Neurophysiology and neuroimaging of sleep inertiaДЇrom an evolutionary standpoint, sleep inertia is counterintuitive, as sudden transitions to wakefulness seem clearly more adaptive. Reference lists were reviewed to identify additional manuscripts. The former two terms were also queried at. ДЇor this review, PubMed was searched for вЂњsleep inertiaвЂќ, вЂњsleep drunkennessвЂќ, вЂњsleep-wake transitionвЂќ, вЂњsleep-wake transitionsвЂќ, вЂњwake upвЂќ, вЂњwake-upвЂќ, вЂњwaking upвЂќ, вЂњwaking-upвЂќ, вЂњawakenвЂќ, вЂњawakeningвЂќ, вЂњneural inertiaвЂќ, вЂњsleep offsetвЂќ, and вЂњsleep-offsetвЂќ. Difficulty awakening is also common in people with mood disorders and may be an important treatment target. Such pronounced sleep inertia is a core feature of idiopathic hypersomnia (IH), a potential consequence of delayed sleep phase syndrome (DSPS), and a contributor to non-REM (NREM) arousal parasomnia severity. In some disease states, a transitional period akin to markedly pronounced sleep inertia is present and is sometimes referred to as вЂњsleep drunkennessвЂќ. Sleep inertia is a normal phenomenon, but one with potentially dangerous ramifications, e.g., in health care workers or military personnel who are woken abruptly in the night and required to make cognitively-taxing decisions.

The intensity and duration of sleep inertia vary based on situational factors, but its effects may last minutes to several hours. вЂњSleep inertiaвЂќ refers to the transitional state between sleep and wake, marked by impaired performance, reduced vigilance, and a desire to return to sleep. This may represent an important treatment target, but evidence-based treatment guidance is not yet available.

Difficulty with awakening is also commonly endorsed by individuals with mood disorders, disproportionately to the general population. Optimal treatment of sleep drunkenness is unknown, although several medications have been used with benefit in small case series. In patients with hypersomnolence disorders, especially but not exclusively idiopathic hypersomnia, a more pronounced period of confusion and sleepiness upon awakening, known as вЂњsleep drunkennessвЂќ, is common and problematic. Recovery sleep after sleep deprivation also amplifies sleep inertia, although the effects of deep sleep vary based on task and timing. Forced desynchrony studies have demonstrated that sleep inertia impacts cognition differently than do homeostatic and circadian drives and that sleep inertia is most intense during awakenings from the biological night. Although the precise substrate of sleep inertia is unknown, electroencephalographic, evoked potential, and neuroimaging studies suggest the persistence of some features of sleep beyond the point of awakening. The transition from sleep to wake is marked by sleep inertia, a distinct state that is measurably different from wakefulness and manifests as performance impairments and sleepiness.

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