Sleepiness is not the inverse of alertness: evidence from four sleep disorder patient groups

The constructs sleepiness and alertness are often assumed to be reciprocal states of consciousness. This distinction is of increasing concern in relation to psychomotor performance tasks such as driving. We developed two separate subjective scales of alertness to complement existing sleepiness scales. Subjective sleepiness and alertness were compared in four groups of sleep-disordered patients. In a 175-patient cohort [25 narcoleptics and 50 each with sleep apnea, insomnia and periodic leg movement disorder (PLMD)], the Epworth Sleepiness Scale (ESS) was used to measure sleepiness while the Toronto Hospital Alertness Test (THAT) and ZOGIM Alertness Scale (ZOGIM-A) were used to measure alertness. Significant differences existed for sleepiness scores, with narcoleptics scoring highest on the ESS, followed by sleep apnea, with similar ESS scores for insomnia and PLMD. By contrast, alertness scores on both the THAT and ZOGIM-A did not differ significantly between the four groups. Sleepiness scores show a correlation of close to nil to alertness scores for the combined sleep disorder patient cohort, with the exception of insomnia patients, where a modest but significant inverse relationship was noted between sleepiness and alertness. Subjective states of impaired alertness and excessive sleepiness are independent constructs in the evaluation of sleep-disordered patients. The specific primary sleep disorder diagnosis may play a relevant role in mitigating this interrelationship.