Megan Cruce, MSN, APRN, FNP-BC Lindsay Melson, MSN, APRN, ACNP-BC Disclaimers

 Lindsay is employed by Jazz pharmaceuticals. All content is free of commercial bias and is independent of Jazz pharma. Content does not necessarily reflect the opinions of Jazz pharmaceuticals and is not sponsored by them.

 Megan, No disclaimers. Objectives:

 Be able to define, identify, screen, and document different parasomnias  Be able to identify risk factors for parasomnias  Be able to understand appropriate therapy options for the treatment of parasomnias  Be able to understand legal ramifications of parasomnias, treatment, and follow up evaluation of them. Parasomnias:

ICSD-3: “Undesirable physical events or experiences that occur during entry into sleep, within sleep, or during arousal from sleep. They can occur in NREM, REM, of transitions to and from sleep.” Parasomnias Encompass

 Complex Movements  Behaviors  Emotions  Perceptions  Dreams  Autonomic Nervous System Oscillating Sleep/Wake State Sleep/Wake Spectrum vs. Dichotomous States Parasomnias = Clinical Disorder

 Risk for injuries  Sleep disruption  Adverse health effects  Psychosocial effects When do they occur?

 NREM Sleep  REM Sleep  Transitions to and from Sleep NREM Parasomnias

 No identifiable neurophysiological changes identified  Functional Changes: Deactivation/Activation→CNS Activation, Autonomic Activation.  Other factors: Sleep Inertia, Instability sleep/wake NREM Parasomnia

 Primal Fixed Action Patterns that should be inhibited by the prefrontal cortex  Aggression  Locomotion  Eating Disorders  Sexual Behaviors Prevalence of Parasomnias

Children prevalence in Adults lifetime Parasomnia % (under 15 years of prevalence in % age) NREM Sleepwalking 22.4 17.0 Confusional arousal 18.5 17.3 Sleep terror 10.4 6.5 Sleep-related eating 4.5 disorder Sexual act during 7.1 sleep/sexsomnia REM REM behavior disorder 15.0 Sleep-related 31.3 groaning/Catathrenia Nightmare 66.2 10-50

https://www.ncbi.nlm.nih.gov/pmc/articles/P MC6402728/ NREM Parasomnias

 Disorders of Arousals  Confusional Arousals (Elpenor Syndrome)  Sleep Walking (Somnambulism)  Sleep Terrors (Night Terrors/Pavor nocturnus)  Sleep Related Eating Disorder  Sexsomnias Disorders of Arousals

 ICSD-3 Criteria (All must be met)  Recurrent episodes of incomplete awakening  Inappropriate/Absent Responsiveness to efforts of others to intervene or redirect the episode  Limited or no associated cognition or dream imagery  Partial or complete amnesia from the episode  No better explanation: Mental, sleep, medical, medication, or substance Disorders of Arousals

 Usually occur in first 1/3 of the night  Individual may appear confused or disoriented for several minutes or longer post incident Confusional Arousals: Elpenor Syndrome

 Meets previously discussed criteria  Characterized by mental confusion or confused behavior that occurs while patient is in bed  Absence of terror or ambulation outside of the bed

 Typically a lack of autonomic arousal: mydriasis, tachycardia, tachypnea, and diaphoresis during an episode

 Often triggered by hypnotic use or alcohol abuse  Benign and more common in children Sleepwalking: Somnambulism

 Meets previous criteria  Arousal is associated with ambulation or other complex behaviors out of bed

 In adults, may be triggered by RLS, OSA, head injury, encephalitis, febrile illness, vitiligo, migraines, strokes, chronic pain syndrome. Medications that may trigger Somnambulism:

 Benzodiazepine receptor agonist (zolpidem related amnesia)  Antidepressants: Amitripyline, Buproprion, Paroxetine  Antipsychotics: Quetiapine, Olanzapine  Beta Blockers: Metolprolol, Propranolol  Flouroquinolones  Anti-epileptics: Topiramate  Montelukast Sleep Terrors/Night Terrors/Pavor Nocturnus

 Meets other NREM criteria of arousals  The arousals are characterized by episodes of abrupt terror, typically beginning with an alarming vocalization such as a frightening scream  Intense fear and signs of autonomic arousal, including mydriasis, tachycardia, tachypnea, and diaphoresis druing and episode Sexsomnias:

 Primarily a confusional arouals.  Usually do not have somnambulism.  Can include:  Violent masturbation  Sexual molestation and assaults  Sexual intercourse  Loud sexual vocalizations

 MORNING AMNESIA!!!! Risks factors for Sexsomnias:

 Shift work  SSRIs  Parkinson Disease patients with impulse control disorder Sleep Related Eating Disorders

 Recurrent episodes of involuntary eating after an arousal during the main sleep period  Loss of partial or complete awareness of the episode and impaired recall.  The presence of at least one of the following:  Consumption of peculiar forms of food or toxic substances.  Sleep related injurious behaviors while in pursuit of food  Adverse health consequences from recurrent nocturnal eating

 Episode is not better explained by another condition. Medical Conditions that may trigger SRED:

 Encephalitis  Autoimmune hepatitis  Narcolepsy  Smoking cessation  Substance Abuse Medications that may cause SREDs:

 Zolpidem  Antidepressants/Antipsychotic medications: Mirtazapine, Quetiapine, Lithium  Anticholinergic medications Who’s Likely To Have a Parasomnia

 No Gender difference in sleep walking, sleep terrors, or confusional arousals  Females: Nightmare Disorders  Males: RBD, Sexsomnias  Individuals with Psychiatric disorders: Nightmares (38.9%), Sleep Paralysis (22.3%), Sleep-related eating disorder (9.9%), Sleep Walking (8.5%), RBD (3.8%)

Case Study 1:  Patient sits up in bed, looks about in a confused manner and returns to sleep, without leaving the bed?  Sleep Walking  Night Terrors  Confusional Arousal Case Study 2:

 Patient bolts from the bed. Patient is violent and is belligerent. He stops screaming and begins masturbating, at the foot of his bed, and then returns to bed, lies down, and does not remember any of it in the morning.  Sexsomnia  Sleep Walking  Sleep Terror Case Study 3:

 Patient arouses, tachypneic, tachycardic, and diaphoretic, with a piericing scream. There are attempts to awake the individual and he becomes combative. When the patient awakens, he is confused and disoriented.  Confusional arousal  REM Behavior Disorder  Sleep Terror Case Study 4:

 Patient is sleeping with 9 yo daughter, when curled up next to her, begins dry humping. She is awoken, and deeply disturbed. She is able to move away from her father. He does not awaken and arouses in the morning, behaving as nothing has occurred.  Confusional Arousal  Sexsomnia  Sleep Terror REM Parasomnias

 Positive Neuropathology  Lack of muscle tone inhibition during REM sleep  May often develop neurodegenerative disorders: Parkinson’s diesase and Lewy body dementia  RBD is the only parasomnia in ICSD-3 criteria that requires video from PSG for Dx. REM Parasomnias

 REM Behavior Disorder  Recurrent Isolated Sleep Paralysis (hypnagogic and hypnopompic paralysis, predormital and postdormital paralysis, kanashibari (Japan))  Nightmare Disorder (Dream Anxiety Disorder) REM Behavior Disorder

 Repeated episodes of sleep related vocalization and/or complex motor behaviors  Documented on PSG occurring in REM or based on clinical history of dream enactment  REM sleep without atonia on PSG  Not better explained by another condition RBD

 Dream Enactment can be in the form of:  Kicking  Punching  Yelling  Jumping  Violent Behavior

 Individuals remember the dream or have a vague remembrance of the dream. Neurological Risk Factors for RBD:

 Strokes  Subarachnoid hemorrhage  Cerebral neoplasm  Alpha-synucleinopathies  Multiple Sclerosis  Narcolepsy Medications that may trigger RBD:

 Withdrawal of sedative-hypnotics  SSRIs  TCAs  Cholinergic medications  MAOIs  Sudden alcohol withdrawal  Biperidon RBD other:

 Excessive caffeine or chocolate consumption may contribute to RBD In what Disease state might someone with RBD have an onset of RBD prior to the usual 90 mins post sleep onset? Recurrent Isolated Sleep Paralysis

 ICSD-3 Criteria:  A recurrent inability to move the trunk and all limbs at sleep onset or offset  Episodes can last from seconds to minutes  May cause distress at bedtime or fear of sleep  Symptoms are not better explained by another sleep disorder (especially Narcolepsy), mental disorder, medical condition, medication, or substance abuse. Recurrent Isolated Sleep Paralysis

 Normal respiratory effort/rate  Consciousness is preserved and can give an account of surroundings  May be aborted by external stimulation: tactile or auditory  Hallucinations may occur in 25-75% of episodes  May be precipitated by sleep deprivation or circadian ryhthm disturbances. Nightmare Disorder

 ICSD-3 Criteria  Repeated occurrences of extended, dysphoric, and remembered dreams that usually involve threats to survival, security, or physical integrity.  On awakening, patient quickly becomes alert and oriented  The dream experince, causes clinical impairment: socially, occupationally, or in one of the following areas….. Nightmare Disorder

 Mood  Sleep  Cognitive  Negative impact on caregiver or family functioning  Behavioral problems  Daytime sleepiness  Fatigue or low energy  Impaired occupational or educational functioning  Impaired interpersonal/social functioning Nightmares

 May be induced by  Traumatic/Stressful events  Beta-blockers  Levodopa  Acetylcholinesterase inhibitors  Sudden discontinuation of REM suppressing medications When do most REM parasomnias occur? True or False: Unlike NREM Parasomnias, REM Parasomnias are often not able to be recalled upon awakening? Other Parasomnias

 Exploding Head Syndrome  Sleep Related Hallucinations  Sleep Enuresis  Parasomnia Due to a Medical Disorder  Parasomnia Due to a Medication or Substance  Parasomnia, Unspecified Exploding Head Syndrome

 ICSD-3 Criteria:  A sudden loud noise or sense of explosion in the head either at the wake sleep transition or upon awakening during the night  The individual experiences an abrupt arousal following the event, often frightenened  Experience is not associated with pain Documentation

 Compiling a series of questions as simple as:  “Do you have any abnormalities that you or a bed partner notice during your sleep periods?”  “Do you have any history of sleep eating, walking, fighting, driving, acting out dreams in your sleep?”  “Any history of nightmares?” Documentation

 If documentation is present in a new patient consult, YOU are responsible for follow up.

 As a sleep provider, not asking, does not mean you are NOT responsible for asking and for follow up. Documentation

 As a sleep provider, after PSG, it is always important on follow up to screen for the disorders and for improvement/worsening. CPAP may cause further sleep fragmentation, however, treatment of the underlying sleep disorder may improve the parasomnia.  It is important to document WORSENING or IMPROVEMENT and PLAN! Documentation

 PSG findings/Tech findings  Clinicians may enquire about family history, review current medications, traumas/life stressors, underlying medical conditions: neurological/psychiatric conditions  PSG/EEG Videos Management/Plan:

 Treatment of underlying sleep disorders  Terminating possible triggers in the medication list (multi-disciplinary): benzodiazepine receptor agonist, antidepressants, anti-psychotics, cardiac meds  Reassurance and Education on safety for both pediatric and adult patients.  In pediatric patients, discuss likelihood of outgrowing symptoms Management:

 Safety Measures:  Removing firearms  Removing sharp objects or furniture near bed  Locks for windows  Bedroom door alarms  Separate beds for violent behaviors, particularly RBD. Management:

 NREM Parasomnias:  Benzodiazepine treatment is highly effective: 0.25mg – 1mg, depending on patient higher doses may be needed. Management

 REM Parasomnias:  Clonazepam 0.25mg-2mg may be beneficial  Melatonin may be effective in higher doses.

 A mix of the two therapies may be found to be beneficial. Management:

 Other tired therapies with limited success  Imipramine  Levodopa  Carbamepine  Pramipexole Legal Implications

 As stated, NOT screening, does not prevent the naming of an individual in an incident that a patient may encounter. A provider that is board certified or practicing in any specialty is responsible for covering disorders that fall within their practice parameters.  Healthcare is changing, increased numbers should not mean a decline in patient care. As this could ultimately lead to the decline in positive outcomes. Case Study:

 29 yo presents with a history of sleep walking as a child, which has continued into adulthood. Patient states this in the middle of their sleep interview. It is documented. OSA was noted on PSG and PAP therapy initiated. On follow up, patient states she is feeling much better since starting CPAP. No questions regarding sleep walking discussed. Patient leaves clinic. 3 months later finds out she is pregnant and falls down the stairs of her home, loosing the baby. She has had 3 follow up visits with the sleep clinic with no documentation of safety regarding her sleep walking discussed and with her stating no one discussed with her. She is very upset.

 Is there any risks to the sleep provider? Case Study:

 32yo male with a history of Narcolepsy and a history of RBD s/sx but not documented on PSG or MSLT. Patient is very violent in his sleep and often attacks his spouse. Since it was not documented on his PSG, the sleep provider did not feel like it was important to discuss further with the patient and his wife, despite reports of symptoms. Case Study Continued:

 Patient’s wife had begun sleeping in a separate room on her own, as she was fearful at night. One night, she did fall asleep while they were watching a movie in their bedroom. She awoke with her husband choking her. She was unable to get him off of her during the attack and died.

 Is the sleep professional liable in any capacity? Liabilities:

 Be Smart! No one will ever protect your license like you!!

 In protecting your license, you should ultimately deliver the BEST care for your patients and protect yourself from liability. Conclusions

 Parasomnias are REAL. They should be screened for and documented with follow up.  Appropriate treatment and follow up of treatment outcomes should be documented.  Appropriate safety precautions should be instituted. References:

 American Academy of Sleep Medicine (2014). International Classification of Sleep Disorders Darien, IL: American Academy of Sleep Medicine  Berry, R. Wagner, M. (2015) Sleep Medicine Pearls. Philadelphia, PA: Elvisier  Fundamentals of Medical Record Documentation. Gutheil, T. Psychiatry (Edgmont) 2014 Nov, 1(3): 26-28.  Parasomnias: A Comprehensive Review. Singh S., Kaur H, Singh S, Khawaja I. Cureus 2018 Dec; 10 (12): e3807  Prevalence of Parasomnias in Patietns with Obstructive Sleep Apnea. A registry-based Cross-Sectional Study. Lundetrae, R, Saxvig, I, et al. Frontiers in Psychology. 2018; 9:1140