Interobserver reliability of ICSD-3 diagnostic criteria for disorders of arousal in adults.

PURPOSE: Disorders of arousal include confusional arousals, sleepwalking and sleep terrors. The diagnosis of disorders of arousal is based on the clinical criteria established in the International Classification of Sleep Disorders, third edition, although the interobserver reliability of these criteria has never been investigated. The aim of this study was to estimate the inter-rater reliability of the diagnostic criteria for disorders of arousal throughout the whole life in order to understand their feasibility in clinical daily activity and in multicenter observational studies. METHODS: Three raters interviewed 126 subjects (patients complaining of sleep disorders, headache, and healthy subjects), aged 18-80 years, with a standardized questionnaire created by applying the International Diagnostic Criteria for Disorders of Arousal. RESULTS: An "almost perfect" inter-rater reliability for disorders of arousal criteria and the final diagnosis was found among the raters (kappa 0.89 for confusional arousals, 0.87 for sleepwalking, and 0.87 for sleep terrors). CONCLUSIONS: The International Classification of Sleep Disorders, Third Edition criteria are adequate for a reliable diagnosis of disorders of arousal. Further validation studies, confirming DOA diagnosis with video polysomnography, are needed to investigate the predictive value of ICSD-3 criteria.

Debating the Role of Arousal in Delirium Diagnosis: Should Delirium Diagnosis Be Inclusive or Restrictive?

Delirium is common in acute, postacute, and long-term care settings, and it can be difficult to recognize, especially without deliberate mental status evaluation. Because delirium typically presents with altered arousal and arousal can be assessed within a matter of seconds, routine assessment of arousal offers an efficient means of delirium screening. Nevertheless, impaired arousal often precludes formal assessment of attention and awareness, the cardinal features of delirium per the current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Here we debate the relative merits of "ruling in" as delirious noncomatose patients with impaired arousal (inclusive approach) vs reserving delirium diagnosis to patients in whom diagnostic criteria can be elicited (restrictive approach). Inclusivism provides efficiency and may prevent missing or delaying delirium diagnosis. The restrictive approach challenges the utility of ruling such patients in as delirious and advocates for identifying mental states that directly inform clinical care. Both positions, however, firmly emphasize the value of routine clinical assessment of arousal.

Defining the borders between Sleep-Related Eating Disorder and Night Eating Syndrome.

OBJECTIVES: Nocturnal eating is a common symptom of two clinical conditions with different pathogenesis and needing different therapeutic approaches: Sleep Related Eating Disorder (SRED) and Night Eating Syndrome (NES). The first is considered a parasomnia while the second is an eating disorder; however, the distinction between SRED and NES is still a controversial matter. The aim of this study was to better define psychological, behavioral, and polysomnographic characteristics of the two syndromes. METHODS: An eating disorders' specialist tested a group of 28 nocturnal eaters diagnosed as affected by SRED by a sleep expert, following the current criteria of the international classification of sleep disorders, to find out if any of them was affected by NES according to the criteria suggested by both sleep and eating disorders specialists during the first international meeting on Night Eating Syndrome (Minneapolis, 2009) and if they had specific psychological or polysomnographic characteristics. RESULTS: Twenty-two subjects were diagnosed to be affected by NES. They scored higher on the physical tension subscale of the Sleep Disturbance Questionnaire (SDQ) and on the mood and sleep subscale of the Night Eating Questionnaire (NEQ), but there were no other significant differences between SRED and NES patients nor for age, Body Mass Index (BMI), or gender distribution. CONCLUSIONS: The overlap between the symptomatology and the polysomnographic characteristics of the two pathologies and the difficulty in making a differential diagnosis between NES and SRED indicate the need for an update of the diagnostic criteria for SRED, as was recently done for NES.

Sleep apnea syndrome in Parkinson's disease. A case-control study in 49 patients.

In PD, the impact of nocturnal respiration on sleep continuity and architecture has not been systematically investigated by polysomnography (PSG). We performed a case-control study with retrospective analysis of PSG data of 49 PD patients. After classifying the PD patients according to their apnea/hypopnea index (AHI), they were matched with 49 controls in terms of age, gender, and AHI. There were 21 PD patients (43%) who had sleep apnea syndrome (SAS), classified as mild (AHI, 5-15) in 10 patients, moderate (AHI, >15-30) in 4 patients, and severe (AHI, > 30) in 7 patients. PD patients had more deep sleep (P = 0.02) and more nocturnal awakenings (P < 0.001) than the controls. Their body mass index (BMI) was lower (P = 0.04), and they maintained a more favorable respiratory profile, with higher mean and minimal oxygen saturation values (P = 0.006 and 0.01, respectively). These differences were preserved when only considering PD patients with AHI > 15. PD patients had less obstructive sleep apneas (P = 0.035), independently from the factor AHI. Only the respiratory changes of 4 PD patients with BMI > 27 and AHI > 15 (8%) approximated those seen in the controls. At an early or middle stage of the disease, non-obese PD patients frequently have AHI values suggesting SAS, however, without the oxygen desaturation profile of SAS. Longitudinal studies of patients with such "abortive" SAS are warranted to establish if this finding reflects benign nocturnal respiratory muscle dyskinesia or constitutes a precursor sign of dysautonomia in PD.