Parasomnias

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1. Parasomnias Presented by:- Dr. Sachin Adukia Moderator:- Dr. Gopal Krishna Dash

2. Stages of sleep

3. Features of each stage Stage N1 transition from wakefulness to sleep. low amplitude mixed EEG frequencies -theta range (4 to 7 Hz) for at least 50 % of the epoch Stage N2 largest percentage –45 to 55% of total sleep time in a normal middle aged adult characterized by theta EEG frequency sleep spindles and K-complexes Stage N3 : "deep sleep" or "slow wave sleep." low frequency (0.5 to 2 Hz), high amplitude delta EEG waves 10 to 20 percent of the total sleep time

4. REM Sleep REM sleep EEG low voltage, mixed EEG pattern. Sawtooth waves :-2-6 Hz wave patterns are sharply contoured occur in brief bursts. Rapid eye movements defined on EOG conjugate, irregular, sharply-peaked eye movements with an initial phase less than 500 milliseconds. EMG atonia , indicating inactivity of all voluntary muscles (except the extraocular muscles and the diaphragm). result of direct inhibition of alpha motor neurons 2 types of REM sleep Phasic and tonic

5. Parasomnias are defined as abnormal movements or behaviors in sleep or during arousals from sleep; intermittent or episodic sleep architecture may not be disturbed Characteristic clinical features with EEG and PSG recordings are essential for differentiation

6. ICD III

7. Disorders of arousal from NREM sleep Confusional arousals, sleep terrors, sleepwalking are the MC AKA disorders of partial arousal as they result from incomplete arousal from NREM sleep. Typically, occur at transition from deep NREM (stage N3) sleep into the lighter stages or awake state. arise during the first third of nocturnal sleep because N3 sleep is most prevalent at this time underlying pathophysiology and course are similar Genetic predisposotion Increased arousal: OSA, GERD, RLS, PLMS Age, triggers

8. Sleepwalking between the ages of 5 and 12 Sometimes persists into adulthood (rarely) begins in adults starts with abrupt motor activity in slow-wave sleep during first 1/3 of sleep, lasts <10 min high incidence of positive family history. Injuries and violence, homicide, reported although can negotiate surroundings may be a/w amnesia and autonomic dysfunction: sweating, flushing precipitated by conditions that deepen slow-wave sleep such as sleep deprivation, fatigue, concurrent illness alcohol probably no role in triggering it

9. Sleep Terrors ( Pavor Nocturnus ) Peak onset age : 5 to 7 years high incidence of familial history occur during slow-wave sleep Episodes : loud, piercing scream. flushed face, sweating, and tachycardia. may jump out of bed as if running away from an unseen threat unresponsive to parental efforts at calming does not remembe the episode later. Patients appear highly confused and fearful. Many also have h/o sleepwalking Precipitating factors are also similar as with sleepwalking migraine is strongly a/w h/o sleep terrors in adolescence

10. Confusional Arousals mostly before age 5. high incidence of familial cases episodes arise out of slow-wave sleep; occasionally stage N2 NREM sleep typically within two to three hours of sleep onset Precipitating factors are the same as previous may also include sleep disordered breathing Usually benign, but sometimes violent and homicidal

11. Episodes: automatic and inappropriate behavior, Can include abnormal sexual behavior (“ sexsomnia ” or sleep sex) when this occurs in adults. child typically sits up, whimpers, cry, or moan, utter words like "no" or "go away," appear distressed, and remain inconsolable regardless of all effort at soothing no sweating, flushing of the face, or stereotypic motor behavior following morning, the patient awakens, feeling alert and refreshed, and has no recollection EEG shows cgeneralized , high amplitude rhythmic delta or theta activity

12. Sleep-related eating disorder (SRED) women aged 20 to 30 recurrent episodes of involuntary eating and drinking during partial arousals from sleep. strange eating behavior (inedible substances: frozen pizza, raw bacon, cat food) Episodes cause sleep disruption with weight gain condition either be idiopathic or comorbid with other sleep disorders sleepwalking, RLS-PLMS, OSAS, irregular sleep/wake circadian rhythm disorders, triazolam , zolpidem , quetiapine , Relationship between amnestic SRED and RLS Clinically, always investigate eating behavior in RLS symptoms abnormal nocturnal eating - major risk factor for increased BMI

13. DDs Nocturnal seizures EEG GERD lead to episodes of abrupt arousal a/w crying or tonic extension of the trunk and extremities suspicion of reflux can be supported by esophageal pH monitoring Panic attacks abrupt awakening from NREM sleep choking or tightness in the chest EEG remains normal. Daytime episodes of anxiety also may occur.

14. Rapid Eye Movement Sleep Behavior Disorder seen in older persons characteristic feature is intermittent loss of REM sleep-related muscle hypotonia or atonia and abnormal quasi dream enactment motor activities during sleep patient experiences violent dream-enacting behavior during REM sleep, often causing self-injury or injury to bed partner, may use restraints idiopathic or secondary; most are secondary, a/w neurodegenerative diseases PD, MSA, CBD DLBD, OPCA, PSP ??? RBD may be an α- synucleinopathy disorder may sometimes be drug induced (sedative-hypnotics, TCA, anticholinergics ) or alcoholism and structural brainstem lesions.

15. Several markers : impaired cognition, visuospatial dysfunction, impaired color vision, olfactory deficits, autonomic dysfunction (particularly orthostatic hypotension) EEG slowing, midbrain hyperechogenicity,and decreased dopamine transporter imaging. REM sleep without muscle atonia - most important PSG findings. When polysomnography N/A: use validated questionnaires eg . Mayo Sleep Questionnaire (MSQ), which asks bed partners if patient appears to “act out his/ her dreams” while sleeping (i.e., punching or flailing arms in the air, shouting, or screaming) MSQ yielded a sensitivity of 100% and specificity 95% for diagnosis of RBD

16. Nightmares (Dream Anxiety Attacks) International Classification of Sleep Disorders 3 defines nightmares as "an internally generated conscious experience or dream sequence that seems vivid and real. They have a tendency to become increasingly more disturbing as they unfold. Emotions are characteristically negative and most frequently involve anxiety, fear, or terror but may also involve anger, rage, embarrassment, and disgust."

17. fearful, vivid, frightening dreams, mostly visual sometimes auditory, during REM sleep. may accompany sleep talking and body movements. Because muscle tone and mobility are inhibited during REM, body movement rare Autonomic manifestations - sweating and flushing - do not occur. Mild tachycardia may occur. duration is brief After waking up, may find it hard to fall back to sleep. occur during the middle to late part of sleep at night. Normal in 50% of children, even more, beginning at age 3 to 5 years  nightmares decrease with age

18. can also occur as side effects : antiparkinsonian drugs ( pergolide , levodopa ) Anticholinergics Antihypertensive particularly beta-blockers. sudden withdrawal of REM sleep-suppressant drugs (TCA, SSRIs) BZP (diazepam, clonazepam ) often suppress nightmares, but withdrawal may ppt after alcohol ingestion or sudden withdrawal from barbiturates. may be the initial manifestation of schizophreniform psychosis, along with severe sleep disturbance. generally only reassurance. Try rescripting , desensitization, hypnotherapy, CBT If recurring and fearful nightmares, can start behavioral or psychotherapy and REM sleep-suppressant medications helpful

19. Sleep paralysis Muscle atonia and transient skeletal muscle paralysis are physiologic properties of REM sleep. may however intrude onto wakefulness at sleep onset or waking up resulting transient inability to move is sleep paralysis During a sleep paralysis episode, consciousness remains intact, and the individual is perfectly aware of the surroundings. For a patient unfamiliar with the phenomenon, a terrifying feeling can arise from the sudden inability to move the body while being fully awake, albeit momentarily.

20. Differential diagnosis partial seizures, periodic paralysis, and narcolepsy. Occasional events are generally due to sleep deprivation and do not require treatment. Recurrent episodes - very bothersome Can try REM-suppressing agents such as low doses of tricyclic agents, clonidine , or clonazepam .

21. Isolated Symptoms, Apparently Normal Variants and Unresolved Issues

22. Sleep Talking ( Somniloquy ) very common, as many as 50% of children In adults, M>F with familial tendency Clinically, consists of utterances of speech or sounds during sleep without awareness brief, infrequent, devoid of signs of emotional stress. course is usually self-limited and benign.

23. Catathrenia (Expiratory Groaning) recurrent episodes of expiratory groaning (high-pitched, loud humming, or roaring sounds) occurs in clusters, predominantly during REM sleep may occur during NREM sleep PSG resembles central apnea with protracted expiratory bradypnea without oxygen desaturation. Simultaneous audio recordings reveals characteristic groaning. clinical relevance and pathophysiology unknown.

24. Hypnic jerks, or “sleep starts,” occur at sleep onset in many normal individuals physiological without any pathological significance sudden brief myoclonic movement of limbs or body lasting for few seconds. Sometimes accompanied by sensory phenomena- sensation of falling. triggered by stress, fatigue, or sleep deprivation. s/ i upto 70% of general population

25. Hypnagogic Foot Tremor rhythmic movement of feet or toes occurring at the transition between wake and sleep or during stages 1 and 2 NREM sleep. common finding, clinical significance unknown

26. Alternating Leg Muscle Activation brief activation of TA in one leg alternating with similar in the other leg during sleep or arousals from sleep clinical significance unknown.

27. Excessive Fragmentary Myoclonus small muscle jerks without visible movements of the fingers, toes, corners of mouth or small muscle twitches resembling fasciculations that do not cause gross movement across the joint space. EFM is seen in all stages and states (NREM and REM) of sleep. clinical significance uncertain

28. Investigations: Evaluation for primary or co-morbid condition causing sleep disturbance Laboratory tests for the diagnosis and monitoring of sleep disorders: Overnight polysomnography (PSG) High-definition video PSG Multiple sleep latency tests (MSLT) Maintenance of wakefulness test (MWT) Actigraphy Video-PSG with multiple muscle montage Laboratory tests for suspected seizure disorders EEG / Video-EEG

29. Investigations: Imaging studies: Upper airway imaging for OSA Neuroimaging (CT, MRI, MRA, DTI, MR tractography ), DSA if suspected neurological illness causing sleep disorder PET/ SPECT Cardian MIBG scintigraphy , midbrain transcranial sonography in idiopathic EBD to uncover preclinical markers for neurodegeneration Fiberoptic endoscopy and cephalometric radiographs of cranial base and facial bones to locate site of upper airway collapse, and to asses posterior airway space in OSA

30. Miscellaneous Standard blood and urine analysis PFT, ABGs in suspected bronchopulmonary and NM disorders HLA DQB1*0602 and CSF hypocretin-1 levels for suspected narcolepsy Serum iron, ferritin levels, transferrin in RLS/ WED EMG/ NCS to exclude comorbid or secondary RLS/WED ECG, Holter , echocardiogram Endocrine tests Autonomic function tests in suspected autonomic and sleep-related breathing disorders

31. Treatment of Parasomnias Most require no special treatment. Evidence level A Protective measures to protect from injuring self or others be instituted Evidence level B- pharmacotherapy If attacks of sleepwalking or sleep terrors are frequent or violent, short duration TCA / BZP ( clonazepam ) Most RBD respond dramatically to small dose clonazepam (0.5–2 mg HS) If no response: try melatonin or pramipexole In resistant cases, combine clonazepam and melatonin

32. Anticipatory awakening Oral Iron in ?? PLS

33. Overview of Parasomnias

34. Reference: Bradley WG, editor. Neurology in clinical practice: principles of diagnosis and management. Taylor & Francis; 2004. Suresh Kotagal , MD. Sleepwalking and other parasomnias . Uptodate Website. 2017

35. Thank You