2/13/2015 THINGS THAT GO BUMP IN THE NIGHT Detection & Management of Potentially Injurious Parasomnias Janet E. Tatman, PhD, PA-C Fellow American Academy of Sleep Medicine Certified in Behavioral Sleep Medicine From ghoulies and ghosties And long‐leggedy beasties And things that go bump in the night, Good Lord, deliver us! Traditional Scottish Prayer Patients’ experience fear embarrassment social isolation injury 1 2/13/2015 PARASOMNIA • an undesirable physical event or experience that occurs during entry to sleep, within sleep, or during sleep, i.e., NREM sleep, REM sleep, or transitions to and from sleep • may encompass abnormal, complex movements, behaviors, emotions, perceptions, dreams, and/or abnormal ANS activity—and may affect patient or bedpartner • as sleep-wake cycle oscillates, the normally distinct states of consciousness (NREM, REM, and wake) may devolve into a state that is not fully declared…a temporary unstable state of dissociation, resulting in a “parasomnia”…an admixture of one or more normal states International Classification of Sleep Disorders, 3rd Ed American Academy of Sleep Medicine “Sleep,” from Wikipedia, downloaded 1/5/15 INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3RD ED. • NREM-Related Parasomnias • Other Parasomnias • Disorders of Arousal (from NREM sleep) • Exploding Head Syndrome • Confusional Arousals • Sleep-Related Hallucinations • Sleepwalking • Sleep Enuresis • Sleep Terrors • Parasomnia Due to Medical Disorder • Sleep-Related Eating Disorder • Parasomnia Due to Medication or • REM-Related Parasomnias Substance • REM Sleep Behavior Disorder • Parasomnia, Unspecified • Recurrent Isolated Sleep Paralysis • Normal Variant • Nightmare Disorder • Sleep Talking American Academy of Sleep Medicine 2 2/13/2015 INTERNATIONAL CLASSIFICATION OF SLEEP DISORDERS 3RD ED. • NREM-Related Parasomnias • REM-Related Parasomnias • Disorders of Arousal (from NREM sleep) • REM Sleep Behavior Disorder (RBD) • Confusional Arousals • Recurrent Isolated Sleep Paralysis • Sleepwalking • Nightmare Disorder • Sleep Terrors • Sleep-Related Eating Disorder no discernible neuropathology not 2o psychiatric disease often serious neuropathology (RBD) failed skeletal muscle paralysis → dream some brain areas deactivated, others activated enactment disinhibition of basic drive states American Academy of Sleep Medicine CASE EXAMPLES CASE 1 • 42-year old ♀ goes to sleep at 11:30 PM and wakes around 1:30 AM in the middle of her backyard with nursery plants she had bought 2 days ago scattered around. ─ She is standing next to a 2’ deep hole, has garden soil on her legs and hands, and is naked in temperature of 55o. 3 2/13/2015 CASE 2 • 72-year old British ♂ conveys wife’s reports of him yelling, punching, kicking, and “speechifying” during sleep. Her sleep is disturbed 3-4 nights a week and he is sometimes tired during the day. CASE 3 • 52-year old ♂ vigorously punches or kicks his wife during sleep every 1-2 months. They both are startled awake and frightened. ≈ once a month he leaves the bed, fumbles in the bedroom closet or stumbles along a wall, feeling it with his hands, returning to bed in response to gentle suggestion from his wife. CASE 4 • 37-year old ♂ police officer was surprised to wake in AM on living room sofa. − Wife says that during the night he was “charging around the house” with a loaded service revolver, periodically “hiding” behind furniture, yelling, and seeming to “chase the bad guys.” 4 2/13/2015 STAGES OF SLEEP NREM Sleep REM Sleep – eyes quiet – rapid eye movements – “idling” brain – “alert” brain – relaxed muscle tone – skeletal muscle paralysis – some dreaming – much dreaming – stable physiology – variability of HR, BP, RR, ANS – brain metabolic activity SLEEP MENTATION NREM Sleep REM Sleep – single, basic image – complex stories – more realistic – usually bizarre – difficult to awaken – easily awakened – relative amnesia – good memory – up to 40% of lab awakenings – 85+% of lab awakenings result in result in dream reports dream reports THE DISORDERS 5 2/13/2015 DISORDERS OF AROUSAL Confusional Arousals Sleepwalking Sleep Terrors DISORDERS OF AROUSAL (NREM SLEEP) • Recurrent episodes of incomplete awakening • Inappropriate or absent response to others’ efforts to intervene or redirect • Limited or no cognitive experience or dream imagery • Partial or complete amnesia • Usually occur during first 1/3 of the sleep period • May be confused or disoriented for several minutes upon awakening ICSD from AASM CONFUSIONAL AROUSALS • Meets criteria for Disorder of Arousal • Mental confusion or confused behavior while still in bed • Absence of terror or departure from bed • Usually a lack of autonomic arousal (e.g., mydriasis, tachycardia, tachypnea, diaphoresis) ICSD from AASM 6 2/13/2015 SLEEPWALKING • Meets criteria for Disorder of Arousal • Ambulation and other complex behaviors out of bed ICSD from AASM SLEEP TERRORS • Meets criteria for Disorder of Arousal • Abrupt terror, typically beginning with vocalization, scream, etc. • Intense fear and signs of autonomic arousal ICSD from AASM SLEEP-RELATED EATING DISORDER (SRED) • Recurrent episodes of dysfunctional eating after arousal from major sleep period • Presence of at least one of the following: Eating odd types of combinations of food, inedible or toxic substances Injurious or potentially injurious behavior while seeking or cooking food Adverse health consequences • Partial or complete loss of consciousness w/subsequent impaired recall ICSD from AASM 7 2/13/2015 CLINICAL EVALUATION • Thorough medical/behavioral history • Include bedpartner or family whenever possible • Assess risk • Screen for history suggestive of other sleep disorders • Polysomnography if risk is significant TREATMENT Environmental safety • bedpartner sleeps separately • move mattress & furniture prn Behavioral safety • AVOID sleep deprivation! • reduce stress whenever possible Clonazepam is usually considered first line • start low & go slow • habituation/tolerance typically not seen Other med options → trial and error 8 2/13/2015 REM RELATED PARASOMNIAS REM Sleep Behavior Disorder Recurrent Isolated Sleep Paralysis Nightmare Disorder REM SLEEP BEHAVIOR DISORDER (RBD) • Repeated episodes of vocalization and/or complex motor behaviors • Documented by PSG to occur during REM or are presumed to occur in REM based on clinical hx of dream enactment • PSG demonstrates REM sleep without atonia ICSD from AASM RBD • First described in 19861 • Strongly associated w/ neurodegenerative disorders (PD, DLB, MSA)2 • Severe injuries reported3 1Schenck et al. Sleep, 1986 2ICSD from AASM, 2014 3Schenck & Mahowald, Intensive Care Med, 1991 9 2/13/2015 RBD EVALUATION • Careful history including reports from bedpartner or family (risk, family reports, other sleep disorders) • Polysomnography is necessary ― sustained muscle activity in chin EMG ― excessive transient muscle activity (bursts) in chin or limb EMG QUESTIONNAIRE? • Single question: • “Have you ever been told, or suspected yourself, that you seem to ‘act out your dreams’ while asleep (for example, punching, flailing your arms in the air, making running movements, etc.” Postuma et al. 2012 Mov Disord 27(7), 913-916 • Mayo Sleep Questionnaire (10) questions Boeve et al. 2011 Sleep Med 12(5), 445-453 10 2/13/2015 RBD TREATMENT • Clonazepam effective in 90% of cases1 (caution in dementia, gait disorders, & OSA) • Melatonin considered a good alternative2 • Pressurized bed alarm?3 1Schenck & Mahowald, Cleve Clin J of Med, 1991 2McGrane et al. Sleep Med, 2015 3Howell et al. J Clin Sleep Med, 2011 RECURRENT ISOLATED SLEEP PARALYSIS • Recurrent inability to move trunk and all 4 limbs at sleep onset or on waking • Episodes last seconds to minutes • Causes significant distress including bedtime anxiety or fear of sleep ICSD from AASM Reassurance NIGHTMARE DISORDER • Extended, dysphoric dreams that usually involve threats • Rapidly alert and oriented on awakening • Clinically significant distress or impairment in social/occupational/other areas of function evident in at least one of the following Mood Sleep resistance Cognitive impairments Family functioning Behavioral problems Daytime sleepiness Fatigue/low energy Impaired occupational/educational/interpersonal/social function ICSD from AASM Behavioral treatments highly effective (eg, Seda et al. J Clin Sleep Med, 2015) 11 2/13/2015 “The Nightmare” Johann Heinrich Füssli EXPLODING HEAD SYNDROME • Sudden loud noise or sense of explosion in the head at wake-sleep transition or on waking during sleep period • Sensation is followed by abrupt arousal, often with great sense of fright • Not associated with complaints of pain ICSD from AASM SLEEP-RELATED HALLUCINATIONS • Recurrent hallucinations just prior to sleep onset or nocturnal or morning awakenings • Hallucinations are predominantly visual ICSD from AASM 12 2/13/2015 SLEEP ENURESIS • Patient is older than 5 • Recurrent involuntary voiding during sleep at least twice a week • Present for at least 3 months Primary Sleep Enuresis Never consistently dry during sleep Secondary Sleep Enuresis Previously consistently dry for at least 6 months ICSD from AASM HYPNOTIC-INDUCED SLEEPWALKING Businessman Grandma College Student uses zolpidem intermittently zolpidem nightly 1st week of zolpidem House alarm goes off 3 AM for unknown reason Irregular schedule 2o classes & job International business travel (Europe), zolpidem when crossing many time She does not wake, police arrive & zones cannot reach her by phone. They Wakes spontaneously