Chest
Volume 141, Issue 2, February 2012, Pages 528-544
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Postgraduate Education Corner
Contemporary Reviews In Sleep Medicine
Sleep-Related Problems in Neurologic Diseases

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There is a strong association between sleep-related problems and neurologic diseases. Neurologic diseases of the CNS can directly cause sleep problems when sleep-wake mechanisms associated with the ascending reticular activating system are involved. The major sleep disorders associated with neurologic problems are outlined in the International Classification of Sleep Disorders, 2nd edition, as hypersomnias of central origin, sleep-related breathing disorders, the insomnias, circadian rhythm sleep disorders, sleep-related movement disorders, parasomnias, and sleep-related epilepsy. In a patient with CNS disease and excessive sleepiness, sleep-related breathing disorders should be a first concern, given the known association between obstructive sleep apnea (OSA) and cerebrovascular disease and the potential confounding effects that OSA might have on an otherwise compromised ischemic CNS penumbra. A basic knowledge of the anatomy and physiology of the sleep-wake mechanisms provides a rationale for pharmacologic intervention. Nonpharmacologic treatments are also important, especially when sleep-related breathing disorders are a concern. In addition, as patients with neurologic diseases are often prone to the adverse effects of many medications, the specific treatment regimen for any given individual should always include good sleep hygiene practices that use cognitive behavioral therapy.

Section snippets

Hypersomnias of Central Origin

Hypersomnia is a primary complaint of excessive sleepiness. Neurologic problems affecting the CNS frequently directly cause dysfunction of central waking mechanisms (Table 1).2 Hypersomnia has been reported with a variety of neurodegenerative and genetic disorders, stroke, head trauma, encephalitis, and brain tumors.2, 3, 4, 5, 6 Wakefulness mechanisms that function through the ascending reticular activating system involve the brainstem, hypothalamus, basal forebrain, and the thalamus (Fig 1).3

Sleep Apnea

Sleep apnea has been associated with stroke, dementia, and encephalitis, especially when there is injury to central respiratory centers.3, 28, 29, 30, 31 Automatic respiration (subject to modulation by multiple CNS sites) depends on the medullary respiratory center, which is composed of the dorsal respiratory group (DRG) (the nucleus solitarius) and the ventral respiratory group (VRG) (includes the nucleus ambiguus) (Fig 4).28, 32, 33 Central sleep apnea has been documented after stroke

Insomnia Due to Medical Condition

Damage to CNS sleep centers can lead to insomnia (difficulties initiating and/or maintaining sleep) (Fig 5).3, 5, 51 In one study of 277 patients with new stroke, 18.7% suffered insomnia acutely, whereas 56.7% developed insomnia within 4 months after stroke.52 In another study of 336 stroke patients, insomnia was most prevalent with brain stem, frontal lobe, and basal ganglion lesions.53 The “sleep switch,” located in the preoptic area of the hypothalamus, uses the neurotransmitters

Circadian Rhythm Sleep Disorder Due to Medical Condition

The ICSD-2 definition of a circadian rhythm sleep disorder is based upon the existence of a persistent or recurrent sleep disturbance that is due to an alteration of systems that affect the timing of sleep. Nevertheless, to truly be considered a disorder, the problem must lead to a level of insomnia or excessive daytime sleepiness that impairs normal functioning.2

Restless Legs Syndrome and Periodic Limb Movements in Sleep

Restless legs syndrome (RLS) is a clinical diagnosis, whereas periodic limb movements during sleep (PLMS) require PSG documentation for accurate definition. RLS is clinically defined by the symptom acronym “URGE”: Urge to move the limbs, worst at Rest, relieved by attempts to Go (move the limbs), and most disturbing in the Evening.2 RLS can lead to insomnia, sleepiness, and problems with concentration, memory, motivation, anxiety, and depression. PLMS are found in up to 90% of patients with

The REM Sleep Behavior Disorder

RBD is a parasomnia: an undesired physical phenomenon during sleep, associated with CNS activation primarily evidenced as increased skeletal muscle activity.2 RBD occurs during REM sleep and is associated with violent dream (oneiric) behaviors, followed by arousals during which the patient describes dreams that parallel the observed behaviors (isomorphism).76 Up to 77.1% of patients with RBD report dream-related injuries, which include subdural hemorrhage.2, 76 Normally during REM (“paralyzed”

Sleep-Related Epilepsy

Nocturnal seizures can occur with elevated motor and autonomic activation, and as such the initial differential diagnosis can include “sundowning” and RBD.3, 76, 86 Analysis of the stereotypic behaviors during continuous, prolonged video-EEG monitoring using an extended montage can confirm the diagnosis.

Patients with cortical lesions from stroke, tumors, trauma, and dementia are prone to seizures. Epileptiform activity associated with generalized seizures tends to increase in non-REM (N) sleep,

Summary

There is a strong association between neurologic diseases and sleep problems, especially when there is injury to central sleep-wake mechanisms. A fundamental knowledge concerning the basic anatomy and physiology of these mechanisms provides a rationale for pharmacologic interventions. Nevertheless, nonpharmacologic treatments are important as these patients are often prone to the adverse effects of many routinely prescribed medications. Nonpharmacologic treatments include the use of CPAP and

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Dyken is a paid advisor on an advisory board for UCB, Inc and has been recently selected as a primary investigator for industry support research by NCGS, Inc. Although the following relationships have been dissolved, Dr Dyken, within the last three years, received grant monies for industry supported research from Merck and Cephalon and has been on speaker bureaus for Cephalon and

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