Drowsiness / Sleepiness and wakefulness are regulated primarily by an interaction between sleep homeostatic and circadian processes.1,2 In general, the homeostatic drive for sleep increases with time awake and dissipates during sleep. The circadian process refers to the biologically determined near 24-hour rhythmic pattern of physiology and behavior governed by the master circadian pacemaker located in the hypothalamic suprachiasmatic nucleus. An alerting signal from the circadian pacemaker counteracts the increasing homeostatic drive for sleep and thus promotes wakefulness during the later part of the day. The circadian pacemaker also promotes sleep at night. Excessive sleepiness is characterized by difficulty maintaining wakefulness and/or an increased propensity to fall asleep when sleep is inappropriate or dangerous.3
Drowsiness or somnolence or sleepiness is a state of strong desire for sleep, or sleeping for unusually long periods (compare hypersomnia). It has distinct meanings and causes. It can refer to the usual state preceding falling asleep, the condition of being in a drowsy state due to circadian rhythm disorders, or a symptom of other health problems. It can be accompanied by lethargy, weakness, and lack of mental agility.
Causes of Drowsiness / Sleepiness
The intrinsic types include
- Advanced sleep phase disorder (ASPD) – A condition in which patients feel very sleepy and go to bed early in the evening and wake up very early in the morning
- Delayed sleep phase disorder (DSPD) – the Faulty timing of sleep, the peak period of alertness, the core body temperature rhythm, hormonal and other daily cycles such that they occur a number of hours late compared to the norm, often misdiagnosed as insomnia
- Non-24-hour sleep–wake disorder – A faulty body clock and sleep-wake cycle that usually is longer than (rarely shorter than) the normal 24-hour period causing complaints of insomnia and excessive sleepiness
- Irregular sleep–wake rhythm – Numerous naps throughout the 24-hour period, no main nighttime sleep episode and irregularity from day to day
- Hypothyroidism – The body doesn’t produce enough hormones that control how cells use energy
- Low blood sodium – Hyponatremia
- Hypercalcemia – Too much calcium in the blood
- Head Injury
- Concussion – A mild traumatic brain injury
- Narcolepsy – Disorder of the nervous system
- Brain tumor
- Skull fractures
- Chronic pains
- Sleeping sickness – caused by a specific parasite
- Mood disorders – Depression, Anxiety, Stress
Medications that may cause drowsiness
- analgesics – mostly prescribed or illicit opiates such as OxyContin or heroin
- anticonvulsants/antiepileptics – such as phenytoin, carbamazepine (Tegretol), Lyrica, Gabapentin
- antidepressants – for instance sedating tricyclic antidepressants, and mirtazapine. Somnolence is less common with SSRIs and SNRIs as well as MAOIs.
- antihistamines – for instance, diphenhydramine and doxylamine
- antipsychotics – for example, thioridazine, quetiapine , olanzapine, risperidone, and ziprasidone but not haloperidol
- dopamine agonists used in the treatment of Parkinson’s disease – e.g. pergolide, ropinirole, and pramipexole.
- HIV medications – such as efavirenz
- hypertension medications – such as amlodipine
- tranquilizers/hypnotics – such as zopiclone, or the benzodiazepines such as diazepam or nitrazepam and the barbiturates, such as amobarbital or secobarbital
- other agents impacting the central nervous system in sufficient or toxic doses
Excessive sleepiness has also been associated with other sleep and circadian disorders such as multiple sclerosis, Parkinson’s disease, lupus, cancer, chronic pain, gastrointestinal disorders, endocrine disorders, head injury, and other somatic disorders. It has also been associated with several psychiatric disorders (eg, depression, schizophrenia, seasonal affective disorders) and the use of some illicit or prescription drugs.4,5
Symptoms of Drowsiness / Sleepiness
Sleep deprivation or disturbance may result in excessive daytime drowsiness, with serious consequences such as:
- Quality of life may diminish as patients cut back on pleasure activities. Daytime naps become necessary and can be embarrassing. At work, productivity decreases.
- Trouble waking in the morning.
- Feeling excessively sleepy or having a general lack of energy during the day.
- Needing or taking frequent naps throughout the day.
- Dozing off during inappropriate times such as during meals, in the middle of conversations, or even while driving.
- Naps don’t relieve symptoms of sleepiness.
- Feelings of irritability or anxiety.
- Difficulty concentrating.
- Lapses in attention.
- Loss of appetite.
- Poor school/job performance.
- Mental changes – short-term memory is disturbed, attention span is shortened,
- Sudden onset
- Head injury
- Behavior change
- Neurological symptoms
- energy levels and libido drop, the patient becomes irritable and shows poor judgment.
- Patients become more accident-prone.
- Breathing problems are frequent, such as sleep apnoea.
- Immune function is decreased.
- There are changes in appetite – sleep-deprived patients have an increased appetite for kilojoule-dense foods with high carbohydrate content.
Treatment of Drowsiness / Sleepiness
- Stimulants, such as methylphenidate or modafinil
- Antidepressants, such as fluoxetine, citalopram paroxetine sertraline
- Sodium oxybate is used to treat excessive daytime sleepiness associated with narcolepsy
- Exercise – Exercise can actually cause drowsiness at first, but over time it has a very powerful effect on energy. Exercise gives the body more natural energy and also has a very strong stress reduction quality that makes it ideal for combatting anxiety.
- Healthy Eating – Healthy eating is unlikely to have much an effect on anxiety. But it does affect energy. With sensations like drowsiness, every little bit makes it worse. So even if anxiety is causing your drowsiness directly, unhealthy and fattening foods also cause drowsiness, and so cutting out those foods should reduce the fatigue you experience.
- Light Therapy – The body is actually programmed to stay awake when confronted with light. You may want to look at light therapy tools, and spend as much time in sunny outdoors as possible.
- Sodium Oxybate – is a strong sedative that may be prescribed for patients to help them sleep at night. It may seem counter intuitive that those with narcolepsy would have trouble sleeping at night, but just as they have trouble staying awake during the day, they have trouble sleeping at night. Sodium oxybate helps to keep them asleep at night.
- Lifestyle remedies. Taking scheduled naps, keeping consistent sleep schedules, avoiding caffeine and alcohol, and regular exercise can all go a long way in helping people with narcolepsy get more frequent, quality sleep.
- Medications/drugs – In general, medications do not help problem sleepiness, and some make it worse. Caffeine can reduce sleepiness and increase alertness, but only temporarily. It can also cause problem sleepiness to become worse by interrupting sleep.
- Sodium oxybate – Sodium oxybate (a sodium salt of γ hydroxybutyrate [GHB]) is a CNS depressant approved by the FDA for the treatment of excessive daytime sleepiness and cataplexy in patients with narcolepsy. Sodium oxybate is a liquid agent that is administered immediately before bedtime, with a subsequent dose 2 to 4 hours later. The effect of sodium oxybate on daytime sleepiness was evaluated in a multicenter, double-blind, placebo-controlled study of 228 adults who had narcolepsy with cataplexy.6 7
Modafinil and armodafinil –Modafinil is a wake-promoting agent that is structurally and pharmacologically distinct from traditional CNS stimulants.8,9 It also has a lower abuse potential and lower risk for adverse cardiovascular events than sympathomimetic agents.10,11 Additionally, because of its negligible sympathomimetic activity, modafinil does not adversely affect nighttime sleep when used as directed.
- Amphetamines – Since their development in the 1930s, amphetamines have historically been used to treat excessive sleepiness and narcolepsy. Dextroamphetamine and methamphetamine, 2 sympathomimetics approved by the US Food and Drug Administration (FDA) for use in narcolepsy, are fast acting and effective in ameliorating symptoms of excessive sleepiness. Methylphenidate, a psychomotor stimulant with pharmacologic mechanisms similar to amphetamine and commonly used in the treatment of attention-deficit/hyperactivity disorder, is also approved to treat narcolepsy. Few studies, however, have examined its effects on daytime excessive sleepiness.
- Behavioral Measures to Improve Sleep – Improving duration of sleep and ensuring proper sleep hygiene (sleep-related behaviors) are essential first steps in helping to alleviate symptoms of excessive sleepiness in all patients. Patients should be encouraged to allow enough time in their schedules for an adequate amount of sleep to feel refreshed or well rested. Additionally, physicians should educate their patients about the practice of good sleep habits. These habits include maintaining a regular sleep-wake schedule (7 days a week); creating a quiet, cool, and comfortable bedroom environment that is conducive to sleep; limiting time spent in bed for activities other than sleep; and ensuring avoidance of caffeine, nicotine, alcohol, heavy metals, and strenuous exercise at least 3 hours before bedtime.
Home Remedies and Over the Counter Medications
- Regular exercise.
- Regular sleep schedules.
- Decreased use of alcohol, caffeine, and tobacco.
- Leg massages.
- Alternating use between heated pads and cold packets on legs.
- Over the counter pain relievers such as acetaminophen.
- Anti-inflammatory drugs such as ibuprofin or naproxen.
- Vitamins and minerals to treat RLS caused by deficiencies icluding iron, folic acid, magnesium, and vitamin B.
- Get a good night’s sleep before leaving
- Avoid driving between midnight and 7 a.m.
- Change drivers often to allow for rest periods
- Schedule frequent breaks
If you are a shift worker, the following may help
- decreasing the amount of night work;
- increasing the total amount of sleep by adding naps and lengthening the amount of time allotted for sleep;
- increasing the intensity of light at work;
- having a predictable schedule of night shifts;
- eliminating sound and light in the bedroom during daytime sleep;
- using caffeine (only during the first part of the shift) to promote alertness at night; or
- possibly using prescription sleeping pills to help daytime sleep on the occasional basis (check with your doctor).