Sudden Onset Of Sleep Research Articles

Teaching NeuroImage: Hypothalamic Involvement in Neuromyelitis Optica Spectrum Disorder in a Child.

A 10-year-old girl presented with a 15-day history of excessive daytime sleepiness and sudden sleep onset, hypnagogic hallucinations, hyporexia, and behavioral changes. An MRI examination of the brain revealed a bilateral hypothalamic lesion (Figure). We found positive AQP4 -IgG antibodies in serum and low hypocretin levels (93 pg/mL) in the CSF. A diagnosis of narcolepsy secondary to neuromyelitis optica spectrum disorder was made. She improved after glucocorticoid administration. After 10 months of immunosuppressive maintenance therapy with azathioprine, she remains asymptomatic without new lesions in the follow-up neuroimages. Any diencephalic clinical syndrome, such as narcolepsy, with hypothalamic involvement, should prompt a serum test for AQP4 -IgG.1,2

Sudden-onset sleep in patients with Parkinson’s disease

Sudden-onset sleep (SOS) is one of the manifestations of excessive daytime sleepiness (ЕDS) in Parkinson’s disease (PD).Aim: сlarify the clinical and polysomnographic characteristics of patients with SOS at the expanded (2 and 3 stages according to Hoehn–Yahr) stages of PD.Material and methods. 42 patients (18 men and 24 women, average age 66.5 ± 7.9 years, duration of PD 8.9 ± 4.6 years, Hoehn–Yahr stage of PD 2.6 ± 0.5) who received combined dopaminergic therapy with levodopa and dopamine agonist were examined. 32 patients had ЕDS, 10 patients did not have it. The Unified Parkinson’s disease rating scale (UPDRS parts II, III in “on” state of dopaminergic medication), the diary of the assessment of the waking period, the Epworth Sleepiness Scale, the Parkinson Disease Sleep Scale I (PDSS I), the Sсales for Outcomes of Parkinsons disease-Cognition (SCOPA-Cog), the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Apathy Scale, the Stroop test. Objective sleep-wake assessment: standard nocturnal video-polysomnography (PSG), multiple sleep latency test (MSLT).Results. SOS was detected in 69% of patients with complaints of ЕDS. Patients with SOS had a shorter latency of falling asleep according to MSLT data (8.1 ± 5.9 min versus 14.2 ± 3.9 min in patients without of ЕDS, p < 0.05).Patients with SOS had a high severity of motor function disorders, apathy and depression (p < 0.05). Рatients with SOS had no significant differences in the main PSG characteristics of night sleep.Conclusion. SOS can be considered as one of the manifestations of a more severe course of PD. A decrease in the effectiveness of night sleep and a change in its structure are not a determining factor in the development of SOS.

Sudden onset of sleep caused by hypothalamic infarction: a case report

BackgroundHypothalamic lesions, such as tumors and demyelinating diseases, reportedly cause abnormal sleepiness. However, stroke involving the hypothalamus has rarely been described. Here, we report a patient with infarction restricted to the hypothalamus who presented with sudden onset of sleep.Case presentationA 42-year-old woman with a history of migraine without aura presented with irresistible sleepiness and developed several episodes of sudden onset of sleep. Neurological examinations were unremarkable except for partial left Horner syndrome. Brain magnetic resonance imaging (MRI) revealed a high-intensity lesion restricted to the left hypothalamus on diffusion-weighted and fluid-attenuated inversion recovery MRI images. Cerebrospinal fluid (CSF) orexin-A levels obtained on hospital day 3 after her sleepiness had resolved were normal (337 pg/mL; normal > 200 pg/mL). Serum anti-nuclear and anti-aquaporin 4 (AQP4) antibodies and CSF myelin basic protein and oligoclonal band were negative. A small hypothalamic infarction was suspected, and the patient was treated with intravenous edaravone and argatroban, as well as oral clopidogrel. Three months later, there had been no clinical relapse, and the hypothalamic lesion had almost disappeared on follow-up MRI. No new lesion suggestive of demyelinating disease or tumor was observed.ConclusionHypothalamic stroke should be considered a cause of sudden onset of sleep.

Top New Drug Approvals of 2018

Top New Drug Approvals of 2018

Falling asleep at the wheel and distracted driving. The High-Risk Professional Drivers study.

Background:Sleepiness at the wheel and driving while engaged in other activities are well known risk factors for traffic accidents. This article estimates the prevalence of these factors among Italian Professional Drivers (PDs) and their impact on reported driving mistakes.Methods:A cross-sectional study was conducted using anonymous questionnaires. PDs (n=497) were divided into two groups: high-risk PDs (HiRis_PDs) (those who self-reported more than one incident during the last 3 years and/or more than one mistake during the past year) and non-HiRis_PDs (subjects who did not meet the above-mentioned inclusion criteria). Logistic regression analyses were performed to assess the association of self-reported sleepiness and/or risky driving behaviour with the condition of being a high-risk driver.Results:161 (32.4%) subjects were defined as HiRis_PDs. Forty-one percent of the interviewees experienced at least one episode per month of sudden-onset sleep at the wheel. Twenty-eight point two percent reported a regular use of a hand-held cell phone. Predictive factors for being HiRis_PDs were: at least one self-reported episode per month of falling asleep at the wheel [odds ratio (OR) 5, 95% confidence interval (CI) 3.21-7.80, P<0.001], driving while regularly engaged in other activities (mainly hand-held cell phone use) (OR 6.11, 95% CI 2.90-12.84, P<0.001), and young age (OR 0.96, OR 1 year of age increase, 95% CI 0.94-0.98, P=0.001).Conclusions:Focusing prevention efforts on recognizing sleepiness at the wheel and on avoiding other distracting activities while driving can reduce the possibility of driving errors on the road by about 5-6 times.

Poor weight control, alcoholic beverage consumption and sudden sleep onset at the wheel among Italian truck drivers: A preliminary pilot study.

The aim of this study was to investigate the prevalence of obesity, alcoholic beverage consumption, unhealthy alcohol use and sudden sleep onset at the wheel among Italian truck drivers. In addition to prevalence rates, this study also aimed at investigating potential predictors for sudden-onset sleepiness and obesity. A sample of truck drivers was extracted from the database of the High Risk Professional Driver Study. Data concerning demographics, anthropometry, medical information and working conditions were collected using anonymous questionnaires. Logistic regression analyses were performed to assess the association of the reported body mass index (BMI), alcohol consumption and sudden sleep onset with working conditions and general lifestyle factors. Three hundred and thirty-five questionnaires were collected. According to their BMI, 45% of the participants were overweight and 21.4% of them were obese. Twenty-four point two percent declared they drank alcoholic beverages during working hours or work breaks and 21.3% of the drivers had an Alcohol Use Disorders Identification Test Consumption (AUDIT C) score ≥ 5 (the threshold value for unhealthy alcohol use). Forty-one point six percent of the interviewees experienced one episode of sudden sleep onset at the wheel per month (5.5% per week and 0.9% daily). Predictive factors for obesity were: length of service (odds ratio (OR) = 1.09, confidence interval (95% CI): 1.04-1.15, p < 0.001) and the AUDIT C total score (OR = 1.34, 95% CI: 1.08-1.66, p = 0.008). Predictive factors for sudden-onset sleepiness at the wheel were: age > 55 years old (OR = 5.22, 95% CI: 1.29-21.1, p = 0.020), driving more than 50 000 km per year (OR = 2.89, 95% CI: 1.37-6.11, p = 0.006) and the Chalder Fatigue Questionnaire (CFQ) score > 11 (adjusted OR = 2.97, 95% CI: 1.22-7.21, p = 0.016). This study strongly emphasizes the need for intervention in order to reduce and prevent important risk factors for the sake of road safety and truck drivers' health.

The Agony of the Agonists: a Review of Impulsivity and Withdrawal Syndromes in Parkinson's Disease Treatment

The introduction of dopamine agonists was a welcome development in the treatment of Parkinson's disease. However, their history has been somewhat checkered with concerns about their side effects including sudden onset of sleep and ‘sleep attacks’ the development of fibrotic side effects with ergot-derived agents; and most recently, the emergence of impulse control disorders. Furthermore, those who develop these behaviors are those most likely to suffer distressing side effects on their withdrawal: the so-called ‘dopamine agonist withdrawal syndrome’ (DAWS). This review examines this complex area and some suggested strategies to avoid and manage these phenomena, and concludes with some discussion of the future agenda for improving the understanding and management of these conditions.

Falling asleep at the wheel among Italian professional drivers (PDs): results from the HiRis PD study.

A high percentage of professional drivers (PDs) often report feeling fatigue during their work, and falling asleep at the wheel (FAW) is a major contributing factor to the occurrence of near-miss or actual accidents. The aim of this study is to evaluate the prevalence of FAW among Italian PDs and the effect of fatigue on this occurrence (corrected for the main predictive factors already known). We performed a cross-sectional questionnaire survey. Data from PDs (N = 497) were used for analyses. Logistic regression analyses were performed to assess the association of reported sudden-onset sleep at the wheel with working conditions and general lifestyle factors. Forty-one percent of the interviewees experienced at least 1 episode per month of sudden-onset sleep at the wheel (4.7% per week). Predictive factors of self-reported FAW were: age > 55 years old (odds ratio (OR) = 4.91, confidence interval (CI): 1.79-13.50, p < 0.01), traveling more than 40 thousand miles per year (OR = 1.86, 95% CI: 1.08-3.22, p < 0.05), body mass index ≥ 30 (OR = 2.16, 95% CI: 1.01-4.64, p < 0.05) and Chalder Fatigue Questionnaire score > 22 (OR = 3.93, 95% CI: 1.90-8.14, p < 0.01). There are different work and human factors underlying FAW among PDs. The Chalder Fatigue Questionnaire might be useful in measuring fatigue in this group and in detecting PDs at high risk of experiencing FAW.

The nature of excessive sleepiness and sudden sleep onset in Parkinson׳s disease

ObjectivesExcessive daytime sleepiness (EDS) and sudden sleep onset (SOS) episodes are frequent in Parkinson׳s disease (PD). The objectives are to identify clinical characteristics and factors associated with EDS and SOS episodes. MethodsClinical demographic data were recorded (N=100, mean age=65.0±10.4). EDS was identified by the Epworth Sleepiness Scale (ESS>10) and SOS episodes were registered. Disease severity was evaluated by the Unified Parkinson׳s Disease Rating Scale (UPDRS, I, II, and III), sleep disturbances by the Parkinson׳s Disease Sleep Scale (PDSS<100), depressive symptoms by the Beck Depression Inventory (BDI>10) and rapid eye movement (REM) sleep behavior disorder (RBD) by the REM sleep behavior scale. Levodopa equivalent dose was measured.Results: PD patients with EDS (67%) were predominately male (73.1%) and had worse disease severity (UPDRS II and III p= 0.005); SOS episodes (39%) were associated with disease duration, diabetes, sleep disturbances (PDSS Scale), disease severity (UPDRS I, II, III) and RBD symptoms (p<0.05). Stepwise regression analysis showed that EDS was independently associated with motor-symptoms severity (UPDRS III scale, p=0.003). SOS episodes were independently associated with disease duration (p=0.006) and sleep disturbances (PDSS scale, p=0.03): patients had more uncomfortable immobility at night, tremor on waking and snoring or difficult breathing. DiscussionEDS and or SOS episodes are frequent and manifest a differential pattern in PD. SOS episodes are associated with longer disease duration, diabetes, sleep disturbances and RBD symptoms indicating that these “sleep attacks” are of multifactorial origin and probably influenced by brain structural abnormalities.

Mechanisms Underlying Dopamine-Mediated Reward Bias in Compulsive Behaviors

Pathological behaviors such as problem gambling or shopping are characterized by compulsive choice despite alternative options and negative costs. Reinforcement learning algorithms allow a computation of prediction error, a comparison of actual and expected outcomes, which updates our predictions and influences our subsequent choices. Using a reinforcement learning model, we show data consistent with the idea that dopamine agonists in susceptible individuals with Parkinson's disease increase the rate of learning from gain outcomes. Dopamine agonists also increase striatal prediction error activity, thus signifying a "better than expected" outcome. Thus, our findings are consistent with a model whereby a distorted estimation of the gain cue underpins a choice bias toward gains.

Clinical risk–benefit assessment of dopamine agonists

Dopamine agonists (DAs) have proven efficacy as monotherapy in early Parkinson's disease (PD) for preventing motor complications such as dyskinesia and as adjunct therapy as the disease progresses. Further, it is increasingly evident that at least some DAs may provide additional benefits, such as reduction in depressive symptoms and treatment of refractory tremor. Different side-effect profiles have been associated with levodopa and ergot or non-ergot DA treatment, such as sudden onset of sleep, reduced impulse control, hallucination, and cardiovascular fibrosis. This paper discusses the evidence for specific associations between particular treatments and side effects as well as the clinical implications for patient care. Ultimately, the choice depends on the risk-benefit assessment as it applies to the individual patient's clinical profile and the physician's preference.

Update on the use of pramipexole in the treatment of Parkinson&amp;rsquo;s disease

Pramipexole is a non-ergot dopamine agonist shown to be efficacious in the treatment of Parkinson's disease (PD). This review addresses the literature concerning pramipexole's efficacy in treating motor and non-motor symptoms in PD, its impact on the development of dyskinesias and response fluctuations, the issue of neuroprotection, and the risk for developing adverse events such as increased somnolence, attacks of sudden onset of sleep, cardiac valvulopathy and impulse control disturbances.

Drugs and driving

Many drugs used therapeutically, and many used for non-medical reasons, can impair the skills needed for driving. The most profound effects occur with sudden onset of sleep caused by dopamine agonists; somnolence as a consequence of taking hypnotics, sedatives, and sedating antihistamines; and the disturbances of perception brought on by cocaine and other stimulants.

Excessive daytime sleepiness and unintended sleep in Parkinson’s disease

Patients with Parkinson's disease and parkinsonian syndromes (eg, dementia with Lewy body disease, multisystem atrophy, and Shy-Drager syndrome) suffer from daytime sleepiness. This sleepiness is common and very real, often approaching levels observed in the prototypical disorder of sudden-onset sleep, namely narcolepsy/cataplexy. Physicians need to be vigilant in assessing parkinsonian patients for sleepiness because treatment can dramatically enhance quality of life and prevent the significant morbidity and mortality that attends daytime sleepiness. Male patients with advanced disease, cognitive impairment, drug-induced psychosis, and orthostatic hypotension are most at risk for developing pathologic sleepiness. Because primary sleep disorders can coexist with parkinsonism (eg, sleep apnea, insufficient or interrupted sleep), these potential causes should be carefully assessed with polysomnography and treated appropriately. Dopaminomimetics exacerbate sleepiness in a small subset of patients in a dose-dependent fashion. Nonetheless, the primary pathologies involved in parkinsonism appear to be the greatest contributors to daytime sleepiness. Sleepiness in parkinsonism, especially a narcolepsy-like phenotype, may necessitate treatment with wake-promoting agents such as bupropion, modafinil, or traditional psychostimulants.

Sudden onset of sleep and dopaminergic therapy in patients with restless legs syndrome

Background and purpose Sudden onset of sleep (SOS) was recently reported in patients with Parkinson's disease (PD) under dopaminergic treatment. Here, we investigated as to what extent SOS is found in patients with restless legs syndrome (RLS), who are frequently treated with dopaminergic drugs, and controls. Patients and methods A questionnaire survey on SOS was administered to 156 RLS patients and 126 controls. Results While no significant difference between RLS patients and controls was detected in Epworth sleepiness scale (ESS) scores ( P=0.76), the prevalence of SOS was higher in RLS patients (32.7%) than in controls (19.8%) ( P=0.02). Significant predictors of SOS in RLS were ESS score (odds ratio (OR) 16.4), male sex (OR 4.6), duration of night-time sleep (OR 3.0), and age (OR 2.9), while no association was observed for duration or severity of the disease. Patients on dopaminergic therapy usually featured a lower risk of SOS than untreated patients. Falling asleep while driving was reported by 14.6% of all RLS patients with a driver's license and associated with increased risk of accident (OR 7.1). Conclusions RLS patients who are untreated, male, and elderly should be assessed for the presence of SOS. In contrast to PD, dopaminergic drugs may reduce the risk of SOS in RLS. The possible benefit of the drugs should be investigated particularly in male patients.

Daytime Sleepiness and the COMT val&lt;sup&gt;158&lt;/sup&gt;met Polymorphism in Patients with Parkinson Disease

A preliminary study by our group suggested an association between daytime sleepiness and the catechol-O-methyltransferase (COMT) val158met polymorphism (rs4680) in patients with Parkinson disease (PD). We sought to confirm this association in a large group of patients with PD. Genetic association study in patients with PD. Movement disorder sections at 2 university hospitals. PD patients with and without episodes of suddenly falling asleep matched for antiparkinsonian medication, disease duration, sex, and age, who participated in a previous genetic study on dopamine-receptor polymorphisms. Not applicable. In this study, 240 patients with PD (154 men; age 65.1 +/- 6.1 years; disease duration 9.4 +/- 6.0 years) were included. Seventy had the met-met (LL), 116 the met-val (LH), and 54 the val-val (HH) genotype. In the combined LL+LH group (featuring reduced COMT activity), the mean Epworth Sleepiness Scale (ESS) score was 9.0 +/- 5.9 versus 11.0 +/- 6.1 in the HH (high COMT activity) group (P = .047). Forty-seven percent of the LL and LH patients had sudden sleep onset compared with 61% of the HH patients (P = .07). Logistic regression, however, showed that both pathologic ESS scores (i.e., > 10) and sudden sleep onset were predicted by subjective disease severity (P < .001 each) but not by the COMT genotype. Our previous finding that the L-allele may be associated with daytime sleepiness could not be confirmed in the present study. Altogether, our data do not support a clinically relevant effect of the COMT genotype on daytime sleepiness in PD.

Pramipexole in the treatment of Parkinson’s disease: new developments

The nonergot dopamine agonist pramipexole is an efficient and safe drug for the treatment of Parkinson’s disease. Clinicians may favor pramipexole over other dopamine agonists because of its suggested higher tolerability with respect to peripheral dopaminergic side effects. Importantly, nonergot dopamine agonists such as pramipexole may not cause restrictive valvular heart disease and may therefore represent the first choice in patients with valvular lesions under treatment with ergot dopamine agonists. However, particular caution has to be exercised in younger Parkinson’s disease patients with a shorter disease duration regarding the occurrence of sudden onset of sleep. In light of cost–effectiveness and quality-of-life issues, its final significance for the initial treatment of patients with early Parkinson’s disease remains to be determined.

Daytime sleep latency in medication‐matched parkinsonian patients with and without sudden onset of sleep

Currently, it is unclear whether sleep attacks in Parkinson's disease (PD) represent a novel entity or just a phenomenon of daytime sleepiness. We investigated 10 PD patients with sleep attacks and compared them with 10 PD patients without any daytime sleepiness. The patients were matched according to their dopaminergic medication and subjected to a sleep medical investigation. The mean sleep latency on the multiple sleep latency test was in the normal range and not significantly different between the groups. These data suggest that sleep attacks can occur against a background of normal alertness.

'Sleep Attacks' in Patients with Sleep-Disordered Breathing. ,,Schlafattacken'' in Patienten mit Schlafbezogenen Atmungsstorungen

The term ‘sleep attack’ is used in patients with Parkinson's disease (PD) to designate a sudden onset of sleep (SOS) without any prior sleepiness. Clinically, sleep attacks can be distinguished from unintended sleep episodes, i.e. SOS with prior sleepiness. This study aimed to assess the prevalence of SOS and to identify its predictors in patients with sleep-disordered breathing (SDB). A total of 114 consecutive patients with the clinical suspicion of obstructive sleep apnoea syndrome (OSAS) and a respiratory disturbance index (RDI) of >5/h were examined using a questionnaire and polysomnography (PSG). Altogether 57.7% reported SOS, with 5.2% of the total population describing exclusively sleep attacks. SOS was observed in both patients with obstructive sleep apnoea-hypopnoea (OSAH) or increased upper airway resistance (UAR). Increased scores on the Epworth Sleepiness Scale (ESS) were the best predictor of SOS. Logistic regression showed a possible association of SOS with a low PLMS index, while no definite effect was observed for other PSG parameters. Our data show that SDB is frequently associated with SOS. Future studies should address in more detail whether SDB patients with sleep attacks pose an increased accident risk.

Preprohypocretin Polymorphisms in Parkinson Disease Patients Reporting “Sleep Attacks”

Previously, we found a significant association between the dopamine D2 receptor gene polymorphism Taq IA and sudden onset of sleep in patients with Parkinson disease. Here we evaluated the association between the preprohypocretin (-909T/C), (-22C/T), and (-20C/A) polymorphisms and sudden onset of sleep in the same population of patients with Parkinson disease. We conducted an association study analyzing the distribution of preprohypocretin polymorphisms in Germanic, caucasian Parkinson disease patients with and without sudden onset of sleep, matched according to drug therapy, disease duration, sex, and age. Movement disorders section at a university hospital. 132 Parkinson disease patients with sudden onset of sleep and 132 Parkinson disease patients without sudden onset of sleep. Blood samples were taken from each participant and used for DNA extraction. Polymorphisms were analyzed by established polymerase chain reaction protocols or direct sequencing. The variant allele T of the (-909T/C) preprohypocretin polymorphism was more commonly found in Parkinson disease patients with sudden onset of sleep. Statistical analysis showed that there were significant differences in the genotype (P = .024) and allele (P = .018) distribution between both groups. For heterozygous and homozygous carriers of allele T, the genotype relative-risk estimates for the presence of sudden onset of sleep were 2.01 (95% confidence interval: 0.76-5.34) and 2.81 (95% confidence interval: 1.09-7.25), respectively. Our results show a significant association between the (-909T/C) preprohypocretin polymorphism and sudden onset of sleep in Parkinson disease. However, we could not demonstrate any interaction between the Taq IA and (-909T/C) polymorphisms with respect to the occurrence of sudden onset of sleep, suggesting that multiple genetic factors may contribute to the pathogenesis of this phenomenon.