Nikolaus C. Netzer MD Hermann Buhl Institute for Hypoxia and Sleep Medicine Research, Bad Aibling Paracelsus Medical University, Salzburg, Austria
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1 Hypersomnolonce in Non-SAHS Patients Nikolaus C. Netzer MD Hermann Buhl Institute for Hypoxia and Sleep Medicine Research, Bad Aibling Paracelsus Medical University, Salzburg, Austria
2 Definitions of Hypersomnolence (DSM IV, AASM, ICSD) Real hypersomnia: Hypersomnolence is measurable with a positive MSLT and ESS score, sleep attacks during the day, extended sleep time, unbearable sleep pressure during day Chronic Fatigue: Hypersomnolence is not measurable in MSLT
3 Definitions of Hypersomnolence (DSM IV, AASM, ICSD) Definition (by Netzer): There is no hypersomnolence in Venice! What about Beijing?
4 Listing of Hypersomnolence by ICSD not caused by Insomnia, Sleep Apnea or otherwise disturbed nighttime sleep (Disomnias) Idiopathic hypersomnolence with extended sleeptime Idiopathic hypersomnolence without extended sleeptime Behavourial caused hypersomnolence Hypersomnolence caused by medications Narcolepsy with and without cataplexy Kline-Levin Syndrome
5 Listing of Hypersomnolence by ICSD not caused by Insomnia, Sleep Apnea or otherwise disturbed nighttime sleep (Disomnias) Hypersomnolence in combination with a psychiatric disorder not caused by medication Hypersomnolence caused by the menstruation cycle Narcolepsy caused by an organic disease Hypersomnolence caused by organic disease
6 Listing of Hypersomnolence by ICSD caused by insomnia, disomnia or parasomnias Idiopathic insomnia Insomnia caused by depression or any other psychiatric disorder Shift Workers syndrome Jet lag Rem Sleep behavioural disorders and other parasomnias like somnambulism etc. Epilepsy RLS- PLMS Parkinsons disease
7 54 year old truck driver (Milk truck with a morning start at 3am, work day finishes at 2pm) Known moderate to severe OSAHS since two years sucessfully treated (2 titration nights) with BiPaP 12/6 cm H2O No other organic disease known Usual bed time 10pm (5 hours sleep at night and 2 in the afternoon) Mildly obese
8 Clinical tests for real hypersomnolence (hypersomnia): MSLT positive, ESS 24, according to patient no additional drugs (see next two slides) Patient history for disomnia: Sleep behaviour before since 30 years without problem, no jet lag, according to bed partner no sleep disbehaviour
9 Hypersomnolence caused by drugs (4806, f 68%, patients with different drugs asked for hypersomnolence): Cetirizin (82/139) 59% Katadolon (48/106) 45% Seroquel (190/462) 41% Keppra (68/176) 39% Doxepin (68/193) 35% Lyrica (144/434) 33% Mirtazapin (185/573) 32% Opipramol (94/295) 32%
10 Hypersomnolence caused by drugs (4806, f 68%, patients with different drugs asked for hypersomnolence): Citalopram (207/714) 29% Cipralex (159/565) 28% Tramadol (70/251) 28% Bisoprolol (51/191) 27% Tilidin (56/210) 27% Cymbalta (109/410) 27% Fluoxetin (80/304) 26% Paroxetin (60/238) 25% Trevilor (123/652) 19% Ramipril (47/308) 15%
11 Testing for Narcolepsy: No early REM-Onset, no kataplexy, No extraordinary orexin levels treatment with Modafinil did not change the complaints, no sleep attacks in the later afternnoon, only sleep attacks in the morning and EDS until siesta at 3pm
12 Testing for Epilepsy: No epilepsy attacks known in the past Regular EEG in two tests No signs of nightly epilepsy in the sleep lab polysomnography
13 Testing for RLS and PLMS: Cave: Up to 30% of OSAHS patients have additional RLS or PLMS In this case no leg movements independent of apneas in 5 polysomnographies
14 Testing for Insomnia with and without depression: According to patient and bed partner no insomnia (sleeps with BiPAP like a stone throughout the night, wake up clock sounds very loud to get him awake) No depression according to neuropsychological counsel and negative for depression in the Becks Inventory No psychiatric disorder (Schizophrenia etc.) known
15 Testing for Dementia: No signs for Alzheimers disease or vascular dementia Negative in the Mini Mental Status Test and clock drawing for cognitive impairment No signs for dementia in the neuropsychological counsel
16 Testing for other drugs: No excessive alcohol use (1-2 0,5 l bavarian beers in the evening, no hard liquor or wine) No known use of opoid like drugs No alcohol consumption in the morning or during day time because of tough police controls
17 Organic disease screening: Regular status of thyroid hormones Kidney functions tests negative for disease Regualr ECG, stress ECG, Heart Ultrasound Normal liver values Normal Head CT (No trauma, no stroke) And so on..
18 Kline-Levin Screening: Male sex: yes No hypersexuality No Eating disorder No Hypersensitivity for light and noise No depression Longer wake period between 5 and 10 pm
19 Parkinson screening: Neurological counsel negative for parkinsons No signs of movement disorder Regular dopamin levels No on- off times etc.
20 Screening for other neurological and neuromuscular diseases: MS ALS Marfan Etc.
21 Screening for sexual hormonal status
22 Our treatment trial: Increasing pressure with BiPAP-Therapy to eliminate all apneas and hyponeas Additional oxygen to keep oxygen level at over 95% Increasing the modafinil dose
23 The final solution of the case? Presented in oral form:??????
24 Searching for unclear hypersomnolence is like beiing a dective in a tv crime show: How far do you want to go with the search, how far does your budget reach! Thank you for the attention!
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Milena Pavlova, M.D., FAASM Department of Neurology, Brigham and Women's Hospital Assistant Professor of Neurology, Harvard Medical School Medical
Milena Pavlova, M.D., FAASM Department of Neurology, Brigham and Women's Hospital Assistant Professor of Neurology, Harvard Medical School Medical Director, Faulkner EEG and Sleep Testing Center Course