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Evidence suggests that untreated obstructive sleep apnea (OSA) is a significant health risk for the development of hypertension, cardiovascular disease, and stroke. OSA is independently associated with obesity, hypertension, and insulin resistance/diabetes mellitus, the three stroke risk factors of the metabolic syndrome. Studies in normal subjects and sleep apneic patients suggest that upper airway occlusion induces arousal from non-rapid eye movement (NREM) sleep once the level of inspiratory effort reaches a certain value, which varies among individuals. During apnea there are several stimuli that are well known to be able to induce arousal, including hypercapnia, hypoxia, and increased airway resistance. Cohort studies have shown OSA to be a risk factor for stroke. OSA is associated with a variety of stroke risk factors that may independently contribute to stroke risk. This suggests the potential for a cause-and-effect relationship between untreated OSA and stroke in some cases.
Sleep-related eating disorder (SRED) is a parasomnia that arises primarily from NREM sleep with recurrent episodes of involuntary eating and drinking. This chapter discusses the case of a 32-year-old woman who presented with sleep-related eating episodes, who also had difficulty with sleep initiation insomnia, somnambulism, somniloquy and symptoms of restless legs syndrome (RLS) since she was 6 years old. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. Overnight diagnostic polysomnography (PSG) was performed. Based on the PSG results, a diagnosis of SRED was made. Complications include obesity, injuries, toxic ingestions and psychological distress with excessive weight gain. Treatment of the underlying sleep disorder, if present, is usually effective. Underlying mood disorder or alcohol or substance abuse should be addressed. Pharmacotherapy consists of administration of antidepressants (e.g. SSRIs), dopaminergic agonists or topiramate.
This chapter discusses the case of a 48-year-old woman who was having episodes of sitting upright in bed, letting out a blood curdling scream and patting the bed with both hands, and often going back to sleep without realizing what had happened. It presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on the patient. The specialist ordered an MRI of the brainwith special thin cuts through the frontal and temporal lobes, and nocturnal polysomnography (PSG) with an additional all-night 16-channel EEG running concomitantly with the PSG. Based on the results of the studies, a diagnosis of sleep terrors or disorder of partial arousal was made. She was prescribed clonazepam 0.5mg and was urged to follow up with the behavior therapist. Six months later, her events were all well controlled by the behavioral therapy recommendations.
This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 25-year old patient who was admitted for the evaluation of insomnia. The specialist made a diagnosis of narcolepsy with possible cataplexy and decided not to pursue a CSF hypocretin analysis in light of the diagnostic certainty of the polysomnography (PSG) results. The multiple sleep latency test (MSLT) showed the presence of REM sleep in all four naps with a latency of 5 minutes. He prescribed modafinil 200 mg to be taken in the morning, a dose that could be increased to 400 mg if necessary. Narcolepsy is a life-long disorder presenting with excessive daytime sleepiness (EDS) and, ironically, with fragmented sleep that may lead to an erroneous diagnosis of insomnia. In addition to modafinil, patients may respond favorably to the administration of methylphenidate and dexedrine.
This chapter presents the clinical history, examination, follow-up, treatment, diagnosis, and the results of the procedures performed on a 38-year-old female patient who was admitted to a university sleep disorders center to address amnestic nocturnal behavior. She was a friendly, non-dysmorphic patient who cooperated throughout the examination. Her vital signs were normal except for a BMI of 26 kg/m2 and borderline systolic hypertension. Her mood and affect were bright and congruent. In particular, there was no evidence on examination of subtle changes suggestive of a dementing illness or a Parkinsonian syndrome. An EEG carried out in 2005 and 2009 demonstrated normal awake and drowsy responses. An MRI carried out in 2009 showed normal brain. Polysomnography (PSG) showed that sleep was initiated without a sedativehypnotic. A diagnosis was made of mixed NREM parasomnia characterized by confusional arousals, sleepwalking (with sleepdriving), sleep-related eating disorder, and sexsomnia exacerbated by zolpidem.
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