Residual Sleepiness in Patients with Obstructive Sleep Apnea a Treatment Challenge for Otolaryngologists

Beyond sleep disorders, several comorbidities contribute to excessive sleepiness. Diabetes can cause fatigue, and medications for heart disease are often sedating. It is important to make sure you have a complete picture of any other health conditions and all medications a patient is taking. Ask directly about OTC products; patients often leave them out, thinking they are not relevant because they are non-prescription. You may find out a patient is taking an OTC sleep formulation that contains Benadryl.

The largest comorbidity contributing to excessive sleepiness is depression. Dr. Shangold pointed out, “With depression, there are disturbances in the pathways that regulate sleep and wakefulness. Also, many depression patients may be on medication with a sedating effect.” Bear in mind that not everyone suffering from depression has been diagnosed. Even if the patient tells you she is not depressed, probe into any family history of depression while taking the sleep history.

There is a small subset of patients for whom the cause of excessive daytime sleepiness remains a mystery. After every other possibility is exhausted, it may be necessary to prescribe modafinil (Provigil) or armodafinil (Nuvigil) as a stimulant. This therapy has been proven effective over the years, with many patients experiencing significant increases in wakefulness and daytime function (Chest. 2003;124:2192-2199; J Clin Sleep Med. 2013;9:751-757). Modafinil has not demonstrated dangerous adverse effects in clinical studies, although none were longer than 12 weeks, said Dr. Shangold. Some patients do experience headaches and personality effects, particularly a tendency to speak their minds more candidly. Dr. Wardrop added, “You have to be careful you aren’t treating sleep deprivation with a stimulant. If they are not wearing their CPAP enough, or not sleeping enough, you do not want to give them a stimulant so they can continue to do that.”

Finding the underlying cause of RES requires a commitment from the sleep professional, but it is important to put in the time and effort. As Dr. Yaremchuk said, “Do not give up when looking for a solution for excessive sleepiness. There is always something that can be done to help these patients feel better.”

Maybelle Cowan-Lincoln is a freelance medical writer based in Morris Plains, N.J.