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Parasomnias and sleep related movement disorders

Parasomnias and sleep related movement disorders. NMAFP 57 th Annual Family Medicine Seminar August 1, 2014 Frank M. Ralls, M.D. Program Director, UNM Sleep Medicine Fellowship Medical Director of Adult Sleep Medicine. “I Wanna be sedated”. OBJECTIVES.

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Parasomnias and sleep related movement disorders

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  1. Parasomniasand sleep related movement disorders NMAFP 57th Annual Family Medicine SeminarAugust 1, 2014 Frank M. Ralls, M.D. Program Director, UNM Sleep Medicine Fellowship Medical Director of Adult Sleep Medicine

  2. “I Wanna be sedated”

  3. OBJECTIVES • To understand the association between sleep deprivation and parasomnias. • To understand how sleep deprivation may shift sleep time into the day and how wake time may shift into the night. • To know the features of common parasomnias. • To know treatments for common parasomnias. • To be aware of two common sleep related seizure disorders.

  4. Parasomnias and sleep relatedmovement disorders • 1sthalf of the Night • Non-REM III • Confusional Arousals • Sleepwalking • Sleeptalking • Night Terrors • Waking Up • Sleep Paralysis • Sleep Related Seizures • Daytime • Narcolepsy • Hypnic Jerks • 2nd half of the Night • REM • Nightmares • REM Behavior Disorder (RBD) • Evening • RLS • Rhythmic Movement Disorder

  5. NORMAL SLEEP PATTERN Typical Child Stage 1 Sleep Stage 3 Sleep Stage 2 Sleep REM Typical Adult Stage 2 Sleep

  6. Normal Sleep Time • Ages 5-12 10-11 hours/night • Ages 13-19 9-10 hours/night • Adults 7.5-9 hours/night • Actual Sleep Time • Ages 5-12 - 9 hours • Ages 13-19; 6-7 hours • Adults < 6.5 hours • Parasomnias

  7. Sleep Deprivation • Family History • Stress • Parasomnias • Medications (Z-drugs) • Sickness (fever)

  8. Sleep Deprivation Increased Risks of Parasomnias. Typical Adult The adult brain is pushed to increase NREM III (slow wave sleep) Typical Child

  9. Sleep Paralysis • Transient inability to move, despite being fully awake • Brief persistence of atonia of REM lingering into wakefulness • 40% of teens and college students • 10% of adults • Triggered by sleep deprivation

  10. Sleep Paralysis • Has been reported to occur in families • SSRIs can be effective when frequent and bothersome • Key is to avoid sleep deprivation

  11. Sleep Paralysis Wake • Shortened Sleep time • Wake up when REM sleep normally occurs • Atonia of REM is present • School • TV • Work • Wake up during REM • Awake • Eyes open • Unable to move

  12. NarcolepsySleep entering into wake • Defect: loss of Hypocretin • Atonia, an element of REM sleep is expressed into wakefulness • Symptoms: • Excessive daytime sleepiness • Sleep paralysis • Hypnagogic hallucinations • Cataplexy

  13. NarcolepsySleep entering into wake • Narcolepsy with cataplexy • Emotional stimuli stimulates the atonia of REM (laughter, e.g.) • Retained consciousness • Reflexes absent • Treatment • Adequate sleep • SSRI • Modafinil • Soduimoxybate

  14. Sleep starts • Otherwise known as hypnic jerks • One or two abrupt myoclonic flexion jerks, often accompanied by a feeling of falling • Associated with insufficient sleep • Benign

  15. Restless Legs Syndrome • Clinical Diagnosis URGES • Urge to move legs • Happens at Rest • Get up, symptoms improve • Evening – when it occurs • Symptoms – no other cause Iron Ferritin > 50 Garcia-Borreguero, Neurology 2014

  16. Restless Legs Syndrome

  17. Periodic Limb Movements OF Sleep (PLMS) • Involuntary • Unilateral or bilateral limb movements, occurring periodically during sleep • Usually involve the legs • Most frequently found in NREM II • Occurs in 1-4% of children • Antidepressants may increase the prevalence by five fold

  18. Treatment of RLS • 1st • Replace iron if ferritin is < 50 • Ferrous gluconate 325 mg with Vitamin C • 2nd • Dopamine agonists, e.g. pramipexole, ropinerole, rotigotine patch. Monitor for compulsive behavior. • α2δ ligands, e.g. gabapentin, pregabalin. Promotes slow wave sleep and REM sleep. • 3rd • Opioid-like drugs, e.g. tramadol, codeine Garcia-Borreguero, Neurology 2014

  19. Hypnic Hallucinations • Occur at sleep onset • Vivid perceptual experiences • Sensation of hearing voices • Feeling someone else is nearby • Precipitated by • Sleep deprivation • Narcolepsy • Excessive caffeine • Emotional stress

  20. Rhythmic Movement Disorder • Rhythmic head banging • Body rocking • Leg rolling • 66% of 9month old babies • 8% by age 4 • Prevalence in adults is not known • Typically persists in those with neurodevelopmental and psychiatric disorders • May follow head trauma

  21. Rhythmic Movement DisorderHypnagoGic Foot Tremor • Hypnagogic foot tremor (HFT) • Occurs during the transition from wakefulness to sleep • May linger into stages NREM I and NREM II • 5-8% of adults • May involve one or both feet • Rarely disturbs the patient • Oscillating movements of the toes or whole foot, occurring q 1-2 seconds • Benign

  22. ParasomniasUnwanted behaviors first third of the night • Last less than 30 minutes • Confusional arousals • Sleepwalking • Sleep talking • Sleep terrors • Sleep related eating behaviors (less common) • Sleep related sexual behaviors (less common)

  23. Childhood nremParasomnias • Occurs in children, ages 30 months to 6 years • 84% have sleep talking • 46% have sleep bruxism • 40% have sleep terrors • 25% have nocturnal enuresis • 30% sleepwalk • 9% exhibit head banging or body rocking

  24. Adult nremParasomnias • 75% of adults have experienced a parasomnia at least once in their life • Most common • Sleep starts (hypnic jerks) • Confusional arousals • Nightmares • Nocturnal wandering Ohayon, Neurology 2012

  25. Confusional arousals • Begin with a sudden arousal from NREM III sleep • Patient sits up in bed, fumble with bedclothes, mutter unintelligible words • Typically lay down, but may proceed to sleepwalk or sleep talk • Risk factors • Sleep deprivation • Stress • Sickness (fever) • Medications • OSA • Psychiatric disorders increase risk 13 fold

  26. Confusional arousals

  27. Sleep talking • 50-80% of children and 5% of adults • Half sleep talk only a few times per year • 10% sleep talk nightly • Risk increases with • Sleep deprivation • Stress • Illness with fever • Medications • Runs in families

  28. Sleep talking

  29. Sleep Terrors • 95% of patients with sleep terrors have a family history of sleep terrors • Individuals are • 3-5 times more likely to have OSA • have nightmares more than once a month • prone to injury-causing behaviors during sleep

  30. Sleepwalking • Prevalence • In a study of 4972 adults, 4% sleep walked at least twice a year and 0.4% sleepwalked nightly • Occurs in 15% of the general population • Highest incidence is ages 4-8 • 40% of children between ages 6 and 16 have had at least one episode • 2-3% of children sleepwalk at least once a month • Sleepwalking generally stops by age 13 • 24% of frequent sleepwalkers continue to sleepwalk as adults Neurology 2012 Ohayon MM

  31. Sleepwalking (Nocturnal Wandering) In a study of of 19,136 people • 30% reported nocturnal wanderings ever • 30% had a relative who had nocturnal wandering • 3% reported nocturnal wandering at least once in the previous year • 1% reported at least two nocturnal wanderings in the previous month • Children with sleepwalking often had a history of sleep talking Ohayon, Neurology 2012 Pressman, Neurology 2013

  32. Sleepwalking • Occurs in NREM III • Patients arise from bed, walk toward a sound or light • Patients may or may not respond to voices • Agitated sleepwalkers flee their beds, screaming or crying • Sleepwalkers may run through the house • Behavior is often followed by a calm return to bed, or lying down somewhere else in the house

  33. Sleepwalking • Patients appear confused • Eyes are open, but objects are misidentified • Patients are slow to respond • Patients exhibit automatic motor behaviors • There is little or no responsive to external environment • Patients are difficult to arouse • Patients often suffer retrograde amnesia

  34. Sleepwalking

  35. Sleepwalking • New onset or late recurrence in teenage years warrants consideration of other primary sleep disorders • Sleep deprivation • Extreme fatigue • Obstructive sleep apnea • RLS • RBD • Infections • Stressful life events often precipitate sleepwalking • Changes in sleep environment • Family conflicts • Personal conflicts • Medications

  36. Violent Behavior During Sleep (VBS) • VBS occurs in 1.6% of adults • VBS behaviors range from simple dream enactment to complex behaviors • VBS • Occurs during the first 2 hours of sleep • 79% of people have vivid dreams • 31% hurt themselves or someone else • Few people consult a physician • Risk factors • Family member with VBS • Age < 35 • Sleep deprivation • Stress • Alcohol Szücs et al, Medical Hypotheses 2014 Ohayon et al, Sleep Medicine 2010 Morrison, Sleep 2014

  37. Violent Behavior while asleep

  38. Sleep bruxism • Teeth grinding during sleep • 33% of children • 8% of young adults • Symptoms of tooth-grinding noises, jaw muscle discomfort, abnormal wear of teeth on dental exam • Risk factors • Emotional stress • Caffeine • Type A personalities Masuko et al, BMC Research Notes 2014

  39. Parasomnias during REM Sleeptypically SECOND half of the night

  40. Nightmare disorder • Long, involved frightening dreams, which cause arousal from REM sleep • 10-15% of children ages 3-6 • May be caused by a daytime traumatic experience, medications, or disruption in routine • Preceded by increased heart rate, increased respiration, increased REM • Produces anxiety or fear • Results in difficulty returning to sleep

  41. Nightmare Disorder • Reduced movement during sleep • Heightened anxiety consistent with the suppression of movement exhibited by animals under conditions of perceived threat, i.e. “freezing” • Treated with reassurance • Medications that decrease REM sleep are also helpful Steinsbeckk, J of DevBeh Pediatrics 2014 Haupt, Pediattric Annals 2014

  42. NREM ParasomniasWhen to treat? • Behaviors are dangerous • Presence of daytime sleepiness • Psychosocial impairment • Affecting function • Injuries

  43. REM sleep behavior disorderin childhood(Physically Acting out dreams) • Associated with • Neurodevelopmental disabilities • Narcolepsy • Medication use • Mean age at diagnosis is 9.5 years • 75% male prevalence • Nightmares occur in >75% • Excessive daytime sleepiness occurs in 30% Lloyd, J Clin Sleep Med 2012

  44. REM Sleep Behavior Disorder (RBD)Acting out dreams • Most movements are benign and involve the extremities • RBD 4% have violent motor behaviors and/or complex vocalizations • Prevalence in the general population is 0.3-0.5%

  45. REM Sleep Behavior Disorder (RBD) • Treatment • Rule out other sleep disorders • Change medications if behavior started after initiation • Melatonin • Clonazepam

  46. Obstructive sleep apneaBehaviors may be worse in REM sleep

  47. Sleep-related epileptic seizures • Isolated sleep epilepsies make up 10% of all cases of epilepsy • Most common is nocturnal frontal lobe epilepsy (NFLE) • Mean age of onset is 14 years old • Diagnosis is often made on clinical grounds • Patients often have multiple attacks at night Cheng, J Fam Medicine, 2013 Nobili, Current NeurolNeurosci 2014

  48. Sleep-related Epileptic Seizures • NREM sleep and sleep deprivation are powerful activators of inter-ictalepileptiform discharges (seizures) • EEG “rhythmic” and synchronized during NREM sleep with sleep spindles, K complexes, and slow waves • Sleep deprivation activates seizures from the frontal cerebral cortex • Nocturnal frontal lobe seizures are often misdiagnosed as sleep terrors, nightmares, or a psychiatric problem

  49. Sleep-related Epileptic Seizures Typical features include • > 90% occur from NREM II sleep • Explosive onset of motor activity • Kicking • Running • Last 20-120 seconds • Patients often aware of seizure but cannot control movements • No post-ictal amnesia • EEG is normal in > 50% Derry, PractNeurol 2014 Derry, Epilepsy Beh 2014 Foldvary, Sleep Disord 2014

  50. Benign Childhood Epilepsy withCentro temporal Spikes(benign rolandic epilepsy) • Most common sleep-related partial epilepsy syndrome in children • 9% of all cases of epilepsy in children • Mean age of onset is 8.8 years • Seizures occurred primarily in sleep (88% of the time) Miano, Epilepsy Behav 2013 Kim, Epilepsy Behav 2014

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