Parasomnias Flashcards
What is isolated sleep paralysis?
An inability to perform voluntary movements at sleep onset or upon waking in the absence of narcolepsy
Characterized by episodes lasting a few seconds to minutes with preserved consciousness and full recall.
What are the two forms of sleep paralysis?
- Hypnagogic (predormital)
- Hypnopompic (postdormital)
These terms refer to the timing of the episodes in relation to sleep onset and waking.
What are common symptoms experienced during sleep paralysis episodes?
- Inability to speak or move
- Intense anxiety
- Visual, auditory, or tactile hallucinations
Patients often report experiences of a presence in the room.
What leads to fear of falling asleep in patients with sleep paralysis?
Intense anxiety during episodes
This can result in insomnia.
What is the differential diagnosis for isolated sleep paralysis?
- Cataplexy
- Atonic seizures
- Nocturnal panic attacks
- Familial periodic paralysis syndromes
Hypokalemic periodic paralysis is a specific concern in this context.
What is the recommended management for isolated sleep paralysis?
- Reassurance that episodes are benign
- Maintain regular sleep schedules
- Avoid sleep deprivation
Extending sleep is often the best first step.
What is hypokalemic periodic paralysis?
An autosomal dominant disorder characterized by episodes of flaccid muscle weakness and low serum potassium levels
First attacks occur between ages 2 and 30 years; episodes can last hours to days.
What factors can worsen hypokalemic periodic paralysis?
- Low temperature
- Anxiety
- Excessive salt ingestion
- Lack of exercise
- Consumption of steroids or alcohol
These factors can trigger or exacerbate episodes.
What role do selective serotonin reuptake inhibitors (SSRIs) play in sleep paralysis?
Used for treatment of cataplexy in narcolepsy; may improve symptoms of sleep paralysis
There is limited literature on the efficacy of SSRIs for isolated sleep paralysis.
What is Sleep-related eating disorder (SRED)?
SRED is characterized by recurrent episodes in which the patient eats and drinks unconsciously after an interval of sleep.
What are the criteria for diagnosing SRED according to the International Classification of Sleep Disorders?
A diagnosis of SRED requires the following criteria to be met:
A. Recurrent episodes of dysfunctional eating, occurring after an arousal during main sleep period.
B. Presence of one of the following in association with recurrent episodes of involuntary eating: 1. Consumption of peculiar forms or combinations of food or inedible or toxic substances; 2. Sleep-related behavior resulting in injury or behaviors possibly resulting in injury, performed while in pursuit of food or while cooking; 3. Adverse health consequences resulting from recurrent nocturnal eating.
C. Partial or complete loss of conscious awareness during eating, with subsequent impaired recall.
D. Absence of a better explanation for disturbance by another sleep, mental, or medical disorder or medication or substance use.
What is the common behavior of patients with SRED?
Most patients with SRED report nightly eating, and some even eat several times during the night.
What type of sleep disturbances are associated with SRED?
SRED episodes can occur any time during sleep and are considered non-REM parasomnias.
What conditions are commonly associated with SRED?
SRED is commonly associated with a history of sleepwalking and occurs more frequently in women. It can also be associated with restless leg syndrome, OSA, narcolepsy, and irregular circadian sleep-wake disorders.
What is the initial treatment for SRED?
Initial treatment for SRED is usually a selective serotonin reuptake inhibitor, but it can also include clonazepam or topiramate.
How does Night-eating syndrome (NES) differ from SRED?
Patients with NES have excessive eating between dinner and bedtime (or after a full awakening from sleep) and are fully awake and aware of the eating.
What behavior might patients with sleep-maintenance insomnia exhibit?
Some patients with sleep-maintenance insomnia can eat overnight out of boredom, as opposed to a voracious need to eat, as would be seen in SRED.
What is the risk for patients with insomnia taking hypnotics?
Patients with insomnia who are actively taking hypnotics at the time of the eating episodes are at risk of experiencing hypnotic-related SRED, which can be identified by the lack of recall of the eating episodes.
What is the treatment for SRED associated with hypnotic medication?
The treatment for SRED in association with a hypnotic medication is to discontinue the medication.
What is REM sleep behavior disorder (RBD)?
A parasomnia characterized by nonviolent or violent dream-enactment behavior arising from REM sleep and associated with loss of REM-related muscle atonia.
RBD can result in injuries to the patient or their bed partner.
What factors can precipitate RBD?
Several factors, including alcohol consumption and farming occupation.
Farming is associated with a higher prevalence of Parkinson disease, which is also linked to RBD.
How does alcohol consumption relate to RBD?
RBD episodes are most likely to occur shortly after cessation of periods of alcohol consumption, possibly due to REM sleep rebound.
Avoidance of alcohol use is an appropriate long-term intervention for RBD.
What are the recommended treatments for RBD according to the American Academy of Sleep Medicine?
Clonazepam at 0.5 to 2 mg and melatonin at 3 to 12 mg.
These treatments received class B recommendations.
What should be considered before prescribing benzodiazepines for RBD?
Careful supervision is required, especially in patients with alcohol dependence.
Addressing potentially reversible factors first is recommended.
Which antidepressants are associated with RBD?
Selective serotonin reuptake inhibitors, venlafaxine, and mirtazapine, among others.
Buproprion is not associated with RBD and may be an alternative for patients with depression.
True or False: Buproprion is associated with RBD.
False.
Buproprion may be considered as an alternative antidepressant.
What is a potential common connection between farming and RBD?
Exposure to pesticides linked to both Parkinson disease and RBD.
Farming has been associated with a higher prevalence of Parkinson disease.
What are some of the chief complaints that sleep specialists manage related to abnormal nocturnal behaviors?
Differential diagnosis including seizures, nonepileptic parasomnias, psychogenic nonepileptic seizures, and confusional arousals
What types of events can occur during abnormal nocturnal behaviors?
Simple movements and complex coordinated behaviors
Examples include hypnic jerks, bruxism, sleepwalking, and REM sleep behavior disorder.
What diagnostic tool can assist in evaluating complex nocturnal behaviors?
Frontal Lobe Epilepsy and Parasomnia (FLEP) scale
What are some signs suggesting an epileptic etiology in abnormal nocturnal behaviors?
Prominent dystonia, limb extension, stereotyped behaviors, multiple recurrences each night
What features are suggestive of seizure activity during nocturnal events?
Short duration (<2 min), abrupt termination, presence of an aura preceding the event
When do seizures and parasomnias typically occur in relation to sleep onset?
Within the first one-third or one-half of the sleep period
What duration of events is suggestive of seizures and what duration is suggestive of parasomnias?
Short events (<2 min) suggest seizures; longer events (>10 min) suggest parasomnias
True or False: Seizures and non-REM parasomnias are usually associated with recall of the behavior.
False
Which condition may allow for dream recall consistent with the enacted behavior?
REM sleep behavior disorder
What is sleep-related eating disorder (SRED)?
SRED consists of recurrent episodes of involuntary eating and drinking during arousals from sleep, with problematic consequences.
SRED occurs typically during partial arousals from sleep and may involve partial recall or complete unawareness.
What are the diagnostic criteria for SRED?
The diagnosis requires:
* Recurrent episodes of involuntary eating and drinking during the main sleep period
* One of the following:
* Consumption of peculiar food combinations or inedible/toxic substances
* Insomnia related to sleep disruption from eating episodes
* Sleep-related injury
* Dangerous behaviors while pursuing food
* Morning anorexia
* Adverse health consequences from binge eating high-caloric foods
Examples of peculiar food items include frozen pizza, buttered cigarettes, and ammonia cleaning solutions.
What is the age range for the onset of SRED?
The age at onset is usually between 22 to 40 years.
SRED is predominantly seen in females, with a prevalence of 60%-83%.
What medications are associated with SRED?
Medications associated with SRED include:
* Zolpidem
* Olanzapine
* Risperidone
* Mirtazapine
* Lithium
* Anticholinergics
* Selective serotonin reuptake inhibitors
Other benzodiazepine receptor agonists like zaleplon may also be implicated.
True or False: The BDI score of 3 indicates significant depression.
False
A BDI score >10 indicates significantly depressed mood.
What is the most effective medication for treating SRED?
Topiramate appears to be the most effective medication for SRED.
Pramipexole and bupropion have also been used.
What are common comorbid conditions associated with SRED?
Common comorbid conditions include:
* Restless legs syndrome (RLS)
* Periodic limb movement disorder (PLMD)
* Sleepwalking
* Obstructive sleep apnea (OSA)
* Rhythmic masticatory muscle activity (RMMA)
Addressing these conditions may help stop SRED.
What behaviors may occur during SRED episodes?
Behaviors may include:
* Involuntary eating
* Dangerous behaviors while cooking
* Injuries from careless use of kitchen utensils
Such behaviors can result in lacerations or burns.
What is the relationship between SRED and sleepwalking?
SRED can occur alongside sleepwalking, and both are types of parasomnia.
SRED and sleepwalking may be seen in the same patient, indicating a parasomnia overlap disorder.
What is a significant health consequence of recurrent binge eating in SRED?
Health consequences include:
* Excessive weight gain/obesity
* Destabilization of diabetes mellitus
* Hypertriglyceridemia/hypercholesterolemia
Other issues can include dental complications and allergic reactions to food.
What is REM sleep behavior disorder (RBD)?
A parasomnia characterized by dream-enacting behaviors due to absent or diminished REM sleep atonia
RBD includes behaviors such as talking, screaming, and arm-flailing.
What types of behaviors are associated with RBD?
Behaviors include:
* Talking
* Screaming
* Swearing
* Gesturing
* Arm-flailing
* Punching
* Kicking
* Leaping or falling off the bed
These behaviors are manifestations of dream enactment.
What percentage of RBD patients report self-injuries?
30% to 70%
Self-injuries can include lacerations, bruising, bone fractures, and subdural hematomas.
What is the typical age range for the onset of RBD symptoms?
45 to 60 years
The mean age at diagnosis is between 52 and 65 years.
What class of medications can complicate symptomatic RBD?
Selective serotonin reuptake inhibitors (SSRIs)
SSRIs can interfere with REM atonia mechanisms.
What percentage of users may experience RBD behaviors as a complication of SSRIs?
Up to 6%
This highlights the potential risk associated with these medications.
What is the relationship between chronic benzodiazepine use and RBD risk?
Chronic benzodiazepine use is not associated with increased RBD risk
This is an important distinction in treatment considerations.
What is clonazepam commonly prescribed for?
As a treatment for RBD
Clonazepam is a long-acting benzodiazepine.
What are synucleinopathies?
A group of neurodegenerative disorders characterized by abnormal accumulation of alpha-synuclein
This includes Lewy body disease, dementia with Lewy bodies, and multiple system atrophy.
What neurodegenerative disorder is associated with RBD?
Lewy body disease
This may present as Parkinson’s disease phenotype or dementia with Lewy bodies.
Is there a consistent association between RBD and Alzheimer’s disease?
No
The risk of RBD in Alzheimer’s disease has not been consistently demonstrated.
True or False: Huntington disease is consistently associated with RBD.
False
Lack of association has been noted for Huntington disease as well.
Fill in the blank: RBD is characterized by the absence of ______ during REM sleep.
atonia
This absence leads to the enactment of dreams.
What is REM sleep without atonia (RWA) associated with?
RBD
Recent literature suggests SSRIs may unmask RBD rather than cause it.
What is sleepwalking?
A disorder of arousal characterized by ambulation or other complex behaviors after arousals from NREM sleep
Sleepwalking involves actions that the individual has no memory of and does not respond to intervention.
How do affected individuals typically respond during a sleepwalking episode?
They have partial or complete amnesia regarding the episode and do not appropriately respond to efforts of others to intervene
This differentiates sleepwalking from REM sleep parasomnias.
What is the key difference between sleepwalking and REM sleep parasomnias?
In REM sleep parasomnias, the individual may remember a dream related to the behaviors
Sleepwalking typically occurs without any memory of the event.
What is the typical state of the eyes during sleepwalking episodes?
Eyes are typically open during sleepwalking episodes
This contrasts with other sleep states.
In which age group is sleepwalking most common?
Children aged 6 to 16 years
Up to 40% of children in this age range may experience sleepwalking.
What happens to the incidence of sleepwalking as children age?
Incidence tends to decrease with increasing age and often remits spontaneously
Most children outgrow sleepwalking as they get older.
Is there a clear relationship between sex and sleepwalking?
No clear relationship
Sleepwalking occurs in both sexes without significant differences.
From which stage of sleep does sleepwalking predominantly occur in children?
Stage N3 sleep
Sleepwalking events typically happen during the first half of the sleep period.
Can sleepwalking occur from other stages of NREM sleep?
Yes, although it is not typical
Sleepwalking is most commonly associated with N3 sleep.
