The Massachusetts General Hospital Handbook of Neurology

Authors: Flaherty, Alice W.; Rost, Natalia S.

Title: Massachusetts General Hospital Handbook of Neurology, The, 2nd Edition

Copyright 2007 Lippincott Williams & Wilkins

> Table of Contents > Adult Neurology > Sleep Disorders and Fatigue

Sleep Disorders and Fatigue

A. See also

Table 28, p. 105.

B. H&P

Distinguish sleepiness that stems from insomnia or sleep deprivation from fatigue from meds or illness. Ask about sleep latency, daytime sleeping, medications, snoring, scratchy throat in AM, cataplexy, sleep paralysis, trouble with initiating vs. maintaining sleep, movements in bed.

C. Insomnia

• 1. DDx: Pain, anxiety, depression, bad sleep hygiene, alcohol or tranquilizer dependence, medications (steroids, -blockers, etc.), nocturnal movement disorders, occasionally sleep apnea or midbrain damage.

• 2. Acute rx: In the elderly, use the lowest, shortest acting dose.

  • a. Nonbenzodiazepine GABA receptor drugs: E.g., zolpidem 5-10 mg. Little addiction, short half-life.

  • b. Benzodiazepines: Good for comorbid anxiety, but rapid tolerance. Avoid these, esp. in elderly pts.

  • c. Melatonin agonists: Melatonin itself soon habituates. Ramelteon 8 mg is nonaddictive; effects last ~8 h.

  • d. Sedating antidepressants: Trazodone: 25-50 mg PO qhs; doxepin: 25-50 mg PO qhs.

  • e. Sedating antihistamines: E.g., diphenhydramine 25-50 mg. Rapid habituation.

• 3. Chronic rx: Stop caffeine, alcohol, offending meds; retire and rise at same time every day; no reading in bed. Consider zolpidem or ramelteon, but cognitive-behavioral therapy may work better than medications.

D. Shift work syndrome and sleep deprivation

• 1. H&P: Flight attendant? Hospital resident? etc.

• 2. R/o mood disorder: Depression and mania can be both cause and effect of odd sleep cycles.

• 3. Rx:

  • a. Maintain constant wake time: Sleep time is less important. This means waking early on weekends to avoid Monday jet lag.

  • b. Light box therapy: 10,000 lux for 30 min, as early in AM as possible. Small boxes are fine (e.g., SunLight Jr., sunbox.com); they fit better beside the computer or box of Cheerios (generalmills.com), and user need not stare at light.

  • c. Drugs:

    • 1) Avoid: Alcohol, stimulants. Caffeine, dexedrine, methylphenidate can cause rebound hypersomnolence that leaves pt. more tired.

    • 2) Consider: Modafinil. More helpful at noon than in AM. Not a substitute for sleep. Do not self-prescribe.

P.113

E. Excessive sleepiness

• 1. DDx: Sleep deprivation, depression, drugs, metabolic disorder.

• 2. Tests: Overnight sleep-EEG study.

• 3. Sleep apnea: Cessation of breathing during sleep.

  • a. Obstructive apnea: If severe, can cause pulmonary hypertension, arrhythmia. Treat with d/c of sedatives, weight loss, AM/noon modafinil 100-200 mg, nightly CPAP.

  • b. Central apnea: From brainstem lesions, dysautonomias, neuromuscular dz. May require tracheostomy.

• 4. Narcolepsy: Lifelong disorder of REM sleep architecture.

  • a. Sx: Frequent daytime sleep attacks, episodes of cataplexy (hypotonia), and more nonspecific signs of sleep deprivation, e.g., sleep paralysis, hypnagogic hallucinations.

  • b. Rx: For sleepiness, modafinil 200 mg q AM/noon has less habituation than methylphenidate 5 mg q AM and noon. For cataplexy: TCAs, e.g., imipramine 25 mg tid.

F. Nocturnal movement disorders

• 1. DDx: Hypnagogic jerks (benign, single), nocturnal seizures (often at REM transitions), akathisia .

• 2. Restless leg syndrome (RLS): While resting but still awake, pt feels an urge to move legs to remove creepy feeling (not really pain). Rx: DA agonists, e.g., ropinirole (raise slowly to ~2 mg qhs).

• 3. Nocturnal myoclonus: While sleeping, pt has rhythmic leg jerking that may awaken him. May occur in combination with restless leg syndrome. Try clonazepam.

• 4. Periodic limb movements of sleep (PLMS): Rhythmic leg jerk, may awaken pt. Often with RLS. Try clonazepam, ropinirole.

G. Parasomnias

• 1. REM behavior disorder: Loss of normal REM atonia; pt acts out his dreams. Associated with alcohol. Treat with safety precautions, clonazepam 0.5-2 mg.

• 2. Sleep walking: Occurs during non-REM sleep. Try clonazepam.