Section 19 - Parasomnias (Rosenberg).ppt

Parasomnias

Essentials of Sleep Technology

From Goulies and Ghosties

And Three‐leggity Beasties

And things that go bump in the night,

Good Lord deliver us.

Old Scottish Prayer


Objectives

• Become familiar with the basic characteristics of NREM and REM parasomnias

• Understand the basis for the diagnosis of parasomnias

• Have a basic understanding of the treatment of parasomnias


General Themes to Keep in Mind

• Age of onset

• Time of Night

• Recall of events

• Consequences of Behavior

• Family history

• Other relevant personal history


Parasomnias

• ICSD‐3 (2014)

“….undesirable physical events or experiences that occur during the initiation of sleep, during sleep or during arousal from sleep.”

Only RBD requires PSG as one of the essential diagnostic criteria


Overlapping States

• Wake and REM=REM Behavior Disorder

• Wake and NREM=

• Confusional Arousals

• Sleep Walking

• Night Terrors


Understanding Parasomnias

Two necessary concepts to consider

• Sleep and wake are not mutually exclusive

• The various components of sleep may dissociate or oscillate rapidly


More on Understanding Parasomnias

• Additional Concepts

• A parasomnia may exist within another parasomnia

• nightmares and sleep terrors.

• Separate sleep disorders can occur concomitantly

• OSA with a parasomnia.


Typical Progression of Sleep Over the Course of the Night

Awake

REM

Stage 1

Stage 2

Stage 3

Stage 4

BodyMovement

24 1 2 3 4 5 6 7WakeTime (h)


Disorders of Arousal

Pathophysiology:

• Incomplete awakening from deep SWS,

leading to prolongation of the normal period of sleep inertia


Common Characteristics of NREM Parasomnias

• Occurs more often in 1st 1/3 of sleep period

• NREM parasomnias occur when deep sleep is most likely to be present

• Can occur during rebound sleep

• Recovery sleep following sleep deprivation

• 1st night of successful CPAP treatment

• Discontinuation of deep sleep suppressing meds

• Benzodiazepines


Other Characteristics

• Impairment of higher cognitive functions

• Amnesia or major memory impairment afterwards

• Complex behaviors may occur

• Predisposed by any factor that deepens sleep or raises arousal threshold


Confusional Arousals

• Usually brief

• Usually benign

• Usually age related

• Simple behaviors

• Not responsive to environment


Sleep Drunkenness

• Also known as Excessive Sleep Inertia

• Usually occurs from final awakening

• Can arise from naps

• May result in violent behavior

• Usually brief in duration


Sleepwalking

General Description:

• “… series of complex behaviors that are usually initiated during partial arousals from slow wave sleep (stages 3 and 4) and culminate in walking around with an altered state of consciousness and impaired judgment .” (ICSD‐3)


SleepwalkingFactors that may predispose…

• Genetics• Incidence increases with each affected parent

• Neither parent = 22%

• 1 parent = 45%

• 2 parents = 60%

• What’s inherited?• Hyperresponsive to trigger?

• Inability to arouse completely?


ICSD‐3 Dx Criteria for Sleepwalking

• Examples of associated complex behaviors• Urinating in closet or waste basket

• Falling down stairs

• Climbing out window

• Eating

• Cooking

• Driving

• Violent acts – typically when confronted


ICSD‐3 Dx Criteria – Sleepwalking

• Difficulty arousing the person• Mental confusion• Amnesia• Routine behaviors occur at inappropriate times inappropriate or nonsensical behavior or dangerous behavior• Depending on study up to 15% of children have at least 1 episode

• Most common in 4 – 8 yrs old• Depending on study up to 1% adults • Males = Females


• 25 yr.‐old woman with no apparent hx of parasomnias presents with several recent episodes of sleep terrors/sleep walking during which she injured self by falling.

• Patient had recently decided to return to school full time while maintaining her full‐time and part‐time jobs. Reduced TST to 4.5 hours

• In adult cases of sleep walking consider stress factors

Sleepwalking Case


Parks Case, 1985

• 25 yr.‐old man reported to have aroused from deep sleep and done the following:• Drove 13 miles from his house to his in‐laws home

• Went to kitchen and took knife

• Stabbed mother‐in‐law to death

• Severely injured father‐in‐law

• Severely cut self without awareness

• No memory of actions

• Acquitted by jury


Violence in Sleep

• Should be a history of similar but less violent acts

• Behavior usually brief

• Out of waking character of the perpetrator

• Followed by shock without attempts at a cover‐up


Sleep Terrors

General Description:

“…sudden arousals from slow wave sleep accompanied by a cry or a piercing scream and autonomic and behavioral manifestation of intense fear.”(ICSD‐3)


Slow-wave sleepAmnesia for the event

Attempts to wakeincrease confusion

Mumbled speech

No response to parents

Sudden Arousal

Sits up & screams

Panic

Tremendous Autonomic DischargesConfusion / Disorientation

Progression of Sleep Terrors


Symptoms of Sleep Terrors

• “Islands of memory” may persist

• “I was scared.”

• “The house was on fire.”

• “Someone was chasing me.”

• Frightening, but static images may be recalled

• Memories are not similar to typical REM sleep

dreams & are not the “acting out of dreams”


• Polysomnographic monitoring demonstrates the onset of episodes during stage 3 and 4 sleep.

• Tachycardia usually occurs in association with episodes.

• Full blown episodes in the sleep laboratory are rare.

• ECG rates may double following episodes

PSG and Sleep Terrors


Sexomnia: Atypical Sexual Behavior

• A special form of sleep violence.

• Subjects are ashamed and reluctant to admit to the behavior

• Bedpartners are typically also reluctant to discuss

• Can become a medico‐legal case


Atypical Sexual Behaviors

• Taking off clothes

• Fondling bedpartner

• Trying to undress bedpartner

• Trying to forcefully have intercourse

• Masturbation

• Moaning


Atypical Sexual Behavior Features

• There is amnesia of the event

• Typically denial upon awakening


Atypical Sexual Behavior During Sleep

Most frequent diagnoses documented have been

• NREM Sleep Somnambulism

• REM Sleep Behavior Disorder

• Frontal Lobe Seizures

• Malingering


Disorders of ArousalWhen to Evaluate Further?

• Potentially injurious or violent behavior

• Severe disruption of other household members

• Resultant excessive daytime sleepiness

• Atypical clinical features


NREM Parsomnias Initial Treatment Approach

• Identify, modify, reduce, eliminate predisposing conditions or triggers• Increase total sleep time

• Reduce stress

• Treat sleep fragmenting disorders

• Eliminate ETOH or other drugs/medication

• Reduce environmental disturbances

• Safety issues, i.e. door and window alarms


• Long acting benzodiazepines• Clonezapam .5‐2 mg hs

• Diazepam

• Short acting benzodiazepines• If episodes occur early in sleep period

• Other CNS depressants• Anti‐convulsants

• Tricyclic Antidepressants

NREM Parasomnia Medication Options


REM Sleep Behavior Disorder (RBD)

• Essential Characteristics:

• .04% of population

• Intermittent loss of EMG atonia

• Complex behaviors/motor activity associated with

• dreaming mentation

• Can be idiopathic or secondary

• Neither finding alone confirms the diagnosis

• The only parasomnia requiring a PSG for diagnosis


PSG Findings

• Elevated muscle tone in chin or limb (EMG) during REM

• Excessive muscle twitching in REM

• Absence of EEG epileptiform activity during REM


ICSD‐3 Dx Definition – REM Sleep Behavior Disorder

“…abnormal behaviors emerging during REM sleep that may cause injury or sleep disruption.” (ICSD‐3)


Factors that may predispose…

• Parkinsonism

• 30% of RBD will develop PD within 10 yrs.

• 15‐25% of PD can have RBD.

• 90% male

• > 50 y.o. (although may begin at any age)

• Other Neurological Conditions


Associated Neurologic Conditions

• Alzheimer’s, Diffuse Lewy Body disease, Olivopontocerebellar degeneration, Shy Drager Syndrome, Parkinson’s disease.

• Brainstem neoplasm, Guillain‐Barre syndrome, Multiple Sclerosis, Cerebrovascular disease.

• Narcolepsy


Pathophysiology

• Unknown

• Brainstem lesions near locus coeruleus

• Reduced dopamine transporters and dopaminergic innervation in the striatum have been demonstrated


Factors that may trigger

• Anything that could increase % of REM sleep

• Sudden withdrawal of REM sleep suppressing substances

• ETOH

• Tricyclic antidepressants/SSRI’s/MAOI’s

• Barbiturates/amphetamines

• Cholinergic dementia agents (Aricept)


Factors that may facilitate…

• Medications may have been known to induce REM sleep EMG dissociation

• SSRI’s

• Consideration especially in young patient


Treatment of RBD• Medications:

• Clonazepam is the drug of choice in 90% of pts.

• Other BZD, i.e. Temazepam, Triazolam

• Dopaminergic Agents

• Mirapex 0.5‐1 mg qhs, Requip, L‐Dopa

• Tegretol, Neurontin

• Tricyclic Antidepressants – although withdrawal may trigger

• Melatonin (3‐15 mg qhs)


More on Treatment

• After treatment with clonazepam

• The PSG may not revert to normal

• The REM without atonia may persist

• There have been case reports of muscle return to normal atonia in REM with melatonin


Nightmare Disorder

ICSD‐3 description:

• “Recurrent nightmares, which are disturbing mental experiences that generally occur during REM and often result in awakening.”


ICSD‐3 Dx Criteria–Nightmare Disorder

• Recall of awakenings from sleep with intense fear, anxiety and feeling of impending harm.

• Full alertness upon awakening

• Delayed return to sleep or episodes occur later half of the sleep period


Nightmare

• Main point that differs nightmares from sleep terrors

• Sleep terrors – full or partial amnesia; no story line, action, etc

• Nightmare – detailed description, story line, action, etc.


• Timing may change due to REM sleep rebound

• Recent discontinuation of REM sleep suppressing drugs or medications

• Alcohol

• Tricyclic antidepressants

• MAOI’s

• SSRI’s

• Any drug with anti‐cholinergic characteristics

Rebound REM and Nightmare Disorder


Treatment of Nightmares

• Evaluate for treatment emergent effect of medications

• Drug‐drug interactions

• Psychotherapy

• REM Suppressing Drugs

• Self Help Book: Crisis Dreaming by Cartwright and Lamberg


Recurrent Sleep Paralysis

Inability to perform voluntary movements at sleeponset or on awakening in the absence of narcolepsy. (ICSD‐3)

• Dream‐like mentation/anxiety may accompany• 40‐50% of normals, may be familial• Women > Men• More often with sleep deprivation, stress• Dx Narcolepsy, atonic seizures, hypokalemia• PSG reveals wakefulness but EMG suppression• Treatment: education, REM suppressing drugs


Sleep Related Eating (SRED)

Symptoms include• Binge eating “out of control”

• Occurs within two hours of sleep onset

• Variable awareness

• Usually high carb foods

• Can be unusual combinations of food

• Confusional behavior

• Unexplained weight gain

• More common in patients with a waking eating disorder

• Treatment: dopamine agonists, topiromate, clonazapam


In all of us, even in good men,

There is a wild‐beast nature

Which peer out in sleep.

Plato, The Republic


Question 1

REM Behavior Disorder is seen most often in:

a. Men under age 40b. Women under age 50c. Men over age 50d. Women over age 50e. Age is not a factor with REM Behavior Disorder


Question 2

The first class of drug to be considered for treating

severe and persistent cases of sleep paralysis is:

a. SSRIsb. Dopamine agonistsc. Orexin antagonistsd. BzRAse. Non‐benzodiazepines


Question 3

According to the International Classification of Sleep Disorders‐3 which of the following disorders requires a PSG for diagnosis?

a. Partial Arousalsb. Sleep Walkingc. Night Terrorsd. REM Behavior Disordere. b and d


Question 4

Recent reports of parasomnia as a treatment emergent effect with hypnotics include which of the following behaviors

a. Drivingb. Eatingc. Self‐injurious behaviord. Sleepwalkinge. All of the above


Documents

Section 19 - Parasomnias (Rosenberg).ppt