This patient with hypersomnolence (despite a sufficient sleep period [ie, 7-9 hr]), obesity, and no obvious behavioral risk factors for daytime sleepiness (eg, shift work, lengthy work hours) most likely has obstructive sleep apnea (OSA). OSA results from laxity of the pharyngeal musculature, leading to transient upper airway obstruction and nocturnal hypoventilation in the reduced-consciousness setting of sleep. These transitory obstructions cause frequent nocturnal arousals and disruptions in the normal sleep architecture, resulting in poor sleep quality and cumulative sleep insufficiency.
Typical manifestations of OSA-related sleep insufficiency include fatigue, excessive daytime sleepiness, falling asleep during sedentary daytime activities (eg, sitting at a desk at work, watching television), and frequent compensatory behaviors (eg, increased caffeine consumption). Patients with OSA will often exhibit restlessness during sleep with snoring and/or periods of apnea or gagging witnessed by bed partners. Morning headaches are frequently reported. Physical examination commonly demonstrates obesity (or increased neck girth) and resistant systemic hypertension, a multifactorial sympathetic response to hypoxemia and hypercapnia.
Patients with suspected OSA should be evaluated with overnight polysomnography (sleep study) to confirm the diagnosis. Symptoms are improved with positive pressure therapy. Alternate treatments include oral appliances (eg, mandibular advancement device) or surgical (eg, uvulopalatopharyngoplasty) interventions.
(Choice A) Intermittent cardiac arrhythmias can cause momentary lapses in consciousness (ie, syncope). However, this patient reports a clear history of falling asleep, not fainting, so ECG monitoring is not required.
(Choice B) A brain tumor or acute intracranial hemorrhage may present with symptoms of increased intracranial pressure (eg, hypersomnolence); however, this patient has no history of headache, head trauma, or neuro-focal deficits concerning for an intercranial lesion requiring a CT scan.
(Choice D) Discussions about good sleep hygiene should be included in the management of patients with difficulties falling or staying asleep (eg, insomnia). Sleep hygiene education is often inadequate when sleep insufficiency is due to poor sleep quality rather than insufficient quantity. This patient is currently sleeping well and regularly gets 8 hours of sleep each night.
Obstructive sleep apnea is frequently implicated in hypersomnolence (excessive daytime sleepiness), especially in in individuals with risk factors (eg, obesity) and comorbid hypertension; nocturnal polysomnography should be ordered to confirm the diagnosis.