Excessive daytime sleepiness . Neurologists are likely to encounter patients with EDS, not only because of the neurological nature of the symptom itself, but also because many primary neurological disorders are associated with disordered sleep, including Alzheimer's disease and other types of dementia, Parkinson's disease, other neurodegenerative conditions, peripheral neuropathy, neuromuscular disorders, epilepsy and chronic pain syndromes. According to the National Sleep Foundation 2. Omnibus Sleep in America Poll: `a sizable proportion of adults (4. A recent study (Powell et al., 1. EDS exacts a significant toll on individuals and on society. On the individual level, the symptom itself not only reduces personal effectiveness at school or work, but it also leads to problems with concentration, memory and mood, which have further negative impacts on performance. Journal of Sleep Medicine & Disorders. Cite this article: Rao BS, Rose A, Sajkov D (2015) The Challenge of Excessive Daytime Sleepiness. J Sleep Med Disord 2(2): 1018. Define daytime: the time of day. Test your visual vocabulary with our 10-question challenge! On the societal level, the negative impacts of sleepiness are likewise significant. In a recent study of professional truck drivers, 4. Hakkanen and Summala, 2. Each year, in the United States, > 5. Mahowald, 2. 00. 0). Sleepiness may be thought of as a physiological state or `urge' which promotes the onset of sleep, and which is reversed or satiated (although not always) by the attainment of adequate sleep. Patients may use other terms, such as `tiredness' or `fatigue' to describe sleepiness, thus leading to potential semantic confusion. It is important for the examiner to be precise in eliciting the medical history, since the pathways for evaluating and treating sleepiness may diverge considerably from those addressing other symptoms, such as physical fatigue. In the recent past, progress has been made in the understanding of several syndromes associated with EDS. Genetic features have been identified which may predispose individuals to this symptom. These probably act in concert with environmental factors to bring about full expression of sleepiness. Anatomy and physiology of sleepiness. The neurological substrates of sleepiness are incompletely understood. Sleepiness may reflect the waning of processes maintaining wakefulness, or it may result from distinct neural systems acting to promote sleep. Numerous areas of the brain are known to participate in the initiation and maintenance of sleep and alertness, such as the brainstem reticular activating system, locus coeruleus, dorsal raphe and other brainstem nuclei, basal forebrain, thalamus, hypothalamic loci and cortex (Mc. Carley, 1. 99. 9). It remains to be determined how these and other brain structures act and interact to produce EDS in various disorders. Many neurotransmitters and peptides are also known to play significant roles in the expression of alertness and sleep, including norepinephrine, serotonin, dopamine, GABA (gamma aminobutyric acid), acetylcholine, histamine, glutamate, adenosine, substance P, interleukin- 1 and prostaglandins, to name but a few (Zoltoski et al., 1. The recently discovered hypocretins appear to have central importance in animal and human narcolepsy (see section on narcolepsy); as further work in this area proceeds, it will be interesting to see whether these substances are involved in other clinical disorders associated with EDS. Diagnosis and evaluation of sleepiness. Daytime sleepiness is common but often unrecognized. As with most medical conditions, diagnosis of EDS begins with a precise history. The patient may present complaints of `tiredness' or `fatigue' rather than more specific symptoms of `sleepiness' or `drowsiness'. Such questions as: `Do you take naps (or would you, if given the opportunity)?', `Do you doze easily in passive or monotonous situations?', `Do you sleep later on weekends and holidays than during the workweek?' and `How long does it take to fall asleep at night?' may help the physician to distinguish true sleepiness from other, less specific complaints. Safety concerns should also be addressed in the history; patients should be queried about any difficulties or mishaps whilst driving or operating machinery. Even if some degree of sleepiness is acknowledged by the patient, secondary problems with performance or neurocognitive function may be ignored or denied. Patients commonly deny symptoms, and physicians may not recognize problems related to EDS. Performance alone may not always be the best indication of sleepiness, as motivation may temporarily override a performance decrement. Compensatory strategies may also be invoked, e. Individuals might also accept lower levels of achievement. Various tools have been developed to assess sleepiness more objectively, but each of these has shortcomings. These instruments explore different aspects of sleepiness, and several tools may be needed to evaluate a given patient. Investigators must recognize the limitations of the available methods and select them according to the clinical problem being addressed. For quite some time, introspective behavioural scales and performance tests have been used to measure sleepiness. Subjective scales query the individual's perception of alertness/sleepiness. One problem with this approach is that subjects must have insight into the problem and be able to distinguish sleepiness from other factors affecting performance. The Stanford Sleepiness Scale (Hoddes et al., 1. Karolinska Sleepiness Scale (Akerstedt, 1. These scales are useful in tracking symptoms during a given time epoch; they are less helpful in examining more global feelings of sleepiness. The Epworth Sleepiness Scale (Johns, 1. It consists of eight questions, each scored with a degree of severity ranging from 0 to 3. One limitation of this scale is that it asks subjects to imagine themselves in situations which they may actually experience rarely or never. Semantic issues also may lead to confusion. There may also be individual variation of scores over time. In our own experience, visual analogue scales, on which the subject indicates a response along a linear 1. It is also useful to ask other individuals who are close to the subject (spouse, bed- partner, co- worker) to complete scales such as the Epworth Sleepiness Scale or visual analogue scales; this adds information which is not entirely subjective to the individual. Performance tests have been used to measure sleepiness, but they are often susceptible to habituation to task and can only be used when a ceiling effect has been reached. The less problematic tests involve measurements of simple or complex reactions. Lapses in reaction time provide an index of sleepiness. Computerized systems are commercially available and permit calculation of multiple parameters, such as mean reaction time, variability of speed of response, longest 1. More objective tests, relying on measurement of physiological parameters, are widely available. Pupillography (Schmidt and Fortin, 1. Sensory evoked potentials are rarely employed. Most commonly, objective testing is based on polygraphic monitoring. The Multiple Sleep Latency Test (MSLT) (Carskadon et al., 1. The test consists of four or five opportunities to nap, spaced across the day at 2- h intervals. Standardized conditions are employed; the subject is placed in a quiet, dark, comfortable room and asked not to resist sleep. Monitored parameters include EEG, EMG and eye movements. During each nap, the subject is allowed 2. If sleep does not occur, that portion of the study is terminated at 2. If sleep onset does occur, monitoring continues for an additional 1. SOREMPs). Outcome measures are mean sleep latency (time from lights- out to unequivocal sleep onset) and presence or absence of SOREMPs. The Maintenance of Wakefulness Test (Doghramji et al., 1. Challenge Daytime Promo Jan 2014. Challenge TV continuity and adverts - Thursday 4th January 2007 - Duration: 9:54. Daniel Mullins 3,960 views.MSLT, but the subject is asked to try to remain awake, and each phase is terminated immediately if sleep onset occurs within 2. The Maintenance of Wakefulness Test is often used for legal purposes (e. On the MSLT, mean sleep latency > 1. Presence of two or more SOREMPs is also pathological. Mean sleep latency < 1. In the evaluation of sleepiness, several methods of assessment may be employed (e. Epworth Sleepiness Scale, MSLT and a reaction time test), although the results of the various tests often lack correlation within individual subjects. Practically speaking, for the generalist or neurologist, simple subjective measures, such as the Epworth Sleepiness Scale or visual analogue scales, represent reasonable starting points in the assessment of EDS. More expensive, objective studies are probably best left to specialized sleep disorders centres. Syndromes of sleepiness. Insufficient sleep. The most common cause of daytime sleepiness is insufficient sleep, which may reflect poor sleep hygiene (behaviours impacting sleep) or self- imposed or socially dictated sleep deprivation. Again citing the National Sleep Foundation 2. Omnibus Sleep in America Poll: `only one- third (3. It should be noted that the proverbial 8 h sleep requirement has been challenged; recent epidemiological evidence suggests that the actual sleep requirement in the general population may be closer to 7 h (Ohayon et al., 1. Busy people tend to regard sleep as a bank from which time can be borrowed as necessary to allow them to accomplish more by prolonging wakefulness. Thus, a sleep- debt is accumulated over time. If the sleep- debt is not repaid in sleep, per se, some other currency must be used—this usually takes the form of daytime dysfunction and may include cognitive impairment, disordered mood, suboptimal performance, physical fatigue or mental drowsiness (Pilcher and Huffcutt, 1. Dinges et al., 1. It is important to recognize the variation in sleep need among individuals. The proverbial 8 h of sleep will be sufficient for most individuals but inadequate to prevent sleep deprivation in those who require more. Adolescents generally need more sleep than adults, but are even less likely to obtain adequate amounts (Carskadon, 1. Our daytime challenge is a transformation program dedicated to those who work split shifts, work offshore, are self employed, or who are Mum's and require flexibility. Find listings of daytime and primetime ABC TV shows, movies and specials. Get links to your favorite show pages. Excessive daytime sleepiness. Challenges were first implemented in Secret of the Realms expansion. Cast Holy Light 50 times during daytime within 20 minutes of a. Mercer et al., 1.
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