History

Fact Explanation
Excessive sleepiness. Prolonged sleep episodes or daytime sleepiness occurring daily at least for period of 1 month. [1]
Excessive sleepiness cause clinically significant distress to the person's life It may Impair work performance and even be involved In accidents at work or while driving, impairs social functioning. [1]
Symptoms of another sleep disorder Other sleep disorders includes, narcolepsy, breathing related sleep disorder, circadian rhythm sleep disorder, parasomnia. If other sleep disorders present with hypersomnia, they should be treated first before the diagnosis of hypersomnia is made. [2]
Symptoms of a depressive disorder Sleep disturbance commonly occurs in major depressive disorder and causes excessive day time sleepiness. [3]
Sleepiness is not due to a medical disorder or due to effects of a substance Respiratory causes as obstructive sleep apnea, and structural lesions such as stroke or head injury, endocrine causes like hypothyroidism, metabolic derangements, can cause hypersomnia. Alcohol abuse, withdrawal from cocaine, caffeine can also cause excessive sleepiness. [4]
Ask for a family history of sleep disorders. individuals with primary hypersomnia are likely to have other family members affected by primary hypersomnia.[1]
Similar previous episodes, and the duration of those symptoms Periods of excessive sleepiness lasting at least 3 days occurring several times a year at least for 2 years is known as 'recurrent hypersomnia'. The recurrent form of hypersomnia is also known as Kleine-Levin Syndrome, often accompanies symptoms of megaphagia, hypersexuality and cognitive disturbances. [5]
References
  1. DAUVILLIERS Y, BUGUET A. Hypersomnia Dialogues Clin Neurosci [online] 2005 Dec, 7(4):347-356 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181743
  2. THORPY MJ. Classification of Sleep Disorders Neurotherapeutics [online] 2012 Oct, 9(4):687-701 [viewed 02 June 2014] Available from: doi:10.1007/s13311-012-0145-6
  3. PLANTE DT, LANDSNESS EC, PETERSON MJ, GOLDSTEIN MR, WANGER T, GUOKAS JJ, TONONI G, BENCA RM. Altered slow wave activity in major depressive disorder with hypersomnia: a high density EEG pilot study Psychiatry Res [online] 2012 Mar 31, 201(3):240-244 [viewed 02 June 2014] Available from: doi:10.1016/j.pscychresns.2012.03.001
  4. ANDERSON KN, PILSWORTH S, SHARPLES LD, SMITH IE, SHNEERSON JM. Idiopathic Hypersomnia: A Study of 77 Cases Sleep [online] 2007 Oct 1, 30(10):1274-1281 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266276
  5. GUPTA R, LAHAN V, SRIVASTAVA M. Kleine-Levin Syndrome and Idiopathic Hypersomnia: Spectrum Disorders Indian J Psychol Med [online] 2011, 33(2):194-198 [viewed 02 June 2014] Available from: doi:10.4103/0253-7176.92048

Examination

Fact Explanation
Thorough and complete neurological examination. Structural brain lesions and stoke can cause similar clinical conditions. Individuals with Kleine-Levin syndrome may show non-specific neurological signs like depressed deep tendon reflexes, dysarthria, nystagmus. [1]
Respiratory system examination: barrel shape chest, increased resonance on percussion, rhonchi on auscultation. Chronic obstructive pulmonary disease (COPD) can give rise to disturbed nocturnal sleep and cause increase day time sleepiness. [2]
Features of hypothyroidism: thyroid goiter, coarse skin, cold intolerance, bradycardia. Hypothyroidism can cause extreme somnolence which can mimic hypersomnia. [1]
Mental state examination (MSE) In patients with hypersomnia alone, MSE should be normal. However, look for sings of depression, and substance abuse. [3]
Mental State Examination: Appearance Crumpled clothes, self neglect suggests alcoholism. Exclude co-morbid conditions like depression where vertical furrows in the brow, hunched shoulders, turned down face can be seen. [3]
Mental State Examination: Speech Normal. May speak slowly if the patient has co morbid depression. [3]
Mental State Examination: Mood Depressed mood. [3]
Mental State Examination: Thinking Suicidal thoughts in severe depression. Nihilistic delusions, defamatory or accusatory auditory hallucinations in severe depressive disorder. [3]
Mental State Examination: Perception Transient hallucinations of vision and hearing in heavy alcohol drinkers usually during withdrawal. [3]
Mental State Examination: Cognitive functions Attention and concentration and memory can be impaired in depression. [3]
Mental State Examination: Insight May be lost in severe depressive disorders otherwise should be good. [3]
References
  1. DAUVILLIERS Y, BUGUET A. Hypersomnia Dialogues Clin Neurosci [online] 2005 Dec, 7(4):347-356 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181743
  2. ANDERSON KN, PILSWORTH S, SHARPLES LD, SMITH IE, SHNEERSON JM. Idiopathic Hypersomnia: A Study of 77 Cases Sleep [online] 2007 Oct 1, 30(10):1274-1281 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266276
  3. DAUVILLIERS Y, LOPEZ R, OHAYON M, BAYARD S. Hypersomnia and depressive symptoms: methodological and clinical aspects BMC Med [online] :78 [viewed 03 June 2014] Available from: doi:10.1186/1741-7015-11-78

Differential Diagnoses

Fact Explanation
Long sleepers Individuals who need more than average amount of sleep. They do not have excessive daytime sleepiness, sleep drunkenness when they get their required amount of sleep. [1]
Inadequate amount of nocturnal sleep An average daily sleep of less than 7 hours with the symptoms suggest inadequate amount of sleep while average sleep more than 9 hours suggest primary hypersomnia. [2]
Primary insomnia Sleepiness is less severe in primary insomnia. When primary insomnia is diagnosed an additional diagnosis of hypersomnia cannot be made. [3]
Narcolepsy In hypersomnia, there is longer and less disrupted nocturnal sleep, greater difficulty in awakening, more persistent day time sleepiness instead of periodic drop attacks, sleep paralysis, hypnogogic hallucinations and cataplexy seen in narcolepsy. [2]
Breathing related sleep disorder: Central apnea syndromes Disordered ventilation during sleep. Respiratory effort is diminished or absent intermittently as a result of central nervous system dysfunction. Examples: primary central apnea, central sleep apnea due to Cheyne-Stokes breathing, central sleep apnea due to high-altitude periodic breathing, secondary form of central sleep apnea due to drug or substance. [2]
Breathing related sleep disorder: Obstructive sleep apnea syndromes Obstruction in the airway resulting in increased breathing effort and in adequate ventilation. [2]
Circadian rhythm sleep disorder There's a persistent or recurrent misalignment between the patient’s sleep pattern and the pattern that is desired or regarded as the social norm. [2]
Parasomnia The parasomnias are undesirable physical or experiential events that accompany sleep.It rarely produces the undisturbed nocturnal sleep or daytime sleepiness characteristic of primary hypersomnia. [2]
Other mental disorders that can cause hypersomnia Major depressive disorder, depressed phase of Bipolar Disorder can cause hypersomnia. [2]
Sleep disorder due to general medical conditions When the hypersomnia is due to a direct physiological cause of a general medical condition. (structural lesions such as stroke or head injury, endocrine causes like hypothyroidism) [4]
Substance induced sleep disorder Drug abuse( withdrawal from cocaine), exposure to a toxin, direct effect due to a medication. [4]
References
  1. GRANDNER MA, DRUMMOND SP. Who Are the Long Sleepers? Towards an Understanding of the Mortality Relationship Sleep Med Rev [online] 2007 Oct, 11(5):341-360 [viewed 02 June 2014] Available from: doi:10.1016/j.smrv.2007.03.010
  2. THORPY MJ. Classification of Sleep Disorders Neurotherapeutics [online] 2012 Oct, 9(4):687-701 [viewed 02 June 2014] Available from: doi:10.1007/s13311-012-0145-6
  3. WILSMORE BR, GRUNSTEIN RR, FRANSEN M, WOODWARD M, NORTON R, AMERATUNGA S. Sleep Habits, Insomnia, and Daytime Sleepiness in a Large and Healthy Community-Based Sample of New Zealanders J Clin Sleep Med [online] , 9(6):559-566 [viewed 03 June 2014] Available from: doi:10.5664/jcsm.275
  4. ANDERSON KN, PILSWORTH S, SHARPLES LD, SMITH IE, SHNEERSON JM. Idiopathic Hypersomnia: A Study of 77 Cases Sleep [online] 2007 Oct 1, 30(10):1274-1281 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266276

Investigations - for Diagnosis

Fact Explanation
Brain Imaging (MRI) To exclude strokes, head injury, space occupying lesions in the brain that can give rise to similar symptoms.
Thyroid function tests (TSH, T4) To exclude hypothyroidism that could be the cause of extreme somnolence.
Polysomnogram- multiple sleep latency test (MSLT) Objectively measures Extreme daytime somnolence. Mean sleep latency <8 minutes is pathological and <5 minutes is severe. [2]
Maintenance Wakefulness Test (MWT) An alternative to the MSLT. The patient sits in bed and attempts to remain awake.Latency <19 minutes is considered as abnormal. [2]
References
  1. ANDERSON KN, PILSWORTH S, SHARPLES LD, SMITH IE, SHNEERSON JM. Idiopathic Hypersomnia: A Study of 77 Cases Sleep [online] 2007 Oct 1, 30(10):1274-1281 [viewed 02 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2266276
  2. DAUVILLIERS Y, LOPEZ R, OHAYON M, BAYARD S. Hypersomnia and depressive symptoms: methodological and clinical aspects BMC Med [online] :78 [viewed 03 June 2014] Available from: doi:10.1186/1741-7015-11-78

Management - General Measures

Fact Explanation
Advice on lifestyle changes Patient education on avoiding dangerous activities such as driving or operating machinery, and possible dangerous situations and suitable precautions. [1]
Explanation of the diagnosis and nature of disorder. Explain that the extreme sleepiness is part of the disorder. In patients with Kleine-Levin syndrome (recurrent hypersomnia) explain the behavioral symptoms that can accompany the episodes of hypersomnia. [2]
References
  1. DE MELLO MT, NARCISO FV, TUFIK S, PAIVA T, SPENCE DW, BAHAMMAM AS, VERSTER JC, PANDI-PERUMAL SR. Sleep Disorders as a Cause of Motor Vehicle Collisions Int J Prev Med [online] 2013 Mar, 4(3):246-257 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3634162
  2. WISE MS, ARAND DL, AUGER RR, BROOKS SN, WATSON NF. Treatment of Narcolepsy and other Hypersomnias of Central Origin: An American Academy of Sleep Medicine Review Sleep [online] 2007 Dec 1, 30(12):1712-1727 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276130

Management - Specific Treatments

Fact Explanation
Maintaining a regular sleep- wake pattern Relieves daytime drowsiness. The combination of planned daytime naps and maintaining regular nocturnal sleep times produces a significant reduction in the severity of daytime sleepiness in treatment of hypersomnia. [1]
Advice on regular daytime napping Relieves daytime drowsiness. [1]
Pharmacotherapy: CNS stimulants Amphetamines are derivatives of catecholamines, that are made more lipophilic so that they enter the central nervous system easily. Side effects of amphetamines are peripheral release of norepinephrine, resulting in cardiac stimulation and vasoconstriction, Increased heart rate and blood pressure, palpitations, sweating, Increased anxiety in predisposed patients, may precipitate psychosis. Monitoring of pulse and blood pressure needed. Contra indications to their administration are cardiovascular disease including moderate to severe hypertension, advanced arteriosclerosis, structural cardiac abnormalities. Methylphenidate is a dopamine transporter (DAT) reuptake inhibitor. It is more lipophilic than Amphetamine with increased central penetration. Contra indications- Anxiety or agitation, severe depression, suicidal ideation, drug or alcohol dependence, psychosis. Side effects - Abdominal pain, nausea, vomiting, dry mouth, anorexia, palpitations, tachycardia, arrhythmia, tics ( very rarely Tourette syndrome).[3]
Pharmacotherapy: Non amphetamine wakefulness promoting medication Modafinil and Armodafinil. Increases wakefulness through dopamine reuptake inhibition and also acts as a unique compound in the treatment of excessive daytime sleepiness. Monitor blood pressure and heart rate in hypertensive patients. Contra indications- Moderate to severe uncontrolled hypertension, arrhythmia, cor pulmonale. Side effects- dry mouth, appetite changes, gastro intestinal disturbances,, tachycardia, vasodilatation. [3]
Pharmacotherapy: Sodium Oxybate Is a rapidly acting sedative. Reduces daytime somnolence. May act via GABA-B or specific GHB receptors. Reduces (Dopamine) DA release. Side effects- nausea, vomiting , abdominal pain, anorexia, hypertension, dizziness, headache. Contra indications- pregnancy. [3]
Pharmacotherapy: Tricyclic antidepressants Contra indications- in the immediate recovery period of myocardial infarction, in arrhythmia, in severe liver disease, in the manic period of bipolar disorder. Side effects- arrhythmia, heart block, postural hypotension. [4]
References
  1. BASTUJI H, JOUVET M. Successful treatment of idiopathic hypersomnia and narcolepsy with modafinil. Prog Neuropsychopharmacol Biol Psychiatry [online] 1988, 12(5):695-700 [viewed 03 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2906157
  2. WISE MS, ARAND DL, AUGER RR, BROOKS SN, WATSON NF. Treatment of Narcolepsy and other Hypersomnias of Central Origin: An American Academy of Sleep Medicine Review Sleep [online] 2007 Dec 1, 30(12):1712-1727 [viewed 17 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2276130
  3. MIGNOT EJ. A Practical Guide to the Therapy of Narcolepsy and Hypersomnia Syndromes Neurotherapeutics [online] 2012 Oct, 9(4):739-752 [viewed 04 June 2014] Available from: doi:10.1007/s13311-012-0150-9
  4. TOUCHON J. [Use of antidepressants in sleep disorders: practical considerations]. Encephale [online] 1995 Dec:41-7 [viewed 04 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8929678