Rapid Eye Movement Sleep Behavior Disorder and Other Rapid Eye Movement Parasomnias.

PURPOSE OF REVIEW: The discovery of rapid eye movement (REM) sleep and, in particular, REM sleep behavior disorder (RBD) have brought elusive nightmarish experiences to scientific scrutiny. This article summarizes a century of sleep research to examine the maladies of dreaming, their pathophysiologic significance, and management. RECENT FINDINGS: Under healthy physiologic conditions, REM sleep is characterized by vivid mentation combined with skeletal muscle paralysis. The loss of REM sleep atonia in RBD results in vivid, potentially injurious dream enactment to patients and bed partners. RBD is common, affecting at least 1% of the population and is primarily caused by α-synuclein pathology of REM sleep-related brainstem neurons. The majority of patients with RBD ultimately develop a neurodegenerative syndrome such as Parkinson disease, dementia with Lewy bodies, or multiple system atrophy. Among patients with Parkinson disease, RBD predicts an aggressive disease course with rapid cognitive, motor, and autonomic decline. RBD is diagnosed by the presence of dream enactment episodes (either recorded or clinically recalled) and physiologic evidence of REM sleep without atonia demonstrated on polysomnography. Bedroom safety is of paramount importance in the management of RBD while pharmacokinetic options include melatonin or clonazepam. SUMMARY: The injurious dream enactment of RBD is common and treatable. It is a syndrome of α-synuclein pathology with most patients ultimately developing Parkinson disease, dementia with Lewy bodies, or a related disorder.

Desarrollos recientes en la evaluación del trastorno de conducta del sueño REM / No disponible

El trastorno de conducta del sueño REM (TCREM) es una alteración caracterizada por la ausencia de atonía muscular durante esta fase del sueño y la emergencia de conductas motoras asociadas a ensoñaciones de contenido generalmente desagradable. Entre estas conductas se incluyen acciones como gritar, saltar, agitar los brazos o dar patadas y puñetazos, que corresponden con el correlato motor de la actividad onírica, de ahí su caracterización como “actuación de los ensueños”. La necesidad de que se requiera evidencia polisomnográfica para confirmar el diagnóstico de TCREM hace que la evaluación de este problema resulte muy costosa, ya que la polisomnografía consume mucho tiempo y recursos. Por ello, el desarrollo de instrumentos de evaluación y, más particularmente, de instrumentos de cribado (screening) que permitan una detección precoz de los individuos afectados por esta patología y que, por consiguiente, podrían requerir una intervención temprana, es una de las líneas más actuales de investigación en este campo. El propósito de este trabajo es analizar los desarrollos recientes en el ámbito de la evaluación del TCREM, presentando las diversas herramientas actualmente disponibles y aportando datos acerca de sus garantías científicas(AU)

Rapid eye movement (REM) sleep behaviour disorder (RBD) is a problem characterized by loss of muscle atonia during this sleep phase and the emergence of motor behaviours generally associated to unpleasant dreams. These behaviours include yelling, jumping, arms waving, kicking and punching, working as a motor correlate for the oneiric activity, hence its characterization as “acting out” their dreams. Polysomnography is necessary to diagnose RBD and this procedure is costly. For this reason, one current research lines is the development of assessment tools and, more specifically, of screening instruments to identify patients with RBD that may require early intervention as early as possible. The aim of this study was to analyse recent developments in the clinical assessment of this disorder, presenting the various tools currently available and providing data about their scientific guarantees(AU)

Functional outcomes in patients with REM-related obstructive sleep apnea treated with positive airway pressure therapy.

STUDY OBJECTIVES: To evaluate functional outcomes in adults with REM-related obstructive sleep apnea (OSA) treated with positive airway pressure (PAP) therapy. DESIGN: Retrospective observational study. SETTING: Outpatient sleep clinic. PATIENTS: 330 adults (171 males) with OSA receiving PAP therapy, including 130 with REM OSA and 200 with OSA not restricted to REM. MEASUREMENTS AND RESULTS: REM OSA was defined as a REM apnea-hypopnea index (AHI) / NREM AHI > 2 and NREM AHI < 15. Patients had baseline and post-PAP functional outcomes, including Epworth Sleepiness Scale (ESS), Fatigue Severity Scale (FSS), Patient Health Questionnaire-9 (PHQ-9), and Functional Outcomes Sleep Questionnaire (FOSQ) scores. We compared functional outcomes, demographic, clinical and polysomnographic features, and PAP adherence in patients with REM OSA and OSA not restricted to REM. Female gender was significantly more common in REM OSA. Age, BMI, neck girth, and baseline ESS, FSS, PHQ-9, and FOSQ were similar between groups. Smoking history and comorbid disorders were also similar except for a higher prevalence of depression and cardiovascular disease in OSA not restricted to REM. All functional outcomes improved significantly after PAP therapy in both groups. Change from baseline to post treatment was similar for all functional outcomes between groups. CONCLUSIONS: The study is the first addressing clinical outcomes in REM OSA using validated measures. Functional outcomes in patients with REM OSA improve after treatment with PAP therapy comparable to that observed in patients with OSA not restricted to REM. COMMENTARY: A commentary on this article appears in this issue on page 249.

Subthalamic nucleus deep brain stimulation restores normal rapid eye movement sleep in Parkinson's disease.

BACKGROUND: In Parkinson's disease, sleep disturbance is a common occurrence. METHODS: We evaluated sleep in 10 patients with Parkinson's disease (age, 57.5 ± 9.8 years; disease duration, 12.3 ± 2.7 years) before and after subthalamic nucleus deep brain stimulation using the Parkinson's disease sleep scale and polysomnography. RESULTS: Their total sleep scale scores and daytime sleepiness subscale scores significantly improved after subthalamic nucleus-deep brain stimulation. The novel findings from this study significantly increased normal rapid eye movement sleep, and decreased abnormal rapid eye movement sleep without atonia after deep brain stimulation in patients with Parkinson's disease. The improved total sleep scale score correlated with decreased wakefulness after sleep onset. Moreover, improved daytime sleepiness correlated with increased normal rapid eye movement sleep time. Sleep improvement did not significantly correlate with resolution of motor complication or reduced dopaminergic dosages. CONCLUSIONS: Subthalamic nucleus-deep brain stimulation may have beneficial effects on sleep disturbance in advanced Parkinson's disease by restoring sleep architecture and normal rapid eye movement sleep.

Parasomnias and movement disorders in children and adolescents.

Childhood parasomnias and movement disorders arise from a variety of etiologic factors. For some children, psychopathology plays a causal role in sleep disorders; in other cases, recurrent parasomnia episodes induce psychopathology. Current research reveals complex interconnections between sleep and mental health. As such, it is important that clinicians consider the impact psychiatric disorders have on childhood parasomnias. This article describes common parasomnias and movement disorders in children and adolescents, with emphasis on psychologic and behavioral comorbidities.

[Parasomnias]. / Albträumer, Knirscher, Schlafwandler. Was manche Schläfer nachts so treiben.

Parasomnias are characterized by undesired behaviour (e.g. sleep-walk, teeth-grinding) or unpleasant experiential phenomenon (e.g. nightmares) during sleep. They are classified as arousal disorder, disturbances in the transitions between sleep states, REM-associated sleep disorders or as other parasomnias. In addition to general therapeutic measures to protect against self-inflicted and externally-inflicted injuries, different diagnostic and therapeutic options are available depending on the symptoms and the type of disorder present.

REM sleep-related brady-arrhythmia syndrome.

Rapid eye movement (REM) sleep-related brady-arrhythmia syndrome is a cardiac rhythm disorder characterised by asystoles lasting several seconds during REM sleep in otherwise healthy individuals. In contrast to arrhythmias associated with obstructive sleep apnea, REM sleep-related sinus arrests and atrioventricular (AV) blocks are not associated with episodes of apnea or hypopnea. In literature, only few cases have been published, suggesting that the prevalence of this nighttime rhythm disorder is very rare. In this paper, we report two new cases of REM sleep-related sinus arrests and one case of REM sleep-related total AV block. To explore the underlying mechanism, an analysis of heart rate variability was performed. In a matched control population, we observed a significant lower low-to-high frequency (LF/HF) ratio in slow wave sleep as compared to REM sleep (2.04 +/- 1.2 vs 4.55 +/- 1.82, respectively [Mann-Whitney U test p < 0.01]), demonstrating a global increase in sympathetic activity during REM. When using the same technique in two of three patients with REM-related arrhythmias, the shift to an increased LF/HF ratio from slow wave sleep to REM sleep tended to be lower. This may reflect an increased vagal activity (HF component) during REM sleep in these subjects. We, therefore, hypothesise that, in our patients with REM sleep-related arrhythmias, the overall dominance of sympathetic activity during REM is present but to a lesser extent and temporarily switches into vagal dominance when the bursts of REMs occur. As it was still unclear whether these REM sleep-related asystoles needed to be paced, we compared our treatment and these of previously reported cases with the current American College of Cardiology/American Heart Association guidelines for implantation of cardiac pacemakers.

Sleepwalking and other ambulatory behaviours during sleep.

Different pathological conditions may lead to somnambulic automatisms arising from nocturnal sleep. Video polysomnography represents the diagnostic tool but, due to the difficulty of capturing complex episodes in the sleep laboratory, audio-video recordings at home of the episodes may help in the differential diagnosis also. Sleepwalking is a disorder of arousal in which the subject arises from deep sleep, even displaying long complex behaviour, including leaving the bed and walking, with memory impairment of the event. Disordered arousal mechanisms with an inability of the brain to fully awaken from slow-wave sleep are thought to lead to these motor automatisms. REM sleep behaviour disorders begin during REM sleep and are accompanied by features of REM sleep. The motor behaviour may be violent and injurious to the patient and/or bed partner. In some patients, however, the behaviour may be similar to that observed in sleepwalking and some patients have an overlap syndrome. In nocturnal frontal lobe epilepsy in particular, and in complex partial seizures in general, stereotypic and repetitive motor attacks may recur, at any time, on the same night and on different nights, with a continuum between minimal or minor attacks and major or prolonged episodes up to agitated epileptic nocturnal wanderings.

Bruxismo en niños / Bruxism in children

Se define bruxismo como el apretamiento habitual, no funcional, de los dientes, caacterizado por la fuerza y el contacto rítmico de las superficies oclusales de los dientes con el movimiento mandibular. El bruxismo puede incluir el frotamiento, apretamiento y rechinamiento de los dientes, de manera consciente o inconsciente, durante el día o durante la noche. Afecta de un 13 a un 26 por ciento de los niños y de un 8 a un 21 por ciento de los adultos. El bruxismo puede estar asociado a los siguientes factores: físicos, psicológicos, del sueño, dentarios

Bruxismo en niños / Bruxism in children

Se define bruxismo como el apretamiento habitual, no funcional, de los dientes, caacterizado por la fuerza y el contacto rítmico de las superficies oclusales de los dientes con el movimiento mandibular. El bruxismo puede incluir el frotamiento, apretamiento y rechinamiento de los dientes, de manera consciente o inconsciente, durante el día o durante la noche. Afecta de un 13 a un 26 por ciento de los niños y de un 8 a un 21 por ciento de los adultos. El bruxismo puede estar asociado a los siguientes factores: físicos, psicológicos, del sueño, dentarios

Prolonged asystolia in a young athlete: a case of sinus arrest during REM sleep.

A young asymptomatic male athlete came to our laboratory to be enrolled in a research protocol on physical fatigue. Routine clinical and cardiological evaluations including echocardiogram were in the normal range. Several consecutive cardiopulmonary tests showed a fairly good tolerance to exercise, with no symptoms even when the effort was abruptly arrested. On the other hand, Holter ECG recordings showed long nocturnal sinus pauses. As he was absolutely asymptomatic and free from any structural heart disease, he underwent a follow-up with repeated Holter monitorings for one year. During this period he decided on his own to stop practising sports; in spite of this sharp reduction in his overall physical activity, consecutive Holter monitorings showed that the sinus pauses were progressively increasing in duration (up to 9.2 seconds). With the hypothesis of a malignant vagotonia, he underwent a tilt test; however, we could not elicit any pauses or symptoms. The pauses grew longer over time; a endocavitary electrophysiologic test was performed, which showed no evidence of disease. To rule out the hypothesis of a sleep apnoea syndrome, he also underwent a polysomnography, including EEG, eye movement electromyography, arterial blood oxygen saturation and thoracic impedance: no alterations were detected with the exception of the sinus pauses, which appeared to be strictly linked to REM sleep, as suggested by the concurrent increase in rapid eye movements and desynchronized EEG. We hence made a diagnosis of sinus arrest during REM sleep (SAdRS), a very uncommon disease belonging to the parasomnias. Pauses were then quantified for one month by implanting a ECG loop recorder. As the patient became more and more upset and worried, and the pauses increased to nearly 12 seconds, we decided to implant a pacemaker, which is the only therapeutic option established in the literature for patients with SAdRS.