A Guide to Diagnosing and Treating Excessive Daytime Sleepiness

How can clinicians efficiently identify the root cause of excessive daytime sleepiness (EDS) and better treat their patients? Nishi Bhopal, MD, founder and medical director of telepsychiatry practice Pacific Integrative Psychiatry, shares her step-by-step clinical framework—combining clinical history-taking, reliable screening tools, and targeted diagnostics—to differentiate between sleep disorders and psychiatric or other contributors to EDS.

Dr Bhopal also discusses practical, evidence-based interventions, including both behavioral strategies and pharmacologic options, to help neurologists improve outcomes for patients struggling with EDS.

For more expert insights, visit the Sleep Disorders Excellence Forum here on Neurology Learning Network.

>>More insights from Dr Bhopal: A Brief Overview of Excessive Daytime Sleepiness

Read the interview transcript:

Nishi Bhopal, MD: I'm Dr Nishi Bhopal, MD, I am a physician, board certified in sleep medicine, psychiatry, and integrative holistic medicine. I'm the founder of Pacific Integrative Psychiatry. We're an online telehealth practice seeing patients across the state of California. I'm also the founder of Intra Balance, which is an online platform teaching physicians, therapists, and other health care practitioners about clinical sleep medicine. I do that through a YouTube channel and online courses.

[0:40] Neurology Learning Network (NLN): What clinical tools do you use to confirm an EDS diagnosis? How do you determine whether sleep studies are needed?

Dr Bhopal: The first reliable or diagnostic tool to use is taking a good history. It really starts by understanding what the patient's symptoms are, how it's affecting them, and how long the symptoms have been going on for. Once you've established a really good clinical history, then there are other tools that we can use as well to see if a sleep study or other types of investigations might be helpful.

Once I do the clinical history, I also like to look at the Epworth Sleepiness Scale. This is a free rating scale that you can use in your clinical practice—I actually have it as part of our intake process in my practice—so you can get a sense of the patient's levels of excessive daytime sleepiness. A score of 11 or more on the Epworth Sleepiness scale is indicative of excessive daytime sleepiness. Then you can determine if the patient needs a sleep study to evaluate another sleep disorder that might be going on, particularly something like obstructive sleep apnea.

We're also thinking about narcolepsy or disorders of central hypersomnolence in this category of EDS. So, if it's indicated, you can then refer the patient for a polysomnogram or an in-lab sleep study. If the patient does not have obstructive sleep apnea, or if the results are inconclusive, or if you suspect narcolepsy, you can follow up with aa multiple sleep latency test (MSLT), which is essentially a test to see how likely the patient is to fall asleep during the day. Now, the MSLT is not something we're going to be jumping to straight away though, because first we're going to start with that clinical history. We're also going to be looking at other things that might be contributing.

We talked about sleep deprivation as being a very common factor. We looked at metabolic issues and symptoms of anxiety and depression. We want to look at circadian misalignments, which is something that I often see as missed in clinical practice where the patient's body clock is misaligned with their day-to-day obligations. We really want to be evaluating all of these things before we jumping straight to a sleep study. However, we don't want to wait too long because when it comes to disorders like narcolepsy, the average time to diagnosis is over a decade.

It's really about finding that balance between taking a really good clinical history, understanding the underlying causes, but not waiting too long to do further evaluation if you feel like you're not getting further with the standard workup with regard to history and lab work.

[3:14] NLN: Can you walk us through your clinical decision-making process when determining the underlying cause of EDS?

Dr Bhopal: It can be difficult to determine whether EDS is due to a sleep disorder or a psychiatric condition, or something else that's going on. So again, it goes back to doing a thorough clinical evaluation, including a detailed sleep history, a detailed medical history, and a psychiatric assessment.

We want to be looking at other contributing factors, like not getting enough sleep, medications that could be causing excessive daytime sleepiness, conditions such as depression and anxiety, metabolic issues, and so on.

What I do in my practice is I actually have quite an extensive intake form that patients fill out before their first visit, because you may not have time to go into all of these questions, especially with regard to their sleep history, their medical history, and everything else in one session. So, I like to use tools where patients can fill the form out before their initial session or in between, before their follow-up session, so you can get that detailed information.

I also really like to look at their daily routines to see how much sleep they're getting, what their day-to-day activities are like, what their circadian rhythm is like, and if that's lined up with their daily routines.

I also like to assess nutrition. Are they eating at regular intervals? Could there be any issues with hypoglycemia or blood sugar fluctuations that could be contributing to fatigue or sleepiness?

I also like to get basic screening labs, including looking at iron levels. I'm screening for anemia, looking at vitamin D, vitamin B12 levels, of course, and assessing thyroid issues.

Then I'm also on the lookout for metabolic issues like type 2 diabetes.

As I mentioned earlier, I'll use subjective measures, such as the Epworth Sleepiness Scale, which is used to quantify the severity of their excessive daytime sleepiness. And then I'm integrating psychiatric rating scales as well into this process like the PHQ-9 or the GAD-7.

I want to make sure that we get the patient onto a good sleep schedule because when it comes to insufficient sleep as a cause of EDS, sometimes patients don't realize that they may actually need more sleep at baseline than they're currently getting. I see this as a very common cause of excessive daytime sleepiness. What I mean by this is a patient might be getting, let's say 7 hours of sleep on average, which according to the guidelines, 7 to 9 hours is what is recommended for the average adult, but if their baseline sleep need is actually 8 hours, that's 1 hour of sleep deprivation every night. This is a simple thing to look into, and I might have patients simply expand their sleep zone if they don't experience insomnia.

That's an important caveat, but I might have them expand their sleep zone so they can get onto a good sleep schedule.

Sometimes, that alone can get to the root cause of the EDS, but of course, if that doesn't treat it, then we want to be looking into all these other factors that I mentioned. Then lastly, once I've done all of these things, if I feel like there might be some issues with sleep disordered breathing, narcolepsy, periodic limb movement disorder, or something else going on that's causing sleep disruption, then I may do a polysomnogram or in lab sleep study or I'll consider home sleep testing as well.

Home sleep testing is much more readily available nowadays, and the technology is improving. There's also now the opportunity to do longitudinal home sleep testing where you can get multiple nights. In my practice, we do up to 30 nights of home sleep testing so that we can get a really good picture as to what's going on with the patient's sleep. Those are the main steps I would follow in assessing EDS.

Okay, great. So the next one, there might be a lot of overlap again from what you just went through. So let me know if you just want to go ahead and skip it, but once you've determined diagnosis and underlying causes, how do you approach treatment of EDS? Please discuss both pharmacological and non-pharmacological interventions.

[7:02] NLN: Once you’ve determined the diagnosis and possible underlying cause, how do you approach EDS treatment? Please discuss both pharmacological and non-pharmacological approaches.

Dr Bhopal: When you approach treatment of EDS, you can break this down into non-pharmacological and pharmacological interventions. Non-pharmacological interventions are just as important as pharmacological interventions.

I want clinicians to really take that home that if you're using pharmacological interventions, without these other behavioral strategies that I'm going to share, they may not be as effective. I've seen that play out in my clinical practice where sometimes the nonpharmacological interventions are even more effective for patients. Some of these non-pharmacological interventions include behavioral and lifestyle modifications, so ensuring adequate sleep hygiene, getting them on a regular sleep schedule so that they're getting sufficient sleep for their baseline sleep needs. Strategic napping can also be helpful for some patients with EDS.

I'm also looking at nutrition, so making sure they're eating regularly throughout the day and eating nutritious foods.

An important aspect with managing EDS that's often missed is the importance of community. A person needs a reason to be up and about. If they're working from home, or if they're very sedentary ,or very isolated, they're going to feel more sleepy and tired.

I have a patient that I'm working with right now who has EDS, and she was working from home at a computer all day, and this was just making her more and more fatigued and more sleepy during the day as well. She ended up changing careers, and now she's working in an active job that requires her to be up and about, and it's much more conducive to her energy levels. She also has some flexibility to be able to rest during the day.

Supporting patients in crafting a lifestyle that supports their energy levels is important. Of course, we want to be managing other conditions that could be contributing to EDS. We've talked about sleep apnea and other sleep disorders, metabolic issues, and psychiatric conditions, and so on.

In this category of non-pharmacological strategies, there's also a form of cognitive behavioral therapy called cognitive behavioral therapy for hypersomnia. It's specific for hypersomnia and excessive daytime sleepiness. This has shown to help manage symptoms and improve patient's overall quality of life when they're struggling with EDS.

Another non-pharmacological intervention that is really important and actually very simple but effective is the use of light therapy.

Most of our patients have a deficiency of light exposure during the day, so they're just not getting enough light exposure. And then we have a deficiency of darkness at night, so we're not getting enough darkness exposure. This light and dark exposure is really important for circadian rhythm regulation, but also important for daytime energy levels. I like to exaggerate light exposure during the day, especially when patients have EDS. What this looks like is going outside and getting bright sunshine first thing in the morning within 30 minutes of waking up. If they're not able to go outside and get sunshine, then the next best thing is using a light therapy device like a light therapy box or a light therapy wearable.

Then I also like to ensure that people are getting adequate sunlight or bright light during the day as well. This can look like going outside for a walk on their lunch break or in the early afternoon, or if they're not able to do that strategically using light therapy, you have to be careful not to delay their circadian phase if you're using it during the day, but ensuring that they have their curtains or blinds open, that they're getting lots of natural light coming in, and that they have the lights on in their room. Really exaggerating that exposure to daytime light can help improve their energy levels and reduce some of their symptoms of EDS.

[11:00] Now, there are pharmacological interventions as well. This includes wakefulness promoting agents. Things like modafinil and armodafinil are first-line treatments for EDS. Stimulants like methylphenidate and amphetamines may also be considered. There's some newer agents as well, solriamfetol and pitolisant which is Sunosi and Wakix that have shown efficacy in promoting wakefulness and are increasingly used. But again, we want to go back to starting with some of those behavioral non-pharmacological interventions and then using medication as an adjunct to those.

Interested readers can explore Dr Bhopal's YouTube Channel here.

Nishi Bhopal, MD, is board-certified in psychiatry, sleep medicine, and integrative holistic medicine. She graduated from the University College Cork School of Medicine, completed her psychiatric residency at Henry Ford Health System, and a fellowship in sleep medicine at Harvard Medical School. She is the founder and medical director of Pacific Integrative Psychiatry, an online practice in California where patients receive a whole-person approach to anxiety, depression, and sleep disorders, including nutrition, psychotherapy, and integrative and functional medicine. In addition to her private practice, Dr Bhopal is the founder of IntraBalance, an educational platform for physicians and therapists that includes a YouTube channel and online courses on clinical sleep medicine for healthcare practitioners. Her passion is making clinical sleep medicine easy to understand and accessible to all.