Sleep Disorders
CASE
A 45-year-old electrician comes to you for his “epilepsy.” He has been treated for years by another neurologist with up to three anti-epileptic drugs at a time without success. He has episodes where he feels “goofed up” and may lose awareness. Friends note that he “just lies there” for a few minutes then comes around. Sometimes he feels weak when he hears a funny joke. He used to fall asleep during high school classes.
Diagnosis
Narcolepsy with cataplexy.
Sleep disorders are more common than generally realized. Approximately 10% to 15% of the population has sleep-related problems. Early diagnosis and proper treatment depend on an awareness of characteristic symptoms.
Sleep disorders are separated into three groups:
Disorders of excessive somnolence (DOES), such as narcolepsy and sleep apnea.
Disorders of initiation and maintenance of sleep (DIMS), such as insomnia.
Abnormal behaviors caused by sleep disorders (parasomnias), such as sleepwalking and night terrors.
Take a sleep history from the patient and the bed partner:
When does the patient go to bed? How long until the patient falls asleep? Does the patient wake up at night? When does the patient awaken in the morning?
What medications or stimulants does the patient take? What beverages does the patient drink? What activities are done before going to bed?
Does the patient toss and turn (unrestorative sleep)? Are there sudden jerking leg movements (“periodic leg movements”)?
Does the patient feel the urge to move the legs from time to time (restless leg syndrome)? Is there loud snoring, or are there long pauses between breaths (sleep apnea)?
Does the patient have unusual activities at night, such as sleepwalking, or violent dreams (parasomnias)? Do they act out dreams, thrashing around in bed (REM behavior disorder)?
Does the patient wake up feeling refreshed, even after a short nap (narcolepsy)?
The examination is usually not helpful in the diagnosis of sleep disorders.
DISORDERS OF EXCESSIVE SOMNOLENCE (DOES)
Manifestations of excessive sleepiness or drowsiness during the day; including falling asleep during activities such as eating, driving, or sitting in a class. The causes include situational sleep deprivation (e.g., students who stay awake too late, parents with small children), use of certain medications or intoxicants (e.g., sedatives, antidepressants, muscle relaxants, ethanol), depression (may decrease or increase sleep time), or disorders of sleep such as narcolepsy or sleep apnea.
NARCOLEPSY
In narcolepsy, a genetically determined disorder, patients have one or more of the following:
Sleep attacks, which are uncontrollable attacks of sleep for short periods.
Cataplexy, consisting of sudden loss of muscle tone, induced by emotion or sudden stimuli.
Sleep paralysis, in which upon waking or in transition to sleep, the patient is unable to move.
Hypnagogic hallucinations, including vivid dreamlike hallucinations just before falling asleep or when just awakening.
Automatic behavior, which is attention lapses in which routine activities are continued, and the patient is amnesic for the behavior.
SLEEP APNEA
In sleep apnea, the patient may have one or more of the following: heavy snoring, apneic episodes during sleep, restless sleep, morning headaches, memory disturbances, learning problems, and
hypertension. Seizure disorders and headache disorders may be worsened by sleep apnea.
hypertension. Seizure disorders and headache disorders may be worsened by sleep apnea.
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