A 40-year-old man with a history of hypertension presents with a primary complaint of feeling tired during the day. He says onset was approximately 2 years ago and the intensity of the feeling has been increasing. He says he feels “weighed down;” that he has to make a special effort to accomplish routine tasks; that his concentration is poor; and that his memory is deteriorating. He describes a sense of “mental fog.” He also has a history of depression, currently treated with fluoxetine, and, when asked about his mood, reports feeling “run down but not depressed.” He reports no sleep difficulties and his weight and appetite have been stable. Thyroid function, blood chemistries and metabolites, and CBC are all within normal limits. The physical examination is unrevealing other than psychomotor slowing.
Answer: B. The Epworth Sleepiness Scale
Excessive daytime sleepiness (EDS) is defined as an exaggerated tendency to fall asleep at inopportune times. This definition distinguishes it from fatigue, which does not necessarily lead to inappropriate sleep. The Epworth Sleepiness Scale (ESS) has been validated in a variety of clinical settings and assesses the proclivity for falling asleep in situations of everyday life. This self-administered scale is easy to use and can be completed in less than a minute. A score of 10 and above is considered to be abnormal.
The determination, based on ESS and other standardized tests, that an individual is highly sleepy has important clinical implications. It indicates that a high likelihood of daytime impairment and heralds the need for appropriate management. The ESS also provides an approximate, yet quantifiable score for the assessment of treatment response. The negative consequences of EDS include slower response time, errors in performance for tasks requiring mental acuity, memory decrement, and diminished concentration. Sleepy individuals are also more susceptible to pain, depression, and major medical conditions such as cardiovascular, pulmonary, and metabolic disease.
The differential diagnostic entities to be considered in the evaluation of sleepy individuals include, among others, sleep deprivation, circadian rhythm sleep disorders (shift work disorder, jet lag, delayed sleep phase syndrome, etc), sleep apnea syndrome, narcolepsy, sedating medications, periodic limb movement disorder, and endocrine disorders (eg, hypothyroidism).
- When confronted with tired and fatigued patients, determine if the patient is truly sleepy.
- Consider utilizing inventories such as the Epworth Sleepiness Scale.
- Perform a thorough evaluation and treat the underlying disorder.
The Epworth Sleepiness Scale
The Official website of the Epworth Sleepiness Scale
by Dr Murray Johns
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Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14:540-545.
Roth T, Bogan RK, Culpepper L, et al. Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management. Curr Med Res Opin. 2010;26(Suppl 2):S3-S24; quiz S25-S27. doi: 10.1185/03007995.2010.532544.