Standing up and still falling asleep? That’s not normal sleepiness.

Standing up and still falling asleep? That’s not normal sleepiness

Dozing off while standing—whether at a meeting, on public transport or in your own home—is a warning sign that something more serious may be happening. Occasional yawning or nodding off after a poor night’s sleep is common. But if you find yourself literally falling asleep upright, it’s time to pay attention.

Why this isn’t “just tiredness”

• Normal sleepiness
  • Happens after a long day, during a boring lecture or after all-nighters
  • Resolves with rest, caffeine or a quick nap
• Abnormal sleepiness
  • You fall asleep in unsafe situations (standing, driving, cooking)
  • You can’t stay awake despite ample rest
  • Daytime “sleep attacks” interfere with daily life

If you’re dozing off while standing, don’t chalk it up to laziness or weak willpower. This level of sleepiness often points to an underlying medical or neurologic problem.

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Possible causes of falling asleep while standing

1. Severe sleep disorders

   • Narcolepsy – sudden, uncontrollable sleep attacks, sometimes with muscle weakness (cataplexy)
   • Idiopathic hypersomnia – extreme daytime sleepiness without clear cause
   • Obstructive sleep apnea – breathing stops briefly during sleep, causing poor sleep quality

2. Medical conditions

   • Heart failure – poor circulation can lead to fatigue and drowsiness
   • Diabetes – low or high blood sugar can trigger lethargy
   • Thyroid disorders – an underactive thyroid (hypothyroidism) can slow your metabolism and energy levels
   • Depression – can manifest as overwhelming tiredness

3. Neurologic issues

   • Seizure disorders – some seizures can look like sudden sleep episodes
   • Parkinson’s disease – medication side effects and disease processes can cause daytime sleepiness

4. Liver disease and hepatic encephalopathy

   • In people with moderate to advanced liver disease, toxins that the liver normally filters can affect the brain, leading to confusion, drowsiness and, in severe cases, coma
   • This spectrum of brain dysfunction is called hepatic encephalopathy (HE)

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Focus on hepatic encephalopathy (HE)

Hepatic encephalopathy is a serious complication of chronic liver disease. It ranges from mild changes in sleep patterns and mood to deep, coma-like sleep. Awareness of HE is crucial: prompt treatment can reverse symptoms.

What is hepatic encephalopathy?

• HE is brain dysfunction caused by liver disease
• The liver can’t clear toxins (especially ammonia) from the blood
• These toxins build up and interfere with brain function

How HE affects sleep and alertness

• Early (minimal) HE
  • Subtle changes: difficulty concentrating, trouble sleeping at night, daytime tiredness
• Overt HE
  • Sleep–wake reversal (you’re awake at night, sleepy by day)
  • Marked drowsiness—even to the point of dozing off sitting or standing
  • Flapping tremor of the hands (asterixis)
  • Confusion, slowed thinking
• Severe HE
  • Stupor, unresponsiveness or coma

Diagnosing HE

1. Clinical assessment
   • Detailed history of liver disease (cirrhosis, hepatitis, alcohol-related liver damage)
   • Neurologic exam (looking for asterixis, confusion)
2. Laboratory tests
   • Blood ammonia level (often elevated, but not perfectly reliable on its own)
   • Liver function tests (ALT, AST, bilirubin, albumin)
3. Psychometric tests
   • Paper-and-pencil or computerized tests to detect mild cognitive changes
4. Guidelines
   • The American Association for the Study of Liver Diseases (AASLD) and European Association for the Study of the Liver (EASL) provide step-by-step algorithms to grade HE severity and guide treatment¹²³

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Treating and managing hepatic encephalopathy

Effective HE management involves reducing ammonia production in the gut, treating precipitating factors, and supporting liver health.

1. Lowering ammonia

• Lactulose
  • A non-digestible sugar that pulls ammonia into the colon for excretion
  • Taken orally or by enema
• Rifaximin
  • An antibiotic that reduces ammonia-producing gut bacteria
  • Often added if lactulose alone isn’t enough

2. Identifying and treating triggers

Common precipitants include:

• Gastrointestinal bleeding
• Infection (pneumonia, urinary tract infection)
• Electrolyte imbalances (low potassium)
• Medications that depress the brain (opioids, sedatives)

3. Nutritional support

• Aim for adequate protein (contrary to old advice to restrict protein)
• Small, frequent meals to stabilize blood ammonia

4. Monitoring and follow-up

• Regular clinical evaluations for mental status changes
• Periodic lab tests
• Adjust medications based on response

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When to worry—and what to do

Falling asleep while standing is a red flag. If you experience any of the following, seek medical help right away:

• Repeated “sleep attacks” in unsafe situations
• Sudden confusion or memory lapses
• Hand tremor (asterixis) or muscle jerks
• Trouble waking up or responding

To get started, consider doing a free, online symptom check for to help you track your symptoms and decide what to do next.

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Don’t wait—talk to a doctor

Falling asleep while standing is not just “normal tiredness.” It can signal serious underlying issues, from sleep disorders like narcolepsy to life-threatening conditions such as hepatic encephalopathy. If you or a loved one experiences these symptoms:

• Keep a log of when and how often you fall asleep
• Note any other symptoms: confusion, tremors, mood changes
• Share this information with your healthcare provider

Always seek prompt medical attention for anything that could be life-threatening or seriously impact your health. Your doctor can run the right tests, confirm a diagnosis and start treatment before complications arise.

¹ Ferenci P, et al. Hepatic encephalopathy–definition, nomenclature, diagnosis. Journal of Hepatology. 2002.
² AASLD & EASL. Hepatic encephalopathy in chronic liver disease: 2014 practice guideline. Hepatology. 2014.
³ EASL. EASL clinical practice guidelines on decompensated cirrhosis. Journal of Hepatology. 2018.