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Melanie Cole (Host):  People often think that being sleepy during the day is normal because of all the responsibilities we have in our daily lives. But it could be a sign of a more serious problem. My guest today is Dr. Sam Kashani. He’s a Physician with the UCLA Sleep Disorder Center. Dr. Kashani, it’s a pleasure to have you back with us today. Tell us a little bit about excessive daytime sleepiness. Is it the same as just being tired, having a cup of coffee, feeling better or is this something more?

Sam Kashani, MD (Guest):  You know you ask a really wonderful question. This is a question that I go over with my patients when I meet them for the very first time, which is let’s define what is excessive sleepiness or daytime sleepiness. Let’s differentiate sleepiness from feeling tired or drowsy or whatever other word that can be used to kind of describe that sort of state. And to go based off of that, how do we define daytime sleepiness?

Well, daytime sleepiness really is exactly as the term itself refers to. Feeling sleepy during the day when you shouldn’t be. If you are sleepy or feeling the need to sleep or feeling that I could sleep if I had the opportunity or if I didn’t have this appointment at 2 p.m. or if I could just lay down for 20 minutes and knock out. When you are kind of feeling these ways, when you are feeling that irrepressible urge or that need to sleep, that’s how we define sleepiness. Because you should not be feeling that way until it is closer to the nighttime and then closer to bedtime. So, understanding and gauging kind of what really your energy level is throughout the day and how effective you are at performing your daily activities without having an urge to rest or need to sleep is a really, really important place to start when determining whether or not somebody really has excessive sleepiness.

There are a number of nighttime issues including untreated sleep disorders, poor sleep hygiene that can contribute to daytime sleepiness, but the causes are really various. So, the important thing is really to start with again, a good history and gauging or not what the energy level is like throughout the day and whether sleepiness is an issue in terms of daily living.

Host:  Tell us what kind of conditions can cause this. We’ve talked before about things like sleep hygiene. Are there certain conditions that really contribute to it and is it then different than just you didn’t get a good night’s sleep tonight, so you are a little more tired during the day and you need a nap?

Dr. Kashani:  Absolutely. Insomnia, sleep apnea, narcolepsy; these are all sleep disorders that when untreated can most certainly cause daytime sleepiness and usually daytime sleepiness is one of the most common symptoms of all of these sleep disorders that we have named including insomnia. Now, that being said, untreated sleep disorders are as we discussed also previously, difficult and underdiagnosed, difficult to assess and underdiagnosed overall in general in the general population.

So, again, gauging what the problem is, the underlying sleep disorder can be difficult which is where bed partners can be really helpful noticing the way that you sleep, noticing how much you sleep. In addition to bed partners, if somebody sleeps alone, the use of a sleep log or a sleep diary to sort of journal in what the overall sleep schedule is like, what the sleep habits are like, whether there are disturbances in the middle of the night that cause a prolonged two to three hour awakening and thereby sacrificing or compromising the amount of sleep that a person may get at nighttime. All of these things are definitely underlying issues that could potentiate the problem.

And in the case of insomnia, that you just named, insomnia generally speaking, we define insomnia as difficulty with initiating sleep and or difficulty with maintaining sleep or just waking up too early. But as you can intuitively kind of determine, any one of those scenarios or all of those scenarios could most certainly potentiate the daytime sleepiness for the person the following day.

So, that’s really just looking at untreated sleep disorders and sleep issues of which there are treatments for insomnia. We use cognitive behavioral therapy for example to treat insomnia which has had wonderful results. In fact, UCLA, we put out a study in 2015 about some patients that were survivors of breast cancer and were experiencing hot flashes, and all kinds of disturbing nocturnal symptoms that were causing insomnia and actually put them through a program of tai chi and the people that were in the tai chi group actually experienced just as much benefit in their sleep with tai chi as patients who received cognitive behavioral therapy for insomnia which is the standard most effective best treatment there is for insomnia to begin with.

So, again, understanding what the problem is and trying to find a treatment for that specific sleep issue or sleep disorder is of critical importance in addressing causes of daytime sleepiness.

Host:  You mentioned keeping a log or something of that nature, with a lot of these wearables now, trackers, they tell you how you slept at night and if you woke up or if you rolled around or what do you think of those?

Dr. Kashani:  For the most part, as of right now, there aren’t really that many clinically validated wearables and for that reason, I find in my practice, at least, that oftentimes wearables can somewhat actually kind of discourage patients in a sense that they may be experiencing a sleep difficulty like insomnia for example, like daytime sleepiness, like interrupted sleep, waking up many times in the middle of the night and they will look at their wearable the next day and it will tell them how many hours they slept, how much deep sleep they got, how much light sleep they got and yet if it says something positive on there, the person is not really feeling positive because they feel well I still have these symptoms. I’m still sleepy during the day but my watch or my wearable says, or my Fitbit says that everything is great.

And then the converse is if it’s negative or something on what the Fitbit is recording is saying that you don’t get enough deep sleep for example, the person becomes even more discouraged thinking that gosh there must be something wrong with me and then that perpetuates this kind of thought process that they actually have a problem when in fact, it’s just their Fitbit which is not a like I said, clinically validated tool nor does it replace a sleep specialist or a physician that can evaluate the problem thoroughly.

So, I think that – I don’t want to say that I don’t like the idea of wearables, I just notice that in my own clinical practice with patients, that it often can cause some degree of harm in that sense. Now, moving away from wearables, when it comes to evaluating and assessing these problems as you said, it’s very important like I said, to get a good sleep history in terms of what the sleep schedule is, how many hours we are talking, whether there is extension or “sleeping in” on the weekends that is compromising for example Sunday night sleep until morning. Or is causing a sort of detriment to the overall consistency of the sleep schedule. These things are all very important to take into mind. We also use another tool called the Epworth Sleepiness Scale and what this is, is basically an eight question questionnaire that is basically asking the person in these normal life situations what is the likelihood of you dozing off or falling asleep. And the score is from zero to three with zero being absolutely no chance that I would doze off and three being I will definitely fall asleep.

Some of those situations that we ask include what if you are sitting inactively in a public place like a theater or a meeting? What if you are driving as a passenger in somebody else’s car and you are driving for a couple of hours and they are driving do you doze off then? What about if you at the red light for a few minutes? Do you doze off then? And we basically add up the points on these questions and if we get a score above ten or eleven; that’s consistent with excessive daytime sleepiness.

Now these situations while everybody may not be in these situations at any given time, some people don’t drive, some people don’t go to movies, some people don’t go to theaters, whatever the case may be, however, it’s just making the point that trying to assess everyday life situations and see whether or not somebody has an actual urge, need or desire to sleep during those times is the most critical part of assessing the problem from the beginning and determining whether or not there could be something environmental, something behaviorally induced or something medical that requires attention. Like we said, untreated sleep apnea or untreated narcolepsy. Which these are very serious disorders that definitely require a good clinical assessment and diagnostic workup.

Therefore, finding out what the problem is takes really just a matter of seeing a sleep specialist, having them assess your sleep history and determining whether or not it’s something that can be addressed in a matter of lifestyle and behavioral changes or if further intervention is required whether medical or behavioral in the sense of like we said, tai chi or yoga which can definitely improve certain sleep difficulties namely insomnia.

Host:  What an interesting topic and so many people suffer from it and they probably just sort of blow it off and assume it’s just normal because they are stressed. Let’s talk a little bit about treatments briefly now. CPAP obviously, we’ve talked a lot about that for sleep apnea. But what do you do as a first line depending on what you assess is the reason for that excessive daytime sleepiness; what are some other things besides CPAP that you might try?

Dr. Kashani:  Usually, daytime sleepiness is multifactorial. Meaning that sure a CPAP will fix the patient’s sleep apnea, but oftentimes sleep apnea is not the only reason that a person may not feel sleepy. In fact, life in America, every day, the rat race that we do getting up early, working hard every single day and coming home late and sleeping late at night. One of the most common causes of daytime sleepiness in the world beyond just America is insufficient sleep. Not enough sleep at nighttime. We are all guilty of this whether it’s short term or long term.

And on top of that, if you have another problem like sleep apnea that’s not treated; well it really requires a multifactorial approach. So, the CPAP most certainly is necessary if somebody has been diagnosed with sleep apnea which let’s also just keep as a side note, recall that sleep apnea is only diagnosed on a sleep study. No matter how many times somebody watches you pause in breathing in the middle of the night, no matter how many times people tell you that you snore loudly; you do not have sleep apnea until you had a sleep study that confirms it. So, therefore when you have that yes, a CPAP will fix that problem.

But again, addressing the issue in terms of making sure the person is getting sufficient nighttime sleep, ruling out insomnia or any other kind of insulting factor that could insult the overall integrity or architecture of a person’s sleep and making sure that again, those behavioral and lifestyle issues are really truly optimized that we are not taking naps at 5 p.m. from 5 to 6:30 p.m. thereby preventing us to be able to fall asleep that night and shortening our sleep duration. That we are not extending by three or four hours on Saturday mornings or Saturday afternoons and Sunday mornings and afternoons because it’s the weekend and we’re trying to basically catch up. All of these things really need to be addressed.

So when I tell my patients for example, during a first visit that we’re going to find out if you have sleep apnea and, in the meantime,, I really want you to work on these things; it’s because usually the sleep apnea once it’s treated is not enough to really kind of optimize the sleep and make sure that all the symptoms of sleepiness and somnolence have been resolved. So, I give them a lot of homework. I give them information on how to practice good sleep hygiene. I encourage them to continue to maintain a very consistent sleep wake schedule seven days a week, not five days a week where you can kind of cheat a little bit on the weekend. I inform patients about all the health risks associated not only with sleep apnea but just with poor sleep and short sleep duration of which there is ample evidence out there to show that.

And really kind of just making sure that we’re not taking a simple medical approach to the problem and trying to find out heh, do you have a sleep disorder that I can fix. But rather really kind of treating the sleep as a house of cards that any kind of gust of wind or any blow towards that house of cards could cause the entire structure to fall apart and that’s how sleep should be treated. Sleep should be treated in a way that it’s a fragile sort of thing, an entity that exists and that any kind of insult that is either not addressed, untreated or is being evoked or induced by the person themselves can cause that house of cards to fall apart.

So, very important to know why one feels sleepy, what to do about it and that any kind of approach that is looking just at one problem for example a medical problem is not sufficient to address the issue. So, to answer your question about treatments now. In addition to CPAP, there are other treatments that we use to improve sleep. However, these are treatments that are targeted towards the underlying sleep disorder and other than CPAP for sleep apnea like I said, we use cognitive behavioral therapy for insomnia. This is a treatment for insomnia that is far superior to all oral hypnotic or sleeping pill medications including Ambien and Lunesta and Sonata that are prescribed left and right.

Cognitive behavioral therapy while hard to find because there are few providers in big cities, even here in Los Angeles we have such a need but not enough access to cognitive behavioral therapy for insomnia providers, but it has been proven to be the best treatment for insomnia worldwide. Narcolepsy, a totally different type of sleep disorder which is characterized by very profound and excessive daytime sleepiness in addition to other what we call REM intrusion phenomena like sleep frequent sleep paralysis or having hallucinations around bedtime also has it’s own treatments. Those include wake promoting agents, the use of stimulants to keep the person up throughout the day as well as the use of certain medications at nighttime that can aid in producing better sleep thereby allowing more rested energy level throughout the next day.

So, once again, it really depends on the underlying sleep disorder what type of treatment that we use but otherwise behavioral and lifestyle modifications are of the utmost importance as part of a comprehensive treatment plan for all of these issues especially daytime sleepiness.

Host:  Dr. Kashani, this is such a fascinating topic. Please wrap it up for us with your best advice. If someone suffers from excessive daytime sleepiness and they are not two months old; what would you like us to know about getting evaluated and sleep hygiene and cognitive therapy and all of the treatment options that are available that can help us with what we’ve learned from the science can be detrimental to our health?

Dr. Kashani:  I think the most important thing to keep in mind is that daytime sleepiness is not normal. And I say that in the context of last week I saw several patients, not one or two but several who said one very similar thing which I hear all the time, but I just thought it was interesting that I heard it so many times last week in preparation for this podcast is when I would ask patients whether they felt sleepy during the day or would they describe themselves as a sleepy person, would they describe themselves as somebody with no energy through the day; a lot of them said the same answer which was I’m always tired but you know, that’s a different issue.

And my response to that was that is not a different issue. And that is not normal. To say that I am always tired, you may have gotten used to that, you may have adjusted to feeling that way, you may have adjusted to the fact that you are only getting five hours of sleep per night and that that’s enough for you to be able to get through the day for the most part, fighting and powering through to stay up an active. But the fact is, if you have insufficient sleep or if you have an untreated sleep disorder like narcolepsy or sleep apnea; just because you are used to the symptoms does not make it normal.

So, again, gauging your energy level throughout the day and determining the likelihood of you falling asleep during an everyday typical ordinary daytime activity is extremely important and not brushing it off and just thinking oh, this is how I always am, I’ve always been the type that I could just lay down and fall right asleep. Well people who have untreated sleep disorders report those same exact symptoms. So, how can we tell whether somebody has sleep apnea or narcolepsy when plenty of people think that it’s just normal.

So, again, goes back to the point that I made earlier which is that sleep disorders are overall very underdiagnosed. Whether it’s just somebody who doesn’t realize that they are having apneas in the middle of the night or snoring or it’s somebody who has just gotten used to feeling sleepy during the day. Sleep disorders are underdiagnosed and knowing that daytime sleepiness is not normal and that you should feel sleepy when it is nighttime and you are getting ready to sleep is really the first and most critical step and once you have realized that you are sleepy on a daily basis and your daily functioning, your performance is suffering because of it; that is the time you need to inform your doctor and that is the time to reach out to a professional that can help you, a sleep specialist.

There are treatments that we as sleep specialists have that are proven, scientific treatments that can address a number of sleep disorders that are untreated whether it’s sleep apnea of which CPAP is not the only treatment, I will say. So, please keep that in mind. Or if it’s insomnia and the best treatment is cognitive behavioral therapy for insomnia. Or if the disease is narcolepsy and the management or the treatment regimen is sort of a multifactorial approach. Whatever the case may be, we have tools. We have options. We have therapies that have been heavily studied and have been proven to improve these things.

So, once you realize daytime sleepiness is a problem for you, that is the time to inform your healthcare provider, that is the time to see a sleep specialist who can help determine the problem and not only the appropriate solution for that problem but overall giving you overall counseling and advice and referring you to whoever is necessary to improve your overall sleep. And again, to treat your sleep as a house of cards. You cannot just take one or two cards out of that house and expect the house of cards to maintain it’s structural integrity. All cards must be intact and there must not be any gusts of wind blowing or deterring or damaging that house of cards which is your sleep.

And I want people to treat their sleep and their energy level throughout the day as fragile as such.

Host:  What a great segment. Dr. Kashani, thank you so much for coming on and sharing your incredible expertise. Sleep is so important for so many people, for all of us really and it certainly is one of my favorite things. So, thank you again for telling us about all this great information. And that concludes this episode of It’s Your Health Radio with Henry Mayo Newhall Hospital. For more information please visit the free health information library at www.library.henrymayo.com. Please remember to subscribe, rate and review this podcast and all the other Henry Mayo Newhall Hospital podcasts. For more health tips and updates please follow us on your social channels. I’m Melanie Cole.