Differential Diagnosis and Treatment of Excessive Daytime Sleepiness

1
Differential Diagnosis and Treatment of Excessive
Daytime Sleepiness
2
What is EDS?

• Excessive daytime sleepiness
• The tendency to fall asleep during normal waking
  hours1
• Contrast with fatigue
• A desire to rest due to feelings of exhaustion1
• Symptom of underlying disorder

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
3
EDS a common complaint

• Almost ½ of all Americans report a sleep-related
  problem1
• EDS is the primary complaint of 1 in 8 people
  seen in sleep clinics2
• More than 1 in 4 patients complain of EDS in the
  primary care setting3

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Roth T Roehrs TA Clin
Ther.,1996 3. Kushida CA, et al. Sleep Breath
2000.
4
EDS characteristics

• Number of daily episodes vary
• Occurs during passive activities
• TV watching, sitting on a plane
• Occurs during more active tasks
• Driving, eating, speaking
  

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Bassetti C Aldrich MS. Neuro
Clin1996.
5
Normal sleep stages1,2
1) Zeman, A. et al. BMJ 2004 2) Beers MH, et
al. Merck Manual of Diagnosis and Therapy 2006.
6
Comparative EDS prevalence
Level II insomnia inability staying asleep daytime dysfunction1 33
EDS2 31
Chronic back pain3 26
Age-related nocturia4 25
Level I insomnia difficulty falling asleep1 14
Migraine5 12
1) Hatoum HT, et al. Am J Manag Care 1998 2)
Roth T Roehrs TA. Clin Ther 1996 3) Hillman
M, et al. J Epidemiol Community Health 1996 4)
Fultz NH Herzog, Urol Clin North Am 1996 5)
Hagen K. Cephalgia 2000.
7
Factors associated with EDS1
Age (Compared to age 50-59) ? 83 in 20-29 ? 48 higher in 30-39 ? 9 higher in 40-49
Marital status (Compared to marrieds) ? 69 in unmarrieds
Sleep duration (Compared to 7 h sleep) ? 371 if lt6 h sleep ? 55 if 6-7 h sleep
Sleep-wake schedule (Compared to regular schedule) ? 78 in weekly irregular ? 270 in daily irregular
1) Doi Y, et al. J Occup Health 2003
8
Factors associated with EDS1
Difficult falling/staying asleep 1/wk (Compared to lt1/wk) ? 47
Depression ? 404
Asthma ? 261
Peptic ulcer ? 203
Muscle-joint pain ? 59
1) Doi Y, et al. J Occup Health 2003
9
The Consequences of EDS
10
Consequences to Self

• ? Productivity1,2
• ? Motivation2
• ? Interpersonal relationship problems2
• ? Depression anxiety1, 3
• ? Insomnia1
• ? Quality of life1,2

1. Hasler G, et al. J Clin Psychiatry 2005 2.
Daniels E, et al. J Sleep Res 2001 3.
Theorell-Haglow J, et al. Sleep 2006.
11
Consequences to Health

• Sleepiness vs. blood pressure1
• ? EDS symptoms
• ? Sleep BP
• ? Daytime systolic/diastolic variability
• ? Anger, depression, anxiety
• More likely to get a diagnosis of hypertension

1. Goldstein IB, et al. Am J Hypertens 2004.
12
Consequences to Health

• Sleepiness vs. CVD in older adults1
• ? EDS symptoms
• ? CVD mortality
• 200 in men 40 in women
• ? CVD morbidity
• 35 more MI and CHF in men 66 more in women

1. Newman AB, et al. J Am Geriatr Soc 2000.
13
Consequences to Society

• Crashes when driver falls asleep1
• 100,000 each year in U. S.
• 1,500 deaths
• Death rate may exceed alcohol-related crashes
• 1/2 of all work-related accidents2
• 1 in 5 public accidents due to falls2

1. Mahowald MW. Postgrad Med 2000 2. Leger D.
Sleep 1994.
14
Drivers beware sleepiness vs. drunkenness

• Study compared effects on performance of sleep
  deprivation and alcohol1
• Drivers who went 17-19 hours without sleep
  drivers with 0.05 BAC
• Sleepy drivers responded 50 more slowly/less
  accuracy than fully awake drivers
• Sleepiness can compromise performance needed for
  road and job safety

1. Williamson AM Feyer AM. Occup Environ Med
2000.
15
Asleep at the wheel

• Sleepiness 1-3 of US vehicle crashes1
• 96 involve drivers of passenger vehicles
• 3 involves drivers of large trucks
• NHTSA 100K crashes/yr
• 1500 or 4 of all traffic fatalities/yr2
• 71,000 injured/yr
• 12.5 billion lost
• Risk factors young age, shift work,
  alcohol/drug use, sleep disorders.

1. Lyznick JM, et al. JAMA 1998 2) NHTSA 2000.
16
Drivers at high-risk for sleep-related crashes

• 60 of sleep-related crashes are caused by
  drivers lt30 yr of age1
• School, job, socializing cuts into total sleep
  time
• Analysis of gt4,000 crash reports shows
• Drivers 25 yr in 55 sleep-related crashes2
• Men in more crashes than women

1). Knipling RR Wang, S-S NHTSA 1994 2) Pack
AI, et al. Accid Anal Prev 1995.
17
Drivers at high-risk for sleep-related crashes

• Truckers 25 fell asleep at the wheel 1 last
  year1
• 66 drove while sleepy in the preceding month
• In 4333 crashes where the driver was asleep, not
  intoxicated2
• Crashes were mostly driving-off-the-road (78)
• Took place at higher speeds (62 were gt50 mph)
• Fatality rate similar to that of alcohol-related
  crashes (1.4 vs. 2.1)
• Occurred mostly 12AM-7AM, mid-afternoon 3PM

1) McCartt AT, et al. Accid Anal Prev 2000 2)
Pack AI. Accid Anal Prev. 1995.
18
Patient assessment
19
Is sleep the new vital sign?

• Growing evidence shows that sleep is an important
  ingredient in good health1
• Few MDs address sleep quality in their practices
• lt10 of patient charts document sleep history2
• Sleep disorders are underdiagnosed, undertreated

1. Wilson JF. Am Coll Physicians 2005 2. Namen
AM, et al. South Med J 2001.
20
Pathophysiology of EDS

• EDS is not a disorder but a symptom1
• Causes2
• CNS abnormalities, e. g. narcolepsy
• Sleep deficiency, e. g. sleep apnea
• Circadian imbalances, e. g. jet lag
• Drug side effects, e. g. marijuana

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Roth T Roehrs TA. Clin Ther
1996.
21
How does the patient report symptoms?

• Im tired
• I feel lazy
• I have low energy
• I feel drowsy
• I feel sleepy

22
Assess for other psychiatric comorbidities

• Symptoms of depression?
• Mood or memory problems?
• Does patient fall asleep suddenly?
• Is the patient a night owl?
• Does the patient drink or take drugs?
• How many hours sleep per night, including
  weekends and weekdays?

23
Epworth SleepinessScale

• A quick, in-office test1
• Assesses whether a person will get sleepy in
  certain situations
• Use this scale for each situation
• 0 would never doze or sleep
• 1 slight chance of dozing or sleeping
• 2 moderate chance of dozing or sleeping
• 3 high chance of dozing or sleeping

1. Johns MW. Sleep 1991.
24
Epworth SleepinessScale
Sitting and reading 0
Watching TV 1
Sitting in a public place 1
Riding in a car as a passenger for 1 hour 2
Lying down in the afternoon 2
Sitting and talking to someone 0
Sitting quietly after lunch (no alcohol) 1
Stopped for a few minutes in traffic while driving 0
1. Johns MW. Sleep 1991.
25
Rule out other medical conditions1

• Stroke
• Tumors/cysts
• Vascular malformations
• Head trauma
• CNS infections (sleeping sickness)
• Parkinsonism
• Alzheimer's, other dementias

1. Black JE, et al. Neurol Clin 2005.
26
Differential Diagnosis
27
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

28
Insufficient sleepsyndrome

• Have patient keep a sleep log1
• Bedtimes
• Number/time of awakenings
• Arising times
• Frequency/duration of naps
• Bedtime events (food, alcohol, physical activity)

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
29
Falling asleep vs. staying asleep

• Difficulty falling asleep1
• Suggests delayed sleep phase syndrome
• Chronic psychophysiologic insomnia
• Inadequate sleep hygiene
• Restless legs syndrome
• Difficulty staying asleep
• Suggests advanced sleep phase syndrome
• Major depression
• Sleep apnea
• Limb movement disorder
• Aging

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
30
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

31
Obstructive sleep apnea

• Absence of breathing during sleep
• Obstruction of airways ? snoring, decrease in
  oxygen saturation of hemoglobin, arousal1
• Result is disturbed sleep and EDS
• Most common diagnosis of patients with complaint
  of EDS who seek care at US sleep centers2
• Almost 7 out of 10 patients

1. Victor LD. Am Fam Physician 1999 2. Punjabi
NM, et al. Sleep 2000.
32
Obstructive sleepapnea

• Associated with
• Not only CVD and obesity, but also
• Metabolic syndrome1
• Untreated OSA ? Direct/deleterious effects on CV
  function and structure3
• Sympathetic activation
• Oxidative stress
• Inflammation
• Endothelial dysfunction

1. Vgontzas AN, et al. Sleep Med Rev 2005 2.
Shamsuzzaman AS, et al. JAMA 2003 3. Narkiewicz
K, et al. Curr Cardiol Rep 2005.
33
Obstructive sleepapnea

• ? Systolic BP and heart rate1
• ? CRP concentrations1
• May contribute to ischemia, CHF, arrhythmia,
  cerebrovascular disease, stroke
• ? Atrial fibrillation can predict OSA2
• 49 vs. 32 who do not have OSA
• 1 in 15 has moderate to severe OSA3
• 1 in 5 has mild OSA

1. Meier-Ewert HK, et al. J Am Coll Cardiol
2004 2. Gami AS, et al. Circulation 2004 3.
Shamsuzzaman AD, et al. JAMA 2003.
34
Obstructive sleepapnea Airflow decrease
35
Physical examfor OSA

• Check for 1
• Obesity, especially at midriff neck
• Jaw and tongue abnormalities
• Nasal obstruction enlarged tonsils
• Expiratory wheezing
• Spinal curvature
• Note signs of R ventricular failure
• Edema, abdominal distention

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
36
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

37
Substance/medication use

• EDS can be a sign of drug-dependent and
  drug-induced sleep disorders1
• Chronic use of stimulants
• Hypnotics, sedatives
• Antimetabolite therapy
• OCs thyroid medications
• Withdrawal from CNS depressants

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
38
Substance/medication use

• Review the patients Rx drug use
• Check for interactions,high doses
• Inquire about OTC medications
• Diphenhydramine, anticholinergics
• Take alcohol history
• Interaction with Rx or OTCs?
• Ask about recreational drug use

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
39
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

40
Shift-work disorder

• Circadian rhythm sleep disorder1
• Internal/environmental sleep-wake cadence out of
  synch
• Insomnia, EDS, or both1
• 10 of the night and rotating shift work
  population2
• 4-fold ? in sleepiness-related accidents,
  absenteeism, depression2

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Drake CL, et al. Sleep 2004.
41
Shift-work disorder

• Resolves as body clock realigns1
• Fixed-shift work is preferable
• Full-time night or evening
• Rotating shifts should go clockwise
• Day ? Evening ? Night
• Helpful Bright light, masks, white noise
• Short t1/2 hypnotics, wake-promoting drugs used
  judiciously

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
42
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

43
Delayed-sleep phase syndrome

• Sleep cycle out of synch with desired wake times1
• Problem Going to sleep and awakening late (3AM
  and 10AM)
• If earlier wake times are necessary, then EDS can
  result
• Poor performance in work/school
• Improved sleep hygiene is key

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
44
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

45
Narcolepsy

• Pathologic sleepiness, sudden loss of muscle tone
  (cataplexy), fragmented sleep, sleep paralysis1
• Affects 1 out of 2,000 people2
• 140,000 Americans2
• Delay of 10 yr from onset to diagnosis is common1
• The cause is unknown

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Ohayon MM, et al. Neurology
2002.
46
Narcolepsy - Pathophysiology

• Cause? ? hypocretin-secreting neurons1,2
• Regulate arousal state in hypothalamus
• Marker REM sleep during 2 daytime naps3
• Dysfunctional switching to REM sleep ?
  wakefulness during sleep3
• Patients are mentally awake but physically in REM
  sleep sleep paralysis syndrome.

1. Thannickal TC, et al. Neuron 2000 2.
Sutcliffe JG de Lecea. Nat Rev Neurosci 2002
3. Scammell T. Ann Neurol 2003.
47
Narcolepsy - Pathophysiology

• Genetic predisposition1
• Familial clustering
• 10- to 40-fold ? vs. general population
• Hallmark symptom cataplexy
• Bilateral weakness2
• Prevalence 752

1. Nishino S, et al. Sleep Med Rev 2000 2.
Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
48
Narcolepsy Neurophysiology

• Show EEG/EMG recording during a narcoleptic
  episode
• Use Figure 4 E in Chemelli, 1999

1. Nishino S, et al. Sleep Med Rev 2000 2.
Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
49
Narcolepsy Diagnosis

• Diagnostic for narcolepsy1
• History of cataplexy
• Nocturnal polysomnography
• Wrist actigraphy
• MSLT
• Differential diagnosis1
• Lesions of brain stem, hypothalamus
• Encephalitis, metabolic disorders
• Urine/blood confirm non-narcoleptic EDS1

1.Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
50
Narcolepsy Diagnosis

• Narcolepsy without cataplexy - phenotypic variant
  of narcolepsy with cataplexy.
• Clinical diagnostic criteria are similar
• Narcoleptics with cataplexy have low levels of
  CSF hypocretin whereas those without cataplexy
  had normal levels1.

1. Kanbayashi T, et al. J Sleep Res. 2002.
51
Most frequent causes of EDS

• Insufficient sleep syndrome
• Obstructive sleep apnea
• Substance/medication use
• Shift-work sleep disorder
• Delayed sleep-phase syndrome
• Narcolepsy
• Periodic limb movement disorders

52
Periodic limb movement disorders

• Abnormal twitching/kicking of legs during sleep1
• Interferes with nocturnal sleep ? EDS
• 10 of adults2
• Restless legs syndrome
• More common in middle/later years
• Creeping/crawling sensations
• Abnormalities in dopamine transmission2

1.Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Hornyak M, et al. Sleep Med
Rev 2006.
53
Periodic limb movement disorders

• Often occurs in narcolepsy and OSA1
• Seen in pregnancy, renal/hepatic failure, anemia
  and other disorders
• Sleep history/partners testimony
• Test Iron, anemia, kidney/liver function
• Dopamine agonists can be helpful

1.Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Hornyak M, et al. Sleep Med
Rev 2006.
54
When to refer?
55
Know when to treatand when to refer

• Can condition be treated via sleep hygiene?
• Insufficient sleep syndrome
• Substance/medication use
• Delayed sleep-phase syndrome
• Shift-work sleep disorder
• Counsel on sleep architecture
• Do blood work, RFTs/LFTs
• Prescribe sedatives prudently

56
Know when to treatand when to refer

• Refer when diagnosis appears to be
• Obstructive sleep apnea
• Pulmonologist, sleep clinic, surgeon
• Narcolepsy
• Neurologist, sleep clinic
• Periodic limb movement disorders
• Internist, endocrinologist, sleep clinic

57
Which physicians refer to sleep clinics?1

• Make as bar chart
• 38 internists
• 17 pulmonologists
• 14 otolaryngologists
• 10 family physicians/GPs
• 6 neurologists
• 4 cardiologists
• 3 psychiatrists

1. Punjabi NM, et al. Sleep 2000.
58
Why do physicians refer to sleep clinics?1

• Make as bar chart
• Apnea 57
• Sleepiness 48
• Fatigue 17
• Insomnia 16
• Snoring 12
• Sleep walking 1

1. Punjabi NM, et al. Sleep 2000.
59
The sleep clinic

• Sleep studies evaluate EDS as well as OSA,
  narcolepsy, periodic limb movement disorders
• Polysomnography1
• Data accumulated from patient as s/he sleeps
• Quantifies sleep adequacy
• Determines what causes EDS

1. AARC-APT. Respir Care 1995.
60
The sleep clinic - Polysomnography

• Measures1
• EEG
• Eye movements
• Heart rate
• O2 saturation
• Muscle tone activity
• All-night test

1. AARC-APT. Respir Care 1995 2. Beers MH, et
al. Merck Manual of Diagnosis and Therapy 2006.
61
The sleep clinic MSLT

• Multiple Sleep Latency Test
• Complimentary test for narcolepsy1
• Assesses speed of sleep onset
• REM sleep is monitored
• All-day test 8-10 hours
• High ESS scores Low MSLT scores2

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006 2. Chervin RD, et al. J Psychosom
Res 1997.
62
Treatment
63
Non-pharmacologictreatment

• Rationale To improve natural sleep
• Counsel patients on good sleep hygiene1
• Regular sleep schedule
• Restrict time in bed
• Sleep-conductive environment
• Exercise
• Avoid stimulants
• Incorporate relaxation techniques

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006
64
Pharmacotherapy Hypnotics

• Rationale To treat insomnia
• Sleep-onset insomnia
• Use drugs with shorter t1/2
• Zalepon, zolpidem, triazolam
• Sleep-maintenance insomnia
• Use drugs with longer t1/2
• Temazepam, eszopiclone

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006
65
Pharmacotherapy Hypnotics

• Use with caution in elderly, pulmonary
  insufficiency
• To ? tolerance, use lower doses for brief
  periods taper off slowly
• In patients who continue to have EDS, stop or
  switch the drug
• Monitor for amnesia, hallucinations,
  incoordination, falls

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006
66
Pharmacotherapy Stimulants

• Rationale To improve alertness
• Methylphenidate, amphetamines
• Indirect-acting sympathomimetics1
• Produce behavioral activation and increased
  arousal, motor activity, alertness
• Used mostly for EDS ineffective for cataplexy1,
  2
• Immediate- or extended-release forms1

1. Mitler MM Hayduk R. Drug Saf 2002 2.
Littner M, et al. Sleep 2001.
67
Pharmacotherapy Stimulants

• MPH and the amphetamines are Schedule II
• Carry the risk of substance abuse/illicit use
• Rebound hypersomnia or tolerance to alerting
  agent can occur1
• Switch to a different drug class or provide drug
  holiday

1. Black JE, et al. Neuro Clin 2005.
68
Pharmacotherapy Modafanil

• Rationale To promote wakefulness
• Approved for narcolepsy-associated EDS
• Ill-defined MOA (not a stimulant)1
• Activates hypocretin-secreting neurons1,2
• Does not control cataplexy1
• Long-acting once-daily dosing
• Peak plasma concentrations 2-4 hr3
• Small afternoon booster dose can be used4

1. US Modafinil. Ann Neurol 1998 2. Willie JT,
et al. Neuroscience 2005 3. Provigil PI 2004
4. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006.
69
Pharmacotherapy Modafanil isomer

• Isomer formulation r-modafanil or armodafanil
  also being evaluated
• Once daily for EDS2
• r-isomer T1/2 10-14 hr vs. 3-4 hr for s-isomer
• Higher peak concentrations vs. racemic mixture
• No efficacy/safety advantage over modafainil2

1. Harsh JR, et al. Curr Med Res Opin 2006 2.
Dinges DF, et al. Curr Med Res Opin 2006.
70
Pharmacotherapy Sodium oxybate

• Rationale To treat EDS, narcolepsy
• FDA-approved for treatment of EDS and cataplexy
  in narcolepsy1
• MOA largely unknown2
• Rapidly acting hypnotic (Tmax 0.5-1.25 hr)2
• Short t½ (0.5-1 hr)2
• ? duration of stages 3, 4 sleep
• First REM sleep ?, then with continued use, REM
  sleep ?

1. FDA. FDA Talk Paper 2002 2006 2. Xyrem PI
2005.
71
Pharmacotherapy Sodium oxybate

• Studies show efficacy in ? cataplexy and EDS1, 2,
  3
• ? cataplexy attacks, ESS scores
• Can be used with modafinil4
• ? nightly awakenings
• Dosing twice nightly
• Taken HS, then at 2.5-4 hrs after the sleep begins

1. Xyrem. Sleep Med. 2005 2. Xyrem. Sleep 2003
3. Xyrem. Sleep 2002 4. Xyrem. Sleep Med 2004
5. Bogan RK. Sleep. 2005 6. Xyrem PI, 2005.
72
Pharmacotherapy Sodium oxybate

• Potential drug of abuse (CIII)1
• Enforced as Schedule I
• Special distribution requirements2
• Use of a central pharmacy
• Registration of prescribing MD
• Pharmacy verification of MDs eligibility to
  prescribe
• Registration/required reading of materials by
  patient

1. FDA. FDA Talk Paper 2002 2006 2. Xyrem PI
2005.
73
Median percent change in cataplexy attacks per
week1

• Use Figure 2 of US Xyrem study, 2002

• 2-week double-blind phase
• Frequency of cataplexy attacks decreases over
  time
• Dose-related effect

1. Xyrem. Sleep 2002.
74
Continuous positiveairway pressure

• Rationale To correct OSA
• Reverses EEG slowing for both REM sleep and
  wakefulness1
• Improves symptoms of EDS1
• ? MSLT scores
• Persistent EDS 2 to obesity
• Used at home but pressure is set in sleep clinic
  first

1. Morisson F, et al. Chest 2001.
75
Surgery

• Rationale To correct anatomical flaws
• UPPP is the most common procedure
• Enlarges airways
• Submucosal tissue resection from tonsillar
  pillars adenoid resection
• Not suitable for obese patients
• Trachestomy last resort
• May take 1 year to heal

1. Beers MH, et al. Merck Manual of Diagnosis and
Therapy 2006
76
Conclusions

• EDS ? quality of life can cause serious
  consequences
• EDS may be a sign of sleep apnea, narcolepsy or a
  symptom of another condition
• Patients who complain of EDS should be assessed
  in a step-wise manner to rule out the various
  conditions that can cause it
• Know when to treat and when to refer