Reviews for Primary Care - Fall 2007 - (Page 46) Insomnia and Neurological Disorders continued RBD was diagnosed by polysomnographic monitoring in 90%, dream-enacting behaviors were reported in 69%, and RBD preceded the clinical presentation of MSA in 44%.51 The data show that RBD represents the most common clinical sleep manifestation and polysomnographic finding in patients with MSA. RBD can frequently herald the appearance of other MSA symptoms by years; therefore, expanded polysomnographic montage consisting of multiple limbs and video monitoring is recommended in patients with MSA when these spells are suspected.41,52 Increasing evidence points to the role of basal ganglia dysfunction in the underlying pathophysiology of RBD in MSA; in fact, a recent study from our center revealed that decreased nigrostriatal dopaminergic projections may contribute to RBD in MSA.53 the well-documented immobility in bed and difficulty with transfers, depression, dysphagia, and frequent nocturia seen in PSP.1,54 that improve sleep disorders may require tailored dosing schedules to maximize their benefit.58 Multiple Sclerosis Epilepsy Sleep and epilepsy have a reciprocal relationship. Sleep can affect the frequency and distribution of epileptiform discharges, whereas epileptic discharges can change sleep regulation and induce sleep disruption.55-57 Patients with epilepsy complain of symptoms such as hypersomnia, insomnia, and even greater breakthrough seizures attributed to sleep disruptions. Sleep disturbances in epilepsy patients probably indicate the presence of an underlying sleep disorder rather than the effect of epilepsy or medication on sleep. Physicians must be able to identify and differentiate between potential underlying sleep disorders and sleep dysfunction related to epilepsy and direct therapy to improve the patient’s symptoms.58 Sleep deprivation was noted to increase interictal discharges in patients with generalized epilepsy.59 The sleep state can promote interictal activity in as many as one third of patients with epilepsy and up to 90% of patients with sleep state–dependent epilepsy.58,60 Antiepileptic drugs (AEDs) also affect sleep architecture.61 Phenytoin increases the amount of non-REM sleep, decreases sleep efficiency, and reduces sleep latency.62 Carbamazepine increases the number of sleep-stage shifts and decreases REM sleep.63 Benzodiazepines decrease sleep latency and reduce SWS.61,64 Gabapentin has been shown to improve sleep efficiency and SWS and to increase REM sleep.65,66 In clinical practice, understanding the unique effects of these AEDs may offer the clinician an opportunity to improve sleep and wakefulness; medications Multiple sclerosis (MS) is the most common nontraumatic cause of neurologic disability in young adults.67 With improved therapy, many patients survive to older age. Sleep disturbances in MS are common but poorly recognized, and almost half of all patients demonstrate sleep disturbances due to leg spasms, pain, immobility, nocturia, or medication.68 Common sleep disorders in patients with MS include insomnia, restless legs syndrome, narcolepsy, and RBD. Sleep disruption in MS may result in hypersomnolence, increased fatigue, and a lowered pain threshold. An increased clinical awareness of sleeprelated problems is therefore warranted in this patient population because they are extremely common and have the potential to negatively affect overall health and quality of life.69 Shy-Drager Syndrome The mechanism of sleep disruption in Shy-Drager syndrome (SDS) is probably the result of pathology in the brainstem structures regulating sleepwake transition. Sleep studies in patients with SDS demonstrate a reduction in SWS, REM sleep, and total sleep time; an increase in sleep latency and frequency of awakenings; the absence of atonia in REM sleep; and an increase in respiratory dysrhythmias. Chronic Pain and Fibromyalgia Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home patients is 40% to 80%, showing that they are at great risk of experiencing pain.70 Sleep and pain, two important vital functions, interact in complex ways that ultimately impact the biological and behavioral capacity of the individual.71 Sleep studies of patients experiencing acute pain during postoperative recovery demonstrate shortened and fragmented sleep with reduced amounts of SWS and REM sleep, and recovery is accompanied by normalization of sleep.71 Chronic pain conditions such as arthritis frequently coexist with insomnia. Chronic pain produces a vicious cycle of inactivity and fatigue Progressive Supranuclear Palsy Sleep problems are encountered in a large proportion of patients with progressive supranuclear palsy (PSP).1,54 Insomnia is probably the most severe sleep problem, noted by decreased total sleep time and significant sleep disruption without a specific clinical complaint. This is probably secondary to the apathy of patients afflicted with this disease. Insomnia in PSP is worse than insomnia in PD or AD. Other sleep disturbances may be related to 46 VOL. 1 NO. 1 2007 REVIEWS FOR PRIMARY CARE
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