REM Sleep Behavior Disorder

[Zenman1]

I recently saw a 40 year old male who reported dreams so vivid and realistic that he was having difficulty telling the difference between dreams and reality. His dreams started in his teens and have become more realistic over the last 2 months. By more realistic he says the dreams are more personal and now involve familiar settings. He has had a ninja figure approach him, grab him by the shoulders, shake him violently, then throw him in the air where he spun around in circles. He had awake sex with his wife once but then started dreaming (?) that he was changing the tires on his car. He endorsed the following:

Hypersomnia, snoring, nightmares, bruxism, waking with headaches and dry mouth, sleep paralysis, terminal insomnia 50% of the time, periods of apnea, talking and yelling in his sleep for last 2 years, RLS, hypnopompic hallucinations, sexsomnia, and probable narcolepsy.

I tacked on REM Sleep Behavior Disorder since there was no note about it in any of his records. When I received records from his pulmonary consult I see they did diagnose possible REM Sleep Behavior Disorder. Pulmonary had already started him on Klonopin and I increased it to 2 mg QHS, started Melatonin 3 mg, and increased the Lexapro 10 mg he had been on for about 5 months to 20 mg due to worsening depression. Other meds are Pregabalin 100 mg tid and Synthroid 112 mcg daily.

In Sept 2014 he started having difficulty “getting my words out.” This has improved somewhat.

In Dec 2014 he woke with the “worse crushing pain” in his chest and abdomen, felt nauseated, went to the toilet and passed out. His wife reported he was out for 30 minutes and his entire body was jerking. When he regained consciousness he felt paralyzed for 30 minutes but could understand clearly everything his family and paramedic were saying. He and his family think he had a stroke. I had never seen him before but there did seem to be a slight droop at corner of his mouth.

In Jan his MRI was unremarkable and his neurologist diagnosed him with persistent speech difficulty; isolated nocturnal seizure, non-recurrent; headaches; h/o concussion; apneic spells; and neck and back pain.

Cardiology saw him in May and did a heart cath. He was diagnosed with L anterior fascicular block; Incomplete RBBB; and unexplained ST to 150 bpm while sleeping.

He complained of some long and short-term memory problems, decreased skill at puzzles and visualizing how projects go together, and “my mind can’t keep up.” He scored 29 on MMSE, however.

He had a sleep study in 2013 that indicted Sleep Disturbance, unspecified, hypersomnia with early onset stage 1 sleep, and snoring. Another study was done in April of this year with impression of snoring and PLMD. Pulmonary requested PSG and MSLT this month but it was denied.

My question, after all the above, is your opinion on whether another sleep study is warranted. I feel it is and would like others thoughts before I try submitting another request. Any other thoughts/recommendations also appreciated.

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[st2205]

What are you looking to get out of another sleep study?

 

[Shikima]

Yes, it's warranted especially since he has documented OSA which isn't being treated. I'd shake that down first, remove BZD while on PAP therapy. Optimize seizure treatment with optimization of CPAP - if there is a next study, it would need a seizure montage. Not a lot going on in terms of explaining that he as Narcolepsy, rather other plausible conditions to explain it all going on.

Would do well with sequential diagnostic studies.

 

[nitemagi]

Other things to think about for the ddx -
TBI, DLB, Kleine-Levin (mostly adolescents but can occur in older men), workup for orthostasis (can mimic SZs). Check family history, travel history, toxin and infectious exposure.

I agree the sleep study would only be useful if you know what you're looking for, which might be progression since his presentation has changed since 2013.

 

[strangeglove]

Sounds like the Klonopin worsened his condition in the ways that Klonopin often does.

 

[st2205]

Sounds like the Klonopin worsened his condition in the ways that Klonopin often does.

"Klonopin is the only thing that works, Doc!"

 

[birchswing]

"Klonopin is the only thing that works, Doc!"

Why is that the sentiment when the OP says she/he's the one who increased the dose?

I obviously can't speak to the larger picture, but I agree with the previous assessment that Klonopin would present with a lot of the symptoms that emerged after the patient started taking it. Klonopin can cause a depressed state along with the memory and other cognitive issues. I went from Ativan in high school to a psychiatrist who switched me to Klonopin in college and deteriorated quickly on it. I would show up places at the wrong times and people around me thought I was high. That psychiatrist then added Ativan on top of the Klonopin until I dropped out of college and was taken off Klonopin but had the Ativan increased. While I will never argue in support of Ativan, it did not cause the same extent of impaired cognition and depression that Klonopin did.

 

[Zenman1]

"Klonopin is the only thing that works, Doc!"

Problems started before Klonopin. Klonopin is also recommended for REM sleep behavior disorder.

 

[xlithiumx]

Problems started before Klonopin. Klonopin is also recommended for REM sleep behavior disorder.

Amen. It's not only indicated, it's just about the only treatment that works. There is some evidence out there for melatonin and pramipexole, but really clonazepam is gold standard treatment of RSBD.

 

[strangeglove]

Amen. It's not only indicated, it's just about the only treatment that works. There is some evidence out there for melatonin and pramipexole, but really clonazepam is gold standard treatment of RSBD.

Sure, but that doesn't mean that Klonopin isn't making THIS patient worse. His history would suggest that it is not helping.

 

[Shikima]

I'd question the diagnostic methods in how they arrived at this diagnosis.

 

[whopper]

The clonazepam could be justified (though in most sleep disorders it's not). But in the case presentation the writer wrote REM sleep disorder was a possibility. It could be the patient doesn't have this disorder at all in which case it'd be a very poor choice as a sleep med.

A pet-peeve of mine is to see someone with a disorder and a psychiatrist tries to treat the disorder with something that is not warranted, coming with some non-evidenced based argument such as "I'm an artist, the medications are my paint, and the patient is my canvass." (I kid you not someone actually told this to me. Not surprisingly all of her patients were over-medicated with regimens that really didn't do much to improve them and made many of them worse).

The apnea needs to be treated appropriately. I assume it's OSA. Sleep meds with OSA aren't the first-line recommendation and in general aren't recommended.

This patient has a heck of a lot more problems than his sleep. I'd work with the other docs treating his physical conditions. His sleep, while important, isn't the highest priority here unless it's severely bad.

MMSE of 29 could still be a stroke and there still could be a cognitive loss especially if his mental cognition was extremely high functioning. E.g. a physics professor can't do his work anymore but could still score a 30 on the MMSE for several months maybe even years while being in the early stages of dementia.

 

[michaelrack]

When in doubt, pressurize the snout


(with CPAP settings determined by a qualified sleep physician)

 

[heyjack70]

Psychological testing for memory disorders and personality inventory. Strange mix of symptoms. Could be conversion disorder. What is the risk with lexapro in patient's with cardiac disease and increased risk for arrhythmia? Anecdotal concerns, or should this patient be switched to an alternate antidepressant?

 

[michaelrack]

What is the risk with lexapro in patient's with cardiac disease and increased risk for arrhythmia? Anecdotal concerns, or should this patient be switched to an alternate antidepressant?

don't think it is much of a concern, but it would be reasonable to check an EKG to monitor QTc

 

[smalltownpsych]

I recently saw a 40 year old male who reported dreams so vivid and realistic that he was having difficulty telling the difference between dreams and reality. His dreams started in his teens and have become more realistic over the last 2 months. By more realistic he says the dreams are more personal and now involve familiar settings. He has had a ninja figure approach him, grab him by the shoulders, shake him violently, then throw him in the air where he spun around in circles. He had awake sex with his wife once but then started dreaming (?) that he was changing the tires on his car. He endorsed the following:

Hypersomnia, snoring, nightmares, bruxism, waking with headaches and dry mouth, sleep paralysis, terminal insomnia 50% of the time, periods of apnea, talking and yelling in his sleep for last 2 years, RLS, hypnopompic hallucinations, sexsomnia, and probable narcolepsy.

I tacked on REM Sleep Behavior Disorder since there was no note about it in any of his records. When I received records from his pulmonary consult I see they did diagnose possible REM Sleep Behavior Disorder. Pulmonary had already started him on Klonopin and I increased it to 2 mg QHS, started Melatonin 3 mg, and increased the Lexapro 10 mg he had been on for about 5 months to 20 mg due to worsening depression. Other meds are Pregabalin 100 mg tid and Synthroid 112 mcg daily.

In Sept 2014 he started having difficulty “getting my words out.” This has improved somewhat.

In Dec 2014 he woke with the “worse crushing pain” in his chest and abdomen, felt nauseated, went to the toilet and passed out. His wife reported he was out for 30 minutes and his entire body was jerking. When he regained consciousness he felt paralyzed for 30 minutes but could understand clearly everything his family and paramedic were saying. He and his family think he had a stroke. I had never seen him before but there did seem to be a slight droop at corner of his mouth.

In Jan his MRI was unremarkable and his neurologist diagnosed him with persistent speech difficulty; isolated nocturnal seizure, non-recurrent; headaches; h/o concussion; apneic spells; and neck and back pain.

Cardiology saw him in May and did a heart cath. He was diagnosed with L anterior fascicular block; Incomplete RBBB; and unexplained ST to 150 bpm while sleeping.

He complained of some long and short-term memory problems, decreased skill at puzzles and visualizing how projects go together, and “my mind can’t keep up.” He scored 29 on MMSE, however.

He had a sleep study in 2013 that indicted Sleep Disturbance, unspecified, hypersomnia with early onset stage 1 sleep, and snoring. Another study was done in April of this year with impression of snoring and PLMD. Pulmonary requested PSG and MSLT this month but it was denied.

My question, after all the above, is your opinion on whether another sleep study is warranted. I feel it is and would like others thoughts before I try submitting another request. Any other thoughts/recommendations also appreciated.

Neuropsych testing might be helpful. Also, psychotherapy can often help a case like this, but you have to frame it carefully since this patient is probably resistant to psychological interpretations. I usually tell patients that I will be helping them cope with the physical ailment as opposed to saying that your psychological distress could be causing your physical ailment. Interstingly enough as I am helping them cope with their chronic gastric pain, back pain, misc complaints, etc.; they often start to go away. That is if I can truly engage them in therapy which is easier said than done.

edited to add: I would still continue treating and evaluating the medical complaints, as well. Never forget that hypochondriacs get sick too. A lot of the medical docs overlook our patients' physical complaints too often.

 

[Zenman1]

I'd question the diagnostic methods in how they arrived at this diagnosis.

Which diagnosis?

 

[thoffen]

I'm certainly NOT a sleep expert, but you're describing a person that seems to have excessive daytime sleepiness with restless sleep at night. Additionally has several symptoms related to disordered REM sleep, but more in particular REM sleep that is close to wakefulness (hypnopompic -- perhaps you meant hypnagogic which would be more typical -- hallucinations, sleep paralysis, sleep sex). All of these are basically the definition of narcolepsy without cataplexy. The diagnostic test of value is a multiple sleep latency test, not a standard sleep study. Of course the apnea needs treating too.

 

[Shikima]

Which diagnosis?

Just read what whopper et al have written. Too many vague statements and possibilities leading to mass confusion. Being academic and arriving at correct diagnoses using defined criteria will be helpful with treatment.

 

[michaelrack]

I'm certainly NOT a sleep expert, but you're describing a person that seems to have excessive daytime sleepiness with restless sleep at night. Additionally has several symptoms related to disordered REM sleep, but more in particular REM sleep that is close to wakefulness (hypnopompic -- perhaps you meant hypnagogic which would be more typical -- hallucinations, sleep paralysis, sleep sex). All of these are basically the definition of narcolepsy without cataplexy. The diagnostic test of value is a multiple sleep latency test, not a standard sleep study. Of course the apnea needs treating too.

MSLT wouldn't be valid until the apnea was treated

 

[thoffen]

MSLT wouldn't be valid until the apnea was treated

See, told you I wasn't a sleep expert!

 

[Zenman1]

Finally received neuropsych report. Moderate impairment in attention and concentration marked by distractibility, slow reaction time, and poor sustained attention with intact performance in all other areas of neuropsych functions. DX: Attention deficit disorder, probably secondary to the burn out syndrome (heck, I have that all the time) and MDD.

 

[birchswing]

Finally received neuropsych report. Moderate impairment in attention and concentration marked by distractibility, slow reaction time, and poor sustained attention with intact performance in all other areas of neuropsych functions. DX: Attention deficit disorder, probably secondary to the burn out syndrome (heck, I have that all the time) and MDD.

Klonopin would not help with MDD or cognitive performance and might skew those results, as would the apnea.

I know someone's going to say he's not a doctor, so I'll say it again: I'm not a doctor. It's underneath my screen name on the thing to the side.

 

[nitemagi]

Finally received neuropsych report. Moderate impairment in attention and concentration marked by distractibility, slow reaction time, and poor sustained attention with intact performance in all other areas of neuropsych functions. DX: Attention deficit disorder, probably secondary to the burn out syndrome (heck, I have that all the time) and MDD.

Those are all findings consistent with sleep deprivation.

 

[shan564]

I feel like anybody with REM sleep behavior disorder warrants following with a specialist, unless you find an obvious cause. At least half the patients I've seen with a REM sleep behavior disorder (note, that's probably only n=5 or 6) have turned out to have Parkinson's disease or DLB or some sort of problem with dopaminergic deficit - especially since this person also has RLS and visuospatial deficits. Visuospatial deficits with normal MMSE combined with RSBD and RLS make me think about early DLB or something similar to that.

I'll bet this patient has a disorder that we haven't discovered yet. I understand that we usually use Klonopin for isolated RSBD, but when there's a bunch of other neuropsychiatric stuff going on, I'd lean toward pramipexole just because I feel like he has something wrong with his dopaminergic systems. It's just a hunch, but I feel like treating him with something dopaminergic will correct something that's broken somewhere.

That said, I probably wouldn't actually start him on anything for the RSBD without talking to his neurologist, who has probably already played the "where's the pathology" game, since that's what neurologists love to do. The language problems make me wonder if there's something more complicated going on.

I'd also guess that the cardiology stuff is a red herring and that the OSA is blurring the sleep picture.

I'd want to know if his mathematical abilities have changed recently. That's another indicator of early DLB.

 

[AcronymAllergy]

I feel like anybody with REM sleep behavior disorder warrants following with a specialist, unless you find an obvious cause. At least half the patients I've seen with a REM sleep behavior disorder (note, that's probably only n=5 or 6) have turned out to have Parkinson's disease or DLB or some sort of problem with dopaminergic deficit - especially since this person also has RLS and visuospatial deficits. Visuospatial deficits with normal MMSE combined with RSBD and RLS make me think about early DLB or something similar to that.

I'll bet this patient has a disorder that we haven't discovered yet. I understand that we usually use Klonopin for isolated RSBD, but when there's a bunch of other neuropsychiatric stuff going on, I'd lean toward pramipexole just because I feel like he has something wrong with his dopaminergic systems. It's just a hunch, but I feel like treating him with something dopaminergic will correct something that's broken somewhere.

That said, I probably wouldn't actually start him on anything for the RSBD without talking to his neurologist, who has probably already played the "where's the pathology" game, since that's what neurologists love to do. The language problems make me wonder if there's something more complicated going on.

I'd also guess that the cardiology stuff is a red herring and that the OSA is blurring the sleep picture.

I'd want to know if his mathematical abilities have changed recently. That's another indicator of early DLB.

In this particular case, with a 40 y/o patient with the above-reported symptoms and a normal neuropsych other than some attention blips, it doesn't throw up my DLB flags (although I'd agree that with the patients I see, RSBD almost always does add DLB to my differential). The visualization deficits described by the patient don't necessarily strike me as uniquely visuospatial; with that neuropsych profile, could very well just be due to attention difficulties. Without the neuropsych data, they could also be related to executive dysfunction, or just general disorganization secondary to chronic sleep deprivation.

It's an interesting case and does make me wonder if there's something other than "just" the OSA and other sleep issues.

 

[splik]

RBD usually means your brainstem is rotting. brainstem rot often means synucleinopathy as shan describes. often RBD can predate the development of frank parkinson's by 20 or 30 years...

 

[Shikima]

Those are all findings consistent with sleep deprivation.

And using BZD would restrict REM sleep thus further contributing to the worsening of sleep deprivation because sleep architecture has been altered.

 

[Shikima]

RBD usually means your brainstem is rotting. brainstem rot often means synucleinopathy as shan describes. often RBD can predate the development of frank parkinson's by 20 or 30 years...

I've caught a few early cases of PD because of screening for parasomnias.