MKSAP Quiz: Evaluation for daytime sleepiness
A 31-year-old woman is evaluated for a 1-year history of daytime sleepiness. She falls asleep while watching TV, at the theater, and occasionally during a meal. Following a physical exam, what is the most appropriate management?
A 31-year-old woman is evaluated for a 1-year history of daytime sleepiness. She falls asleep while watching TV, at the theater, and occasionally during a meal. She usually falls asleep between 10:00 PM and midnight and wakes during the workweek at 6:00 AM. On weekends, she wakes at 9:00 AM. Her husband reports snoring but he hasn't observed breathing pauses. She has no cataplexy or symptoms of restless leg syndrome. She takes no medications.
On physical examination, vital signs are normal. BMI is 24.5. The physical examination, including inspection of nasal passages and oropharynx, is normal.
Which of the following is the most appropriate management?
A. Actigraphy
B. Modafinil
C. Multiple sleep latency testing
D. Polysomnography
MKSAP Answer and Critique
The correct answer is A. Actigraphy. This content is available to MKSAP 18 subscribers as Question 72 in the Pulmonary and Critical Care Medicine section. More information about MKSAP is available online.
The most appropriate management is testing with actigraphy. The initial step in the evaluation of the patient with excessive daytime sleepiness is to ensure adequate quantities (7 to 8 hours) of sleep on a regular basis. This patient's self-report of a variable bedtime and restricted sleep schedule during the workweek raises the possibility of insufficient sleep syndrome. Wrist actigraphy measures movement and ambient light to estimate nightly sleep periods during a 1 to 2 week time frame. Actigraphy is more accurate than patient reports of sleep duration and is likely more accurate than sleep diaries. When actigraphy isn't available, a sleep diary can be a useful alternative. Insufficient sleep syndrome suggested by either actigraphy or sleep diary should prompt a trial of sleep extension.
Modafinil is a stimulant medication used in hypersomnia syndromes such as narcolepsy. It would not be appropriate therapy without first excluding insufficient sleep syndrome.
Multiple sleep latency testing can be useful in the evaluation of pathologic daytime sleepiness (for example, narcolepsy) and may help establish a diagnosis of narcolepsy, but it is resource intensive and expensive. It should be performed only after addressing insufficient sleep quantities and polysomnography has ruled out common sleep disorders such as sleep apnea.
Polysomnography or home sleep testing would be indicated if the clinical history strongly suggested a primary sleep disorder such as obstructive sleep apnea. However, obstructive sleep apnea is unlikely in a young woman who is not overweight and does not have obvious upper airway abnormalities. In addition, the patient is suspected of having a restricted sleep schedule that should be evaluated first with actigraphy.
Key Point
- The initial step in the evaluation of the patient with excessive daytime sleepiness is to ensure adequate quantities of sleep on a regular basis using either actigraphy or a sleep diary.