A Scream in the Night. ARTP Conference 2010 Dr Christopher Kosky

Transcription

1 A Scream in the Night ARTP Conference 2010 Dr Christopher Kosky

2 Parasomnia Slow Wave Sleep Arousal Disorder REM Sleep Behaviour Disorder Nocturnal Epilepsy Catathrenia

3 Slow Wave Sleep Arousal Disorders Sleepwalking Sleep (night) terrors Sleep talking Sleep eating Sexsomnias

4 SWAD characteristics Sudden large arousal from slow wave sleep with (delta waves overlapping) motor activity First hours of sleep Amnesia Childhood history Family History

5 Night terrors Wake in the night screaming Confused, terrified, pale and sweaty Fall back to sleep No memory Danger-embarrassment/neighbours/partner

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10 Sleepwalking La Sonnambula (the sleepwalker) Vincenzo Bellini 1831.

11 Sleepwalking Stereotyped (switching light switch on and off) Bizarre (urinating into cupboards) Dangerous (climbing onto balconies, roofs) Aggressive if confronted Associated nightmares, dreams Little or no memory Danger-harming self and others.

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16 Sleep eating Get up during sleep and make and eat food Bizarre (cigarette butt sandwiches!) Crumbs and wrappers in bed Put on weight Usually associated with sleep walking

17 Sexsomnias Sex advance or intercourse during sleep with bed partner Amnesia

18 Co-existing sleep disorders 174 patients with sleep walking 75 (44%) abnormal npsg 29 confusional arousals from stage 3 NREM 27 OSA 10 Overlap (RBD and SWAD) 5 Narcolepsy 4 UARS

19 SWAD triggers Stress Alcohol Sleep deprivation Foreign sleeping environment

20 Treatment Avoid triggers/sleep Hygiene Avoid Alcohol, Sleep deprivation Relaxation therapy, Hypnosis Treat other sleep disorders Benzodiazipines (Clonazepam) Anti-depressants Anti-epileptics (Topirimate?)

21 REM sleep behaviour disorder (RBD) Loss of normal REM sleep muscle atonia and dream enactment 2 nd part of a nights sleep Violent Fall out of bed but don t sleep walk No Family or Childhood history Schenk et al. Sleep.1986

22 RBD associations <50 years Parkinson s Disease >50 years Narcolepsy Drugs- Anti-depressants, Beta-blockers Obstructive sleep apnoea Bonakis et al. Sleep Med. 2009

23 RBD in cats-pathphysiology Jouvet and Delorme (1965), Morrison ( ) RBD from (bilateral) dorsolateral pontine tegmental lesion REM sleep otherwise normal Excessive limb movements during NREM sleep

24 RBD in cats Behaviour depended on size/location of pontine tegment- limb jerking exploratory-head raising, reaching, grasping striking prey locomotor

25 RBD PSG scoring rules (tonic) An epoch REM at least 50% duration of the epoch having chin EMG amplitudes greater than the minimum amplitude than in NREM. (phasic) In a 30 second epoch of REM sleep divided into 10 sequential 3 second mini-epochs, at least 5 (50%) of the mini-epochs contain bursts of muscle activity. In RBD, excessive transient muscle activity are seconds in duration and at least 4 times as high as the amplitude as the background EMG. AASM Manual for Scoring Sleep, 2007

26 Polysomnograph 60 second demonstrating loss of REM atonia

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28 Treatment Stop causative medication Treat co-existing OSA Clonazepam Zopiclone Melatonin Combination Novel-sodium oxybate?

29 Nocturnal epilepsy Seizures may only occur night History of daytime seizures or childhood seizures Generalized tonic/clonic seizures Complex partial seizures Lip-smacking Confused awakening Automated behaviour (wandering through the house)

30 Temporal lobe epilepsy Inter-ictal activity/seizure activity Spike and wave Mastoid electrodes (A1, A2) closest to the temporal lobes Spikes most prominent in a combination of either central (C3, C4) or occipital (LOC, ROC) electrodes that contain a mastoid electode on the same side a seizure the focus

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33 Tips for nocturnal seizures Full EEG montage Change to 10 second epoch Look at the video-if not associated with motor activity unlikely to be significant Show to an EEG specialist

34 Treatment Anti-epileptics 60-70% remission with complex partial seizures 80-85% with primary generalised seizures Surgery Refer to a neurologist

35 Catathrenia Rare Loud monotonous groaning in sleep Any stage of sleep (commoner in REM) During exhalation Vetrugno et al. Neurology. 2001, 2007

36 Catathrenia Snoring in inspiration Catathrenia in expiration Lasts 30 seconds Terminates in a snort or sigh Look peaceful

37 Catathrenia (VPSG) PSG shows groaning with long expiration No desaturation Slow RR Normal respiration alternating with groaning Mild upper airway expiratory obstruction (oesophageal balloon)

38 Catathrenia Normal fibre optic laryngoscopy, neurology exam and respiratory function

39 Catathrenia-treatment? Not dangerous 5 year follow-up no consequence No effect on sleep quality Earplugs for partner CPAP or dental device? (but inspiratory) Guilleminault et al. Sleep. 2008

40 Thanks Sean Higgins-senior sleep technician Patients