Confusional Arousals

What are confusional arousals?

Confusional arousals are episodes where you partially wake up from non-rapid eye movement (NREM) sleep with confusion and disorientation. You might mumble or stare off into space or be unable to respond when someone talks to you. Then, you’ll fall back to sleep.

Something usually interrupts your sleep to trigger symptoms, like hearing a phone ringing or having the urge to pee. Episodes usually last about 5 minutes but can last up to an hour.

“Confusional arousal” may be used interchangeably with sleep drunkenness. Your healthcare provider might refer to confusional arousals as confusional arousal disorder or Elpenor syndrome.

How common are confusional arousals?

The exact frequency of confusional arousals varies. Studies estimate that a range of 4.2% to 15.2% of adults around the world experience confusional arousals in a year. It affects an estimated 17% of children under 15 years of age.

What are the symptoms of confusional arousals?

Symptoms of confusional arousals include:

• Appearing like you’ve suddenly woken up (but you’re not awake yet).
• Confusion or disorientation.
• Eyes glazed over.
• Not responding or incoherently responding to others who talk to you (making vocalizations, mumbling or talking slowly).
• Falling back to sleep shortly after symptoms happen.

When you do fully wake up, you likely won’t remember that you were in a confusional arousal state. A sleeping partner may mention it to you.

When do symptoms of confusional arousal happen?

Confusional arousals happen during non-rapid eye movement sleep. There are different stages of sleep. Non-REM sleep includes the first three stages before you move into REM sleep.

For adults and children, confusional arousals happen during slow-wave sleep or deep NREM (N3) sleep. This is the third stage of sleep.

What causes confusional arousals?

The exact cause of confusional arousals isn’t well known. Research suggests NREM disorders of arousal are primarily genetic.

You may be more likely to experience increased arousals or circadian misalignment that might lead to arousals from deep NREM sleep if you have:

• Bipolar disorder.
• Circadian rhythm sleep disorders.
• Hypersomnia.
• Narcolepsy.
• Obstructive sleep apnea.
• Panic disorder.
• Periodic limb movements of sleep.
• Shift work sleep disorder.

Antidepressant medications and other medications you take regularly may also lead to confusional arousals.

What triggers confusional arousals?

An interruption to your sleep usually triggers the arousal, like:

• Bright lights.
• Hearing a loud noise.
• The need to go to the bathroom.

At what age do confusional arousals start?

Confusional arousals can happen at any age. Most often, they start in children around age 2. Studies show that confusional arousal frequency decreases after age 5.

What are the risk factors for confusional arousals?

You may be more at risk of confusional arousals if you have:

• Hypersomnia (excessive sleep).
• Sleep deprivation (not enough sleep).
• Stress.
• A biological family history of NREM parasomnias.

What are the complications of confusional arousals?

Confusional arousals can affect how you feel during the daytime. Studies show that confusional arousals make you feel the same way that sleep deprivation (not getting enough sleep) does. You might experience:

• Daytime sleepiness.
• Lack of alertness.
• Slow reaction times.
• Performance difficulties at work or school.

Is confusional arousal dangerous?

It’s rare for confusional arousals to be dangerous. They’re usually not associated with dreaming or feeling fear. It isn’t common for you to get out of bed during a confusional arousal, but you can fall out of bed or knock over something on a nightstand, for example.

How are confusional arousals diagnosed?

A healthcare provider will diagnose confusional arousals after performing a physical exam and testing. During the exam, your provider will:

• Take a complete medical history and biological family medical history.
• Learn more about your symptoms.
• Ask you about your sleeping habits and schedule.
• Take note of what medications you currently take.

Your provider may ask you to keep a sleep diary. This is a list of notes about your sleep like when you go to bed and when you wake up or if you had any sleep disturbances. Parents or caregivers may need to complete a sleep diary for children. Adults may need to ask a sleeping partner if they notice any unusual behaviors at night because you likely won’t remember having a confusional arousal.

Your provider will offer tests to rule out conditions with similar symptoms. They may recommend a sleep study (polysomnography). A sleep study monitors your brain activity and behavior during sleep. This will require an overnight stay at a sleep center. Your provider may review home recordings from sleep, which can be very helpful when making a diagnosis.

How do you treat confusional arousals?

Treatment for confusional arousals includes maintaining good sleep hygiene. This could include:

• Emptying your bladder before sleep.
• Not eating late in the evening.
• Avoiding alcohol and caffeine late in the day.
• Treating sleep apnea and other sleep disorders that disrupt sleep.
• Managing stress.
• Setting a regular bedtime schedule.

Making changes to your routine isn’t easy, especially if your favorite TV show comes on late at night or you want to sleep in on the weekends. Try adding one change to your routine at a time. Once you’ve mastered it, add another. It can be overwhelming to adjust to multiple changes all at once.

Your provider will review your medical history to learn more about what may be causing your symptoms. Sometimes, treating or changing how you manage an underlying condition (like the medications you currently take) may improve your sleep. Your provider will make changes to the medications you currently take if they suspect that your current drug regimen causes symptoms.

Confusional arousal medication

Medications usually aren’t the first line of treatment for confusional arousals. But if sleep hygiene changes and managing any underlying conditions didn’t help, your provider may recommend the following medications for NREM parasomnias like confusional arousals:

• Benzodiazepines.
• Antidepressants.

Your provider will closely monitor how these medications affect you because side effects are possible.

Can confusional arousals be prevented?

There isn’t a sure way to prevent confusional arousals. You can reduce your risk by:

• Improving your sleep hygiene.
• Putting your phone on “do not disturb” or “sleep mode” to prevent a call or text from waking you up.
• Managing any underlying conditions.
• Keeping your sleep environment safe in case of a sudden wakeup (swap a glass of water with a plastic cup, for example).
• Reducing stress and/or talking to a mental health professional.

What can I expect if I have confusional arousals?

Confusional arousals can disrupt your sleep and cause daytime symptoms like fatigue. They tend to reduce with age, but many factors can cause them throughout your life. Someone will likely tell you if they noticed an arousal episode because you won’t remember it.

A healthcare provider can help you find the best ways to improve your sleep hygiene, manage any underlying conditions or offer medications to help you get restful sleep.

When should I see a healthcare provider?

Visit a healthcare provider if you feel like you’re not getting enough sleep at night or if a sleeping partner tells you about abnormal nighttime behaviors. A provider can help you find out what’s causing your symptoms.

What questions should I ask my healthcare provider?

Questions to ask your provider include:

• Do I have confusional arousals or another type of sleep disorder?
• Do I need to participate in a sleep study?
• What information should I include in a sleep diary?
• What changes to my sleep hygiene and routine can you recommend?