今日の臨床サポート

日中の眠気

著者: 黒田浩一 亀田総合病院 感染症科

監修: 山中克郎 福島県立医科大学会津医療センター総合内科

著者校正/監修レビュー済:2016/04/22
患者向け説明資料

概要・推奨   

症状のポイント:
  1. 日中の眠気は、文字通り、日中の眠気を訴えることである。英語ではExcessive daytime sleepiness(EDS)と記載され、「日中仮眠」「日中の過度な眠気」と訳される。
  1. わが国で行われた調査で、一般人口の15%が日中に眠気の問題を抱えているとされ、ありふれた症候である。
 
緊急対応:
  1. 緊急の対応が必要な疾患はほとんどない。
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
黒田浩一 : 未申告[2021年]
監修:山中克郎 : 未申告[2021年]

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 日中の眠気は、文字通り、日中の眠気を訴えることである。英語ではExcessive daytime sleepiness(EDS)と記載され、「日中仮眠」「日中の過度な眠気」と訳される。
  1. わが国で行われた調査で、一般人口の15%が日中に眠気の問題を抱えていると報告された[1]。別の調査では、運転中など眠ってはいけないときに眠ってしまう重度の日中の眠気の問題をもつ人は、一般人口の2.5%と報告された[2]
  1. 脳内の覚醒維持機構に何らかの異常があるために生じる一次性過眠症と、何らかの睡眠障害によって発生した睡眠不足の結果として日中の過眠を来す二次性過眠症がある。
  1. 日中の眠気を来す疾患は多岐にわたるが、最も頻度が高いものは閉塞型 睡眠時無呼吸症候群 (OSAS)である。わが国では、日中の眠気などの症状を有するOSAS患者が約200万人という調査結果がある[3]。自覚症状の有無を問わず無呼吸低呼吸指数(AHI)が5以上に達する睡眠呼吸障害(sleep disordered breathing、SDB)の有病率は、米国(30~60歳を対象)からの報告で、男性24%、女性9%とされ、日中の眠気などの自覚症状を認める睡眠時無呼吸症候群(SAS)は、男性4%、女性2%とされた[4]。韓国(40~69歳を対象)[5]やスペイン(30~70歳を対象)[6]からも、同程度のSDB・SASの有病率が報告され、ありふれた疾患(common disease)と考えられている。
  1. 一次性過眠症のナルコレプシー、特発性過眠症、反復性過眠症、二次性過眠症のOAS(閉塞型、中枢型、混合型)、睡眠不足症候群、むずむず脚症候群、周期性四肢運動障害(periodic limb movement disorder、PLMD)、概日リズム睡眠障害、うつ病などの気分障害、薬剤性、身体疾患(せん妄、その他意識障害を来す疾患)などが鑑別疾患となる
問診・診察のポイント  
  1. 鑑別疾患を想定して、睡眠について包括的に評価する[7][8]。睡眠の状況、いびき、睡眠時の無呼吸、眠気の原因となる身体的な基礎疾患や眠気の原因となる薬剤の使用、などを問診することが重要である。エプワース眠気尺度(ESS)<図表>で自覚的な眠気の評価を行う[9]

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文献 

著者: X Liu, M Uchiyama, K Kim, M Okawa, K Shibui, Y Kudo, Y Doi, M Minowa, R Ogihara
雑誌名: Psychiatry Res. 2000 Feb 14;93(1):1-11.
Abstract/Text There are few epidemiological studies on sleep loss and daytime sleepiness in the general adult population of Japan. A total of 4000 adult people, aged 20 and over, were randomly drawn from five areas of Japan, and 3030 individuals were interviewed and completed a questionnaire including information about sleep duration and sleep problems. Overall, 29% slept less than 6 h at night, 23% reported having insufficient sleep, and 6% took sleep enhancing medications. The prevalence rates were 21% for symptoms of insomnia and 15% for excessive daytime sleepiness. Symptoms of insomnia were more prevalent in the elderly, whereas young people were more likely to report short sleep duration, subjective insufficient sleep and excessive daytime sleepiness. A multiple logistic regression model revealed that excessive daytime sleepiness had significant associations with young people, short sleep duration, insomnia symptoms, subjective insufficient sleep and sleep enhancing medication use. Short sleep duration was the strongest predictor of excessive daytime sleepiness. The findings indicate that sleep loss and excessive daytime sleepiness in the Japanese adult population are common, and comparable to those reported in Western countries. Excessive daytime sleepiness in the general adult population seems more likely to be attributed to short sleep duration.

PMID 10699223  Psychiatry Res. 2000 Feb 14;93(1):1-11.
著者: Yoshitaka Kaneita, Takashi Ohida, Makoto Uchiyama, Shinji Takemura, Kazuo Kawahara, Eise Yokoyama, Takeo Miyake, Satoru Harano, Kenshu Suzuki, Yuko Yagi, Akiyo Kaneko, Takako Tsutsui, Tsuneto Akashiba
雑誌名: J Epidemiol. 2005 Jan;15(1):1-8.
Abstract/Text BACKGROUND: Excessive daytime sleepiness is one of the principal symptoms of sleep disturbances, and is often associated with serious consequences including traffic and industrial accidents, decreased productivity, and interpersonal problems. However, there are few epidemiologic studies on excessive daytime sleepiness in a large scale sample targeting Japanese general population.
METHODS: The survey was performed using a self-administered questionnaire in June 2000, targeting a population randomly selected from among 300 communities throughout Japan. This questionnaire included information about sleep habits and sleep problems. Excessive daytime sleepiness measured according to a question "Do you fall asleep when you must not sleep (for example when you are driving a car)?"
RESULTS: A total of 28,714 subjects completed the questionnaire. The prevalence of excessive daytime sleepiness was 2.5% (male=2.8% and female=2.2%). Backward elimination analysis showed that the following were associated with excessive daytime sleepiness: male sex, young age, short sleep duration, subjective insufficient sleep, loss of deep sleep, disagreeable sensations in the legs, interruption of sleep by snoring or dyspnea, and feeling psychological stress. Interruption of sleep by snoring or dyspnea was the strongest associated factor (adjusted odds ratio=2.46, 95% confidence interval=1.76-3.43) of excessive daytime sleepiness.
CONCLUSIONS: These results suggest that excessive daytime sleepiness in Japanese is associated with several sleep problems. These findings may be useful in attempts to prevent excessive daytime sleepiness in the general population of Japan.

PMID 15678919  J Epidemiol. 2005 Jan;15(1):1-8.
著者: T Young, M Palta, J Dempsey, J Skatrud, S Weber, S Badr
雑誌名: N Engl J Med. 1993 Apr 29;328(17):1230-5. doi: 10.1056/NEJM199304293281704.
Abstract/Text BACKGROUND: Limited data have suggested that sleep-disordered breathing, a condition of repeated episodes of apnea and hypopnea during sleep, is prevalent among adults. Data from the Wisconsin Sleep Cohort Study, a longitudinal study of the natural history of cardiopulmonary disorders of sleep, were used to estimate the prevalence of undiagnosed sleep-disordered breathing among adults and address its importance to the public health.
METHODS: A random sample of 602 employed men and women 30 to 60 years old were studied by overnight polysomnography to determine the frequency of episodes of apnea and hypopnea per hour of sleep (the apnea-hypopnea score). We measured the age- and sex-specific prevalence of sleep-disordered breathing in this group using three cutoff points for the apnea-hypopnea score (> or = 5, > or = 10, and > or = 15); we used logistic regression to investigate risk factors.
RESULTS: The estimated prevalence of sleep-disordered breathing, defined as an apnea-hypopnea score of 5 or higher, was 9 percent for women and 24 percent for men. We estimated that 2 percent of women and 4 percent of men in the middle-aged work force meet the minimal diagnostic criteria for the sleep apnea syndrome (an apnea-hypopnea score of 5 or higher and daytime hypersomnolence). Male sex and obesity were strongly associated with the presence of sleep-disordered breathing. Habitual snorers, both men and women, tended to have a higher prevalence of apnea-hypopnea scores of 15 or higher.
CONCLUSIONS: The prevalence of undiagnosed sleep-disordered breathing is high among men and is much higher than previously suspected among women. Undiagnosed sleep-disordered breathing is associated with daytime hypersomnolence.

PMID 8464434  N Engl J Med. 1993 Apr 29;328(17):1230-5. doi: 10.1056/・・・
著者: JinKwan Kim, KwangHo In, JeHyeong Kim, SeHwa You, KyungHo Kang, JaeJeong Shim, SangYeub Lee, JungBok Lee, SeungGwan Lee, Chan Park, Chol Shin
雑誌名: Am J Respir Crit Care Med. 2004 Nov 15;170(10):1108-13. doi: 10.1164/rccm.200404-519OC. Epub 2004 Sep 3.
Abstract/Text With many epidemiologic studies made to establish the prevalence of sleep-disordered breathing (SDB) and obstructive sleep apnea syndrome (OSAS) in Western countries, no such data have been reported in Korea. The purpose of this study was to examine the prevalence of SDB and OSAS, and their related factors in Korean adults aged 40-69 years. Among the total of 5,020 participants at the baseline examination of the Korean Health and Genome Study, a random sample of 457 men and women was studied with employment of overnight full polysomnography to determine the prevalence of SDB and OSAS. The prevalence of SDB (apnea-hypopnea index > or = 5) was 27% and 16% in men and women, respectively. When OSAS was defined by an apnea-hypopnea index > or = 5 plus excessive daytime sleepiness, its prevalence was 4.5% in men and 3.2% in women. Logistic regression analyses showed that sex, body mass index, and hypertension were closely associated with the risk of SDB. Our findings show that SDB is a common problem in the Korean adult population. Understanding and treatment of SDB may be essential in terms of intervention to reduce the risk of related medical problems.

PMID 15347562  Am J Respir Crit Care Med. 2004 Nov 15;170(10):1108-13.・・・
著者: J Durán, S Esnaola, R Rubio, A Iztueta
雑誌名: Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):685-9. doi: 10.1164/ajrccm.163.3.2005065.
Abstract/Text The prevalence and related clinical features of obstructive sleep apnea-hypopnea (OSAH) in the general population were estimated in a two-phase cross-sectional study. The first phase, completed by 2,148 subjects (76.9%), included a home survey, blood pressure, and a portable respiratory recording, whereas in the second, subjects with suspected OSAH (n = 442) and a subgroup of those with normal results (n = 305) were invited to undergo polysomnography (555 accepted). Habitual snoring was found in 35% of the population and breathing pauses in 6%. Both features occurred more frequently in men, showed a trend to increase with age, and were significantly associated with OSAH. Daytime hypersomnolence occurred in 18% of the subjects and was not associated with OSAH. An apnea-hypopnea index (AHI) > or = 10 was found in 19% of men and 15% of women. The prevalence of OSAH (AHI > or = 5) increased with age in both sexes, with an odds ratio (OR) of 2.2 for each 10-yr increase. AHI was associated with hypertension after adjusting for age, sex, body mass index, neck circumference, alcohol use, and smoking habit. This study adds evidence for a link between OSAH and hypertension.

PMID 11254524  Am J Respir Crit Care Med. 2001 Mar;163(3 Pt 1):685-9. ・・・
著者: Lawrence J Epstein, David Kristo, Patrick J Strollo, Norman Friedman, Atul Malhotra, Susheel P Patil, Kannan Ramar, Robert Rogers, Richard J Schwab, Edward M Weaver, Michael D Weinstein, Adult Obstructive Sleep Apnea Task Force of the American Academy of Sleep Medicine
雑誌名: J Clin Sleep Med. 2009 Jun 15;5(3):263-76.
Abstract/Text BACKGROUND: Obstructive sleep apnea (OSA) is a common chronic disorder that often requires lifelong care. Available practice parameters provide evidence-based recommendations for addressing aspects of care.
OBJECTIVE: This guideline is designed to assist primary care providers as well as sleep medicine specialists, surgeons, and dentists who care for patients with OSA by providing a comprehensive strategy for the evaluation, management and long-term care of adult patients with OSA.
METHODS: The Adult OSA Task Force of the American Academy of Sleep Medicine (AASM) was assembled to produce a clinical guideline from a review of existing practice parameters and available literature. All existing evidence-based AASM practice parameters relevant to the evaluation and management of OSA in adults were incorporated into this guideline. For areas not covered by the practice parameters, the task force performed a literature review and made consensus recommendations using a modified nominal group technique.
RECOMMENDATIONS: Questions regarding OSA should be incorporated into routine health evaluations. Suspicion of OSA should trigger a comprehensive sleep evaluation. The diagnostic strategy includes a sleep-oriented history and physical examination, objective testing, and education of the patient. The presence or absence and severity of OSA must be determined before initiating treatment in order to identify those patients at risk of developing the complications of sleep apnea, guide selection of appropriate treatment, and to provide a baseline to establish the effectiveness of subsequent treatment. Once the diagnosis is established, the patient should be included in deciding an appropriate treatment strategy that may include positive airway pressure devices, oral appliances, behavioral treatments, surgery, and/or adjunctive treatments. OSA should be approached as a chronic disease requiring long-term, multidisciplinary management. For each treatment option, appropriate outcome measures and long-term follow-up are described.

PMID 19960649  J Clin Sleep Med. 2009 Jun 15;5(3):263-76.
著者: M W Johns
雑誌名: Sleep. 1991 Dec;14(6):540-5.
Abstract/Text The development and use of a new scale, the Epworth sleepiness scale (ESS), is described. This is a simple, self-administered questionnaire which is shown to provide a measurement of the subject's general level of daytime sleepiness. One hundred and eighty adults answered the ESS, including 30 normal men and women as controls and 150 patients with a range of sleep disorders. They rated the chances that they would doze off or fall asleep when in eight different situations commonly encountered in daily life. Total ESS scores significantly distinguished normal subjects from patients in various diagnostic groups including obstructive sleep apnea syndrome, narcolepsy and idiopathic hypersomnia. ESS scores were significantly correlated with sleep latency measured during the multiple sleep latency test and during overnight polysomnography. In patients with obstructive sleep apnea syndrome ESS scores were significantly correlated with the respiratory disturbance index and the minimum SaO2 recorded overnight. ESS scores of patients who simply snored did not differ from controls.

PMID 1798888  Sleep. 1991 Dec;14(6):540-5.
著者: Richard P Allen, Daniel Picchietti, Wayne A Hening, Claudia Trenkwalder, Arthur S Walters, Jacques Montplaisi, Restless Legs Syndrome Diagnosis and Epidemiology workshop at the National Institutes of Health, International Restless Legs Syndrome Study Group
雑誌名: Sleep Med. 2003 Mar;4(2):101-19.
Abstract/Text BACKGROUND: Restless legs syndrome is a common yet frequently undiagnosed sensorimotor disorder. In 1995, the International Restless Legs Syndrome Study Group developed standardized criteria for the diagnosis of restless legs syndrome. Since that time, additional scientific scrutiny and clinical experience have led to a better understanding of the condition. Modification of the criteria is now necessary to better reflect that increased body of knowledge, as well as to clarify slight confusion with the wording of the original criteria.
SETTING: The restless legs syndrome diagnostic criteria and epidemiology workshop at the National Institutes of Health.
PARTICIPANTS: Members of the International Restless Legs Syndrome Study Group and authorities on epidemiology and the design of questionnaires and scales.
OBJECTIVE: To modify the current criteria for the diagnosis of restless legs syndrome, to develop new criteria for the diagnosis of restless legs syndrome in the cognitively impaired elderly and in children, to create standardized criteria for the identification of augmentation, and to establish consistent questions for use in epidemiology studies.
RESULTS: The essential diagnostic criteria for restless legs syndrome were developed and approved by workshop participants and the executive committee of the International Restless Legs Syndrome Study Group. Criteria were also developed and approved for the additional aforementioned groups.

PMID 14592341  Sleep Med. 2003 Mar;4(2):101-19.
著者: A Chesson, K Hartse, W M Anderson, D Davila, S Johnson, M Littner, M Wise, J Rafecas
雑誌名: Sleep. 2000 Mar 15;23(2):237-41.
Abstract/Text Chronic insomnia is the most common sleep complaint which health care practitioners must confront. Most insomnia patients are not, however, seen by sleep physicians but rather by a variety of primary care physicians. There is little agreement concerning methods for effective assessment and subsequent differential diagnosis of this pervasive problem. The most common basis for diagnosis and subsequent treatment has been the practitioner's clinical impression from an unstructured interview. No systematic, evidence-based guidelines for diagnosis exist for chronic insomnia. This practice parameter paper presents recommendations for the evaluation of chronic insomnia based on the evidence in the accompanying review paper. We recommend use of these parameters by the sleep community, but even more importantly, hope the large number of primary care physicians providing this care can benefit from their use. Conclusions reached in these practice parameters include the following recommendations for the evaluation of chronic insomnia. Since the complaint of insomnia is so widespread and since patients may overlook the impact of poor sleep quality on daily functioning, the health care practitioner should screen for a history of sleep difficulty. This evaluation should include a sleep history focused on common sleep disorders to identify primary and secondary insomnias. Polysomnography, and the Multiple Sleep Latency Test (MSLT) should not be routinely used to screen or diagnose patients with insomnia complaints. However, the complaint of insomnia does not preclude the appropriate use of these tests for diagnosis of specific sleep disorders such as obstructive sleep apnea, periodic limb movement disorder, and narcolepsy that may be present in patients with insomnia. There is insufficient evidence to suggest whether portable sleep studies, actigraphy, or other alternative assessment measures including static charge beds are effective in the evaluation of insomnia complaints. Instruments such as sleep logs, self-administered questionnaires, symptom checklist, or psychological screening tests may be of benefit to discriminate insomnia patients from normals, but these instruments have not been shown to differentiate subtypes of insomnia complaints.

PMID 10737341  Sleep. 2000 Mar 15;23(2):237-41.
著者: J W Winkelman, H Goldman, N Piscatelli, S E Lukas, C M Dorsey, S Cunningham
雑誌名: Sleep. 1996 Dec;19(10):790-3.
Abstract/Text Thyroid evaluation is frequently performed in patients with sleep apnea because of a suspected causal relationship between hypothyroidism and obstructive sleep apnea (OSA). The aim of this study was to determine the actual prevalence of hypothyroidism in patients referred for polysomnography and evaluate whether its rate was higher in patients with OSA than those without OSA. Ultrasensitive thyroid stimulating hormone (TSH) was performed on 255 of 279 consecutive patients referred for polysomnography from the neurology service of a large HMO. Hypothyroidism was detected in 1.6% (4/243) of all patients, 1.5% (3/194) of patients referred to evaluate OSA, and 2.0% of patients referred to evaluate the presence of periodic leg movement disorder (PLMD)/narcolepsy/parasomnia. There was no significant difference in rates of hypothyroidism in patients with documented OSA (2.9%, 3/103) compared to those without OSA (0.7%, 1/135). Two of the four patients with elevated TSHs had previously documented hypothyroidism and were on thyroxine replacement. Rates of hyperthyroidism were as high or higher than those of hypothyroidism in all groups. We conclude that thyroid screening does not appear to be appropriate for patients with suspected, or confirmed, OSA in the absence of signs or symptoms consistent with hypothyroidism or unless they are in a high risk group (women over the age of 60).

PMID 9085487  Sleep. 1996 Dec;19(10):790-3.

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