Daytime sleepiness assessment

FIGURE 38-1. Primary assessment and initial treatment for complaint of excessive daytime sleepiness. RLS, restless-legs syndrome NPSG, nocturnal polysomnography OSA, obstructive sleep apnea DA, dopamine agonist MSLT, multiple sleep latency test BZDRA, benzodiazepine receptor agonist SNRI, serotonin and norepinephrine reuptake inhibitor TCA, tricyclic antidepressant CPAP, continuous positive airway pressure. 

Newman, J. and Bough ton, R., Pupillometric assessment of excessive daytime sleepiness in narcolepsy-cataplexy, Sleep, 14, 121, 1991. 

Howard and colleagues (31) suggested a reform of residents work and duty hours based on a study that assessed the levels of physiological and subjective sleepiness in 11 anesthesia residents in three conditions (1) during a normal (baseline) work schedule, (2) after an in-hospital 24-hr on-call period, and (3) after a period of extended sleep. MSLT scores were shorter in the baseline (6.7 min) and postcall (4.9 min) conditions, compared with the extended-sleep condition (12 min), and there was no significant difference between the baseline and postcall conditions. Residents daytime sleepiness on the MSLT in both baseline and postcall conditions was near or below levels associated with clinical sleep disorders, and residents were subjectively inaccurate determining EEG-defined sleep onset. 

Monitoring parameters for pharmacotherapy of narcolepsy include reduction in daytime sleepiness, cataplexy, hypnagogic and hypnopompic hallucinations, and sleep paralysis. Patients should be evaluated regularly during medication titration, then every 6 to 12 months to assess adverse drug events (e.g., mood changes, sleep disturbances, and cardiovascular abnormalities). If symptoms increase during therapy, PSG should be done. 

In 2004 Okrm and colleagues studied the role of cytokines and growth hormone in the regulation of sleep and narcolepsy. Collectively, proinflammatory cytokines and human growth hormone (HGH), were found to be possibly involved in the development of or the exacerbation of narcolepsy (a disabling neurological sleep disorder characterized by excessive daytime sleepiness and abnormal sleep manifestations). As the role of the immune system in sleep becomes clearer, a better interpretation will be available to assess why narcoleptics have altered cytokine and HGH levels. Future studies should be conducted to fuUy characterize the sources, patterns, and significance of alterations in patterns of proinflammatory cytokines and HGH in narcolepsy. ... 

Using the MSLT as an objective laboratory assessment of the clinical symptom of sleepiness, as well as abnormal sleep structure, has greatly facilitated the diagnosis, differentiation, and treatment of various disorders of excessive daytime somnolence (EDS). A brief review of its applications is described below. 

Daytime vigilance has been assessed in 14 newly diagnosed never medicated adults with focal epilepsy at baseline and 2 months after slow titration of topiramate to 200 mg/day (653). Multiple Sleep Latency Test (MSLT), visual simple and choice reaction time (VRT), and selfrating with the Epworth Sleepiness Scale were used for quantification of sleepiness, and compared with 14 healthy volunteers. At baseline MSLT scores were comparable. Two months after topiramate monotherapy, MSLT, VRT, and self-rating did not change significantly. 

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