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STAVING OFF DAYTIME SLEEPINESS

By Dr. George V. Roberson/FOR YOUR HEALTH
Saturday, May 2, 2009 9:33 PM CDT

Q. I am having trouble falling asleep during the daytime. I work in a local office and have fallen to sleep at my desk. I am a little overweight. I take high blood pressure medicine but no other medications. I do not drink alcohol. Are there medications which safely keep you awake during the day?

A. Excessive daytime sleepiness is not an uncommon sleep related disorder, occurring in 1 out of 5 adults. It frequently interferes with daily activities and job performance. It is most common in adolescents, older individuals, and shift workers. It can compromise professional performance including that of physicians and judges. It may impact your ability to maintain employment. Individuals may be perceived as lazy or unmotivated.

It can have other diverse serious consequences contributing to more than 100,000 motor vehicle accidents resulting in approximately 70,000 personal injuries and 1,500 deaths per year. According to the National Transportation Safety Board up to 52% of single vehicle crashes involving heavy trucks are fatigue related with the driver falling asleep.

For adolescents it manifests as a lower level of academic performance, increased school tardiness, and subsequently lower graduation rates.

The main causes of excessive daytime sleepiness are: sleep deprivation, medication, drug effects, and obstructive sleep apnea.

Sleep deprivation is the most common cause. It can occur in otherwise healthy persons even after mild sleep restrictions. One study has shown that healthy adults restricted to 6 hours of sleep at night for 2 weeks show a cumulative impairment effects. Cognitive and performance deficiencies begin to show up after short periods of sleep deprivation.

Sleepiness is the most commonly reported side effect of most medications. It is particularly prevalent with agents which act on the central nervous systems. Antihistamines such as Benadryl are readily available and widely used during allergy season. These can be associated with decreased performance on driving tests. Even hypertensive medications may produce tiredness, fatigue and daytime sleepiness. This is not uncommon with beta blockers such as Propranolol (Inderal). Sedation is a common side effect of Catapres (Clonidine), a commonly used hypertensive medication.

Ethanol is the most widely used agent with sedative effects.

Obstructive sleep apnea is a disorder caused by blockage of the upper airway resulting in reduced airflow during sleep. Obstructive sleep apnea may be a significantly under recognized disorder. It is associated with increased age and obesity. The prevalence of both are ever increasing. People with obstructive sleep apnea have a significantly increased risk of motor vehicle accidents. Statistics show that during the year 2008, there were 800,00 drivers involved in obstructive sleep apnea related motor vehicle collisions.

Increasing anxiety and stress over economic turmoil, job loss, family distress is probably becoming a more troubling reason for sleep depravation.

Evaluation of excessive sleepiness should include a medical history, physical examination, and laboratory examination. Of course, a history of medication or drug abuse is very important. Occupation may be a contributing factor, especially for shift workers, resulting in a disorder of the circadian rhythm.

Obstructive sleep apnea can be treated by positive airway pressure systems. Treatment by positive pressure devices, during sleep reduces symptoms of daytime sleepiness in most individuals. Provital is a medication for treatment of excessive daytime sleepiness but is only indicated for treatment of presistant sleepiness associated with obstructive sleep apnea in patients who are already being treated with continous positive air pressure.

Amphetimenes which increase alertness are restricted to physician prescription because they have a high potential for abuse.

Physicians treating patients with excessive daytime sleepiness, particularly those using drugs likely to influence driving performance, have a responsibality to make a clinical assessment of a patient's overal risk of unsafe driving. This should be documented and precausions noted. Legal requirements, for reporting excessive daytime sleepiness which has been documented indicating impaired driving, varies from state to state.

Dr. George Roberson is a general, thoracic, vascular surgeon in Pine Bluff and medical director at Jefferson Regional Medical Center. To have a medical related question answered, write to Medical Reviews, P.O. Box 2916, Pine Bluff, Ark. 71611.

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