Clinical significance of sleepiness: an American Academy of Sleep Medicine position statement.

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Learn more: PMC Disclaimer | PMC Copyright Notice J Clin Sleep Med . 2025 Jun 1;21(6):1103–1107. doi: 10.5664/jcsm.11658 Clinical significance of sleepiness: an American Academy of Sleep Medicine position statement Thomas M Heffron 1 , Indira Gurubhagavatula 2, 3 , Lynn Marie Trotti 4 , Fariha Abbasi-Feinberg 5 , Alexandre Rocha Abreu 6 , Anuja Bandyopadhyay 7 , Vishesh K Kapur 8 , David Kuhlmann 9 , Jennifer L Martin 10, 11 , Eric J Olson 12 , Susheel P Patil 13, 14 , Anita V Shelgikar 15 , Emerson M Wickwire 16, 17 , James A Rowley 18, ✉ Author information Article notes Copyright and License information 1 American Academy of Sleep Medicine, Darien, Illinois 2 Division of Sleep Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 3 Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania 4 Emory Sleep Center and Department of Neurology, Emory University School of Medicine, Atlanta, Georgia 5 Sleep Medicine, Millennium Physician Group, Fort Myers, Florida 6 Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, Florida 7 Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana 8 Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington 9 Sleep Medicine, Bothwell Regional Health Center, Sedalia, Missouri 10 Geriatric Research, Education and Clinical Center, Veteran Affairs Greater Los Angeles Healthcare System, North Hills, California 11 David Geffen School of Medicine at the University of California, Los Angeles, California 12 Division of Pulmonary and Critical Care Medicine, Center for Sleep Medicine, Mayo Clinic, Rochester, Minnesota 13 Sleep Medicine Program, University Hospitals of Cleveland, Cleveland, Ohio 14 Case Western Reserve University School of Medicine, Cleveland, Ohio 15 University of Michigan Sleep Disorders Center, University of Michigan, Ann Arbor, Michigan 16 Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland 17 Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland 18 Rush University Medical Center, Chicago, Illinois ✉ Address correspondence to: James A. Rowley, MD, Rush University Medical Center, 1653 W. Congress Pkwy, Chicago, IL, 60612-3833; Email: james_rowley@rush.edu Received 2025 Mar 11; Accepted 2025 Mar 11; Collection date 2025 Jun 1. © 2025 American Academy of Sleep Medicine PMC Copyright notice PMCID: PMC12134574  PMID: 40078104 Abstract Alertness is a necessity for well-being and performance, and sleepiness is associated with cognitive and functional impairments that can have a negative impact on performance, health, mood, safety, and quality of life. In severe cases, sleepiness can lead to debilitation, injury, or death. Sleepiness is a marker of insufficient sleep and is the major patient-reported symptom associated with disorders of sleep and wakefulness such as narcolepsy and obstructive sleep apnea. Excessive sleepiness—the inability to stay awake and alert during the major waking episodes of the day—is reported by one third of US adults. It is the position of the American Academy of Sleep Medicine that sleepiness is a critical patient-reported outcome that is associated with increased risk for adverse health effects and diminished quality of life. The evaluation and management of sleepiness is essential for patient safety and patient-centered care. The health care system must support the evaluation and management of sleepiness so that patients can experience restorative sleep and daytime alertness. More research and innovation are needed to improve the treatment of sleep–wake disorders, including studies in diverse populations that support the development of tailored therapies for daytime sleepiness. Citation: Heffron TM, Gurubhagavatula I, Trotti LM, et al. Clinical significance of sleepiness: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2025;21(6):1103–1107. Keywords: sleepiness, patient-reported outcomes, position statement INTRODUCTION The American Academy of Sleep Medicine is a professional society that advances sleep care and enhances sleep health to improve lives. It advocates for policies guided by the understanding that sleep and circadian care is fundamental to health care. Excessive sleepiness is reported by one third of US adults, 1 and it is associated with a variety of neurobehavioral deficits that lead to diminished quality of life and impaired performance, health, and mood. 2 The consequences of excessive sleepiness include increased risks of human error, accidents, and active suicide ideation, 3 , 4 making sleepiness an important target for interventions to improve public health and safety. 5 Sleepiness is recognized as the major patient-reported symptom and disability associated with disorders of sleep and wakefulness such as narcolepsy and obstructive sleep apnea (OSA), and it is a critical variable in clinical trials evaluating treatments for sleep–wake disorders. 6 Sleep is recognized as essential to health, 7 and the resolution of sleepiness is well-established in the scientific literature as a long-term, patient-centered, clinically significant outcome in sleep and circadian medicine. 8 BACKGROUND Alertness and sleepiness are critical factors that dramatically affect human performance, safety, health, well-being, and quality of life. According to the International Classification of Sleep Disorders , third edition, text revision: Adequate alertness is necessary for well-being and performance in modern society. Sleepiness predisposes an individual to serious performance decrements in multiple areas of function as well as potentially life-threatening domestic, occupational, and vehicular accidents. Excessive daytime sleepiness is defined as the inability to stay awake and alert during the major waking episodes of the day, resulting in periods of irrepressible need for sleep or unintended lapses into drowsiness or sleep. Children may also present with inattentiveness, emotional lability, hyperactive behavior, or decreased performance in school. 9 Several scientific and clinical tools are available to assess sleepiness and alertness. 10 , 11 The most common, evidence-based tools include objective assessments such as the Multiple Sleep Latency Test, 12 Maintenance of Wakefulness Test, 13 Oxford Sleep Resistance Test, 14 Psychomotor Vigilance Task, 15 and Sustained Attention to Response Task, 16 and self-reported instruments including the Epworth Sleepiness Scale, 17 Stanford Sleepiness Scale, 18 Karolinska Sleepiness Scale, 19 and Patient-Reported Outcomes Measurement Information System (PROMIS) Sleep-Related Impairment item bank. 20 POSITION It is the position of the American Academy of Sleep Medicine that sleepiness is a critical patient-reported outcome that is associated with increased risk for adverse health effects and diminished quality of life. The evaluation and management of sleepiness is essential for patient safety and patient-centered care. DISCUSSION Sleepiness is a potentially debilitating symptom of sleep–wake disorders, making the resolution of excessive sleepiness a clinically significant, long-term, patient-centered outcome of sleep disorders treatment. Sleepiness is associated with cognitive and functional impairments that can have a negative impact on performance, health, mood, safety, and quality of life. In severe cases, sleepiness can lead to debilitation, injury, or death. Sleepiness also has clinical relevance as a critical marker of insufficient sleep, symptom of medical and mental health conditions, and side effect of medications. Symptom of sleep–wake disorders Excessive daytime sleepiness is a primary symptom of multiple sleep–wake disorders. It is a defining feature of central disorders of hypersomnolence such as narcolepsy and idiopathic hypersomnia. 9 Daytime sleepiness is also a key symptom that results from sleep fragmentation in disorders such as OSA, delayed sleep onset in disorders such as chronic insomnia disorder and restless legs syndrome, and misalignment between the internal body clock and sleep timing in circadian rhythm sleep–wake disorders such as shift work disorder. Patient-centered outcome of treatment The amelioration of daytime sleepiness is a key marker of therapeutic effectiveness for sleep–wake disorders such as narcolepsy, idiopathic hypersomnia, and OSA. Some patients may use terms such as “tired” or “fatigued” instead of “sleepy.” Although interrelated, sleepiness and fatigue, which refers to physical exhaustion, are distinct phenomena. 21 Excessive daytime sleepiness is reported by patients who have narcolepsy to be the most significant symptom that affects their lives, and this sleepiness tends to persist to some degree even with treatment. 22 Sleepiness in narcolepsy has a negative impact on health-related quality of life, which can include deleterious effects on education, recreation, driving, sexual life, and personality. 23 Similarly, daytime sleepiness in patients with idiopathic hypersomnia is associated with poor quality of life and impaired functioning, including cognitive effects, depressive symptoms, diminished work productivity, and lower overall activity. 24 Daytime sleepiness is a common symptom experienced by patients with OSA. Although such sleepiness tends to decrease with adherence to treatment for OSA, residual sleepiness remains problematic for some patients. 25 This residual sleepiness can have a negative impact on the health-related quality of life of patients and their partners 26 ; is associated with poorer mental and physical health and well-being, lower disease-specific functional status, more activity and work impairment, and more driving impairment 27 ; and is associated with lower patient satisfaction with health care providers and overall care. 28 Cause of cognitive and functional impairments Sleepiness is associated with a variety of performance deficits, including slower response times, lapses in attention, and increased errors, and these effects can be like those caused by alcohol intoxication. 29 Sleepiness at the wheel is associated with a higher risk of motor vehicle accidents, 30 and this risk is applicable to all transportation operators including pilots, rail operators, and operators of marine vessels. 31 – 33 In the workplace, sleepiness is associated with increased risks of accidents, absenteeism, and reduced productivity, 34 and these risks are heightened in professions that require shift work. 35 Sleepiness also is associated with worse school performance in children, adolescents, and college students. 36 , 37 Marker of insufficient sleep Although individual sleep needs vary, the American Academy of Sleep Medicine and Sleep Research Society recommend that the average adult should sleep 7 or more hours per night on a regular basis to promote optimal health, 38 and the National Sleep Foundation and American Thoracic Society provide similar consensus recommendations of 7–9 hours of sleep for adults. 39 , 40 Consensus recommendations from the American Academy of Sleep Medicine for pediatric populations vary by age range, with younger children generally requiring more sleep. 41 Insufficient sleep from sleep deprivation—for example, getting no sleep in the previous 24 hours—results in sleepiness as the homeostatic process causes sleep pressure to increase, and this sleepiness is maximal during the hours of the typical sleep period due to the circadian process. 42 , 43 The pressure to sleep eventually becomes overwhelming, and its sudden onset can take the form of “microsleeps” that intrude into wakefulness. 44 Insufficient sleep also can result from an inadequate opportunity to sleep—for example, restricting time in bed to only a few hours at night. When sleep opportunity is restricted for several days, self-reported sleepiness tends to increase acutely and then plateau or show only small increases on subsequent days, whereas cognitive performance continues to deteriorate. 45 Objectively measured sleepiness continues to increase during a prolonged period of inadequate sleep opportunity. 46 In addition to sufficient duration and the absence of sleep–wake disorders, healthy sleep also requires appropriate timing and regularity, and it needs to be of good quality. 47 Behavioral and environmental factors can result in poor sleep quality, contributing to daytime sleepiness. These factors include consuming excessive amounts of caffeine or alcohol, having a sedentary lifestyle, and having an excessively noisy, hot, cold, or bright bedroom environment. Symptom of medical and mental health conditions Daytime sleepiness may be caused by a variety of medical and mental health conditions. 9 Medical conditions that may cause sleepiness include infectious (eg, encephalitis, chronic viral infection); inflammatory (eg, rheumatoid arthritis, allergies); structural (eg, traumatic brain injury, stroke, benign or malignant brain tumors); endocrinological (eg, hypothyroidism); genetic (eg, Prader–Willi syndrome, myotonic dystrophy); and neurodegenerative diseases (eg, Parkinson’s disease, dementia). Psychiatric conditions that may cause sleepiness include mood disorders (eg, depression, bipolar disorder, and seasonal affective disorder); behavioral disorders (eg, substance abuse); and schizophrenia. Sleepiness may also result from iron deficiency. 48 Side effect of medications Sleepiness is a common side effect of both prescription and over-the-counter drugs, 9 , 49 making the potential risk of sleepiness an important consideration when clinicians are choosing a pharmacological agent for a patient. This side effect can be either a direct result of a drug or withdrawal of a drug, or it can be an indirect result of disturbed sleep. 50 Drug classes that commonly cause sleepiness as a side effect include benzodiazepines, nonbenzodiazepine hypnotics, anticonvulsants, antipsychotics, anticholinergics, and some antidepressants and antihistamines; sleepiness also can result from some dopamine agonists such as pramipexole or ropinirole and from many antiseizure medications; and the abrupt withdrawal of a stimulant can cause severe daytime sleepiness. 9 The risk of excessive sleepiness is higher when these medications are used in older adults or those with multiple medical conditions. The abuse of drugs such as alcohol, barbiturates, marijuana, and opiates and opioids also can cause sleepiness, posing a significant risk for drowsy driving. 51 FUTURE DIRECTIONS Sleepiness has been and must continue to be a primary outcome measure in clinical trials that evaluate treatments of sleep–wake disorders, and more research and innovation are needed to improve these treatments. This research needs to be conducted in diverse populations. It is necessary to develop objectively measured and reliable biomarkers of excessive sleepiness, including blood biomarkers, other physiologic markers, and metrics derived from the analysis of electroencephalogram recordings obtained during wakefulness and sleep. 52 Deep phenotyping of clinical data, including polysomnographic variables, holds promise for developing patient-centered care pathways that optimize long-term health outcomes. There remains a need for large prospective studies to better define the causal mechanisms and predictive baseline characteristics of residual sleepiness. 53 Improved pharmacologic options that manage daytime sleepiness more effectively are needed, 54 and it is necessary to identify the genetic variations that affect the therapeutic actions and adverse effects of these medications. 55 Research needs to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to stimulate the development of tailored therapies for daytime sleepiness that target specific endotypes. 56 Finally, more research is needed to provide a better understanding of how sleepiness impairs daytime functioning and quality of life. 57 CONCLUSIONS As a patient-centered outcome improved by sleep disorders treatment, sleepiness is an essential metric for sleep health care. Excessive daytime sleepiness is detrimental to productivity, health, well-being, quality of life, and safety, making interventions that target sleepiness of critical importance to patients. It is essential for the health care system to support the evaluation and management of sleepiness so that patients can experience restorative sleep and daytime alertness. DISCLOSURE STATEMENT Mr. Heffron is employed by the American Academy of Sleep Medicine, and the other authors are the 2023–2024 and 2024–2025 members of the American Academy of Sleep Medicine board of directors. Dr. Martin has received consulting compensation from ResMed. Dr. Patil has received consulting compensation from Kramer Levin Naftalis & Frankel LLP for a sleep-related legal case and is key personnel on a sleep-related research or education grant from Apnimed. Dr. Wickwire has received compensation as a scientific consultant or advisor for Axsome Therapeutics, Eisai, EnsoData, Idorsia, Merck, Nox Health, Primasun, and ResMed, and he is key personnel on sleep-related research or education grants from Merck and ResMed Foundation. This statement is published by the American Academy of Sleep Medicine as an advisory that is to be used for educational and informational purposes only. ACKNOWLEDGMENTS This position statement has been endorsed by the following organizations: American Academy of Cardiovascular Sleep Medicine, American Academy of Dental Sleep Medicine, American Academy of Emergency Medicine, American Academy of Neurology, American College of Chest Physicians (CHEST), American College of Lifestyle Medicine, American College of Occupational and Environmental Medicine, American Society for Metabolic and Bariatric Surgery, California Sleep Society, Circadian Sleep Disorders Network, Dakotas Sleep Society, Hypersomnia Foundation, Louisiana Academy of Sleep Medicine, National Safety Council, Obesity Medicine Association, Project Sleep, Society for Research on Biological Rhythms, Society of Behavioral Sleep Medicine, Southern Sleep Society, Start School Later, and Wake Up Narcolepsy. This position statement is supported by the American Academy of Family Physicians. The American Society of Anesthesiologists affirms the value of this position statement. 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