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Sleep Disorders

Wakening Confused and Disoriented

03/19/2008

Question:

When I take a nap during the daytime, I will awaken and be in a very `dazed` and confused disoriented state. I describe this to friends as coming out of anethesia. This does NOT occur in the mornings - only after an afternoon nap. This nap could be 15 minutes to 4 hours long - time doesn`t make a difference. I literally walked out in front of a car while going to get my mail out of the box - simply because while in this `state` I either didn`t see it or didn`t register it in my brain that there was a danger ... brain and body didn`t work `together`. I am not taking ANY medications - I sleep well at night - eat right - exercise daily... not depressed .. so WHY do I wake up in this `out of it` state of mind - it lasts for at least 30 minutes - sometimes up to 3-4 hours afterwards.

Answer:

What you are describing is "Sleep Inertia" or "Sleep Drunkenness." This is defined as severe sleepiness and disorientation upon awakening. This condition is not uncommon, but can be very severe and disabling, depending on your job and living arrangements.

One way to understand this phenomenon is to think of it as inability to shake sleep off, that is sleep impinges on wakefulness. Individuals with this condition demonstrate sleep type brain activity while they are seemingly awake. An extreme version of this condition is called "Confusional Arousal", in which the individual is completely confused to the surroundings and agitated. This is most common in children and is usually considered a part of normal sleep physiology. However, sleep inertia may persist into adulthood, where it may not be related to any serious psychological or mood disorder.

Normal sleep consists of several sleep stages spanning from NREM sleep (stage 1 to stage 4) to REM sleep (or dream sleep). Stages 3 and 4, also known as Slow Wave Sleep (SWS), are the deepest sleep stages, from which it is most difficult to arouse. Awakening from other stages of sleep is typically easier than awakening from SWS. In the case of sleep inertia, the individual awakens from SWS and experiences severe disorientation and confusion. They may not have any recollection of the events and this may constitute a major problem, particularly if the individual is required to make quick decision or take immediate action upon awakening.

There are several aggravating factors that may increase the amount of SWS and lead to an increased likelihood of awakening from SWS, resulting in sleep inertia. Some of these include sleep deprivation, medications, alcohol use, and irregular sleep schedule. As such, the evaluation of an adult with sleep inertia includes an assessment of the degree of sleepiness in relation to the amount of sleep obtained. Commonly, patients with sleep inertia do not obtain enough sleep creating a state of sleep restriction that could be contributing to their problems.

Aside from sleep inertia, other conditions that should be considered include "Idiopathic hypersomnia," a sleep disorder that can be associated with long sleep time and non-refreshing naps, and certain types of seizures. Night time and daytime sleep studies may be required to evaluate for these two conditions.

If other sleep disorders are ruled out, then several conservative measures can be taken as first steps in the treatment. It is critical to obtain adequate sleep. In some cases, individuals may require up to 10-11 hours of sleep at night to feel rested, though this is relatively unusual and most individuals do fine with 7.5-8.5 hours per night. Life style and environmental modifications should be also considered. For example, a patient with severe sleep inertia should avoid jobs requiring night or rotating shifts. Avoidance of alcohol and sleep aids may be needed.

When specific therapies are needed, the use of certain medications may be considered by the Sleep Physician once other sleep disorders have been ruled out. Some medications can shorten the duration spent in SWS, thereby reducing the possibility that one would experience an awakening from that stage. However, these medications may also create a state of sleep restriction, particularly when the individual does not extend their sleep hours. Other interventions that are promising include relaxation therapy and hypnosis.

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Response by:

Rami N Khayat, MD Rami N Khayat, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University