Searching for a Marker of REM Sleep Behavior Disorder: Submentalis Muscle EMG Amplitude Analysis during Sleep in Patients with Narcolepsy/Cataplexy

REM Sleep Behavior Disorder Searching for a Marker of REM Sleep Behavior Disorder: Submentalis Muscle EMG Amplitude Analysis during Sleep in Patients with Narcolepsy/Cataplexy Raffaele Ferri, MD 1 ; Christian Franceschini, PhD 2 ; Marco Zucconi, MD 3 ; Stefano Vandi, RPSGT 2 ; Francesca Poli, MD 2 ; Oliviero Bruni, MD 4 ; Carlo Cipolli, PhD 5 ; Pasquale Montagna, MD 2 ; Giuseppe Plazzi, MD 2 1 Sleep Research Centre, Department of Neurology I.C., Oasi Institute (IRCCS), Troina, Italy; 2 Department of Neurological Sciences, University of Bologna, Bologna, Italy; 3 Department of Neurology, Sleep Disorders Center, H San Raffaele Scientific Institute, Università Vita-Salute San Raffaele, Milan, Italy; 4 Center for Pediatric Sleep Disorders, Department of Developmental Neurology and Psychiatry, University of Rome La Sapienza, Rome, Italy; 5 Department of Psychology, University of Bologna, Bologna, Italy. Study Objectives: To evaluate the amplitude of submentalis muscle EMG activity during sleep in patients with narcolepsy/cataplexy with or without REM sleep behavior disorder (RBD). Design: Observational study with consecutive recruitment. Settings: Sleep laboratory. Patients: Thirty-four patients with narcolepsy/cataplexy and 35 agematched normal controls. Measurements and results: Half the patients (17 subjects) had a clinical and video polysomnographic diagnosis of RBD. The average amplitude of the rectified submentalis muscle EMG signal was used to assess muscle atonia, and the new REM sleep Atonia Index was computed. Chin muscle activations were detected and their duration and interval analyzed. REM sleep Atonia Index was lower in both patient groups (with narcolepsy patients with RBD showing the lowest values) with respect to controls, and it did not correlate with age as it did in controls. The total number of chin EMG activations was significantly higher in both patient groups than controls. No significant differences were found between the two groups of patients, although more chin EMG activations were noted in narcolepsy patients with RBD than those without. Conclusions: Elevated muscle activity during REM sleep is the only polysomnographic marker of RBD. This study shows that polysomnographically evident RBD is present in many patients with narcolepsy/ cataplexy. This condition might be specific to narcolepsy/cataplexy, reflecting a peculiar form of REM sleep related motor dyscontrol (i.e., status dissociatus), paving the way to enacting dream behaviors, and correlated with the specific neurochemical and neuropathological substrate of narcolepsy/cataplexy. Keywords: Narcolepsy/cataplexy, REM sleep behavior disorder, submentalis EMG, quantitative analysis, polysomnographycitation: Ferri R; Franceschini C; Zucconi M; Vandi S; Poli F; Bruni O; Cipolli C; Montagna P; Plazzi G. Searching for a marker of rem sleep behavior disorder: submentalis muscle emg amplitude analysis during sleep in patients with narcolepsy/cataplexy. SLEEP 2008;31(10):1409-1417. REM SLEEP BEHAVIOR DISORDER (RBD), FIRST DE- SCRIBED AS A CLINICAL ENTITY IN 1986 BY SCHENCK AND COWORKERS, 1 HAD BEEN OBSERVED EVEN earlier in narcoleptic patients and termed ambiguous sleep 2 because of its low phasic atonia with an extreme abundance of twitches and muscular discharges. RBD is currently classified as a parasomnia related to REM sleep, characterized by loss of the stage-specific muscle atonia, and a frequent enactment of violent dream content resulting in self or bed-partner injuries. Polygraphically, tonic and phasic electromyographic activity is evident during REM sleep. When not symptomatic, this activity is called REM sleep without atonia (RWA). The importance of this altered sleep stage-dependent muscular activity was stressed in the latest international classification of sleep disorders, the ICSD-2. 3 Indeed, this classification advises considering a diagnosis of RBD in the presence of REM sleep without atonia, but no quantitative parameters are given. The prevalence of RBD in narcolepsy/cataplexy seems to be fairly high: according to two recent studies, it is clinically evident in 45% to 61% of patients and polysomnographically detectable in 36% to 43% of them. 4,5 Patients with narcolep- Submitted for publication February, 2008 Accepted for publication June, 2008 Address correspondence to: Raffaele Ferri, MD, Sleep Research Centre, Department of Neurology I.C., Oasi Institute for Research on Mental Retardation and Brain Aging (IRCCS), Via C. Ruggero 73, 94018 Troina, Italy; Tel: +30-0935-936111; Fax: +39-0935-936694; E-mail: rferri@oasi.en.it SLEEP, Vol. 31, No. 10, 2008 1409 sy/cataplexy are more frequently affected by RBD than those without cataplexy 4 and in many narcolepsy/cataplexy patients RBD can be induced or aggravated by anti-cataplectic treatment (antidepressants). 6 RBD may also be an early sign in childhood narcolepsy/cataplexy. 7 An increased electromyographic activity during REM sleep has frequently been observed in narcoleptic patients without RBD. 8 The prevalence of RWA, phasic EMG activity, and REM density is also higher in these patients than in controls, 9 whereas patients with idiopathic RBD have a higher prevalence of RWA and a lower REM density than narcoleptic patients and controls. 10 RBD in narcolepsy also differs from the idiopathic form because of its much earlier age of onset 5,6 and different sex ratio (in the idiopathic form, RBD mostly affects men). 4-6 Despite the crucial relevance of the increased chin EMG activity during REM sleep for the diagnosis of RBD, the reliability of polysomnographic criteria for the identification of RWA is largely unexplored. 11 There have been very few systematic attempts to measure submentalis muscle EMG activity during sleep, 12 probably because of decades of paper recordings in sleep research. Few literature reports have quantified submentalis muscle EMG activity in RBD patients, 13-15 and only one included narcoleptic patients. 10 This study aimed to evaluate the quantitative amplitude of submentalis muscle EMG activity during sleep in patients with narcolepsy/cataplexy, without or with RBD, in comparison to normal controls. In addition to a visual quantitative approach

Nocturnal Polysomnography Figure 1 Example of polysomnographic recording of REM sleep without atonia. following the criteria set by Lapierre and Montplaisir in 1992, 13 we adopted a new computer quantitative analysis describing both basal and transient modifications in chin EMG amplitude during sleep in normal controls and idiopathic and symptomatic RBD patients. 16 SUBJECTS AND METHODS Subjects Thirty-four patients with narcolepsy/cataplexy were consecutively recruited for this study at the Sleep Disorders Center of the Department of Neurological Sciences, University of Bologna, together with 35 age-matched normal controls. Clinical and demographic characteristics of patients are listed in Table 1. The diagnosis of narcolepsy/cataplexy was based on the International Classification of Sleep Disorders (ICSD-2) criteria. 3 All patients had 2 sleep onset REM-sleep episodes upon the multiple sleep latency test (MSLT), cataplexy and excessive daytime sleepiness, reflected by a mean sleep latency at the MSLT 8 min, and all carried the human leukocyte antigen (HLA) DQB1*0602. Diagnosis of RBD was also based on the ICSD-2 criteria, 3 including presence of REM sleep without atonia, sleep related injurious-disruptive behaviors by history following a semistructured clinical interview described elsewhere, 17 administered to the patients and, whenever possible, to their bed partners, evaluating RBD symptomatology and frequency of episodes 18 and abnormal sleep behaviors documented during polysomnographic monitoring, absence of EEG epileptiform activity during REM sleep, and sleep disturbance not better explained by another sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder. Patients were recorded on average within 18.6 years (SD 2.81, range 2 57 years) from the beginning of narcolepsy clinical symptoms, and all had been drug-free 3 weeks at the time of the polysomnographic recording. None of the 35 normal subjects had any physical, neurological or psychiatric disorder or history of sleep problems, and none was taking medication at the time of recording. Exclusion criteria included (a) a sleep disorder diagnosis (including sleep apnea); (b) a major mental illness; (c) a significant history of cognitive difficulties; (d) prior (within one year) or current use of a neuroleptic agent or SSRIs, venlafaxine; and (e) history of alcohol or other substance abuse. Nocturnal polysomnography was carried out after a night of adaptation in a standard sound-attenuated (noise level to a maximum of 30 db nhl) sleep laboratory room, under video recording monitoring. Subjects were not allowed caffeinated beverages the afternoon preceding the recording and were allowed to sleep until they awoke spontaneously in the morning. Lights-out time was based on individual habitual bedtime and ranged between 21:30 and 23:30. The following signals were recorded: EEG (at least 2 channels, one central and one occipital, referred to the contralateral earlobe); electrooculogram (electrodes placed 1 cm above the right outer cantus and 1 cm below the left outer cantus and referred to A1), electromyogram (EMG) of the submentalis muscle (bipolar derivations with 2 electrodes placed 3 cm apart and affixed using a collodion-soaked gauze pad), impedance was kept less than 10 KΩ (typically <5 KΩ), EMG of the right and left tibialis anterior muscles, and ECG (one derivation). Sleep signals were sampled at 200 or 256 Hz and stored on hard disk in European data format (EDF) 19 for further analysis. The sleep respiratory pattern of each patient was monitored using oral and nasal airflow thermistors and/or nasal pressure cannula, thoracic and abdominal respiratory effort strain gauge, and by monitoring oxygen saturation (pulseoximetry). This had been performed in all subjects in a previous recording (within one week) by means of a portable cardiorespiratory monitor or during the study recording; patients with an apnea/ hypopnea index 5 were not included. Sleep stages were scored following standard criteria 20 on 30-sec epochs; since muscle atonia can be absent in RBD, REM sleep was scored without submental EMG atonia, using electroencephalogram and electrooculogram only. According to a method specifically developed for RBD, 10,13 onset of a REM sleep period was defined as the occurrence of the first rapid eye movement in the presence of an EEG signal characteristic of REM sleep (low amplitude mixed frequencies, absence of sleep spindles and K complexes). Offset of a REM sleep period was determined by the occurrence of a specific EEG feature indicative of another stage (K complex, sleep spindle, or EEG signs of arousal) or absence of rapid eye movements during 3 consecutive minutes. Figure 1 shows an example of REM sleep without atonia scored following these criteria. Epochs containing technical artifact or extremely elevated muscle activity causing saturation of amplifiers were carefully detected and marked for exclusion from the subsequent quantitative EMG analysis. Quantification of Submentalis Muscle EMG Amplitude For visual quantitative analysis, we first quantified the 2 parameters proposed by Lapierre and Montplaisir, 13 adapted to our recordings, in REM sleep of all groups. First, each 30-sec epoch was scored as tonic or atonic, depending on whether tonic chin EMG activity was present for > 50% of the epoch; then, we calculated the percentage of total REM epochs scored as tonic. Second, we evaluated phasic EMG density as the percentage of the total number of 2-sec mini-epochs of REM sleep containing phasic EMG events (defined as any burst of EMG activity lasting 0.1 5 s, with an amplitude exceeding 4 times the background EMG activity). For computer quantitative analysis, the submentalis muscle EMG signal was digitally band-pass filtered at 10 100 Hz, SLEEP, Vol. 31, No. 10, 2008 1410

Table 1 Clinical and Demographic Characteristics of Patients Patient Sex Age Age at onset, years SP HH AB DNS Therapy withdraw one month before admission, daily EDS Cataplexy RBD dose 1 M 36 10 18 + + + + Valproic Acid 1,250 mg; Citalopram 20 mg 2 M 41 33 33 + + drug naive 3 F 52 49 50 Paroxetine 20 mg 4 M 35 13 15 + drug naive 5 M 44 33 33 + + + + drug naive 6 F 33 18 n.a. + + + drug naive 7 F 20 12 12 + + + drug naive Therapy at PSG time, daily dose 8 F 73 45 44 + Enalapril 10 mg Thyroxine sodium 50 mg; Furosemide 25 mg 9 F 18 10 16 + + + Modafinil 100 mg 10 F 23 9 22 + + drug naive 11 M 31 18 18 + drug naive 12 F 37 29 29 + + + + Modafinil 100 mg; Venlafaxine 75 mg 13 M 59 48 n.a. Fluoxetine 60 mg 14 M 67 13 13 + + drug naive Nifedipine 40 mg; Perindopril 2 mg 15 M 44 40 n.a. drug naive 16 M 35 15 15 + + drug naive 17 F 34 19 19 + + + drug naive 18 M 66 10 40 50 Sertraline 50 mg; Flurazepam 15 mg 19 F 36 24 24 24 + + + drug naive 20 M 25 10 10 15 + + Imipramine 30 mg 21 M 32 11 11 12 + Modafinil 100 mg 22 F 41 15 16 20 + + + Modafinil 100 mg 23 F 59 45 47 50 + + + + Modafinil 200 mg; Clomipramine 50 mg 24 M 75 18 20 22 + Modafinil 100 mg 25 M 31 15 26 28 + + + + drug naive 26 M 55 44 44 50 + + + drug naive 27 M 38 17 20 20 + + + + drug naive 28 M 24 7 n.a. 16 drug naive 29 M 44 22 22 19 + + + drug naive 30 M 50 16 15 18 + + drug naive 31 M 30 18 20 24 + + + + Modafinil 200 mg 32 F 35 14 14 25 + + + drug naive 33 M 36 28 n.a. 30 drug naive 34 M 20 18 19 19 drug naive Metformin 500 mg; Alfuzosin 10 mg EDS = Excessive daytime sleepiness; SP = sleep paralysis; HH = hypnagogic/hypnopompic hallucinations; AB = automatic behaviors; DNS = disturbed nocturnal sleep; n.a. = not available; + = present; = absent. SLEEP, Vol. 31, No. 10, 2008 1411

Table 2 RBD Video-Polysomnographic Features of Narcolepsy+RBD Subjects Included in this Study Patient Sex Age Age at onset, years Vocalizations Simple and Complex Behaviors EDS Cataplexy RBD 18 M 66 10 40 50 talking upper limb movements 19 F 36 24 24 24 talking, crying reaching, crawling 20 M 25 10 10 15 talking lower limb movements 21 M 32 11 11 12 talking 22 F 41 15 16 20 talking Grabbing 23 F 59 45 47 50 shouting 24 M 75 18 20 22 laughing Grabbing 25 M 31 15 26 28 talking reaching, grabbing 26 M 55 44 44 50 shouting arm flailing, gesturing, crawling 27 M 38 17 20 20 reaching, grabbing 28 M 24 7 n.a. 16 laughing, shouting upper/lower limb movements, sitting 29 M 44 22 22 19 laughing, shouting upper/lower limb movements, arm flailing, reaching, crawling 30 M 50 16 15 18 arm flailing, reaching 31 M 30 18 20 24 talking grabbing, punching, kicking, attempts to jump out of bed 32 F 35 14 14 25 laughing, talking Crawling 33 M 36 28 n.a. 30 laughing, talking Grabbing 34 M 20 18 19 19 grabbing, gesturing, crawling with a notch filter at 50 Hz and rectified. Subsequently, each sleep epoch included in the analysis was divided into 30 1-sec mini-epochs. The average amplitude of the rectified submentalis muscle EMG signal was then obtained for each mini-epoch. The values of the submentalis muscle EMG signal amplitude in each mini-epoch were used to draw normalized distribution histograms for each sleep stage (REM, S1, S2, and SWS) of the percentage of values in the following 20 amplitude (amp) classes (expressed in µv): amp 1, 1 < amp 2,, 18 < amp 19, amp > 19. In these graphs, muscle atonia is expected to be reflected by high values of the first left column while phasic and tonic activations are expected to increase the value of the other columns. 16 As proposed in our recent validation study, 16 an index summarizing the degree of preponderance of the first column in these graphs in a single value was used in REM sleep: Sleep Atonia Index = amp 1 /(100 1<amp 2). Mathematically, this index can vary from 0 (absence of miniepochs with amp 1), i.e., complete absence of EMG atonia, to 1 (all mini-epochs with amp 1) or stable EMG atonia in the epoch. Finally, we also counted all sequences of consecutive miniepochs exceeding the value of 2 µv and calculated their number per hour for REM sleep. These data were also used to draw normalized distribution histograms within the following 20 duration (dur) classes (expressed in s): dur = 1, dur = 2,, dur = 19, dur > 19. Statistical Data Analysis All data were coded and analyzed blind to the subject group upon completion of recruitment. Comparisons between groups were carried out using the nonparametric Mann-Whitney test for independent data sets, with the Bonferroni correction for multiple comparisons when needed. The correlation between REM sleep Atonia Index and age of subjects was evaluated by the nonparametric Spearman rank correlation coefficient. Finally, the Chi-square test was used for the comparison of the gender composition of the groups and the nonparametric Kruskal-Wallis ANOVA for the comparison of their age. Differences and correlations were considered significant when P < 0.05. The data analysis software system STATISTICA (Stat- Soft, Inc. 2004, version 6. www.statsoft.com) was used for statistical analysis. RESULTS After the application of the current criteria for the diagnosis of RBD 3 and the analysis of the video-polysomnographic recordings, 17 of the 34 patients with narcolepsy/ cataplexy were diagnosed with RBD (Narcolepsy+RBD) and 17 were not (Narcolepsy RBD). Table 2 shows the details of the RBD signs observed at videopolysomnography, in each Narcolepsy+RBD patient; the complete narcolepsy symptom tetrad was present in 3 patients with Narcolepsy RBD (21.4%) and in 4 Narcolepsy+RBD (28.6%) patients. All subsequent statistical analyses were carried out taking into account these 2 subgroups. Age and Sex Table 3 reports age and gender composition of the groups; only the Narcolepsy+RBD group is male predominant, with the SLEEP, Vol. 31, No. 10, 2008 1412

Table 3 Subjects Included in this Study total, n males females Age, years ± SD (range) 1. Normal Controls 35 15 20 40.2 ± 16.72 (24.5 76) 2. Narcolepsy RBD 17 9 8 40.1 ± 15.35 (18 73) 3. Narcolepsy+RBD 17 13 4 41.0 ± 15.36 (20 75) other 2 groups having almost equal gender composition. This was due to the consecutive character of the recruitment that prevented us forming gender-balanced groups; however, the group differences in gender composition did not reach statistical significance (Chi-square test = 5.209, 0.1 > P > 0.05). The age of the subjects in the 3 groups was not statistically different at the nonparametric Kruskal-Wallis ANOVA. Sleep Architecture Table 4 shows the comparison between the different sleep scoring parameters obtained in the 3 groups of subjects. Both groups of patients showed the expected changes with respect to controls: namely longer time in bed, sleep period time, and total sleep time, shorter REM sleep latency, smaller percentage of sleep stage 2 and higher percentages of sleep stage 1 and REM sleep. No significant differences were found in sleep architecture between the 2 groups of patients with narcolepsy/ cataplexy. Visual Analysis of Submentalis EMG Amplitude The comparison between the chin EMG amplitude visual analysis parameters obtained in the 3 groups of subjects is reported in Table 5. Both groups of patients with narcolepsy/ cataplexy showed an increased percentage of REM sleep miniepochs containing phasic EMG events (defined as any burst of EMG activity lasting 0.1 5 s, with an amplitude exceeding 4 times the background EMG activity). 13 No significant difference was found between the 2 patient groups for this parameter or among all groups for the percentage of tonic REM sleep epochs. Computer Quantitative Analysis of the Submentalis EMG Amplitude Figure 2 shows the normalized distribution histograms of mini-epoch amplitude for each subject group. Small but clear differences can be seen among the 3 groups. The graph pertaining to normal controls (on the left) was characterized by a very high and prominent first column indicating that approximately 80% of mini-epochs during this sleep stage have amp 1. The amplitude of the same column was lower in the Narcolepsy RBD and lower still in the Narcolepsy+RBD group, with a shift of the respective graphs towards the other columns representing higher values of amp. The REM sleep Atonia Index, which summarizes the distribution of these graphs, was significantly lower in both patient Figure 2 Normalized distribution histograms of mini-epochs amplitude for each subject group. (The percentage of values in 20 amplitude (amp) classes are shown (1 = amp 1, 2 = 1 < amp 2,, 19 = 18 < amp 19, 20 = amp > 19. All values are shown as means and standard errors (whiskers). The statistical analysis of the differences in REM sleep Atonia Index is also shown. groups than controls. Again, no significant differences were found in REM sleep Atonia Index between the 2 groups of patients. Figure 3 shows the individual values of the REM sleep Atonia Index in the different subject groups. Both patient groups showed a wide distribution of their individual values, largely overlapping with those of normal controls, but more often below the arbitrary threshold of 0.7 (Chi-square test = 10.006, P < 0.01), indicated with a dotted line in this figure and already indicated as a possible supporting criterion for the diagnosis of RBD. 16 Also in this figure it is possible to note that REM sleep Atonia Index did not differ between the 2 groups of patients. Figure 2 also demonstrates data from a recent study in idiopathic and symptomatic RBD (multiple system atrophy), carried out by our group; 16 this shows that both narcolepsy subgroups seem to show mean values of REM sleep Atonia Index between those of young normal controls and idiopathic RBD patients, with multiple system atrophy patients showing the lowest average value. Figure 4 reports the relationship of REM sleep Atonia Index and age in the 3 groups of subjects. Even if this index tended to decrease with age in all graphs, the correlation coefficient reached statistical significance only for normal controls who showed individual values less scattered around the linear regression line than those of the patient groups. This result was confirmed also by the analysis reported in Table 6 in which 2 age subgroups ( 40 years and > 40 years) were obtained in each subject group; a statistically significant difference was found only in normal controls. The same table reports the comparison between gender subgroups in each subject group; none of these comparisons reached statistical significance. Figure 5 contains the normalized distribution histograms of consecutive mini-epoch sequences exceeding 2 µv for each subject group. These graphs show a similar type of distribution for all groups, with a tendency for patients with Narcolepsy RBD and those with Narcolepsy+RBD to show higher values mostly for columns in the left part of the graphs (shorter activations). The same figure shows the differences in the total number of SLEEP, Vol. 31, No. 10, 2008 1413

Table 4 Comparison Between Sleep Scoring Parameters in the 3 Groups of Subjects 1. Controls (n=35) 2. Narcolepsy RBD (n=17) 3. Narcolepsy+RBD (n=17) Mann-Whitney U test* 1 vs. 2 1 vs. 3 2 vs. 3 mean SD mean SD mean SD P < P < P < TIB, min 457.4 63.19 508.4 79.72 521.0 73.47 0.021 0.006 NS SPT, min 429.9 52.11 496.6 75.12 498.6 84.49 0.005 0.007 NS TST, min 367.4 69.50 423.9 70.69 436.6 70.70 0.03 0.007 NS SOL, min 20.1 24.01 6.2 2.77 16.8 33.13 NS NS NS FRL, min 98.0 76.49 31.2 31.29 39.2 42.71 0.0009 0.006 NS SE% 81.4 16.91 83.9 10.22 84.1 9.93 NS NS NS WASO, % 14.1 15.65 14.1 9.82 12.3 7.63 NS NS NS S1, % 4.1 4.07 12.6 6.71 12.9 5.81 0.00002 0.00001 NS S2, % 46.5 10.50 32.6 7.93 34.7 8.25 0.00009 0.0006 NS SWS, % 17.3 9.92 18.3 6.73 17.0 8.68 NS NS NS REM, % 18.1 6.93 22.4 5.57 23.0 6.17 NS NS NS TIB = Time in bed; SPT = sleep period time; TST = total sleep time; SOL = sleep onset latency; FRL = 1st REM latency; SE%= sleep efficiency; WASO = wakefulness after sleep onset; S1 = NREM sleep stage 1; S2 = NREM sleep stage 2; SWS = slow wave sleep; REM = rapid eye movement sleep. *Bonferroni corrected P values. chin EMG activations detected in the 3 groups of subjects; this is significantly higher in both patient groups than controls. No significant differences were found in the total number of chin EMG activations between the 2 groups of patients. DISCUSSION Figure 3 REM sleep Atonia Index in the 3 groups of subjects in this study and in patients with idiopathic RBD (irbd) and multiple system atrophy (MSA) (*data from Ferri et al. 16 ): values are shown as means (black-filled squares) and 95% confidence intervals (whiskers). Individual values are also shown (circles). To our knowledge, this is the first computerized quantitative study of the EMG signal in narcolepsy, designed to evaluate polysomnographically signs of RBD in narcolepsy patients. RBD is prevalent in narcolepsy, 4,6 but it has an even higher prevalence in narcolepsy-cataplexy. 4,5 The percentage found in our narcolepsy/cataplexy patients fits with previous data. Interestingly, several findings suggest that narcoleptic patients without clinical RBD also frequently have increased electromyographic activity during REM sleep 8 and have a higher prevalence of RWA, phasic EMG activity, and REM density than controls. 10 Previous studies suggest that although it is frequent, RBD is not an every night phenomenon in narcolepsy/ cataplexy 4,5 and is more frequently disclosed by questionnaires or by clinical interview than by (video)polysomnography. This finding is peculiar, and differentiates narcolepsy/cataplexy from neurodegenerative diseases (i.e., multiple system atrophy) in which the typical RBD dream enacting is easily documented by videopolysomnography. 21 In this light, the availability of a tool to detect subclinical signs of RBD on polysomnographic tracings might be of great interest not only for research but also for clinical decision making. The recent availability of more quantitative and computerized methods of analysis of the EMG signal, especially designed for the evaluation of the chin motor phenomena accompanying RBD 22,23 prompted us to apply this new approach to the study of RBD in narcolepsy/cataplexy. The main finding of this study is the confirmation and quantification of polysomnographic signs of motor dyscontrol in the SLEEP, Vol. 31, No. 10, 2008 1414

Table 5 Comparison Between Chin EMG Amplitude Visual Analysis Parameters Obtained in the 3 Groups of Subjects 1. Controls (n=35) 2. Narcolepsy RBD (n=17) 3. Narcolepsy+RBD (n=17) Mann-Whitney U test* 1 vs. 2 1 vs. 3 2 vs. 3 mean SD mean SD mean SD P < P < P < Phasic REM mini-epochs, % 1.5 0.96 6.5 2.79 8.0 3.51 0.000003 0.000003 NS Tonic REM epochs,% 10.1 13.04 7.6 8.01 6.5 5.80 NS NS NS Data expressed as a percentages of the total. *Bonferroni corrected P values. Figure 4 Correlation between REM sleep Atonia Index and age in normal controls (top graph), patients with narcolepsy RBD (middle graph), and patients with narcolepsy+rbd (bottom graph). The Spearman correlation coefficient is also reported for each graph together with its statistical significance and the linear regression line. chin EMG of patients with narcolepsy/cataplexy. This allowed us to discover an abnormal quantity of motor activity in patients without a clear clinical complaint of RBD, as specified by the P current diagnostic criteria. 3 Although these signs were always more evident in subjects with clinically evident RBD, the difference from those without was not statistically significant. If we consider REM sleep Atonia Index 0.7 as a cut-off for RWA, 13 of our 34 (38%) narcolepsy/cataplexy patients had RWA, a figure similar to that found by others using visual scoring. 10 As shown above, both narcolepsy subgroups seem to show mean values of REM sleep Atonia Index intermediate between those of young normal controls and idiopathic RBD patients, with multiple system atrophy patients showing the lowest average value; for this reason, the degree of motor dyscontrol expected in narcoleptic patients should be expected to be somewhat milder than that of idiopathic or symptomatic RBD. The increased index of motor dyscontrol in REM sleep in the 2 groups of patients with narcolepsy/cataplexy can thus be considered an intrinsic finding of the disease and a sort of status dissociatus (a condition characterized by ambiguous, multiple, or rapid oscillation of state-determining variables which can be observed in a wide variety of experimental and clinical situations), 24,25 opening the way to acting out dream contents (i.e., RBD). Another important finding of this study is that the altered REM sleep atonia index in all patients with narcolepsy/cataplexy was mostly caused by an increase in short-lasting EMG activity (approximately from 0 to 5 s), as shown in Figure 4. This phenomenon, already described by Geisler et al., 9 is also consistent with the increased limb phasic EMG activity in NREM sleep, 26 and might differentiate patients with narcolepsy/cataplexy and RBD from patients with other forms of secondary RBD (i.e., multiple system atrophy), if confirmed by additional studies. A third important finding is that the visual analysis of the same signal, following criteria established in the past, 13 yielded results similar to those of the automatic analysis only for the count of short-duration (phasic) EMG activations, whereas analysis of the tonic REM epochs failed to disclose differences among our 3 groups of subjects. This is only partially in agreement with our previous study 16 in idiopathic and symptomatic RBD and with the results reported in another study in a different group of symptomatic RBD patients using another quantitative method. 22 The results of this study need to be compared with those obtained in idiopathic RBD patients. 16 RBD in patients with narcolepsy differs from idiopathic RBD: patients with idiopathic RBD have a higher prevalence of RWA than narcolepsy subjects, with smaller REM density, 10 and RBD in narcolepsy has a much earlier age at onset and a different sex ratio (in the idiopathic form, RBD mostly affects men). 4,6 The present study clearly shows that the pattern of motor dyscontrol found in our narcoleptic subjects is less severe than that found in idiopathic SLEEP, Vol. 31, No. 10, 2008 1415

Table 6 Comparison Between REM Sleep Atonia Index Obtained in 2 Age Subgroups ( 40 Years and >40 Years), in Normal Controls, Patients with Narcolepsy RBD, and Patients with Narcolepsy+RBD; Comparison Between Genders is also Reported in the Same Subject Groups Age 40 years Age >40 years Mann-Whitney U test* n mean SD n mean SD P < Controls 24 0.937 0.077 10 0.815 0.170 0.006 Narcolepsy RBD 10 0.747 0.300 7 0.681 0.229 NS Narcolepsy+RBD 10 0.706 0.187 7 0.666 0.175 NS Males Females n mean SD n mean SD P < Controls 15 0.940 0.045 20 0.869 0.151 NS Narcolepsy RBD 9 0.710 0.221 8 0.731 0.327 NS Narcolepsy+RBD 13 0.692 0.179 4 0.679 0.201 NS *Bonferroni corrected P values. Figure 5 Normalized distribution histograms of consecutive mini-epoch sequences exceeding 2 µv for each subject group. The number per hour of sleep stage in 20 duration (dur) classes is shown (20 = dur>20 s). All values are shown as means and standard errors (whiskers). The statistical analysis of the differences in total number of movements per hour of REM sleep is also shown. RBD and also different from that of symptomatic RBD in patients with multiple system atrophy. MSA patients present a very high number of RWA epochs compared to idiopathic RBD. Thus, this new quantitative approach seems to be not only able to disclose differences between normal controls and patients, but also among nosologically different groups of patients who might present a different type of REM sleep motor dyscontrol (which is currently referred to as RBD in all cases). These differences might indicate different neurochemical and neurophysiological mechanisms underlying an apparently similar sleep disturbance, from a strictly clinical point of view, occurring in different conditions such as narcolepsy, idiopathic RBD, and MSA. 21,27 Besides these conditions, RBD has been reported to occur in neurological diseases such as Parkinson disease, 28,29 spinocerebellar ataxia, 30 supranuclear palsy, 31 Lewy body disease, 28 Alzheimer disease, 32 amyotrophic lateral sclerosis, 33 multiple sclerosis, 34,35 and Tourette syndrome. 36 Lastly, RBD can be induced by medications, especially the tricyclic antidepressants and serotonin-specific reuptake inhibitors. 33,37 For this reason, the new quantitative approach proposed in the present study may also yield insights into the specific patterns of chin EMG activation during REM sleep in these disorders. This study also provided further evidence of a significant effect of age on our REM sleep Atonia Index in normal controls, an effect which was mild and statistically nonsignificant in both groups of patients. This seems to indicate that the age of subjects is a critical factor to take into account in these studies, and that there is a significant interaction between disease and age, with the pathological condition masking the effects of age. In conclusion, a certain degree of polysomnographically evident RBD is present in many patients with narcolepsy/cataplexy. This disorder might be specific and correlated to the specific neurochemical and neuropathological substrate of narcolepsy/ cataplexy. Our approach represents an improvement over previous visual methods of analysis of chin EMG during REM sleep and yields useful and practical indices for the quantitative and nonsubjective evaluation of EMG atonia during REM sleep, and EMG activations. The combination of atonia and activation indices allows investigation of different clinical conditions characterized by abnormal chin EMG activation during sleep. Our proposed REM sleep Atonia Index is an additional useful parameter to be used in conjunction with the other criteria for the diagnosis of RBD. Future research is now needed to verify this new method in evaluating the clinical effects of drugs for RBD treatment. Disclosure Statement This was not an industry supported study. The authors have indicated no financial conflicts of interest. REFERENCES 1. Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep 1986;9:293-308. 2. de Barros-Ferreira M, Lairy GC. Ambiguous sleep in narcolepsy. In: Guilleminault C, Dement WC, Passouant P, editors eds. SLEEP, Vol. 31, No. 10, 2008 1416

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