2/13/2015 THINGS THAT GO BUMP IN THE NIGHT

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1 THINGS THAT GO BUMP IN THE NIGHT Detection & Management of Potentially Injurious Parasomnias Janet E. Tatman, PhD, PA-C Fellow American Academy of Sleep Medicine Certified in Behavioral Sleep Medicine From ghoulies and ghosties And long leggedy beasties And things that go bump in the night, Good Lord, deliver us! Traditional Scottish Prayer Patients experience fear embarrassment social isolation injury 1

2 PARASOMNIA an undesirable physical event or experience that occurs during entry to sleep, within sleep, or during sleep, i.e., NREM sleep, REM sleep, or transitions to and from sleep may encompass abnormal, complex movements, behaviors, emotions, perceptions, dreams, and/or abnormal ANS activity and may affect patient or bedpartner as sleep-wake cycle oscillates, the normally distinct states of consciousness (NREM, REM, and wake) may devolve into a state that is not fully declared a temporary unstable state of dissociation, resulting in a parasomnia an admixture of one or more normal states International Classification of Sleep Disorders, 3 rd Ed American Academy of Sleep Medicine Sleep, from Wikipedia, downloaded 1/5/15 INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3 RD ED. NREM-Related Parasomnias Disorders of Arousal (from NREM sleep) Confusional Arousals Sleepwalking Sleep Terrors Sleep-Related Eating Disorder REM-Related Parasomnias REM Sleep Behavior Disorder Recurrent Isolated Sleep Paralysis Nightmare Disorder Other Parasomnias Exploding Head Syndrome Sleep-Related Hallucinations Sleep Enuresis Parasomnia Due to Medical Disorder Parasomnia Due to Medication or Substance Parasomnia, Unspecified Normal Variant Sleep Talking American Academy of Sleep Medicine 2

3 INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3 RD ED. NREM-Related Parasomnias Disorders of Arousal (from NREM sleep) Confusional Arousals Sleepwalking Sleep Terrors Sleep-Related Eating Disorder no discernible neuropathology not 2 o psychiatric disease some brain areas deactivated, others activated disinhibition of basic drive states REM-Related Parasomnias REM Sleep Behavior Disorder (RBD) Recurrent Isolated Sleep Paralysis Nightmare Disorder often serious neuropathology (RBD) failed skeletal muscle paralysis dream enactment American Academy of Sleep Medicine CASE EXAMPLES CASE 1 42-year old goes to sleep at 11:30 PM and wakes around 1:30 AM in the middle of her backyard with nursery plants she had bought 2 days ago scattered around. She is standing next to a 2 deep hole, has garden soil on her legs and hands, and is naked in temperature of 55 o. 3

4 CASE 2 72-year old British conveys wife s reports of him yelling, punching, kicking, and speechifying during sleep. Her sleep is disturbed 3-4 nights a week and he is sometimes tired during the day. CASE 3 52-year old vigorously punches or kicks his wife during sleep every 1-2 months. They both are startled awake and frightened. once a month he leaves the bed, fumbles in the bedroom closet or stumbles along a wall, feeling it with his hands, returning to bed in response to gentle suggestion from his wife. CASE 4 37-year old police officer was surprised to wake in AM on living room sofa. Wife says that during the night he was charging around the house with a loaded service revolver, periodically hiding behind furniture, yelling, and seeming to chase the bad guys. 4

5 STAGES OF SLEEP NREM Sleep eyes quiet idling brain relaxed muscle tone some dreaming stable physiology REM Sleep rapid eye movements alert brain skeletal muscle paralysis much dreaming variability of HR, BP, RR, ANS brain metabolic activity SLEEP MENTATION NREM Sleep single, basic image more realistic difficult to awaken relative amnesia up to 40% of lab awakenings result in dream reports REM Sleep complex stories usually bizarre easily awakened good memory 85 + % of lab awakenings result in dream reports THE DISORDERS 5

6 DISORDERS OF AROUSAL Confusional Arousals Sleepwalking Sleep Terrors DISORDERS OF AROUSAL (NREM SLEEP) Recurrent episodes of incomplete awakening Inappropriate or absent response to others efforts to intervene or redirect Limited or no cognitive experience or dream imagery Partial or complete amnesia Usually occur during first 1/3 of the sleep period May be confused or disoriented for several minutes upon awakening CONFUSIONAL AROUSALS Meets criteria for Disorder of Arousal Mental confusion or confused behavior while still in bed Absence of terror or departure from bed Usually a lack of autonomic arousal (e.g., mydriasis, tachycardia, tachypnea, diaphoresis) 6

7 SLEEPWALKING Meets criteria for Disorder of Arousal Ambulation and other complex behaviors out of bed SLEEP TERRORS Meets criteria for Disorder of Arousal Abrupt terror, typically beginning with vocalization, scream, etc. Intense fear and signs of autonomic arousal SLEEP-RELATED EATING DISORDER (SRED) Recurrent episodes of dysfunctional eating after arousal from major sleep period Presence of at least one of the following: Eating odd types of combinations of food, inedible or toxic substances Injurious or potentially injurious behavior while seeking or cooking food Adverse health consequences Partial or complete loss of consciousness w/subsequent impaired recall 7

8 CLINICAL EVALUATION Thorough medical/behavioral history Include bedpartner or family whenever possible Assess risk Screen for history suggestive of other sleep disorders Polysomnography if risk is significant TREATMENT Environmental safety bedpartner sleeps separately move mattress & furniture prn Behavioral safety AVOID sleep deprivation! reduce stress whenever possible Clonazepam is usually considered first line start low & go slow habituation/tolerance typically not seen Other med options trial and error 8

9 REM RELATED PARASOMNIAS REM Sleep Behavior Disorder Recurrent Isolated Sleep Paralysis Nightmare Disorder REM SLEEP BEHAVIOR DISORDER (RBD) Repeated episodes of vocalization and/or complex motor behaviors Documented by PSG to occur during REM or are presumed to occur in REM based on clinical hx of dream enactment PSG demonstrates REM sleep without atonia RBD First described in Strongly associated w/ neurodegenerative disorders (PD, DLB, MSA) 2 Severe injuries reported 3 1 Schenck et al. Sleep, , Schenck & Mahowald, Intensive Care Med,

10 RBD EVALUATION Careful history including reports from bedpartner or family (risk, family reports, other sleep disorders) Polysomnography is necessary sustained muscle activity in chin EMG excessive transient muscle activity (bursts) in chin or limb EMG QUESTIONNAIRE? Single question: Have you ever been told, or suspected yourself, that you seem to act out your dreams while asleep (for example, punching, flailing your arms in the air, making running movements, etc. Postuma et al Mov Disord 27(7), Mayo Sleep Questionnaire (10) questions Boeve et al Sleep Med 12(5),

11 RBD TREATMENT Clonazepam effective in 90% of cases 1 (caution in dementia, gait disorders, & OSA) Melatonin considered a good alternative 2 Pressurized bed alarm? 3 1 Schenck & Mahowald, Cleve Clin J of Med, McGrane et al. Sleep Med, Howell et al. J Clin Sleep Med, 2011 RECURRENT ISOLATED SLEEP PARALYSIS Recurrent inability to move trunk and all 4 limbs at sleep onset or on waking Episodes last seconds to minutes Causes significant distress including bedtime anxiety or fear of sleep Reassurance NIGHTMARE DISORDER Extended, dysphoric dreams that usually involve threats Rapidly alert and oriented on awakening Clinically significant distress or impairment in social/occupational/other areas of function evident in at least one of the following Mood Sleep resistance Cognitive impairments Family functioning Behavioral problems Daytime sleepiness Fatigue/low energy Impaired occupational/educational/interpersonal/social function Behavioral treatments highly effective (eg, Seda et al. J Clin Sleep Med, 2015) 11

12 The Nightmare Johann Heinrich Füssli EXPLODING HEAD SYNDROME Sudden loud noise or sense of explosion in the head at wake-sleep transition or on waking during sleep period Sensation is followed by abrupt arousal, often with great sense of fright Not associated with complaints of pain SLEEP-RELATED HALLUCINATIONS Recurrent hallucinations just prior to sleep onset or nocturnal or morning awakenings Hallucinations are predominantly visual 12

13 SLEEP ENURESIS Patient is older than 5 Recurrent involuntary voiding during sleep at least twice a week Present for at least 3 months Primary Sleep Enuresis Never consistently dry during sleep Secondary Sleep Enuresis Previously consistently dry for at least 6 months HYPNOTIC-INDUCED SLEEPWALKING Businessman uses zolpidem intermittently Grandma zolpidem nightly College Student 1 st week of zolpidem International business travel (Europe), zolpidem when crossing many time zones After short sleep is awakened by partner to attend meeting w/ client. They discuss, negotiate, sign 3 contracts, and he returns to bed to complete a full night of sleep. No recall for any events in the AM. House alarm goes off 3 AM for unknown reason She does not wake, police arrive & cannot reach her by phone. They break into home, find her safely sleeping & difficult to rouse. They jointly call her daughter, much discussion, police secure home, and she returns to sleep. Talks w/ daughter in AM and says Did I call you last night? Irregular schedule 2 o classes & job Wakes spontaneously in AM after single night use of zolpidem & finds Jack-in-the-Box bag with half-eaten burger inside (she does not usually patronize them). Register receipt dated 3:36 AM that day from location 2 miles away. Lives alone, has no recall for events. STRATEGIES Use your consultant well PSG complexities Be aware of liability 13

14 CASE RESOLUTION CASE 1 42-year old goes to sleep at 11:30 PM and wakes around 1:30 AM in the middle of her backyard with nursery plants she had bought 2 days ago scattered around. She is standing next to a 2 deep hole, has garden soil on her legs and hands, and is naked. Has no idea how she got there No dream recall Days later she reflects on pressure she felt to complete the garden task Sleep Study? CASE 1 History of benign childhood sleepwalking, stopped age 9 until two other recent incidents Sleepwalking 14

15 CASE 2 72-year old British conveys wife s reports of his yelling, punching, kicking, and speechifying. Her sleep is disturbed 3-4 nights a week and he is sometimes tired during the day. Gives complex dream reports upon awakening Behaviors correlate well with recalled dream content Wife has sustained minor bruises; feels she must protect him during episodes Sleep Study? CASE 2 Sleep study showed sustained chin EMG for 50% of time in 2 of 3 REM periods also large EMG bursts in arms and legs during REM and a single period of loud shouting lasting 15 seconds REM Sleep Behavior Disorder CASE 3 52-year old punches or kicks his wife during sleep every 1-2 months. Once a month he leaves the bed, fumbles in the bedroom closet or stumbles along a wall, feeling it with his hands, returning to bed in response to gentle suggestion from his wife. Recalls dream after vigorous behavior in bed, but has no idea what happened in times when he gets out of bed, no recall for the latter Has bruised wife with former event type, but no injuries with latter type Sleep Study? 15

16 CASE 3 Sleep study shows elevated chin EMG periodically during each of 4 REM periods and excessive EMG bursting in arms during an episode in which patient is seen via videography vigorously flexing his right elbow. Recalls in AM that he dreamed of being attacked from behind and trying to punch attacker in his stomach. REM Sleep Behavior Disorder (explains aggressive behavior w/dream recall) Sleepwalking is also an appropriate dx on clinical grounds = Parasomnia Overlap Disorder CASE 4 37-year old police officer wakes in AM on living room sofa. Wife says that during the night he was charging around the house with a loaded service revolver, periodically hiding behind furniture, yelling, and seeming to chase the bad guys. Vaguely recalls a dream about being in a shootout similar to one he actually experienced several months earlier. Vaguely recalls a dream fragment about being in a shoot-out similar to one he actually experienced several months earlier Wife says similar episodes start w/patient sitting bolt upright in bed, screaming, and often fleeing bed, running down hallway Sleep Study? CASE 4 Sleep study shows moderate OSA with apnea/hypopnea index of 25.8 Lowest SaO2 = 87% CPAP was not applied per order Sleep Terrors, likely triggered or aggravated by untreated OSA 16

17 THE END That we are not much sicker and much madder than we are is due exclusively to that most blessed and blessing of all natural graces, sleep. Aldous Huxley 17