Aging of core and optional sleep.

Two consecutive 24-hr ambulatory recordings of 14 healthy elderly persons (7 women, 7 men, ages 88-102) and of 19 healthy young adults (10 women, 9 men, ages 25-35) were evaluated. In addition to the classical sleep parameter analysis, sleep structure was also analyzed in terms of a proposed distinction between "core" and "optional" sleep (Horne 1989). Core sleep is the essential part of the sleep and is mainly slow wave sleep. This type of sleep is composed of stages 3 and 4 on non-REM sleep (NREM 3-4). Core sleep is obtained during the first three sleep cycles and the remainder of the night sleep is considered optional sleep. Optional sleep is more altered than core sleep. However, in both optional and core sleep, NREM sleep and REM are reduced. There is also an increase in drowsiness and in the time spent awake after sleep onset; however, the extent of these effects are more obvious in elderly men. Aging effects of slow wave sleep probably represent an amplification of the changes as observed in awake electroencephalic (EEG) patterns in healthy seniors. The decrease in slow wave sleep (stages NREM 3-4) is gender related and prevails in elderly men. REM sleep diminishes with increasing age. In the elderly, most REM sleep occurs at the beginning of the night. This contrasts to younger persons where the duration of REM sleep is longer at the end of the night. Furthermore, a decrease in REM sleep latency is particularly obvious in elderly men and probably secondary to the curtailment of slow wave sleep. The ultradian NREM-REM cycle rhythm (as defined by the periodic occurrence of REM sleep) shows a monophasic trend suggesting a diminished adaptive function of aged sleep. The informative value of true, continuous ambulatory recordings in the assessment of sleep-wakefulness patterns in normal and pathological aging is stressed.

Toxic ictal delirium.

Delirium, also known as acute confusional state, is a common reversible organic psychiatric syndrome. This paper focuses on toxic delirium associated with prominent paroxysmal electroencephalogram (EEG) dysfunction occurring in nonepileptic patients. Our data derive from observations in two conditions, viz., delirium induced by hypnosedative drug withdrawal and confusion activated by psychotropic drug overdosage. It is suggested that in these conditions, delirium represents a generalized symptomatic nonconvulsive epileptic state following a transient transmitter dysfunction. Dramatic relief of both clinical and EEG dysfunction by intravenous benzodiazepines is reported in detail. Finally, the informative value of the EEG in the differential diagnosis of acute confusional states is emphasized.

Alternative electrode placement in (automatic) sleep scoring (Fpz-Cz/Pz-Oz versus C4-A1).

The purpose of this study is to investigate whether the international standard electrode placement (C4-A1) can be replaced by an alternative placement (Fpz-Cz/Pz-Oz) in an automatic sleep monitoring system without losing Rechtschaffen and Kales (R-K) balances. Single night-sleep polygraphic recordings of 10 patients, screened in a clinical sleep disorder setting, were recorded simultaneously with both placements, and visual sleep classification was performed separately by two independent observers. Interobserver and interplacement agreement were evaluated by way of average (dis)agreement matrices and kappa values computed for overall and individual stage scoring. Interobserver agreement for both the test and the standard electrode placements and interplacement agreement for both observers were assessed as fair to good or excellent. Scoring differences were evaluated by the rank sign test applied to clinical and theoretical difference scores. It appears that the interplacement differences are about equal to the interobserver differences, except for a slight tendency for sleep to be scored in a deeper stage with the proposed alternative placement. The data are presented and discussed in relation to current literature concepts.

Psychopathology in paraneoplastic encephalopathy: an electroclinical observation.

The psychopathologic, electroclinical, and pathologic signs in a patient suffering from paraneoplastic encephalomyelopathy are discussed. The occurrence of the syndrome is stressed since this topic is scarcely mentioned in the psychiatric literature. If mental disturbances are particularly prominent, as is often the case in limbic involvement, they may lead to referral to a psychiatric ward and even diagnostic error.

Ambulatory monitoring of sleep-wakefulness patterns in healthy elderly males and females (greater than 88 years): the "Senieur" protocol.

OBJECTIVE: The study was designed to investigate sleep-wake patterns in healthy elderly men and women (greater than 88 years) using ambulatory recording techniques. DESIGN: Cross-sectional observations on 2 consecutive days. METHODS: Two consecutive 24-hour recordings were made. Each 30-second period of the recording was scored as characteristic of wakefulness, REM, and non-REM sleep (stages 1-4). SETTING: Interviews and recordings were done in the home of the elderly, not interfering with the habitual routine. PARTICIPANTS: Among eligible members of the "Senieur" protocol, screened for wellness, seven females (88-102 years) and seven males (88-98 years) volunteered to participate. MAIN OUTCOME MEASURES: Organization of sleep, sleep structure, and daytime mapping. RESULTS: There was no difference between the first and second night recording. Important gender differences were observed: males had significantly less total sleep, shorter REM latency, more transitions to wake from REM, less NREM 3 sleep, and virtually no NREM 4. Daytime napping, REM amount, and distribution did not show sex differences. Although the variability in the amount of napping was considerable, it occupied less than 10 percent of the total sleep time in both women and men. Daytime napping was unrelated to sleep characteristics. CONCLUSIONS: Ambulatory sleep-wake recordings allow an objective and critical evaluation of sleep function in normal aging. Interesting findings include a shift of REM sleep to the first part of the sleep period an increased cycle variability, and non-correlation of night-time sleep with daytime napping. In contrast to earlier findings in elderly persons, a polygraphic and subjective first-night effect was lacking.

Ambulatory first night sleep effect recording in the elderly.

The concept of a first night effect on sleep patterns, specifically in relation to age is a controversial topic in the literature. Our data are obtained during two consecutive 24-h ambulatory home sleep-wake recording in 10 elderly persons with a mean age of 85.5 years. Polysomnographic recordings indicated that a first night effect is present in old age, even using home recording, and that several types of insomnia can be differentiated, stressing that sleep cycle parameters should be taken into account. It is suggested that the first night effect is a 'miniature' replication of a psychophysiological insomnia.

Ambulatory monitoring in sleep apnoea presenting with nocturnal episodic phenomena.

Episodic nocturnal phenomena represent a separate cluster of disturbances within the classification of sleep disorders. The reported case history covers paroxysmal signs occurring secondary to a REM-dependent mixed sleep apnoea syndrome. The pathophysiology of similar episodes in elderly (non)epileptic patients is discussed. Ambulatory monitoring is an appropriate technique for investigation if respiratory and motor activity, and EEG and ECG are recorded simultaneously.

The EEG in chronic alcoholism.

The EEG has only rarely been considered in discussions on psychosis in alcoholism. The main topic of this paper is the question whether the EEG is capable of revealing elements for elucidating the pathophysiology of some of the psychotic conditions or symptoms occurring in alcoholism. Although EEG abnormalities are a-specific in nature and no particular EEG signs may be consistent with psychosis, some types of EEG patterns are more frequently observed in certain clinical conditions such as delirium tremens and amnestic-confabulatory states. Taking these 'common' EEG-patterns into account, it may be possible to use the EEG as a diagnostic tool in differentiating between clinical psychopathological syndromes. The pathogenetic importance of tissue hypoxidosis for the development of psychosis in alcoholism is discussed.

Para-infectious encephalopathies in childhood. EEG-aspects and familial occurrence.

The authors report on infectious-allergic encephalopathy, occurring in a nine-year old boy. The clinical picture is that of a generalized myoclonic epileptic state. The EEG shows bilaterally occurring stereotyped rhythmic complexes with a short interval. The child recovered completely. The diagnostic value of periodically occurring EEG-features and the familial occurrence of para-infectious encephalopathies are discussed.

Sleep and the temporal lobe.

The main interest in the association between sleep and temporal lobe dysfunction is based on the activation of ictal and interictal epileptic phenomena. The clinical semiology of NREM and REM parasomnias may resemble complex partial seizures. The differentiation between epilepsy and dissociated states of wakefulness and sleep is of high diagnostic and therapeutic importance. Systems within temporal lobe structures are also responsible for disturbed sleep or dyssomnia. The limbic brain is connected with different nodal points in the network underlying sleep organisation and participates in both sleepinducing and arousal mechanisms. Experimental amygdala kindling, an animal epilepsy model involving temporal structures, induces disturbed sleep patterns favouring waking and light sleep. In epilepsy unstable disrupted and superficial sleep patterns prevail without overt seizures. Sleep-fragmentation and deprivation may impair daytime functioning and cognitive performance by lowering the seizure-threshold. The recognition of dyssomnia and of excessive sleepfragmentation and sleepiness has obvious implications for behavioural and drug treatment.

VPA syrup in childhood epilepsy. Results of an international clinical multicentre trial.

The anticonvulsive effectiveness of VPA syrup is evaluated in an international open phase III clinical trial. The study includes 96 childhood epilepsies and encompasses a rather heterogeneous test population regarding type of epilepsy and/or seizures. Clinical results stress the good therapeutic outcome in single drug treatment, regardless of the underlying epileptic syndrome, seizure type or serum concentration. Therapeutic failure is more often associated with combined drug treatment, symptomatic generalized epilepsies and serum levels below the therapeutic range. The anticonvulsive spectrum, tolerance and dose/level ratio are comparable with the characteristics of the drug's other galenic forms.

Facilitation of early and masking of late cortical responses in dementia.

Topographic differences in longlatency SSEP and flash VEP data are compared in 3 different psychiatric patient groups. Differences between schizophrenia and affective disorder are restricted to somatosensory P100 amplitude gradients along the antero-posterior axis. In contrast EP-differences between psychiatric patients and dementia are prominent, encompassing both late and early (< 100 ms) responses. Our flash P 2 and somatosensory P 3 data are in accordance with previous findings. Multi-modal positive responses with a latency of 40-80 ms are significantly increased in dementia. This facilitation suggests cortical dysfunction and/or subcortical gating impairment.

Impaired early visual processing in disorganised schizophrenia.

Topographic differences in flash/pattern shift VEP data are evaluated in paranoid (n: 38), disorganized (n: 23) and residual (n: 23) schizophrenic subtypes and compared to normal controls. Increased early P1 and a restricted diffusion of the late P2 responses suggest dopaminergic over- and cholinergic underactivity in paranoid and residual schizophrenia. A distinctive pattern N145 reflects well-preserved attentional resources in the paranoid subtype. Latency increase and amplitude decrease of the pattern N145 concur with abnormal antisaccades documented in disorganized behaviour. VEP-data might help differentiate between schizophrenic subtypes.

EEG dysfunction in geropsychiatry.

Electro-clinical correlations are reported in 200 elderly patients admitted to a psychiatric ward of a general hospital. Normal EEG characteristics were generally associated with functional psychiatric disorder. Abnormal EEG features correlated with organic brain syndromes (O.B.S.). The diagnostic and pathogenetic considerations and restrictions of EEG foci, intermittent rhythmic delta activity (Irda) and diffuse EEG slowing are discussed. The informative value of EEG dysfunction in geropsychiatry is emphasised.