M E D iC A L
JO U R N A L
Stella Tavares, Flavia Aloe, Valen tim G entil, M ilberta Scaff
Excessive somnolence
I n t e r d e p a r t m e n t a l C e n t e r f o r S l e e p S t u d i e s ; H o s p i t a l d a s C l i n i c a s ,
U n i v e r s i t y o f S l i o P a l l l o ( C I E S H C - F M U S P ) - S l i o P a u l t j , B r a z i l
E x c e s s iv e s o m n o le n c e c a n b e q u ite a in c a p a c ita tin g m a n ife s ta tio n , a n d is fre q u e n tly n e g le c te d b y p h y s ic ia n s a n d p a tie n ts . T h is a rtic le re v ie w s th e d e te rm in a n t fa c to rs , th e e v a lu a tio n a n d q u a n tific a tio n o f d iu rn a l s o m n o le n c e , a n d th e d e s c rip tio n a n d tre a tm e n t o f th e m a in c a u s e s o f e x c e s s iv e s o m n o le n c e .
U N IT E R M S : E x c e s s iv e s o m n o le n c e . S le e p a p n e a . N a rc o le p s y . N o c tu rn a l m y o c lo n ia s .
E
x c e s s i v ea s d i f f i c u l t ys o m n o l e n c ei n m a i n t a i n i n g( E S ) , w h i c ht h e d e s i r e dm a y b e d e f i n e dl e v e l o f a l e r t n e s s , o r a s a n e x c e s s i v e q u a n t i t y o f s l e e p , i s ac o m m o n c o m p l a i n t , p r e v a l e n t i n 0 .5 - 5 p e r c e n t o f t h e
g e n e r a l p o p u l a t i o n . I B e s i d e s r a i s i n g i m p o r t a n t p r o b l e m s
i n d i a g n o s i s a n d t r e a t m e n t , i t i s f r e q u e n t l y n e g l e c t e d b y
t h e p h y s i c i a n a n d e v e n b y t h e p a t i e n t . T h i s r e p r e s e n t s a
s e r i o u s r i s k , s i n c e E S m a y b e a w a r n i n g s i g n o f a p o t e n t i a l l y
l e t h a l d i s e a s e , s l e e p a p n e a s y n d r o m e . I n a d d i t i o n , E S m a y
i n c a p a c i t a t e p a t i e n t s , c a u s e s o c i a l a n d f a m i l y p r o b l e m s ,
j o b a c c i d e n t s a n d f i r i n g s , a n d c r e a t e p r o b l e m s a t s c h o o l .
T h e n e w c l a s s i f i c a t i o n o f s l e e p d i s o r d e r s ( I C S D ) 2
i n c l u d e s m o r e t h a n 3 0 c a u s e s o f E S ( T a b l e I). T h u s , i n c a s e s o f E S c o m p l a i n t s , t h e p h y s i c i a n s h o u l d c a r r y o u t a
t h o r o u g h i n v e s t i g a t i o n i n o r d e r t o d i a g n o s e i t p r o p e r l y .
A d r e s s fo r c o r r e s p o n d e n c e : Stella Tavares
Rua Sabara, 402 apta. 8 2 , Higienopalis
Sao PaulolSP - Brasil- CEP 01239-010
T h e r e f o r e , i t i s r e l e v a n t t o d i s c u s s t h e d e t e r m i n a n t f a c t o r s
o f E S , s l e e p h i s t o r y , a n d d i a g n o s t i c m e t h o d s o f E S .
D E T E R M IN A N T F A C T O R S O F E S
1. Q uantity and/or quality of sleep
T h e i n t e n s i t y o f E S i s d i r e c t l y r e l a t e d t o t h e
q u a n t i t y o f n o c t u r n a l s l e e p .3 P a r t i a l o r t o t a l s l e e p
d e p r i v a t i o n c a u s e s d a y t i m e s o m n o l e n c e i n n o r m a l
i n d i v i d u a l s , a s e v a l u a t e d b y t h e m u l t i p l e s l e e p l a t e n c y
t e s t . F u r t h e r m o r e , m i l d r e s t r i c t i o n s o f s l e e p (e.g., a 1 -h o u r r e d u c t i o n i n s l e e p p e r n i g h t ) g r a d u a l l y a c c u m u l a t e ,
l e a d i n g t o a p r o g r e s s i v e i n c r e a s e i n d a y t i m e s l e e p i n e s s ,
w h i c h i s r e v e r s e d i f t h e d u r a t i o n o f n o c t u r n a l s l e e p i s
i n c r e a s e d .3
D a y t i m e s l e e p i n e s s i s a l s o a s s o c i a t e d w i t h t h e q u a l i t y
o f n o c t u r n a l s l e e p .4 S o m e s l e e p d i s o r d e r s (e.g., s l e e p a p n e a s y n d r o m e , p e r i o d i c l i m b m o v e m e n t d i s o r d e r ) a r e
c h a r a c t e r i z e d b y a w a k e n i n g s o f s h o r t d u r a t i o n , r e c o r d e d
2. Age group
W h e n e v a lu a tin g a p a tie n t w ith s le e p c o m p la in ts , it
is v ita l to c o n s id e r th e a g e g ro u p , s in c e s le e p p a tte rn s a re
k n o w n to c h a n g e w ith th e a d v a n c e o f a g e .5 .(i C e rta in a g e
g ro u p s h a v e c le a r s le e p p a tte rn s th a t d e s e rv e to b e
m e n tio n e d , k e e p in g in m in d th a t in d iv id u a l v a ria tio n s
o c c u r w ith in ' th e s a m e a g e g ro u p .
D u rin g a d o le s c e n c e , s e v e ra l p h y s ic a l, h o rm o n a l, a n d
p s y c h o lo g ic a l c h a n g e s o c c u r, a s w e ll a s c h a n g e s in
n o c tu rn a l s le e p a n d d a y tim e a le rtn e s s .5 T a n n e r 1 37
d e m o n s tra te d th a t d a y tim e a le rtn e s s (a s e v a lu a te d b y th e
m u ltip le s le e p la te n c y te s t) d im in is h e s d e s p ite th e s a m e
a m o u n t o f n o c tu rn a l s le e p ; s u g g e s tin g th a t th e n e e d fo r
s le e p in c re a s e s in a d o le s c e n c e . A ls o , E S u s u a lly m a n ife s ts
a s n a rc o le p s y a n d id io p a th ic h y p e rs o m n ia d u rin g th e
s e c o n d d e c a d e o f life .2
B illia rd e t a I.5 s tu d ie d y o u n g m e n ( 1 7 to 2 2 y e a rs ),
a n d d e te rm in e d th e p re v a le n c e a n d c o n trib u to ry fa c to rs
o f
ESY
A ro u n d 5 p e rc e n t o f th e in te rv ie w e d p e rs o n sre p o rte d th a t E S a ffe c te d th e ir d a y tim e a c tiv itie s , a n d E S
w a s a s s o c ia te d w ith th e u s e o f h y p n o tic s , in s o m n ia (in itia l,
in te rm e d ia te a n d fin a l), irre g u la r s le e p -w a k e c y c le s ,
s n o rin g , a n d th e n u m b e r o f h o u rs o f s le e p « 5 h o u rs a n d
> 1 1 h o u rs ). A ls o , th e p ro p o rtio n o f in d iv id u a ls w ith E S
w a s h ig h e r a m o n g th o s e w h o re p o rte d th e p re s e n c e o f
c a ta p le x y (a u x ilia ry s y m p to m o f n a rc o le p s y ). A n
in te re s tin g fin d in g w a s th e re la tio n s h ip b e tw e e n E S a n d
th e n u m b e r o f h o u rs s le p t p e r n ig h t. A c o m p la in t o f E S is
n o t s u rp ris in g w h e n n o c tu rn a l s le e p is re d u c e d , h o w e v e r,
a re la tio n s h ip b e tw e e n p ro lo n g e d s le e p a n d d a y tim e
s o m n o le n c e is u s u a lly n o t e x p e c te d . T h is w o u ld e ith e r
re p re s e n t a " h a n g o v e r" d u e to e x c e s s iv e s le e p , o r a
m a n ife s ta tio n o f a p a th o lo g ic a l p ro c e s s (e .g . id io p a th ic
h y p e rs o m n ia ).
T h e e ld e rly s h o w s e v e ra l s le e p p a tte rn m o d ific a tio n s ,
s u c h a s : a n in c re a s e in s le e p la te n c y a n d th e n u m b e r o f
a w a k e n in g s d u rin g th e n ig h t; a d e c re a s e in d e lta s le e p ;
a n d a n in c re a s e in d a y tim e n a p s .lll In th is p o p u la tio n , th e
fra g m e n ta tio n o f n o c tu rn a l s le e p d u e to re s p ira to ry a n d
m o to r d is o rd e rs is a n im p o rta n t fa c to r re s p o n s ib le fo r
E S .II.1 2
3. Circadian Rhythms
T h e s le e p -w a k e c y c le , in a n a d u lt in d iv id u a l, p re s e n ts
a tw o -p h a s e p a tte rn w ith tw o p e rio d s o f s le e p te n d e n c y ,
E x a m p le s o f E S d u e to rh y th m d is o rd e rs a re s e e n in
s h iftw o rk e rs a n d p e o p le tra v e lin g q u ic k ly th ro u g h d iffe re n t
tim e s z o n e s G e tla g ).
4. Drugs
S e v e ra l d ru g s a lte r s le e p p a tte rn s . E x a m p le s o f d ru g s
th a t in d u c e E S a re : b e n z o d ia z e p in e s , b a rb itu ra te s , H 1
-a n tih is t-a m in ic s (d ip h e n y d ra m in e ), b e ta -b lo c k e rs a n d
a lc o h o I.4 .'4 -'(i
6. Illnesses
T a b le I lis ts th e c a u s e s o f E S a c c o rd in g to th e IC S D
c rite ria .2 A s c a n b e o b s e rv e d , E S m a y b e d u e to p s y c h ia tric
a n d re s p ira to ry d is o rd e rs , c e n tra l n e rv o u s s y s te m d is o rd e rs ,
e tc . S o m e d is o rd e rs w ill b e d is c u s s e d la te r o n .
P A T IE N T 'S S L E E P H IS T O R Y
T h e p re s e n c e o f E S d e m a n d s a c o m p le te " s u rv e y "
o f th e 2 4 -h o u r a c tiv itie s o f th e p a tie n t. T h e tim e th a t
th e p a tie n t g o e s to b e d ; s le e p la te n c y (h o w lo n g th e
p a tie n t ta k e s to fa ll a s le e p ); n u m b e r o f a w a k e n in g s
d u rin g th e n ig h t; tim e th e p a tie n t w a k e s u p c o m p le te ly ;
a n d q u a lity o f s le e p (d u rin g w o rk in g d a y s , a s w e ll a s
o n w e e k e n d s a n d v a c a tio n s ) m u s t a ll b e in v e s tig a te d . It
is im p o rta n t to a s k a b o u t th e v a rio u s s itu a tio n s in w h ic h
(e .g ., te le v is io n w a tc h in g , re a d in g , m e e tin g s , c a r
d riv in g , e tc .) a n d th e tim e s in w h ic h s le e p in e s s o c c u rs .
D a y tim e n a p s s h o u ld b e in v e s tig a te d in re g a rd to th e
tim e a n d fre q u e n c y o f o c c u rre n c e , q u a lity (re p a ire r o r
n o t), a n d th e o c c u rre n c e o f d re a m s .
T h e s o m n o le n t p a tie n t u s u a lly re p o rts s le e p in g o n e
o r m o re tim e s d u rin g th e d a y , m a n y tim e s in u n u s u a l
s itu a tio n s . R itu a ls to " re p e l E S " a re fre q u e n tly d e v e lo p e d ,
s u c h a s : w a s h in g th e fa c e w ith c o ld w a te r, p a in fu l
m a n e u v e rs , a n d th e u s e o f c a ffe in e . M o re o v e r, th e p a tie n t
m a y re fe r to s o m n o le n c e a s fa tig u e , lo s s o f e n e rg y ,
o r
p ro s tra tio n . T h e in v e rs e m a y a ls o o c c u r, w ith th e p a tie n t
in te rp re tin g fa tig u e a s s o m n o le n c e . T h e p a tie n t m a y e v e n
d e n y th e s y m p to m s , e ith e r b e c a u s e h e h a s a lre a d y
in c o rp o ra te d th e m a s h a b its (e .g ., " I d o n o t h a v e a s le e p
p ro b le m s in c e I s le e p in a n y p la c e " ) o r b e c a u s e E S m ig h t
b e in te rp re te d a s la z in e s s o r in d o le n c e . A s le e p lo g , k e p t
1 2 3 3
T a b le 1
C a u s e s O f E x c e s s iv e S o m n o le n c e (E S ) 1 . B e h a v io ra l/P s y c h o p h y s io lo g ic D is o rd e rs :
In a d e q u a te s le e p h y g ie n e In s u ffic ie n t s le e p
2 . P s y c h ia tric D is o rd e rs : M o o d d is o rd e rs A lc o h o lis m
3 . E n v iro n m e n ta l F a c to rs :
E n v iro n m e n ta l s le e p d is tu rb a n c e T o x in -in d u c e d s le e p d is tu rb a n c e 4 . D ru g U s e
5 . R e s p ira to ry D is o rd e rs D u rin g S le e p : O b s tru c tiv e A p n e a S le e p S y n d ro m e (O A S S ) C e n tra l A p n e a S le e p S y n d ro m e
C e n tra l A lv e o la r H y p o v e n tila tio n S y n d ro m e N e u ro g e n ic ta c h y p n e a re la te d to s le e p 6 . M o v e m e n t D is o rd e rs :
P e rio d ic lim b m o v e m e n t d is o rd e r
d u r in g s o m e w e e k s ( 2 o r m o r e ) , m a y b e u s e f u l, e s p e c ia lly
in c ir c a d ia n r h y th m d is o r d e r s .
T h e a g e th a t s y m p to m s b e g a n m a y f u r n is h im p o r ta n t
in f o r m a tio n . F o r n a r c o le p s y , E S u s u a lly s ta r ts d u r in g th e
s e c o n d d e c a d e o f lif e ; f o r s le e p a p n e a s y n d r o m e ( a lth o u g h
E S m a y o c c u r in a n y a g e g r o u p ) , o c c u r r e n c e is m o r e
c o m m o n in m e n a f te r 4 0 y e a r s , a n d in w o m e n a f te r
m e n o p a u s e .
S o m e a d d itio n a l s y m p to m s m a y h e lp d e te r m in e
th e c a u s e o f s o m n o le n c e , s u c h a s : s n o r in g , r e s p ir a to r y
a r r e s ts d u r in g s le e p , m o r n in g h e a d a c h e s , c a ta p le x y ,
h y p n a g o g ic h a llu c in a tio n s , s le e p p a r a ly s is , a n d
a u to m a tic b e h a v io r . 1 7
A n in te r v ie w w ith b e d p a r tn e r s a n d r e la tiv e s is u s e f u l
to o b ta in d a ta a b o u t th e n o c tu r n a l b e h a v io r o f th e p a tie n t.
O b v io u s ly , a g e n e r a l c lin ic a l h is to r y o f th e p a tie n t s h o u ld
b e o b ta in e d a n d , w h e n n e c e s s a r y , a n e v a lu a tio n b y o th e r
s p e c ia lis ts .
7 . A lte ra tio n s o f S le e p -W a k e C y c le : L o n g p e rio d s o f s le e p
T im e z o n e c h a n g e s S h iftw o rk e rs
D e la y e d p h a s e o f s le e p p h a s e A d v a n c e d p h a s e o f s le e p p h a s e N o n 2 4 -h o u r s le e p -w a k e c y c le Irre g u la r s le e p -w a k e p a tte rn
8 . D is o rd e rs o f th e C e n tra l N e rv o u s S y s te m : N a rc o le p s y
Id io p a th ic h y p e rs o m n ia P o s ttra u m a tic h y p e rs o m n ia R e c u rre n t h y p e rs o m n ia F ra g m e n te d m y o c lo n ia s S u b v ig il s y n d ro m e P a rk in s o n 's D is e a s e D e m e n tia
S le e p in g s ic k n e s s 9 . O th e r C a u s e s o f E S :
S le e p d is o rd e rs a s s o c ia te d w ith m e n s tru a tio n S le e p D is o rd e rs a s s o c ia te d w ith p re g n a n c y
M E T H O D S F O R Q U A N T IF IC A T IO N
A N D
D IA G N O S IS O F E S
T h e q u a n tif ic a tio n o f E S is c o m p le x a n d m a y in c lu d e
o b je c tiv e a n d s u b je c tiv e m e a s u r e s . T h e s u b je c tiv e e v a lu a tio n
e n c o m p a s s e s th e p r e s e n c e o f b e h a v io r a l s ig n s - s u c h a s :
y a w n in g , p a lp e b r a l p to s is , a le l1 n e s s la p s e s , r u b b in g o f th e
e y e s , s h a k in g o f th e h e a d , e tc .- a n d m e th o d s f o r s e lf
-e v a lu a tio n , s u c h a s : th e S ta n f o r d S le e p in e s s S c a le , IX v is u a
l-a n l-a lo g ic l-a l s c a le s 1 9a n d th e E p w o r th S le e p in e s s S c a le .2 0
P u p illo m e tr y is a m e th o d f o r o b je c ti v e e v a lu a tio n ,
s in c e th e p u p illa r y d ia m e te r is a n in d e x o f a u to n o m ic
a c tiv ity , a n d c o n s tr ic tio n o c c u r s d u r in g s le e p .2 1
T h e te s t o f m u ltip le s le e p la te n c y 2 2 is th e m o s t u s e d
e x a m i n a tio n f o r o b je c ti v e q u a n tif ic a tio n o f d a y ti m e
s o m n o le n c e . F o u r to f iv e p o ly g r a p h ic r e a d in g s a r e ta k e n
D u rin g e a c h re a d in g , th e tim e th a t th e p a tie n t ta k e s to fa ll
a sle e p is m e a su re d , a n d th e m e a n sle e p la te n c y is c a lc u la te d
(v a lu e s b e lo w 5 m in u te s a re c o n sid e re d a b n o rm a l). T h is
te st, b e sid e s q u a n tify in g th e se v e rity o f E S , a lso d e te c ts th e
p re se n c e o f e a rly R E M sle e p , w h ic h is im p 0 l1 a n t fo r th e
d ia g n o sis o f n a rc o le p sy . S o m e b a sic p re c a u tio n s sh o u ld b e
c o n sid e re d w h e n c a rry in g o u t th is te st, su c h a s: su sp e n d in g
th e u se o f so m e d ru g s (tric y c lic a n tid e p re ssa n ts, m o n o a m in e
o x id a se i n h i b i to rs, sti m u la n ts, se d a ti v e s, h y p n o tic s,
a n tih ista m in e s) a t le a st 1 4 d a y s p rio r to th e e x a m in a tio n ; m a in ta in in g a re g u la r sle e p -w a k e c y c le o n e w e e k b e fo re ;
a n d p e rfo rm in g a sle e p p o ly g ra p h th e n ig h t b e fo re th e te st.I
A la b o ra to ry sle e p e v a lu a tio n , o r sle e p p o ly g ra p h , is
re c o m m e n d e d to e v a lu a te n o c tu rn a l sle e p in p a tie n ts
c o m p la in in g o f E S . T h e p a tie n t sle e p s o n e o r m o re n ig h ts
a t th e sle e p la b o ra to ry , a n d se v e ra l p a ra m e te rs a re
e v a lu a te d (e le c tro e n c e p h a lo g ra m , o c u la r m o v e m e n ts,
m u sc u la r a c tiv ity , re sp ira tio n , a rte ria l o x y g e n sa tu ra tio n ,
e le c tro c a rd io g ra m , e tc ). A p re lim in a ry in te rv ie w w ith th e
sle e p p o ly g ra p h ist is e sse n tia l to e v a lu a te th e p a tie n t's
h isto ry , sle e p h a b its, a n d u se o f d ru g s th a t c o u ld in te rfe re
w ith re su lts (e .g . a n tid e p re ssa n ts, h y p n o tic s, a n x io ly tic s),
th u s p re p a rin g e a c h p a tie n t fo r th e e x a m in a tio n . T h is te st
is n o t n e c e ssa ry w h e n E S is c le a rly se c o n d a ry to c h ro n ic
sle e p d e p riv a tio n o r to d ru g u se .
S O M E D IS E A S E S T H A T C A U S E E S A R E
D IS C U S S E D
B E L O W
1. Sleep apnea syndrome
S le e p a p n e a is d e fin e d a s a n a rre st o f th e a ir p a ssa g e
th ro u g h th e u p p e r re sp ira to ry a irw a y s (U R A ) fo r lo n g e r
th a n 1 0 se c o n d s.
T h re e ty p e s o f re sp ira to ry a rre sts a re :
1 . C e n tra l a p n e a : a c o m p le te re sp ira to ry a rre st o c c u rs.
2 . O b stru c tiv e a p n e a : a n o b stru c tio n o f a ir p a ssa g e th ro u g h th e U R A o c c u rs, w ith p e rsiste n c e o f th e
re sp ira to ry e ffo rt.
3 . M ix e d a p n e a : th e a rre st is in itia lly c e n tra l a n d e v o lv e s to o b stru c ti v e .
S le e p h y p o p n e a s a re a lso d e sc rib e d , a n d a re
c h a ra c te riz e d b y a 5 0 -p e rc e n t d e c re a se in a ir flo w , 4 -p e rc e n t d e c re a se in a rte ria l o x y g e n sa tu ra tio n , a n d th e
a w a k e n in g o f th e p a tie n t.
T h e se e v e n ts m a y c a u se in so m n ia o r E S ; c e n tra l
a p n e a is u su a lly a sso c ia te d w ith c o m p la in ts o f in so m n ia , a n d o b stru c tiv e a p n e a is a sso c ia te d w ith h y p e rso m n ia .
2. Obstructive Apnea Sleep Syndrome (OASS)
O b stru c tiv e A p n e a S le e p S y n d ro m e (O A S S ) is
c h a ra c te riz e d b y re p e titiv e e p iso d e s o f U R A o b stru c tio n
w h ic h o c c u r o n ly d u rin g sle e p .T h e o b stru c tio n m a y b e th e
re su lt o f a n y fa c to r th a t in c re a se s th e re sista n c e o f th e U R A ,
c a u sin g th e o c c lu sio n o f th e o ro p h a ry n x Y T h e re fo re , m a n y
c o n d itio n s m a y p re d isp o se o r a g g ra v a te O A S S , su c h a s:
a d e n o to n silla r h y p e rtro p h y ; m a c ro g n a th ia ; m ic ro g n a th ia ;
re tro g n a th ia ; o b e sity ; tu m o rs; p o ly p s; n a sa l o b stru c tio n s;
a lle rg ic rh in itis; h y p o th y ro id ism ; a c ro m e g a ly ; c h ro n ic
o b stru c tiv e p u lm o n a ry d ise a se ; re stric tiv e p u lm o n a ry
d ise a se s; n e u ro m u sc u la r d ise a se s a ffe c tin g th e th o ra x (e .g .,
p o lio m y e litis, k y p h o sc o lio sis, m y o to n ic d y stro p h y ); a lc o h o l
c o n su m p tio n o r n e rv o u s sy ste m d e p re ssa n ts.2 4
D u rin g o b stru c tio n , a re d u c tio n in a rte ria l o x y g e n
sa tu ra tio n o c c u rs, w ith a n in c re a se in p C 0 2 and system ic and p u lm o n a ry a rte ria l p re ssu re ; c a rd ia c a rrh y tm ia s a lso o c c u r
(b ra d y c a rd ia -ta c h y c a rd ia , a sy sto lia , a trio v e n tric u la r b lo c k ,
e tc .).2 5 T h e se a lte ra tio n s, w h ic h m a y b e o f v a ria b le se v e rity ,
a c tiv a te stru c tu re s in th e b ra in ste m th a t c a u se th e p a tie n t's
a w a k e n in g w ith th e re tu rn o f re sp ira to ry re fle x e s. T h e su d d e n
o p e n in g o f th e U R A c a u se s a c h a ra c te ristic in sp ira to ry sn o re .
P a tie n ts c o m p la in a b o u t E S , w h ic h m a y b e v e ry
in c a p a c ita tin g . F a tig u e , m e n ta l c o n fu sio n u p o n a w a k e n in g ,
m o rn in g h e a d a c h e s, m e m o ry d iso rd e rs, d e p re ssio n ,
irrita b ility , se x u a l im p o te n c e , a n d n o c tu rn a l e n u re sis m a y o c c u r. D u rin g sle e p , sn o rin g is q u ite lo u d , b e in g in te rru p te d
b y p a u se s (a p n e a s) o f v a ry in g d u ra tio n . E x c e ssiv e
m o v e m e n t m a y a lso o c c u rY '
A lth o u g h it m a y o c c u r in a n y a g e g ro u p , O A S S is
m o re c o m ~ o n ly o b se rv e d in m id d le -a g e d m a le s. If n o t
tre a te d , it in a y c a u se sy ste m ic a rte ria l h y p e rte n sio n ,
p u lm o n a ry h y p e rte n sio n , c o r p u lm o n a le , p o ly c y th e m ia ,
c a rd ia c a rrh y tm ia s, o r e v e n d e a th w h ile sle e p in g .2 h
D ia g n o sis is o b ta in e d b y u sin g a sle e p la b o ra to ry
e v a lu a tio n th a t m o n ito r a n d c a rd io re sp ira to ry v a ria b le s a n d
re c o rd s th e p e rio d s o f o b stru c tio n , a n d th e d istu rb a n c e s o f c a rd ia c rh y th m a n d o f a rte ria l o x y g e n sa tu ra tio n Y T h e
c h o ic e o f tre a tm e n t re q u ire s a n a n a ly sis o f th e fa c to rs
re sp o n sib le fo r o b stru c tio n , a n d a n e v a lu a tio n b y a n
e a r, n o se a n d th ro a t sp e c ia list, a p n e u m o lo g ist, a n d a n
e n d o c rin o lo g ist.
T h e th e ra p e u tic p o ssib ilitie s fo r O A S S in c lu d e :
I. G e n e ra l a p p ro a c h : a v o id d e p re ssa n ts o f th e c e n tra l n e rv o u s sy ste m (h y p n o tic s, a n x io ly tic s, a lc o h o l);2 (1 .2 x
a v o id sle e p in g in th e h o riz o n ta l su p in e p o sitio n ;2 ')
2 . w e ig h t lo ss,3 0 w h e n n e c e ssa ry ;
3 . d ru g tre a tm e n t w ith v a ria b le re su lts:
a ) tric y c lic a n tid e p re ssa n ts - fo r m i Id to m o d e ra te c a se s;
b ) m e d ro x y p ro g e ste ro n e a c e ta te - fo r p a tie n ts w ith h y p e rc a p n ia ;3 !. 3 2
1235
4 . a m a s k fo r c o n tin u o u s p o s ItIv e a Ir p re s s u re
(n C P A p ):3 3 -3 6 w ith th e u s e o f a n a s a l m a s k , th e U R A
a re k e p t o p e n u s in g lo w p re s s u re le v e ls (5 -1 8 c m
H 20 ) ;it h a s b e e n th e p re fe rre d tre a tm e n t fo r m o d e ra te to s e v e re c a s e s ;
5 . re m o v a b le o ra l d e v ic e s ;3 7 -4 1
6 . s u rg e ry : u v u lo p a la to p h a ry n g o p la s ty ,4 2 .4 3 to n s ille c
-to m y a n d a d e n o id e c to m y ,4 4 n a s a l s u rg e ry ,4 5 tra c h e
-o s t-o m y (ra re ly ),4 6 o r m a n d ib u la r a n d /o r m a x illo fa c ia l s u rg e ry .4 7
3. Upper Respiratory Airways Resistance Syndrome
A lth o u g h th is d is o rd e r is n o t s h o w n in th e
IC S D T a b le , it w a s re c e n tly d e s c rib e d 4 x a n d d e s e rv e s
to b e d is c u s s e d . S o m e p a tie n ts w h o s n o re lo u d ly
w h ile s le e p in g a n d a re s le e p y d u rin g th e d a y d o n o t
s h o w O A S S . T h e la b o ra to ry s le e p e v a lu a tio n
s h o w s , h o w e v e r, a fra g m e n ta tio n o f s e c o n d a ry
s le e p a n d b rie f a w a k e n in g s a s s o c ia te d w ith
a b n o rm a l re s p ira to ry e ffo rt, m e a s u re d b y e s o p h a g e a l
p re s s u re . T h e s e a b n o rm a l e ffo rts a re a s s o c ia te d w ith
th e s n o rin g , a n d re m is s io n o f e x c e s s iv e s o m n o le n c e
m a y b e o b ta in e d b y u s in g th e n a s a l C P A P .
4. Periodic Limb Movement Disorder
T h is d is tu rb a n c e , a ls o k n o w n a s n o c tu rn a l
m y o c lo n ia s , is c h a ra c te riz e d b y th e o c c u rre n c e , d u rin g
s le e p , o f re p e titiv e a n d s te re o ty p e d m o v e m e n ts th a t m a in ly
a ffe c t th e lo w e r lim b s . T h e s e m o v e m e n ts , w h ic h la s t 0 .5
-5 s e c o n d s a n d a re u s u a lly re p e a te d a t in te rv a ls o f 2 0 4 0
-s e c o n d -s , o c c u r u n i- o r b i la te ra lly a n d a re c h a ra c te riz e d b y
fo o t d o rs ifle x io n , to e e x te n s io n a n d p a rtia l fle x io n o f th e
k n e e , a n d s o m e tim e s , o f th e h ip .4 9 T h e y s h o u ld n o t b e
c o n fu s e d w ith m a s s iv e m u s c u la r d is tu rb a n c e s , w h ic h
o c c a s io n a lly a c o m p a n y th e s e n s a tio n o f " fa llin g in to s p a c e "
th a t o c c u rs d u rin g th e w a k e -s le e p tra n s itio n .
M y o c lo n ia e p is o d e s m a y la s t fro m m in u te s to h o u rs ,
le a d in g to c o m p la in ts o f in s o m n ia (fre q u e n t a w a k e n in g s
d u rin g th e n ig h t) a s w e ll a s E S .5 0 T h e y c a n b e re la te d to o r
a g g ra v a te d b y s e v e ra l m e d ic a l c o n d itio n s , s u c h a s c h ro n ic
u re m ia , d ia b e te s a n d o th e r m e ta b o lic d is e a s e s , th e u s e o f
tric y c lic a n tid e p re s s a n ts a n d m o n o a m in e o x id a s e
in h ib ito rs , a n d th e in te rru p tio n o f h y p n o tic s a n d
a n tic o n v u ls a n ts .2 T h e p a th o p h y s io lo g y o f th is d is o rd e r is
u n k n o w n , a s is its n a tu ra l h is to ry . P re v a le n c e in c re a s e s
w ith th e a g e .1 1
P ro p e r d ia g n o s is is o b ta in e d u s in g a s le e p la b o ra to ry
e v a lu a tio n a n d b y m o n ito rin g th e a c tiv ity o f th e tib ia lis
a n te rio r m u s c le . D ru g s u s e d fo r tre a tm e n t in c lu d e :
c lo n a z e p a m (0 .5 -2 m g a t n ig h t);5 1 d o p a m in e (c a rb id o p a /
L -d o p a l:4 ; b e n z e ra z id e /L -d o p a 1 :4 )5 2 .5 3a n d o p ia te s .5 3 .5 4
5. Narcolepsy
N a rc o le p s y is a n E S d is o rd e r o f u n k n o w n c a u s e s
a c o m p a n ie d b y a u x ilia ry s y m p to m s (c a ta p le x y , h y p n a g o g ic
h a llu c in a tio n s , s le e p p a ra ly s is ) w h ic h re fle c t d is s o c ia te d
fra g m e n ts o f R E M s le e p .2 A b o u t 2 0 -2 5 p e rc e n t o f
n a rc o le p s y p a tie n ts h a v e a ll th e s e s y m p to m s .5 5
D a y tim e s le e p in e s s is u s u a lly th e firs t s y m p to m , a n d
is c h a ra c te riz e d b y c o n tin u o u s s o m n o le n c e o r " irre s is tib le
s le e p a tta c k s ," a n d b y d a y tim e n a p s o f v a ria b le d u ra tio n
w h ic h a re re s to rin g (a fte r th e n a p th e p a tie n t fe e ls m o re
a le rt fo r s o m e h o u rs ).5 6 F re q u e n tly , p a tie n ts re fe r to th e
o c c u rre n c e o f d re a m d u rin g th e n a p s .
C a ta p le x y is p ra c tic a lly p a th o g n o m o n ic o f
n a rc o le p s y . It is c h a ra c te riz e d b y a s u d d e n lo s s o f m u s c u la r
to n u s o f o n e o r m o re m u s c u la r g ro u p s , a n d is a lw a y s
p re c ip ita te d b y a n a b ru p t e m o tio n . T h e d u ra tio n is u s u a lly
s h o rt, v a ry in g fro m a fe w s e c o n d s to m in u te s , a le rtn e s s is
p re s e rv e d , a n d p a tie n ts m a y p re s e n t p e rc e p tio n
d is tu rb a n c e s . It is a q u ite in c a p a c ita tin g s y m p to m a n d
o c c u rs in d e p e n d e n tly o f s le e p e p is o d e s , a lth o u g h th e s e
m a y o c c u r fo llo w in g a c a p le c tic c ris is . A b o u t 7 0 p e rc e n t
o f p a tie n ts w ith n a rc o le p s y h a v e c a ta p le x y .2
H y p n a g o g ic h a llu c in a tio n s a re q u ite re a lis tic
p e rc e p tio n e x p e rie n c e s , u s u a lly v is u a l, th a t o c c u r d u rin g
th e w a k e -s le e p tra n s itio n (th e y a re d e n o m in a te d
h y p n o p o m p ic w h e n th e y o c c u r d u rin g fu ll a w a k e m e s s ).
P a tie n ts re p o rt fe e lin g in te n s e fe a r d u rin g th e s e e p is o d e s ,
w h ic h o c c u r in 5 0 p e rc e n t o f n a rc o le p s y c a s e s .
S le e p p a ra ly s is is a g e n e ra l tra n s ito ry in c a p a c ita tio n
o f th e o rg a n is m to m o v e , w h ic h o c c u rs a t th e b e g in n in g
o r e n d o f s le e p . T h e s e e p is o d e s , d e s c rib e d b y th e p a tie n ts
a s te rrify in g , la s t fro m o n e to s e v e ra l m in u te s , a n d o c c u r
in 5 0 p e rc e n t o f th e c a s e s o f n a rc o le p s y a n d in 5 p e rc e n t
o f n o rm a l in d iv id u a ls . T h e n a rc o le p s y p a tie n ts a ls o
c o m p la in a b o u t in s u ffic ie n t n o c tu rn a l s le e p , w ith fre q u e n t
a w a k e n in g s .
B e c a u s e th is is a c h ro n ic d is e a s e w ith o u t s ig n ific a n t
re m is s io n o r a d e fin itiv e tre a tm e n t, th e d ia g n o s is s h o u ld
b e c a rrie d o u t w ith e x tre m e c a u tio n . A la b o ra to ry s le e p
e v a lu a tio n a n d m u ltip le s le e p la te n c y te s t a re in d ic a te d .
T h e tre a tm e n t is s y m p to m a tic a n d in c lu d e s :5 5
I . E d u c a tio n o f p a tie n ts a n d re la ti v e s .
2 . A d e q u a te s le e p h y g ie n e , w ith a re g u la r s le e p s c h e m e
a n d s c h e d u le d d a y tim e n a p s .
3 . P s y c h o lo g ic a l a s s is ta n c e .
4 . S tim u la n ts to c o n tro l E S :
- dextroanfetam ines: 5-60 m g/day
- pem oline: 18.75-112.5 m g/day
- m azindole: 3-6 m g/day
T hese drugs m ay be prescribed for daily usage or
according to the patient's needs (in situations that require
alertness), and should be avoided during w eekends and
vacations, to inhibit the developm ent of tolerance.
5. T ricyclic antidepressants to control cataplexy:
- im ipram ine: 25-100 m g/day
- chlom ipram ine: 25-100 m g/day
6. I di opat hi c H y per s om ni a
Idiopathic hypersom nia Is characterized by a
persistent com plaint of E S, presum ably due to a central
nervous system disorder.2 N octurnal sleep is usually long
(> 8 hours), and daytim e naps are prolonged (1-2 hours),
but not repairative. It occurs usually in adolescence and
during the third decade of life.
A uxiliary sym ptom s m ay include m igraine crises,
headaches, fainting, and R aynaud's phenom enon, w hich
suggests a dysfunction of the autonom ic nervous system .57
A laboratory sleep valuation does not evidence any
abnorm ality, except for periods of prolonged sleepY T he
m ultiple sleep latency test reveals latencies shorter than
10 m inutes in the absence of R E M sleep. It is a chronic
disease, w ith a partial therapeutic response to stim ulants,
tricyclic antidepressants and m onoam ine oxidase
inhibitors.5x
7.R ec ur r ent H y per s om ni a
T he m ost w ell-know n type of recurrent hypersom nia
is K leine-L evin's syndrom e.59 It is a rare disorder,
characterized by periods of E S, lasting days to w eeks,
occurring at intervals of m onths or years. T he sym ptom atic
phase is characterized by prolonged sleep (18-20 hours/
day) associated w ith overeating and psychiatric sym ptom s
(depression, anxiety, hyper or hyposexuality,
hallucinations). In the atypical form , overeating does not
occur. Patients are norm al during the intervals.
R ecurrent hypersom nia usually begins during the
second or third decades of life and seem s to have a benign
evolution, disappearing after som e tim e of illness.2 E ven
though there is no specific treatm ent, there are reports of
satisfactory responses to central nervous system stim ulants,
tricyclic antidepressants, and lithium carbonate.59
Periodical hypersom nia associated. w ith
m enstruationW usually occurs at the end of the m enstrual
period and lasts for som e days, and m ay be accom panied
by overeating and sexual behavior disorders. T he
pathophysiology of this disorder is unknow n and the
treatm ent is achieved w ith anovulatories.
8. Pos t t r aum at i c H y per s om ni a
Posttraum atic hypersom ina is defined as excessive
sleepiness that occurs follow ing cranio-encephalic traum a.2
T his E S is usually associated w ith other sym ptom s, such
as headaches, fatigue, difficulty in concentrating, m em ory
disorders, and psychiatric disturbances.
9. ES As s oc i at ed W i t h Ps y c hi at r i c D i s t ur banc es
Som e patients present E S and dayti m e naps in
stressful situations. U sually, the episodes are of short
duration, becom ing less intense w ith the disappearance of
the causati ve factor.
In m ood disorders, insom nia is the m ost com m on
com plaint, but E S m ay also occur, especially in bipolar
disturbances, and in the so-called atypical depressions, w ith
the inversion of the norm al pattern: increase in the total
tim e of sleep, afternoon deterioration, increase in appetite and w eight.61
10.ES As s oc i at ed W i t h C l i ni c al Di s eas es
E S m ay be associated w ith m etabolic disorders, such
as diabetes, hypothyroidism , urem ia, hepatic failure, and
infectious diseases. T he m anifestation of som nolence is
quite variable in these conditions, and other signs and
sym ptom s usually predom inate.
11.I ns uf f i c i ent s l eep
M any persons sleep less than they need to, either
because of social pressure or by their ow n initiative. T his
situation causes E S, but is reversed w hen the individual
sleeps norm ally again, e.g., on w eekends or during
vacations.
1237
RESUMO
S o n o ll~ n cia e xce ssiva p o d e se r u m a m a n ife sta < ;a o b a sta n te in ca p a cita n te , se n d o fre q u e n te m e n te n e g lig e n cia d a p e lo m e d ico e p e lo p a cie n te . E ste a rtig o e u m a re visa o so b re o s fa to re s d e te rm in a n te s, a a va lia < ;a o e a q u a n tifica m d e so n o le n cia d iu rn a , e a d e scric;:a o e 0 tra ta m e n to d a s p rin cip a is ca u sa s d e so n o le n cia e xce ssiva .
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