Reviews for Primary Care - Fall 2007 - (Page 45) Insomnia and Neurological Disorders Cursor: 04:50:49, Epoch: 711 - REM LOC-A2 128 uV ROC-A1 128 uV Chin1-Chin2 68.3 uV C3-A2 85.3 uV C4-A1 85.3 uV O1-A2 85.3 uV O2-A1 85.3 uV ECG2-ECG1 1.37 mV ECG2-ECG3 1.37 mV LAT1-LAT2 42.7 uV 1 min/page 1 min/page SNORE 256 uV N/O 204.8 uV THOR 1.09 mV ABD 546.1 uV 100 SpO2 % 0 999999999999888888888889999999999999999999999999999999999999 000110000000999999999990000111111111110000111111111111100000 Figure 3. Polysomnographic example of rapid eye movement (REM) sleep behavior disorder. A 60-second epoch from a diagnostic polysomnogram of an 80-year-old man with Parkinson’s disease who was referred to the sleep disorders clinic for evaluation of recurrent violent nighttime awakenings. Illustrated here is a typical spell that this patient was experiencing during the night. He was noted to yell, jump from bed, and have complex body movements. The figure shows abnormal augmentation REM-muscle atonia in the left anterior tibialis muscle and chin electromyogram (EMG) channel. The patient was diagnosed with REM sleep behavior disorder (RBD) and was treated successfully with 0.25 mg of clonazepam. Channels are as follows: electro-oculogram (left, LOC-A2; right, ROC-A1), chin EMG, electroencephalogram (left central, right central, left occipital, right occipital), 2 electrocardiogram (ECG) channels, limb EMG (LAT), snore channel, nasal-oral airflow, respiratory effort (thoracic, abdominal), and oxygen saturation (SaO2). Modified from Avidan AY.107 RBD, which is often the initial manifestation of DLBD and is now recognized as a feature of the disease. Awareness of the presence of this sleep disorder in patients with DLBD is important, and treatment with lowdose clonazepam or levodopa may help.44,46 Recent findings suggest that rapid loss of striatal vesicular monoamine transporter protein (VMAT2) binding is associated with onset of DLBD.47 Earlier studies, as well as this present one, led to the hypothesis that RBD is related to reduced activity of the midbrain dopaminergic neurons. The demonstration that levodopa improved RBD symptoms in a patient with DLBD is consistent with this hypothesis.46,48 These patients often present with rapidly progressive dementia associated with attention deficit, hallucinations, and fluctuation in their cognitive abilities. RBD is very often the initial manifestation of DLBD.42 Sleep Disturbances in Multiple System Atrophy Patients with multiple system atrophy (MSA) experience degeneration of the pontine tegmentum, nucleus tractus solitarius, nucleus ambiguous, hypoglossal nucleus, reticular formation of the brainstem, and at times, the cervical and thoracic spinal cord. Therefore, the diffuse neurodegenerative process that encompasses these key structures involved in the regulation of the sleep-wake transition and respiratory function in MSA may account for the most frequent sleep disturbances in MSA: sleep-disordered breathing (SDB) and RBD.49,50 Patients with MSA are commonly affected with RBD. In a large study involving MSA patients, VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE 45
For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.