Shaking off sleepiness with integrative approaches

Photo Cred: Morgan Lane/Unsplash

By Catherine Darley, ND

This week, March 8-14, 2020, marks National Sleep Awareness Week, sponsored by the National Sleep Foundation. The celebration immediately follows Daylight Savings Time, a part of the year where we see an immediate increase in accidents and cardiovascular events due to acute sleep deprivation.  

According to a recent study published in the International Journal of Environmental Research and Public Health, there is a 3 percent increased daily mortality rate during the week following the time. National Sleep Awareness Week is an ideal time for integrative practitioners and patients to focus on ways sleep affects overall health and wellbeing.

As part of this effort, the National Sleep Foundation sponsors the annual Sleep in America Poll, highlighting a different topic each year. This years’ focus was on sleepiness, looking at how often people are sleepy, how it impacts them, and what they do to cope.

The survey was conducted in December 2019 and included 1,011 adults, both men and women. The researchers found 44 percent of respondents are sleepy two to four days per week, and 28 percent are sleepy five to seven days per week. Women are sleepier, 3.4 days per week versus men who are sleepy 2.7 days per week.

Health complaints stemming from sleepiness include:

• Impaired mood, 58 percent
• Irritability, 55 percent
• Headaches, 36 percent
• Generally feeling unwell, 33 percent

Other affects include avoiding going out in the evening (52 percent), trouble focusing (48 percent), inability to exercise (47 percent), poor work performance (33 percent), and weakened relationships with family and friends (26 percent).

According to the survey, 55 percent attribute sleepiness to sleep quality or not sleeping well, while 44 percent say it’s due to not having enough time to sleep. Seniors report fewer consequences of sleepiness.

The sleepier the respondent was, the lower their Sleep Health Index (SHI). The SHI developed by the National Sleep Foundation is based on a patient’s sleep duration, sleep quality, and sleep disorders.

People with more stress report that sleepiness impacts their day more than it does in those with low stress. In terms of how people cope with sleepiness, the majority report trying to “shake off” sleepiness. Other strategies used include fresh air, coffee, napping, prescription stimulants, and over-the-counter stimulants.

Sleepiness can only be relieved by sleep, whereas a feeling of fatigue can be relieved by either rest or sleep. Simply resting will not relieve sleepiness. Experts believe that, in part, the buildup of adenosine in the brain during wakefulness is what creates sleepiness. During sleep, adenosine levels in the brain decline, and wake is restored.

A useful way to think about this and talk about it with your patients is in terms of sleep drive, thought to correlate with adenosine levels. From the moment of waking, sleep drive builds throughout the day, until it reaches the sleep threshold and we fall asleep. During the night, the sleep drive is discharged, so we can easily wake up and begin our day. However, if sleep is insufficient, either due to inadequate time in bed or low sleep quality, our sleep drive may not have been fully dispelled, leading us to feel sleepy during the day.

For your patients who are sleepy, a nap may be a good strategy. Naps should be either less than 30 minutes, or a full sleep cycle of 90 minutes, to avoid waking from deep sleep, which can result in a poor feeling of sleep inertia. Naps should be taken early in the afternoon during the circadian lull, so as not to interfere with nighttime sleep.

A great tool to use in the clinic is the Epworth Sleepiness Scale (ESS). The ESS is a self-administered questionnaire with eight questions developed in 1990 and subsequently modified in 1997.  It is considered the gold standard used both in research and in clinics around the world. Patients are asked to rate, on a four-point scale (0-3), their usual chances of dozing off or falling asleep while engaged in eight different activities, such as watching television or attending a meeting. The ESS score, or sum of the eight item scores can range from zero to 24. The higher the ESS score, the higher that person’s average sleep propensity in daily life (ASP), or “daytime sleepiness.”

A score of 10 or above indicates problematic sleepiness, and 16 or above indicates severe sleepiness, as would be seen in severe obstructive sleep apnea or narcolepsy. The ESS can be used as part of the initial evaluation, and again at the end of treatment to verify that sleepiness has resolved.

If it is necessary to quantify sleepiness, as is sometimes required for occupational reasons in the transportation industry or for diagnosis of chronic conditions like narcolepsy, the Multiple Sleep Latency Test can be conducted at a sleep center. The test is a series of four to five daytime naps every two hours throughout the day wherein the amount of time to fall asleep is measured and extrapolated to determine sleepiness.

As a clinician, the most concerning finding from the Sleep in America Poll is that the primary coping mechanism is to “shake it off and keep going.” This is true even in the sleepiest patients, the 28 percent of respondents who feel sleepy five or more days per week.

The problem with the idea of “shaking it off” is that it’s a misperception; there is no shaking off sleepiness. When a person is sleep deprived, they will have what we call microsleeps, brief periods of sleep that happen seconds at a time. These lapses are so brief that the individual is not aware of them, but can have a big impact during highly demanding tasks, such as driving. Similar to being impaired by too much alcohol, people tend to underestimate how impaired they are by being sleepy.

From my perspective as a sleep-focused clinician, some ways to use these poll results are to first ask patients how often they are sleepy, and possibly have them complete the Epworth Sleepiness Scale. Next find out how they are coping with sleepiness and take the opportunity to provide education about effective versus ineffective strategies. Follow this with evaluation of the root cause. Is sleepiness due to chronic sleep restriction, such as not giving themselves enough time in bed, or is there an underlying sleep disorder leading to sleepiness?

Your patients will be well served by making this an annual conversation following the time change.

References

D’Ambrosio, S., Castelnovo, A., Guglielmi, O., Nobili, L., Sarasso, S., and Garbarino, S. (2019) Sleepiness as a local Phenomenon. Frontiers in Neuroscience. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/31680822

Johns, M. (1991) A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/1798888

National Sleep Foundation (2020) Sleep in America Poll 2020. Retrieved from: https://www.sleepfoundation.org/sites/default/files/2020-03/SIA%202020%20Q1%20Report.pdf

Potesher, M. and Moshammer, H. (2020) Daylight saving time transitions: impact on total mortality. International Journal of Environmental Research and Public Health. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/32131514

Urry, E., Landolt, H. (2015) Adenosine, caffeine, and performance: from cognitive neuroscience of sleep to sleep pharmacogenetics. Current Topics in Behavioral Neurosciences. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/24549722