10/12/2015
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Case PresentationsAre these for real????
• Timothy L. Grant, M.D.,F.A.A.S.M.
• Medical Director Baptist Sleep Center at Sunset and Miami Lakes
• Medical Director Baptist Sleep Education Series
• Medical Director Sleep Division Miami Research Associates
November 2015
Timothy Grant, MD, FAASM
� SLEEP_RUNNERS_DELUXE - Bonus 11.avi
Multiple Parasomnias Following Head Trauma
Timothy Grant, MD, FAASM
10/12/2015
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73 yo woman doctorate level health professional
• Vacationing in the Carolinas with slip and fall on 4/25/15.• Three episodes of “sleep walking” in May, 2015• One episode dreamed she was in a train station and needed to
use the bathroom, then suddenly aware she was in her living room urinating on the floor . ? RBD
• Another episode of taking her car keys and walking into another hotel room and speaking gibberish.
•• No history of sleep walking in childhood, MRI & PSG neg
• No further episodes on melatonin.
Timothy Grant, MD, FAASM
Lesson Learned
A myriad of sleep disorders have been described following head trauma, including:� parasomnias (slow wave and REM)
� insomnia� hypersomnolence� sleep apnea� narcolepsy
Timothy Grant, MD, FAASM
Review of Narcolepsy, the basics
The narcolepsy tetrad1) Excessive daytime sleepiness2) Sleep paralysis3) Hypnogogic hallucinations4) Cataplexy• Also, sleep fragmentation, daytime automatisms, vivid
dreams (esp. depersonalization).
Timothy Grant, MD, FAASM
10/12/2015
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Narcolepsy diagnostic criteria
• History
• Low CSF hypocretin levels (research)
• HLA serotyping (not adequate or necessary)
Timothy Grant, MD, FAASM
Narcolepsy diagnostic criteria
• PSG without alternative etiology of EDS, i.e. no OSA, PLM’s, sleep deprivation, fragmentation, etc. – at least 360 minutes of TST– shortened REM latency on PSG (<15 minutes)
• can count as SOREM (sleep onset REM)
• MSLT– MLTS < 8minutes (usually < 5, often < 3)
– > 2 SOREM’s
Timothy Grant, MD,
“Lions, tigers and bears, oh my!”
Timothy Grant, MD, FAASM
10/12/2015
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19 yo college student
• 2009 developed viral illness (?suspected mononucleosis).• Subsequent EDS, sleep paralysis, cataplexy-like events.• Automatisms and episodes of “zoning out”.• Vivid dreams (as if she is “out of her body watching herself in a movie”).
• Bizarre Hypnogogic Hallucinations:– Visual—seeing a dark shadow standing over her, kaleidoscope– Auditory—nondescript people whispering in her ear– Tactile—being touched and hugged by someone
Timothy Grant, MD, FAASM
19 yo college student
• PSG with REM latency of 18 minutes, TST 329 minutes• MSLT with MLTS of 11.5, 2 SOREM’s • Rx
– Armodafanil/Nuvigil– Buproprion/Wellbutrin– Soldium Oxybate/Xyrem deferred
Timothy Grant, MD, FAASM
Lessons Learned
• AASM strict criteria recommends at least 360 minutes on preceding PSG, before MSLT.
• Can see a false negative MSLT in true narcolepsy, i.e MLTS > 8 minutes
• 30% of general population has MLTS on MSLT < 8 min.• MSLT positive in 2-3%. General population• 2-3% of normal population may have an abnormal MSLT
– One half of those don’t complain of EDS.
• Most common reason for EDS is insufficient sleep
Timothy Grant, MD, FAASM
10/12/2015
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Just how sleep can someone be?
Timothy Grant, MD, FAASM
23 yo musician
• ESS of 21/24 (< 10 normal)• Sleep paralysis, hypnagogic hallucinations, cataplexy• Also episodes of dream enactment (biting her boyfriend)• PSG with REM latency of 5 minutes (normal 80-120)• MSLT MLTS of 1.6 minutes (1.5,4.5,1.0,0.5, 0.5), < 8min w narcolepsy.
• 5 SOREM’s in 5 separate naps (normal zero, > 2 w Narcolepsy)
• HLA serotyping positive• Rx Nuvigil, zolpidem, and Effexor (did not want Xyrem)
Timothy Grant, MD, FAASM
Lessons Learned
• New ICSD 3rd edition– counts SOREM’s on both the MSLT and preceding nocturnal
PSG.
• For instance, – If one SOREM on the MSLT and – A shortened REM latency on the nocturnal PSG (<15 minutes)
– Would be counted as 2 SOREM’s, consistent with the Dx of Narcolepsy.
Timothy Grant, MD, FAASM
10/12/2015
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You mean I need to take medicine ANDwear that f*&#*ing mask!!
Timothy Grant, MD, FAASM
53 yo crime investigator
• Narcolepsy without cataplexy (sleep paralysis, hh)• HLA negative, MRI negative• PSG with AHI of 33, min O2 of 82• MSLT with MLTS of 4.3 and no SOREM’s (on Wellbutrin)• Preferred oral appliance to CPAP (PSG w AHI of 7 w MAD and Xyrem)• Xyrem 9.5 gm (4.5 + 4.5)• Off Nuvigil (“jaw clenching”)• ESS 11, originally 22
Timothy Grant, MD, FAASM
Lessons Learned
• Not uncommon for OSA and Narcolepsy, need to treat both. • REM suppressing medications may alter MSLT data.• Although it is recommended to stop all sedatives and REM
suppressing meds prior to MSLT, may need to maintain for patient’s psychological wellbeing.
• ESS need not return to normal for patient to feel dramatically improved.
Timothy Grant, MD, FAASM
10/12/2015
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Lessons Learned
• Xyrem/sodium oxybate is a potential respiratory suppressant – (may need overnight oximetry, repeat PSG, or download data).
• Modafanil/Armodafanil– In addition to usual stimulant side effects, exist potential side effect of jaw
clenching and Stevens Johnson Syndrome.
– Potential drug interactions with oral contraceptives and Warfarin.
Timothy Grant, MD, FAASM
Narcolepsy treatment must be multidimensional
• Pharmacological treatment.
• Behavioral (scheduled napping, food regimen, sleep hygiene)
• Supportive (work environment, driving, support groups, narcolepsy, association)
Timothy Grant, MD, FAASM
Narcolepsy pharmacologic therapy
1) Stimulants (target EDS)Modafanil, Armodafanil, methylphenidate, D-amphetamine)
2) TCAD’s/SSRI’s (target cataplexy)Protriptyline, Imipramine, fluoxetine, venlafaxineCaution against abrupt cessation, exists “status cataplexicus”
3) Xyrem/sodium oxybate/GHB (target EDS, cataplexy, sleep fragmentation)
4) Sedative hypnotics (target fragmented sleep)
Timothy Grant, MD, FAASM
10/12/2015
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“Those jackalopes are vicious!”
•
Timothy Grant, MD, FAASM
JackalopeWikipedia definition
The jackalope is a mythical animal of North American folklore (a so-called fearsome critter) described as a jackrabbit with antelope horns.
Timothy Grant, MD, FAASM
53 yo restaurant worker
• Snoring• Recurrent episodes of punching, kicking, and yelling. • Same theme of fighting off a Jackalope with • “gnawing teeth, deadly claws, and spear-like antlers”.
• PSG with AHI 36, supine AHI of 66, min O2 85, Unequivocal REM without atonia.
• MRI negative.
• Rx CPAP, Clonazepam and Melatonin.
Timothy Grant, MD, FAASM
10/12/2015
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“Are my dreams crazy, or what!”
Timothy Grant, MD, FAASM
27 yo television manager
• Symptoms beginning in 8th grade when developed facial contortions while watching television.
• Eventual full blown episodes or slumping and collapsing• Sleep paralysis, hh (people speaking, shadows in his room)
• ESS of 23, with meds 1 (<10 normal)• Rx Concerta alone • PSG and MSLT “classic for narcolepsy” performed when younger.
Timothy Grant, MD, FAASM
Lessons Learned
• Cataplexy– In children, may not be triggered by emotion.– May look more like “tics”.– May present in more supple fashion.
– EDS can precede cataplexy by 1-40 years. – Deep tendon reflexes absent during cataplexy.
•
Timothy Grant, MD
10/12/2015
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27 yo television manager
Frequent dreams:�Realistic dreams (at times not able tell if awake or asleep)
Feels as if “living a separate life in her dreams”.
�Depersonalization (stepping our of her body)
�Can manipulate her dream content, as if “tuning a radio”.Can change scenes and “songs” at her whim.
Timothy Grant, MD, FAASM
Lets reviewFive Basic Types of Dreams
1) Normal dreaming
2) Vivid dreams
3) Lucid dreams
4) Nightmares
5) RBD/REM Sleep Behavior Disorder
Timothy Grant, MD, FAASM
Lessons LearnedTypes of Dreaming
Normal dreaming
Vivid dreams: a sensation that feels real or as though you are immersed in the dream environment.
Lucid dreams: when a sleeper recognizes they are dreaming and may even be able to manipulate the dream’s content.
Nightmares: repeated awakenings, generally occurring in the second half of the night, accompanied by detailed recollections of frightening dreams
RBD: a loss of paralysis, and the patient thereby “acts out a dream” rather than just dreaming it.
Timothy Grant, MD, FAASM
10/12/2015
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48 yo health professional
• PSG AHI of 96 with a REM AHI of zero as no REM achieved during the baseline.
• CPAP 14, AHI 2.3 with REM rebound from 0-36%.
“Gee Doc, I can’t believe it. I
can now remember my dreams”.
Timothy Grant, MD, FAASM
“Wait a minute, that means I stop breathingevery 30 seconds?”
Timothy Grant, MD, FAASM
30 yo computer entrepreneur
• Snoring, gasping, choking, and reported apnea as observed by his wife (patient unaware).
• PSG with AHI of 118, supine AHI of 125, with a minimum O2 of 79 with over 300 minutes spent below 90%.
• Rx Auto BIPAP.
Timothy Grant, MD, FAASM
10/12/2015
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Lessons Learned
• Poor patient insight as to snoring not uncommon• 1/3 of OSA patients may have normal BMI• Women with OSA may present with more subtle
symptoms as compared with male counterparts. • Severity of AHI does not necessarily correlate with level of
CPAP level required for event resolution. • OSA may persist in the absence of snoring. • With labile HTN or difficult to control atrial fib, think OSA.
Timothy Grant, MD, FAASM
Let's Review
Timothy Grant, MD, FAASM
Lessons Learned
1) A myriad of sleep disorders have been described following head trauma (insomnia, hypersomnolence, narcolepsy, sleep apnea, parasomnias).
2) Sleep apnea can exist in the absence of snoring and normal BMI, especially in women.
3) With labile HTN and atrial fibrillation, think OSA.4) Sleep apnea arousals can trigger parasomnias. 5) Multiple sleep disorders often exist concomitantly. Treat them all.
Timothy Grant, MD, FAASM
10/12/2015
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Lessons Learned
6) Shortened REM latency on nocturnal PSG can count as a SOREM, in addition to those seen on the MSLT.
7) Cataplexy may not have a classic presentation, especially in younger patients, i.e. tic, subtle head tilt, shoulder slump, slurred speech, etc.
8) Narcolepsy treatment is multidimensional and must be individualized.
9) The PSG and ESS don’t need to normalize. 10)Safety issues and sleep hygiene important for all sleep disorders.
Timothy Grant, MD, FAASM
Bibliography
• Orff HJ. Ayalon L. Drummond SP. Traumatic Brain Injury and Sleep Disturbance: A Review of Current Research, J Head Trauma Rehabil, Bol. 24, No. #, pp. 155-165, 2009.
• Rao V. Prevalence and types of sleep disturbances acutely after traumatic brain injury. Brain Injury. 22(5):381-6, 2008 May.
• Verma A. Sleep disorders in chronic traumatic brain injury. Jr of Clinical Sleep Medicine. 3(4):3457-62, 2007 Jun 15.
• The International Classification of Sleep Disorders, Third Edition. American Academy of Sleep Medicine
• Kyrger MH, Roth T, Dement WC, editors. Principles and Practices of Sleep Medicine. Philadelphia:Elsevier/Saunders;
• Amit Agrawal. Traumatic Brain Injury and Sleep Disturbances, Journal of Sleep Medicine, 2008 April 15; 4 (2): 177.
• Richard J. Castriotta, M.D. Daytime Sleepiness and Sleep Disorders After Traumatic Brain Injury, CHEST, October 31, 2005.
Timothy Grant, MD, FAASM
Timothy Grant, MD, FAASM
Bibliography
• Foster, GD, et al. OSA among obese patients with type 2 DM. Diabetes Care 2009.
• Lee SA, et al Heavy snoring as a cause of atherosclerosis, Sleep 2008;31:1207-1213
• Kohler M, et al. Effect of CPAP on systemic inflammation in patients with moderate to severe OSA Thorax 2009; 64:67-72.
• Young T, et al. Sleep Disordered Breathing and Mortality. Wisconsin Sleep Cohort. Sleep; 31:1071-1078
• Marin JM, et al. Long-term cardiovascular outcomes in men with SOA with or without treatment with CPAP. Lancet 2005;365:1046-53.
• Parish JM, et al. Relationship of metabolic syndrome and OSA. J. Clin Sleep Med, 2007; 3 (5): 467-472.
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Bibliography
• Littner M, Kushida C, Wise M, et al. Practice parameters for clinical use of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. Sleep 2005; 28:113-121.
• Merrill S. Wise. Narcolepsy and other disorders of excessive sleepiness. Medical Clinics of North America; 88:597-610, page 599.
• Artz M Young, et al. Association of SDB and the occurrence of stroke. Am J Respir Crit Care Med 2005;172:1447-51.
• Mehra R, et al. Assoc of nocturnal arrhythmias with SDB. The Sleep Heart Study. Am J Resp Cirt Care Med. 2006;173:910-6.
Timothy Grant, MD, FAASM
