients regularly attending a diabetes clinic at the University Hospital of the Federal University of Ceará. The subjects' quality of sleep was assessed by the Pittsburgh Sleep Quality Index, and excessive daytime sleepiness (EDS) was measured by the Epworth Sleepiness Scale. The RLS was diagnosed using the four minimum criteria defined by the International Restless Legs Syndrome Study Group. Other relevant clinical and laboratory parameters were obtained by interview and chart review. RESULTS: RLS was found in 27% of patients. Poor sleep quality was present in 45% of cases and was associated with age (P = 0.04), peripheral neuropathy (P = 0.001), and RLS (P = 0.000). EDS was found in 26% of patients. Logistic regression analysis revealed an association between RLS and peripheral neuropathy (odds ratio 12.85 [95% CI 2.83-58.40], P = 0.001). CONCLUSIONS: RLS is common in type 2 diabetic patients and can be a major cause of sleep disruption in these patients.     

Disorders of glucose metabolism and insulin resistance in patients with obstructive sleep apnoea syndrome

Objective: Insulin resistance (IR) and disorders of glucose metabolism (DGM) are risk factors for cardiovascular diseases. There are different reasons for development of DGM in patients with obstructive sleep apnoea syndrome (OSAS) and this association is controversial. We investigated the frequency of DGM and IR in patients with OSAS and determining factors for these disorders. Method: One hundred and twelve untreated patients with OSAS and 19 non‐apnoeic snoring subjects upon polysomnography were included in this study. Oral glucose tolerance test (OGTT) was performed in all subjects who had fasting blood glucose < 125 mg/dl. IR method was analysed using homeostasis assessment model (HOMA‐IR). Diabetes mellitus (DM), impaired glucose tolerance (IGT) and impaired fasting glucose (IFG) were defined according to values of OGTT. DGM was defined as having one of the diagnoses of DM, IGT or IFG. Subjective sleepiness of all subjects was assessed with Epworth Sleepiness Scale (ESS). Excessive daytime sleepiness (EDS) was described as ESS score ≥ 10. Results: Fasting glucose and the rate of DGM in patients with OSAS were higher than in non‐apnoeic snoring subjects. DGM were shown in % 15.7 of non‐apnoeic snoring subjects, 29.6% of mild sleep apnoea, 50% of moderate sleep apnoea and 61.8% of severe sleep apnoea. The rate of DGM in patients with moderate and severe OSAS was higher than in non‐apnoeic snoring subjects and in patients with severe OSAS higher than in patients with mild OSAS. DGM are associated with body mass index (BMI), severity of OSAS, arousal index and EDS. In addition, IR is associated with apnoea hypopnoea index, BMI, arousal index and ESS score. Conclusion: Obstructive sleep apnoea syndrome is associated with high frequency of DGM. In addition, the progression of disease from simple snoring and mild OSAS to severe OSAS increases the rate of DGM. Thus, DGM especially in patients with severe OSAS should be examined in regular periods.     

帕金森病患者睡眠障碍相关因素分析及其对生活质量的影响

目的探讨帕金森病(PD)患者伴发睡眠障碍(SD)的特点、影响因素、与运动症状(MS)及非运动症状(NMS)的相关性及其对患者生活质量的影响。方法收集2010年4月至2011年11月就诊于北京天坛医院神经内科的132例PD患者的人口学资料,采用匹兹堡睡眠指数量表(PSQI)、爱泼沃斯瞌睡量表(ESS)评估患者睡眠状况,完成相关MS、NMS及生活质量量表的评定。结果 (1)132例PD患者中86例(65.2%)伴发SD(PSQI评分≥5分),为SD组,PSQI平均分为(9.7±3.9)分;46例(34.8%)不伴发SD(PSQI评分<5分),为NSD组;同时完成ESS量表评定的114例患者中,15例(13.2%)有白天困倦(ESS评分≥10分),ESS平均分为(13.5±3.2)分,99例(86.8%)无白天困倦(ESS评分<10分)。(2)PD患者PSQI量表前三位因子及评测结果分别为白天功能紊乱(1.6±1.0)分,睡眠紊乱(1.3±0.5)分,主观睡眠质量(1.3±0.8)分。(3)SD组和NSD组除受教育水平(P=0.032)外,性别、年龄、起病年龄、病程、起病侧别及临床类型均无显著差异(P>0.05)。(4)SD组和NSD组除了统一帕金森病量表(UPDRS)Ⅲ评分外(P=0.007),H-Y分期、改良Webster评分、剂末现象个数、UPDRSⅣ评分均无显著差异(P>0.05)。(5)SD组NMS个数、运动症状期后NMS个数明显多于NSD组(P=0.000),而运动症状期前NMS无显著差异(P>0.05);SD组眩晕、噩梦、入睡困难、白天思睡、性生活障碍、性冷淡、焦虑、抑郁、淡漠、注意力下降、疼痛及梦游的发生率明显高于NSD组(P<0.05);SD组UPDRSⅠ、汉密尔顿抑郁量表(HAMD)、汉密尔顿焦虑量表(HAMA)、ESS、自主神经症状量表(SCOPA-AUT)、疲劳量表(FS-14)、疲劳严重度量表(FSS)及不宁腿综合征严重程度评定量表(RLSRS)评分均明显高于NSD组(P<0.05)。(6)SD组UPDRSⅡ、日常生活能力量表(ADL)评分明显高于NSD组(P<0.05);SD组39项帕金森病生活质量问卷(PDQL-39)量表评分明显低于NSD组(P<0.05)。(7)相关分析发现,焦虑、抑郁与PSQ     

Effect of nootropic drugs on normal and disturbed sleep of the elderly: controlled studies with pyridoxilate and street noise

The effect of the nootropic drug, piridoxilate on normal and on exogenously (by traffic noise) disturbed sleep and awakening quality was investigated in a double-blind placebo-controlled study. 10 elderly subjects with a mean age of 62 years spent 13 nights in the sleep laboratory: 2 adaptation nights, 1 baseline night, 3 drug nights (placebo, 300 and 600 mg piridoxilate), as well as 2 drug nights with nocturnal traffic noise (placebo and 600 mg piridoxilate) and the subsequent wash-out nights. Polysomnographic recordings (including EEG, EMG and EOG) were carried out between 10:30 p.m. and 6.00 a.m. Traffic noise was pre-recorded at a busy Viennese street and presented continuously by a loudspeaker with a sound pressure level at the ear of between 68 and 83 dB (A) [mean 75.6 dB (A)]. In the morning the subjects completed a sleep questionnaire for the subjective evaluation of their quality of sleep and awakening. Thereafter objective awakening quality was measured by a psychometric test battery. Piridoxilate did not induce any significant changes in objective and subjective sleep variables. Nocturnal traffic noise produced a decrease in total sleep time and sleep efficiency, an increase in wakefulness and drowsiness (stage 1), as well as a decrease in REM and deep sleep stages, the last-mentioned being of statistical significance. Subjectively, the elderly subjects reported a deterioration in sleep quality due to traffic noise, an increase in middle and late insomnia, as well as a deterioration in awakening quality (dizziness, tiredness, headaches). Piridoxilate did not ameliorate these sleep disturbances.(ABSTRACT TRUNCATED AT 250 WORDS)     

Foot pain and disability in individuals with Ehlers-Danlos syndrome (EDS): impact on daily life activities

PURPOSE: To investigate the amount and severity of podiatric problems in individuals with EDS as well as the consequences on daily life activities, and to compare these results with the results from a comparison group of the general population. METHOD: The Manchester Foot Pain and Disability Schedule (MFPDS) and a demographic and foot-specific form were mailed. RESULTS: One hundred and thirty-six individuals with EDS and 292 from the comparison group responded. The median MFPDS total score in the EDS group was 33 (range 17-49) (mean 32, SD 8) and in the comparison group 17 (range 17-41) (mean 19, SD 4) (P < 0.001). The items most frequently marked with 3 points in the EDS group were: 'I avoid standing for a long time', 'I catch the bus or use the care more often', and 'I get irritable when my feet hurt' (56, 46 and 43%, respectively). When comparing the NRS score (i.e. Numeric Rating Scale) regarding pain intensity between the EDS group (median 5) and the comparison group (median 0), a statistically significant difference was found (P < 0.001). Other foot problems than pain were reported by 73% (n = 100) of the EDS group and by 21% (n = 60) of the comparison group (P < 0.001). The presence of flat feet in the EDS group and the comparison group was reported by 55% (n = 75) and 8% (n = 23) respectively. CONCLUSION: Individuals' with EDS endure difficulties with their mobility due to their foot problems and related disability. It is therefore of utmost importance to find ways to assess the actual foot status for this group and to support the individuals with solutions to their problems with ambulation.     

Aggressive change of a carotid-cavernous fistula in a patient with Ehlers–Danlos syndrome type IV

The authors report a rare case of a carotid-cavernous fistula (CCF) secondary to Ehlers–Danlos syndrome (EDS) type IV which showed an aggressive angiographical change.A 59-year-old woman presented with headache, right pulsatile tinnitus, and diplopia on the right side. The diagnostic angiography demonstrated a right CCF. Accordingly transarterial embolization of the fistula was attempted 5 days later. The initial right internal carotid angiography showed an aneurysm on the petrous portion of the internal carotid artery (ICA) which was not recognized in the diagnostic angiography. Spontaneous reduction of the shunt flow and long dissection of the ICA were also revealed. The aneurysm was successfully occluded with coils, and only minor shunt flow was shown on the final angiogram. EDS type IV was diagnosed with a skin biopsy for a collagen abnormality. After the operation, the stenosis of the right ICA gradually progressed, although there was no recurrence of the CCF.Interventional treatment for patients with EDS can cause devastating vascular complication. We should be aware of the possibility of EDS type IV when a spontaneous CCF shows unusual angiographical change because early diagnosis of EDS type IV is crucial for determination of the optimum treatment option.     

Correlation of the M-mode atrioventricular plane early diastolic downward slope and systolic parameters

BACKGROUND: The early diastolic downward slope (EDS) of the left atrioventricular plane displacement (AVPD) is a parameter of early left ventricular (LV) diastolic filling, particularly useful in revealing pseudonormalisation of the transmitral Doppler early to atrial (E/A) ratio. In recent studies LV early diastolic function seems to be closely linked to LV systolic function. In order to further examine this relationship we studied the correlation between EDS and traditional Doppler parameters of LV diastolic function as well as between EDS and systolic parameters. METHODS: LV diastolic function was assessed by echocardiography/Doppler in 62 consecutive patients by measurement of EDS and using a traditional four-grade scale based on a combination of the E/A ratio, the E-wave deceleration time (Edt), and the systolic/diastolic ratio of the pulmonary venous inflow (S/D). LV systolic function was evaluated by ejection fraction (LVEF) and AVPD. EDS was assessed from AVPD registrations. RESULTS: In univariate analysis of variance (ANOVA), EDS was not significantly related to overall diastolic function, but highly significantly related to both LVEF (p = 0.001) and AVPD (p < 0.0001). CONCLUSIONS: EDS was more closely related to LV systolic parameters than to LV diastolic function assessed traditionally by Doppler, using a combination of E/A, Edt and S/D. This relationship between the early filling of the LV and the LV systolic function is in line with some earlier findings. It is suggestive of a relationship between the systolic and early diastolic performance of the LV.     

Obstructive sleep apnea: recognition and management considerations for the aged patient

Sleep-disordered breathing (SDB) problems are estimated to affect between 2% to 4% of Americans with an even higher incidence occurring as one ages. This article focuses on obstructive sleep apnea (OSA) as a risk to safety and a leading contributor to interrupted sleep and disease morbidity in the aged population. Obstructive sleep apnea is caused by interruption in upper airway airflow during sleep that leads to oxygen desaturations and disruptions in sleep continuity. The symptoms, diagnosis, and initial management of OSA are discussed that provide direction for the advanced practice nurse who encounters patients with this disease.     

Homozygous factor V Leiden mutation in type IV Ehlers-Danlos patient

Ehlers-Danlos syndrome (EDS) is a group of inherited connective tissue disorders caused by collagen synthesis defects. Several hemostatic abnormalities have been described in EDS patients that increase the bleeding tendencies of these patients. This case report illustrates a patient with an unusual presentation of a patient with type IV EDS, platelet δ-storage pool disease and factor V Leiden mutation. Young woman having previous bilateral deep vein thrombosis and pulmonary emboli coexisting with ruptured splenic aneurysm and multiple other aneurysms now presented with myocardial infarction. Presence of factor V Leiden mutation raises the possibility that the infarct was due to acute coronary thrombosis, although coronary artery aneurysm and dissection with myocardial infarction is known to occur in vascular type EDS. This is the first report in the medical literature of factor V Leiden mutation in an EDS patient which made the management of our patient challenging with propensity to both bleeding and clotting.     

山莨菪碱和蜕皮激素对内毒素致体外内皮细胞能量代谢的保护作用

目的：探讨山莨菪碱（６５４－２）和蜕皮激素９ＥＤＳ）对内毒素（ＬＰＳ）致伤培养脐静脉内皮细胞（ＨＵＶＥＣｓ）能量代谢的保护作用。方法：采用反相市郊和液相色谱分析法测定ＬＰＳ损伤后培养ＨＵＶＥＣｓ ＡＴＰ、ＡＤＰ、ＡＭＰ及能量负荷（ＥＣ）的变化以及６５４－２、ＥＤＳ的保护作用。结果：ＬＰＳ与内皮细胞孵育后低浓度、早期内皮细胞被激活,ＬＰＳ同一浓度刺激后,随刺激时间延长,ＨＵＶＥＣｓ ＥＣ降低,与正常     

Site-specific Effects of Transcranial Direct Current Stimulation on Sleep and Pain in Fibromyalgia: A Randomized, Sham-controlled Study

Objective: To investigate whether active anodal transcranial direct current stimulation (tDCS) (of dorsolateral prefrontal cortex [DLPFC] and primary motor cortex [M1]) as compared to sham treatment is associated with changes in sleep structure in fibromyalgia. Methods: Thirty‐two patients were randomized to receive sham stimulation or active tDCS with the anode centered over M1 or DLPFC (2 mA, 20 minutes for five consecutive days). A blinded evaluator rated the clinical symptoms of fibromyalgia. All‐night polysomnography was performed before and after five consecutive sessions of tDCS. Results: Anodal tDCS had an effect on sleep and pain that was specific to the site of stimulation: such as that M1 and DLPFC treatments induced opposite effects on sleep and pain, whereas sham stimulation induced no significant sleep or pain changes. Specifically, whereas M1 treatment increased sleep efficiency (by 11.8%, P = 0.004) and decreased arousals (by 35.0%, P = 0.001), DLPFC stimulation was associated with a decrease in sleep efficiency (by 7.5%, P = 0.02), an increase in rapid eye movement (REM) and sleep latency (by 47.7%, P = 0.0002, and 133.4%, P = 0.02, respectively). In addition, a decrease in REM latency and increase in sleep efficiency were associated with an improvement in fibromyalgia symptoms (as indexed by the Fibromyalgia Impact Questionnaire). Finally, patients with higher body mass index had the worse sleep outcome as indexed by sleep efficiency changes after M1 stimulation. Interpretation: Our findings suggest that one possible mechanism to explain the therapeutic effects of tDCS in fibromyalgia is via sleep modulation that is specific to modulation of primary M1 activity. ?