Archive for the ‘Hypersomnia’ Category

Treatment of Hypersomnias

This post focuses on treatment of the hypersomnias of central origin as defined in the second edition of the International Classification of Sleep Disorders (ICSD-2). Rational therapy begins with an understanding of the normal anatomy, physiology, and neurochemistry of central wake / sleep mechanisms. Basic Wake Systems The ascending reticular activating system, defined in part through Bremer's "isole" preparations and the early studies of Moruzzi and Magoun, promotes wakefulness through monoaminergic and cholinergic neurotransmitter systems. Monoaminergic elements include the hypothalamic histaminergic tuberomammillary nucleus and the brainstem noradrenergic locus coeruleus. The cholinergic system functions through the pedunculopontine / lateral dorsal tegmental nuclear complex and is composed of "rapid eye movement (rapid eye movement) sleep-off" and "rapid eye movement sleep-on" cells that are respectively most active during wakefulness and rapid eye movement sleep. The pedunculopontine / lateral dorsal tegmental nuclear has two waking pathways, leading to diffuse cortical projections. A ventral hypothalamic system excites the tuberomammillary nucleus and the orexin / hypocretin neurons in the perifornical lateral Read more [...]

Hypersomnia: Pharmacologic Therapy

Narcolepsy: Pharmacologic Therapy Recurrent Hypersomnias The recurrent hypersomnias described in the ICSD-2 are the Kleine-Levin syndrome and menstrual-related hypersomnia. Kleine-Levin Syndrome The Kleine-Levin syndrome was first described by Antimoff in 1898, detailed by Willi Kleine in 1925, clearly summarized by Max Levin in 1929, and formally named the Kleine-Levin syndrome by Critchley and Hoffmann in 1942. Originally described, and perhaps more common, in males, Kleine-Levin syndrome is characterized by periods of hypersomnia, hyperphagia, and encephalopathy, can last several weeks, and may recur up to 10 times a year. Spells tend to improve over four years, and rarely continue after 10 to 20 years. The neurologic examination (other than cognitive concomitants) and brain magnetic resonance imaging (MRI) are generally normal, but single photon emission computed tomography (SPECT) scans have shown reduced thalamic blood flow. Case reports of Kleine-Levin syndrome associated with head trauma, encephalitis, stroke, and reduced cerebrospinal fluid (cerebrospinal fluid) orexin / hypocretin levels support autopsy evidence of hypothalamic injury (although endocrinologic studies suggesting reduced hypothalamic dopaminergic Read more [...]

Narcolepsy: Pharmacologic Therapy

The Standards of Practice Committee of the American Academy of Sleep Medicine (AASM) provides a periodically updated list of medicines recognized for the treatments of hypersomnolence associated with narcolepsy. The list has included modafinil, amphetamines, and amphetamine-like drugs (methylphenidate), whereas sodium oxybate, non-sedating tricyclic antidepressants (TCAs, protriptyline), selective serotonin reuptake inhibitors (SSRIs, fluoxetine), and monoamine oxidase inhibitors (MAOIs, selegiline) have been suggested for the auxiliary symptoms of cataplexy, sleep paralysis, and hypnagogic / hypnopompic hallucinations (Table Medications Commonly Used in the Treatment of Narcolepsy). Table Medications Commonly Used in the Treatment of Narcolepsy Medications commonly used in the treatment of narcolepsy Usual adult daily doses (maximums) Medication class Major side effects Amphetamine 30 mg (100 mg) Stimulant, amphetamine Insomnia, restlessness, tachycardia, psychotic episodes, dizziness, diarrhea, constipation, hypertension, impotence Amphetamine (sustained release) 30 mg (100 mg) a a Methamphetamine 40 mg (80 mg) a a Methylphenidate 30 mg (100 mg) Stimulant, otherwise not defined Nervousness, Read more [...]

Hypersomnia: Nonpharmacologic Theory

Behavioral Therapy Good sleep hygiene is a mandatory part of treating hypersomnolence. It is a positive set of habitual sleep-related behaviors that involve exercise, appropriate diet (in regard to meal size, frequency, and composition), regular sleep-wake schedules, and a proper sleep environment (with optimal dark-light contrast and temperature and noise level control). Good sleep hygiene utilizes behavioral interventions that include cognitive, sleep restriction, stimulus control, and relaxation therapies. Specific strategies vary with diagnosis, symptom severity, health-related factors, and individual patient goals. Formal individualized counseling can minimize the overall impact of sleepiness, while maximizing an individual's strengths. Great benefits in home, academic, and occupational settings can be derived by learning a priority system to develop an organized, highly structured daily routine with well-defined and reasonably attainable goals, while avoiding monotonous and potentially hazardous tasks that include evening, night, shifting, and 24-hour work schedules. Behaviorally Induced Insufficient Sleep Syndrome The behaviorally induced insufficient sleep syndrome is due to voluntary, but unintentional, Read more [...]

Special Considerations for Treatment of Hypersomnias

Side Effects Of Treatment Adverse Effects of Treatment Drugs in Short-Term Use Adverse Effects of Treatment Drugs in Long-Term Use Age And Gender Effects Of Treatment There are no major age effects of treatment, with the exception of some recent reports regarding the possibility of sudden death in children and adolescents with cardiac disease who were taking dextroamphetamine. With respect to gender, family studies revealed no sex differences in the frequency of birth of patients with narcolepsy. In outpatient sleep clinics, however, male dominance is typically found. This may be due to the sex differences of social functioning. Social regulations are stricter for working male narcoleptic patients. Teratology studies performed in animals do not provide any harmful changes to the fetus. The use of tricyclics during the pregnancy of depressive patients did not increase teratology. However, narcoleptic pregnant women may prefer to discontinue or minimize the use of psychostimulants and tricyclics during pregnancy, especially in the early stages of pregnancy. Scheduled pregnancy is recommended. Cataplexy with sudden loss of facial as well as bodily muscle tone may produce awkwardness and despair more frequently in female Read more [...]

Adverse Effects of Treatment Drugs in Short-Term Use

Short-Term Use of Psychostimulants Psychostimulants, such as methylphenidate and dextroamphetamine, are effective in controlling the somnolence of narcolepsy. However, they often show side effects due to stimulation of the sympathetic nervous system. Constitutional factors may contribute to the development and severity of side effects. These include dry mouth, headache, palpitations, sweating, tremor, anorexia, gastritis, nausea, insomnia, irritation, and hyperactivity. The half-life of methylphenidate is approximately three to four hours, and administration twice a day, in the morning and at lunchtime, is recommended. Pemoline has a longer half-life of about 12 hours and can be used in one dose in the morning. It has less sympathetic nervous system stimulation and longer effectiveness as compared with methylphenidate. However, because of its association with idiosyncratic hepatic failure leading to transplantation or death, it is no longer available in the United States. Half-lives of amphetamine and methamphetamine are reported to be 8 to 20 hours. Development of paradoxical somnolence may occasionally appear, usually 15 minutes after ingestion of psychostimulants. Such somnolence usually lasts for less than half Read more [...]

Adverse Effects of Treatment Drugs in Long-Term Use

Long-Term Adverse Effects of Psychostimulants Psychostimulants have been used for many years for the treatment of narcolepsy. Adequate control of somnolence in the daytime is usually possible. However, this control is not always possible because of side effects and nonadherence. The awakening effects of psychostimulants should not be extended beyond evening meals to minimize remaining brain concentrations of the drugs at night to ensure a sound night's sleep. The most serious long-term side effect is the development of mental symptoms of psychosis, which are not very rare. Special attention for psychiatric symptoms is required for the patients under psychostimulant medication. Individual interviewing of patients should be done at least every two to three months to detect any pathological change of mental state as early as possible. Initial stages of a psychotic state are the ideas of observation and reference. Activation of hypnagogic hallucinations is another early change. If these initial signs are left unnoticed, development of auditory and / or tactile hallucinations with delusions in the daytime may ensue. In some patients, aggravation of preexisting schizophrenic psychosis may develop. On the other hand, intensified Read more [...]

Driving Risk And Medicolegal Aspects

A driver's license is typically suspended or revoked when the diagnosis of narcolepsy and / or sleep-related breathing disorders is established in some countries. However, the regulations vary from country to country, and are less severe in other countries. In the United States, the regulations differ by state, with California having the strictest regulations. When a physician identifies a narcoleptic patient, narcolepsy is classified as a disorder characterized by lapses of consciousness, and a confidential morbidity report is submitted to the state department of health services. The department of motor vehicles is notified, and a doctor's certification is indispensable to attest to the patient's ability to safely operate a motor vehicle before his or her driving privileges can be restored. The regulations on sleepy drivers vary among European countries. In the United Kingdom, an initial version of the regulatory document restricted the application of the regulation to "sleepiness leading to a sudden and disabling event at wheel." But this was later changed to "excessive awake time sleepiness." A sleep-related breathing disorder is not specifically mentioned, but "sleep disorders" appear in the section on respiratory Read more [...]

Other Considerations For Treatment: Psychosocial Problems Of Hypersomnia Patients

Special attention on the mental state of patients is always needed in the treatment of narcolepsy and hypersomnia. The major problem that disturbs the life of patients with these disorders is the daily recurrence of intolerable daytime sleepiness. The patients fail to remain awake at work, at home, during examinations, and while participating in recreational activities. Patients cannot maintain alertness even at very important occasions. A pitiful example of this behavior was described by one of my male narcoleptic patients, who mentioned that his girlfriend disappeared while he unintentionally slept at the movies. Because of daily, frustrating failures, narcoleptic patients often lose friendships and are often forced to change jobs. The patients often feel frustrated and depressed and become pessimistic about their future. But in the long run, the patients become much more accustomed to their sleepiness, and it becomes an accepted part of their daily life. However, a small proportion of narcoleptic patients may deny their sleepiness, even while the electroencephalogram (EEG) is showing sleep patterns. This is called the "denial of sleepiness" in narcolepsy and may indicate long-standing excessive sleepiness in the Read more [...]

Types of Hypersomnias

Somnolence is a complex state, impacted by multiple determinants such as quantity and quality of prior sleep, circadian time, drugs, attention, motivation, environmental stimuli, and various medical, neurological, and psychiatric conditions. Clearly, somnolence is welcomed when sleep is desired, but at other times often becomes an unwanted symptom. Pathological or inappropriate somnolence is clinically termed hypersomnia or excessive daytime sleepiness. Subjects with hypersomnia are unable to stay alert and awake during the major waking episodes of the day, resulting in unintended lapses into sleep. Sleepiness may vary in severity and is more likely to occur in boring, monotonous situations that require no active participation. In some cases, sleepiness is associated with large increases in the total daily amount of sleep without any genuine feeling of restoration. In other cases, sleepiness can be alleviated temporarily by naps but recurs shortly thereafter. In most cases, excessive sleepiness is a chronic symptom. It must occur for at least three months prior to diagnosis. In the second revision of the International Classification of Sleep Disorders (ICSD-2), hypersomnia of central origin was defined as a category Read more [...]