Medicolegal aspects of non-rapid eye movement parasomnias

INTRODUCTION@#In a subset of adults with non-rapid eye movement (NREM) parasomnias, clinical variants might be violent in nature and can potentially result in unintentional but considerable harm. As such, there is substantial interest on the forensic ramifications of these sleep behaviours.@*METHODS@#This review examined the diagnostic criteria for parasomnias established in the context of international classification systems; medicolegal case reports; legal frameworks; and court cases in and outside of Singapore, to provide an overview of the implications of NREM parasomnias.@*RESULTS@#Violent or injurious behaviours that occurred in the context of somnambulism, otherwise known as sleepwalking, have challenged traditional legal theories of criminal culpability. Yet little has changed in the application of sleep science to criminal responsibility. In Singapore, the defence of somnambulism has hitherto not been directly raised. Nonetheless, sleep medicine practitioners may increasingly be requested to render their opinions on legal issues pertaining to violent or injurious behaviours allegedly arising during sleep. Although the understanding of NREM parasomnias has improved, there is still a dearth of evidence to support both medical and legal decisions in this area.@*CONCLUSION@#NREM parasomnias come with disquieting legal and forensic implications for adjudicating criminal responsibility. There is a need to critically examine legal perspectives on behaviours occurring during sleep. More reliable empirical studies investigating the pathophysiology of NREM parasomnias can offer clearer diagnostic guidelines and address complex behaviours of NREM that often come with medicolegal implications.

Psychoanalytic therapy for a child with somnambulism: a case report / 南方医科大学学报

Somnambulism is defined as a state of dissociated consciousness triggered by impaired arousal, which results in partial wakefulness and partial sleep. No effective therapy or medication has been available for treating children with somnambulism. Herein we present a case in a 4.5-year-old girl, who presented with somnambulism associated with separation anxiety disorder every night in a week. The girl received formal assessment and appropriate interventions, and the symptoms disappeared within a week. The treatment was carried out in 5 stages: diagnosis of the disease, establishment of trust, information collection, supervision, and individualized psychotherapy. Although dreams in childhood can be difficult to interpret, close observation of the behaviors in sleepwalking, as a special form of dream, in addition to the more precise description by the guardians, still provides useful clues to understand those dreams. For children with somnambulism, early intervention with psychotherapy can significantly decrease the false revival of the unconscious desires, and thus may serve as a treatment option other than medications.

Sleep problems in children and adolescents at pediatric clinics / 소아과

PURPOSE: To investigate the frequency of childhood sleep problems at pediatric clinics in Seoul and Gyeonggi provinces. METHODS: Children (n=936) and their parents who visited 5 primary and 1 secondary pediatric outpatient clinics were invited to complete a Pediatric Sleep Questionnaire. RESULTS: Among patients, 901 (96.3%) answered questionnaires in sufficient detail for evaluation. The participant's mean age was 4.35±3.02 years (range, 0–18 years). The male to female ratio was 1:0.93 (466 boys, 435 girls). Habitual snoring (>3 day/week) was reported in 16.9% of the participants. The prevalence of habitual snoring in children 2 years. Insomnia was reported in 13.2% of children. The prevalence of sleepwalking, night terrors, and bruxism, is 1.6%, 19%, and 21.1%, respectively. Snoring was associated with increased incidence of sleepwalking, night terrors, and bruxism. Age was associated with insomnia and habitual snoring (P<0.05). Insomnia was more prevalent in younger (21%) than in older children (6%). Snoring was more frequent in both preschool (34%) and school-aged children (33%). The frequency of sleep disordered breathing and insomnia did not vary significantly with gender. However, snoring was more prevalent in boys. CONCLUSION: Sleep problems are frequent among children in Korea. Children with snoring have an increased risk of sleepwalking, night terror, and bruxism. Primary clinicians should consider children's sleep habits to improve their health.

A Case of Re-Emergent Sleepwalking in Adulthood, Primed by Sleep Deprivation and Triggered by Sleep Apnea

Non-rapid eye movement sleep parasomnias including sleepwalking tend to disappear spontaneously during late childhood and adolescent period. Sleepwalking is not as common in adults as in children. Sleepwalking in adults could happen with triggering factors such as hypnotics or metabolic derangement including hypoglycemia. We report a case of an adult patient with recurrent, frequent sleepwalking and complex motor behaviors during sleep in his mid- twenties after spontaneous remission of sleepwalking in the childhood. The triggers were severe sleep deprivation and obstructive sleep apnea. No more sleepwalking was reported after the treatment of sleep apnea by tonsillectomy.

Sonambulismo y Homeopatía / Sleepwalking and Homeopathy

La presente comunicación está referida al cuadro clínico de sonambulismo, los medicamentos que se presentan con más frecuencia en el estudio semiológico homeopático y la presentación de un caso clínico y su evolución en el tiempo.

Death Related to the Dehumidifying Agent / 대한법의학회지

Dehumidifying agents are commonly used to remove moisture and odors and are not meant for oral ingestion. The hazards of accidental oral ingestion of dehumidifying agents are not well known. A 31-year-old man with autism drank the liquid desiccant contained in the barrel of a dehumidifier while sleepwalking. The desiccant mainly consisted of calcium chloride. He was taken to the emergency center with persistent vomiting and underwent gastric lavage. The patient was treated for hypercalcemia due to calcium chloride poisoning. He eventually died of multiple organ failure. Autopsy findings were as follows: acute suppurative pneumonia, intra-abdominal inflammation, liver necrosis, acute pancreatitis, and gastrointestinal hemorrhage. Calcium chloride has relatively low toxicity; however, when ingested orally, it can cause severe internal damage, and even death. We suggest active preventive measures to ensure the safe use of dehumidifying agents.

Sleep Problems and Daytime Sleepiness in Children with Nocturnal Enuresis

PURPOSE: Nocturnal enuresis (NE) is one of the most common problems in childhood. NE has a multifactorial etiology and is influenced by sleep and arousal mechanisms. The aim of the present study was to prospectively evaluate sleep problems and patterns in children with NE compared with normal healthy controls. METHODS: Twenty-eight children with NE and 16 healthy controls were included in the study. To evaluate sleep habits and disturbances, parents and children filled out a questionnaire that included items about sleep patterns and sleep-related behaviors prior to treatment for NE. Demographic factors and other data were compared for the two groups based on the responses to the sleep questionnaire. RESULTS: Night awakening, sleepwalking, and periodic limb movements were more prevalent in children with NE, but symptoms of sleep-disordered breathing were not increased in this group. There were statistically significant differences in periodic limb movements and daytime sleepiness between the two groups. CONCLUSION: Children with NE seemed to have more sleep problems such as night awakening, sleepwalking, and periodic limb movements. In addition, a higher level of daytime sleepiness and hyperactivity in patients with NE suggested a relationship between NE and sleep disorders.

Sleepwalking Triggered by Hypoglycemia

Sleepwalking is a rare parasomnia in the elderly. We report two cases of the patients who presented complex motor behaviors during sleep triggered by hypoglycemia. A 76-year-old male patient with diabetes mellitus presented to the sleep clinic for recurrent sleepwalking with amnesia. Night polysomnogram showed REM sleep without atonia with sleep talking and distal arm movements. While taking clonazepam, he had a few more episodes of sleepwalking. The last episode finally revealed severe hypoglycemia when he was found very far from his house. The second patient, a 67-year-old male showed four episodes of nocturnal confusion and sleepwalking lasting 20 minutes during sleep. His blood glucose and HbA1c were low. After decrease of the dose of oral hypoglycemic agent, no more recurrent sleepwalking occurred. Our cases showed hypoglycemia can induce sleepwalking in the older adults, rather than decreased mentality. Metabolic workup should perform for evaluation of sleepwalking, especially in the elderly.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

An unexpected increase of entropy in a sleepwalking disorder patient during propofol and remifentanil anesthesia: a case report / 대한마취과학회지

We report a case of increased values of entropy parameters Response Entropy (RE) and State Entropy (SE) during intravenous general anesthesia in a sleepwalking patient. An ASA class II, 64-year-old woman with stress incontinence underwent mid-urethral sling surgery. Prior to surgery, the patient had been administered paroxetine, valproic acid and clonazepam for the treatment of sleepwalking disorder. After 10 min of target-controlled infusion of propofol and remifentanil, entropy values increased up to 94 (RE) and 88 (SE) for 10 min. The target effect-site concentrations of anesthetics increased from 4 to 7 microg/ml propofol and 4 ng/ml remifentanil, at which point values fell back to adequate anesthesia levels. Episodes of recall or of explicit memories did not occur during the anesthesia. In conclusion, sleepwalking patients with long-term use medications may need increment of anesthetic dose caused by the anesthetic drug metabolism activation or impairment or immaturity of inhibitory circuits in brain.

Pain consequences in patients undergoing elective craniotomy / Las consecuencias del dolor en pacientes sometidos a craneotomía electiva

El dolor en la craneotomía postoperatoria compromete el cuadro clínico-quirúrgico de los pacientes. El estudio tuvo como objetivo identificar las consecuencias del dolor en pacientes sometidos a craneotomía electiva. Ésta es una visión de un estudio descriptivo, longitudinal. La muestra estuvo constituida de 100 pacientes sometidos a craneotomía electiva. Los datos fueron recolectados entre septiembre de 2010 y octubre de 2011. Las variables estudiadas fueron el insomnio, tos, apetito y la deambulación. Se realizó un análisis descriptivo de las variables, se utilizaron medidas de tendencia central, dispersión y el análisis de las proporciones. Los datos muestran que del 1º al 8º día postoperatorio, el insomnio estuvo presente en 19 por ciento y 6,4 por ciento de los casos, respectivamente, el 19 por ciento de los pacientes reportaron que el dolor le impedía la tos en los primeros días después de la cirugía. Disminución del apetito en el 11 por ciento de los pacientes en la evaluación del primer día y en el octavo día después de la cirugía en el 4,3 por ciento de los casos este síntoma persistía. En el tercer día después de la cirugía 8,24 por ciento de los encuestados informaron que el dolor impidió la deambulación, este síntoma es menos común durante el seguimiento. Se concluye que la evaluación y el tratamiento del dolor postoperatorio adecuado es fundamental para evitar las complicaciones quirúrgicas y el sufrimiento de los pacientes.

The pain in postoperative craniotomy compromises the charts of surgical patients. This study aimed to identify the consequences of pain in patients undergoing elective craniotomy. This is a descriptive study, longitudinal. The sample was comprised of 100 patients undergoing elective craniotomy. Data collection occurred in September 2010 to October 2011. The variables studied were insomnia, coughing, appetite and ambulation. A descriptive analysis of the variables was conducted; measures of central tendency, dispersion and analysis of proportions were used. The data show that from the 1st to the 8th postoperative day the insomnia was present in 19 percent and 6.4 percent of the cases, respectively, 19 percent of patients reported that the pain prevented coughing on the first postoperative day. Appetite decrease in 11 percent of patients on the first evaluation day and on the eighth day post-operative in 4.3 percent of the cases this symptom persisted. On the third post-operative day 8.24 percent of those interviewed reported that the pain prevented ambulation, being that this symptom was less frequent during the follow-up. It is concluded that the adequate assessment and postoperative pain treatment are fundamental in avoiding surgical complications, and patients’ suffering.

Sedative Hypnotics Induced Parasomnias / 수면정신생리

Parasomnias induced by hypnosedatives are rare but serious side effect. Such parasomnias have not been reported with all hypnosedatives. However, frequent use of hypnosedatives, particularly nonbenzodiazepine receptor agonists is associated with parasomnias. Associated symptoms are sleep eating, sleepwalking with object manipulation, sleep conversations, sleep driving, sleep sex and sleep shopping etc. Mechanisms include high affinity for GABAA receptor, interruption of the consolidation phase of memory formation by drug, pharmacokinetic or pharmacodynamic drug-drug interaction and concomitant administration with alcohol. Managements for parasomnias induced by hypnosedatives involve stopping medication, switch to other medications or nonpharmacological treatment, lowest effective dose of NBRAs (Non-Benzodiazepine Receptor Agonists), taking into consideration drug-drug interactions, identification and treatment of underlying disease states.

Sleep-Related Eating Disorder / 수면정신생리

Sleep-related eating disorder (SRED) is a newly recognized parasomnia that describes a clinical condition of compulsive eating under an altered level of consciousness during sleep. Recently, it is increasingly recognized in clinical practice. The exact etiology of SRED is unclear, but it is assumed that SRED might share features of both sleepwalking and eating disorder. There have been also accumulating reports of SRED related to the administration of various psychotropic drugs, such as zolpidem, triazolam, olanzapine, and combinations of psychotropics. Especially, zolpidem in patients with underlying sleep disorders that cause frequent arousals, may cause or augment sleep related eating behavior. A thorough sleep history is essential to recognition and diagnosis of SRED. The timing, frequency, and description of food ingested during eating episodes should be elicited, and a history of concurrent psychiatric, medical, sleep disorders must also be sought and evaluated. Interestingly, dopaminergic agents as monotherapy were effective in some trials. Success with combinations of dopaminergic and opioid drugs, with the addition of sedatives, has also been reported in some case reports.

Prevalence of parasomnia in school aged children in Tehran

Parasomnias can create sleep disruption; in this article we assessed parasomnias in school-aged children in Tehran. In spring 2005, a total of 6000 sleep questionnaires were distributed to school-aged children in 5 districts of Tehran [Iran]. A modified Pediatrics sleep questionnaire with 34 questions was used. Parasomnias varied from 0.5% to 5.7% among the subjects as follows: 2.7% sleep talking, 0.5% sleepwalking, 5.7% bruxism, 2.3% enuresis, and nightmare 4%. A group of children showed parasomnias occasionally- this was 13.1% for sleep talking, 1.4% for sleepwalking, 10.6% for bruxism, 3.1% for enuresis and 18.4% for nightmares. A high proportion of children starting school suffer from sleep problems. In many cases this is a temporary, developmentally related phenomenon, but in 6% of the children the disorder is more serious and may be connected with various stress factors and further behavioral disturbances

Percepção dos pais sobre hábitos de sono de seus filhos - estudo piloto / Parent´s perception about sleeping habits of their children - pilot study

Introdução: O sono normal varia ao longo do desenvolvimento humano, sendo uma função biológica fundamental na qualidade de vida do homem. Quando ocorrem distúrbios do sono, esses são, muitas vezes, subdiagnosticados, podendo ser identificados por meio de questionários específicos, que são ferramentas de avaliação autoaplicável, as quais podem identificar sintomas dessa anomalia e possuem baixo custo. Objetivo: Avaliar a percepção dos pais ou responsáveis quanto à existência de eventuais sintomas de distúrbios do sono em seus filhos. Métodos: Foi aplicado o questionário do sono em 65 pais ou responsáveis de crianças com idade entre 2 e 16 anos, atendidas na Clínica de Odontopediatria da Uninove. Resultados: Do total da amostra, 35% apresentaram alguma doença respiratória e dentre os distúrbios do sono encontrados, verificou-se alta incidência de insônia. Conclusão: Constatou-se que a maioria dos pais ou responsáveis, aparentemente, desconhece o que são distúrbios do sono.

Introduction: Normal sleep varies over human development, being a fundamental biological role on his quality of life. When sleep disorders occurs, these are not always diagnosed, but they can be identified by specific questionnaires, assessment tools that are self-administered, identify symptoms of sleep disorders and have low cost. Objective: To evaluate parent?s or legal guardians? perceptions regarding the presence of sleep disorders symptoms in children. Method: It was applied a sleep questionnaire in 65 parents or guardians of children aged between 2 and 16 years treated by Uninove Pediatric Dentistry Clinic. Results: Thirty-five per cent of the sample has some respiratory disease, and, among other sleep disorders found, there was a high incidence of insomnia. Conclusion: It was found that the majority of parents or legal responsibles, apparently, does not know what sleep disorders are.

Síndrome de ingesta nocturna como efecto colateral del zolpidem / Sleep related eating disorders as a side effect of zolpidem

El zolpidem es una droga hipnótica utilizada para el tratamiento del insomnio. Disminuye la latencia del sueño, el número total de despertares y aumenta el tiempo total del sueño respetando en general su arquitectura. Se cree que aumenta la fase 3 del sueño lento profundo. Nuestro objetivo es comunicar 8 casos de síndrome de ingesta nocturna relacionado al sueño y conductas automáticas complejas asociadas a sonambulismo como efecto colateral del zolpidem. Se analizaron las historias clínicas de 8 pacientes tratados con zolpidem que referían ingesta nocturna de alimentos con amnesia total o parcial del episodio. Se presentan 6 mujeres y 2 hombres, entre 32 y 72 años (media: 58 años), 7 tratados con zolpidem 10 mg/noche y 1 con zolpidem 12.5 mg/noche de liberación prolongada. El tiempo de exposición previo al desarrollo de eventos fue de 1 a 180 días (media de 39.8). El número de episodios relatados era de 1 a 8/noche (media 2.5) asociado con amnesia. Los episodios desaparecieron por completo en el 100% de los casos al suspender la medicación. El síndrome de ingesta nocturna relacionado al sueño es una parasomnia de sueño lento profundo que consiste en episodios de ingesta de alimento o bebida durante la noche, con amnesia parcial o completa del episodio. El zolpidem podría inducir el síndrome de ingesta nocturna relacionado al sueño en aproximadamente el 1% de pacientes, aunque creemos que es un efecto adverso que está subdiagnosticado. Se resuelve simplemente suspendiendo la medicación.

Zolpidem is a hypnotic drug used in sleep disorders. It binds selectively to alpha 1 subunit of the GABA A benzodiazepine receptor. Zolpidem reduces sleep latency, number of arousals and increases the total time of sleep. However, it is considered that it may increase phase 3 of non rapid eye movement sleep, where somnambulism can take place. Our aim is to report 8 cases of sleep related eating disorders associated with the use of this drug. We have evaluated the medical history of 8 patients who had received zolpidem for sleeping disorders and who have presented sleep related eating disorders. Eight patients (6 women, 2 men) aged between 32 to 72 years old, which received 10 mg of zolpidem/night except 1 that received 12.5 mg, were presented. They have referred strange eating behavior compatible to sleep related eating disorder. Symptoms appeared at a mean of 39.8 days after starting the medication. The numbers of nocturnal episodes recorded by the family or by the patient were 1 to 8 episodes of nocturnal eating per night. The morning after, patients found leftovers from the night before which they did not recall to have eaten. The remission was complete after discontinuing zolpidem. Zolpidem may induce sleep related eating disorder in about 1% of patients, although we consider there may be a subdiagnosis of this phenomenon. It will be important to bear in mind and look for this side effect because all the episodes could easily be controlled by withdrawing the drug.

Obstructive sleep apnea syndrome in children: Epidemiology, pathophysiology, diagnosis and sequelae / 소아과

The prevalence of pediatric obstructive sleep apnea syndrome (OSAS) is approximately 3% in children. Adenotonsillar hypertrophy is the most common cause of OSAS in children, and obesity, hypotonic neuromuscular diseases, and craniofacial anomalies are other major risk factors. Snoring is the most common presenting complaint in children with OSAS, but the clinical presentation varies according to age. Agitated sleep with frequent postural changes, excessive sweating, or abnormal sleep positions such as hyperextension of neck or abnormal prone position may suggest a sleep-disordered breathing. Night terror, sleepwalking, and enuresis are frequently associated, during slow-wave sleep, with sleep-disordered breathing. Excessive daytime sleepiness becomes apparent in older children, whereas hyperactivity or inattention is usually predominant in younger children. Morning headache and poor appetite may also be present. As the cortical arousal threshold is higher in children, arousals are not easily developed and their sleep architectures are usually more conserved than those of adults. Untreated OSAS in children may result in various problems such as cognitive deficits, attention deficit/hyperactivity disorder, poor academic achievement, and emotional instability. Mild pulmonary hypertension is not uncommon. Rarely, cardiovascular complications such as cor pulmonale, heart failure, and systemic hypertension may develop in untreated cases. Failure to thrive and delayed development are serious problems in younger children with OSAS. Diagnosis of pediatric OSAS should be based on snoring, relevant history of sleep disruption, findings of any narrow or collapsible portions of upper airway, and confirmed by polysomnography. Early diagnosis of pediatric OSAS is critical to prevent complications with appropriate interventions.