An Unusual Case of Drunk Driving in Japan: Alcohol-Related Sleepwalking.

Alcohol has been identified as a potential precipitating factor for parasomnia, particularly sleepwalking (SW). We report an unusual case of a Japanese drunk driver who may have experienced alcohol-related SW, based on the statements of the suspect, pharmacokinetic analyses of the suspect's breath alcohol concentration, testimonies of witnesses, driving recorder data, and medical records. The existence of sleep-related criminal acts performed while a suspect experiences memory loss under the influence of alcohol has not been sufficiently recognized, and awareness of such acts should be raised among the police, public prosecutors, and the general public in Japan.

Parasomnia overlap disorder with adolescent-onset presumed REM sleep behavior disorder converting to Parkinson's disease after 48 years.

BACKGROUND: It is now recognized that the vast majority of individuals with typical RBD will develop a synucleinopathy; usually 11-16 years after symptom onset. Parasomnia Overlap Disorder (POD) with adolescent-onset dream enactment behavior with phenoconversion to neurodegenerative disease after a long latency has not been previously described. PATIENT: We present a case of a 65-year-old man with presumptive POD who had co-morbid childhood onset sleep walking and adolescent-onset dream enactment behavior beginning at age 17, with subsequent evolution to an increasingly troublesome REM sleep behavior disorder (RBD) at age 64 with Parkinson's Disease (PD) developing a year later. RESULTS: Polysomnography performed at age 64 was consistent with a diagnosis of RBD. Dream enactment behavior preceded PD diagnosis by at least 48 years. Our case represents the youngest reported RBD case who developed PD. CONCLUSIONS: We report the first case of adolescent onset, presumed RBD in the context of presumptive POD developing neurodegenerative disease. Adolescent-onset RBD may have similar prognostic implications as typical RBD, where future phenoconversion to a synucleinopathy is expected.

Medication induced sleepwalking: A systematic review.

Medications that trigger sleepwalking may inadvertently put the patient at risk of injury to themselves and/or others, and contribute to poor treatment adherence. The aim of this study was to systematically review the literature to identify drugs that may increase the risk of sleepwalking. A search of CINAHL, EMBASE, PsycINFO, PubMed, and ScienceDirect was conducted with the keywords 'sleepwalking' OR 'somnambulism'. Of the original 83 sourced papers, 62 met the inclusion criteria and were subsequently included for review. Twenty-nine drugs, primarily in four classes-benzodiazepine receptor agonists and other gamma aminobutyric acid (GABA) modulators, antidepressants and other serotonergic agents, antipsychotics, and ß-blockers-were identified as possible triggers for sleepwalking. The strongest evidence for medication-induced sleepwalking was for zolpidem and sodium oxybate. All other associations were based on case reports. This research highlights the importance of considering sleepwalking in risk profiles in clinical trials, particularly for drugs that enhance GABA activity at the GABAA receptor, enhance serotonergic activity, or block the activity of noradrenaline at ß receptors. The results also have implications for prescribers to consider sleepwalking as a potential adverse effect and ensure that: 1) the patient is educated about a safe sleep environment; 2) they are encouraged to report the onset or exacerbation of sleepwalking, and 3) alternative treatments are considered if sleepwalking occurs.

Adult-Onset Sleepwalking Secondary to Hyperthyroidism: Polygraphic Evidence.

ABSTRACT: Sleepwalking is a disorder characterized by complex motor behaviors arising from slow wave sleep usually occurring in children. The adult onset of sleepwalking suggests the presence of an external precipitating factor leading to the occurrence of the disorder. Hyperthyroidism has been reported to be the possible cause of sleepwalking in a few cases. We present the case of a 36-year-old man who reported a sudden appearance of nocturnal episodes of sleepwalking. He underwent a complete video polysomnography (VPSG), which showed a polygraphic pattern arising from stage N3 sleep related to the presence of simple motor behaviors. Routine blood tests showed a mild hyperthyroidism. After 4 months of thyrostatic treatment, the patient reported no more sleepwalking events. A VPSG performed at the last follow-up showed the absence of pathological electroclinical events arising from stage N3 sleep. Therefore, we hypothesize that there is a link between sleepwalking and thyroid dysfunction in our patient.

Demographic, Clinical and Polysomnographic Characteristics of Childhood- and Adult-Onset Sleepwalking in Adults.

BACKGROUND: Sleepwalking (SW) is found to affect children predominantly, but it can persist or appear de novo even among adults. In this study, we assessed the demographic, clinical and polysomnographic profile, trigger factors and associated comorbidities of adult-onset (AO-SW) and childhood-onset (CO-SW) adult sleepwalkers. METHODS: In adult sleepwalkers, a structured clinical interview, a battery of questionnaires, video-polysomnography (v-PSG) and standard electroencephalography (EEG) were performed. RESULTS: Among 63 sleepwalkers, 45% had ≥1 episodes/month, 54% had partial recall of the episodes and 36% reported trigger factors for SW. Almost all subjects reported co-occurring parasomnias. In v-PSG, 4% exhibited episodes of SW, 17% confusional arousals, 21% had an increased apnea-hypopnea-index and 6% exhibited features of an overlap parasomnia disorder. In our cohort, 73% reported CO-SW and 27% AO-SW. In subjects with AO-SW, positive family history for parasomnias was found in 33% (vs. 49% in CO-SW), neurological comorbidities in 44% (vs. 14%), psychiatric comorbidities in 25% (vs. 33%), EEG abnormalities in 50% (vs. 29%). Violence during SW episodes was more frequent in males and in subjects with CO-SW (45% for self-injury and 44% for violent behaviour vs. 33 and 29% respectively in the AO-SW group). CONCLUSIONS: Adult SW represents a complex and potentially dangerous condition. The characteristics of AO-SW often differ from those of CO-SW.

[REM-sleep behavior disorder and sleepwalking in a patient with Parkinson's disease and essential tremor]. / Rasstroistvo povedeniia v faze bystrogo sna i snokhozhdenie u patsienta s nachal'noi bolezn'iu Parkinsona i éssentsial'nym tremorom.

REM-sleep behavior disorder (RBD), a form of parasomnia, is characterized by motor and/or speech activity during sleep corresponding to the dream content. RBD is currently considered as a marker of onset of neurodegenerative diseases (sinucleinopathies) and as a most specific early symptom of Parkinson's disease (PD). The authors describe a clinical case of a patient with the combination of essential tremor, initial signs of PD and RBD. A polysomnographic study has confirmed clinical signs of RBD and determined the disturbances of sleep architecture: the increase in falling asleep, number of awakenings, wakefulness during sleep, the absence of deep slow-wave sleep. The particular features of the patient were essential tremor and sleep walking.

Sleepiness in sleepwalking and sleep terrors: a higher sleep pressure?

OBJECTIVE: To identify the determinants of excessive daytime sleepiness in adults with sleepwalking or sleep terrors (SW/ST). METHODS: We collected the charts of all consecutive adult patients admitted from 2012 to 2014 for SW/ST. They had completed the Paris Arousal Disorders Severity Scale and the Epworth Sleepiness Scale, and had undergone one (n = 34) or two consecutive (n = 124) nocturnal videopolysomnographies. The demographic, clinical, and sleep determinants of excessive daytime sleepiness (defined as an Epworth Sleepiness Scale score of greater than 10) were analyzed. RESULTS: Almost half (46.8%) of the 158 adult patients with SW/ST reported excessive daytime sleepiness. They had shorter sleep onset latencies (in night 1 and night 2), shorter REM sleep latencies, longer total sleep time, and higher REM sleep percentages in night 2, but no greater clinical severity of the parasomnia than patients without sleepiness. The level of sleepiness correlated with the same measures (sleep onset latency on both nights, REM sleep onset latency, and total sleep time in night 2), plus the latency to N3. In the regression model, higher sleepiness was determined by shorter sleep onset latency on night 1, lower number of awakenings in N3 on night 1, and higher total sleep time on night 2. CONCLUSION: Daytime sleepiness in patients with SW/ST is not the consequence of disturbed sleep but is associated with a specific polygraphic phenotype (rapid sleep onset, long sleep time, lower numbers of awakenings on N3) that is suggestive of a higher sleep pressure that may contribute to incomplete arousal from N3.

The course and character of sleepwalking in adulthood: a clinical and polysomnographic study.

To describe characteristics of adult sleepwalking (potential triggers and correlates with polysomnography), 52 patients were interviewed regarding their sleepwalking episodes and underwent video-polysomnography on two consecutive nights. Sleepwalking history averaged 12 years and frequent episodes (more than once per week) occurred in 62%. Higher frequency was associated with earlier onset of sleepwalking (p < 0.005) and 53.8% reported dangerous sleepwalking behavior. The most common self-reported triggers were sleep deprivation and stressful events, while no specific trigger was reported in 37% of patients. More awakening from slow-wave sleep was associated with a higher frequency of sleepwalking episodes (p < 0.001). A longer history of sleepwalking was associated with more sleepwalking episodes, even without the presence of sleep comorbidities or other known precipitating factors.

Parasomnias and isolated sleep symptoms in Parkinson's disease: a questionnaire study on 661 patients.

BACKGROUND: Sleep disorders are among the most common non-motor symptoms in Parkinson's disease. METHOD: The prevalence of parasomnias and their association with other symptoms were studied in a questionnaire study among 1447 randomly selected Parkinson patients, aged 43 to 89 years. The response rate was 59.0% and of these 77% had answered to all questions that were used in the analyses (N = 661). RESULTS: The prevalence of REM sleep behavior disorder (RBD) evaluated by the RBDSQ ≥ 6 was 39.0%. The occurrences of other parasomnias (≥ 1/week) in patients with PD were: nightmares 17.2%, night terrors 3.9%, sleepwalking 1.8%, enuresis 21.0%, and hallucinations 15.3%. Occurrences (≥ 1/week) of the isolated sleep symptoms were: nocturnal sweating 28.8%, bruxism 4.7%, and sleep talking 21.7%. Association of RBD with sleepwalking (parasomnia overlap disorder) was found in 1.7% of all PD patients. Adjusted logistic regression analysis showed that weekly nightmares (OR 12.5; 95% CI 5.3 to 29.7), hallucinations (OR 5.1; 2.1 to 12.4), sleep talking (OR 11.6; 5.9 to 22.8), male gender (OR 1.9; 1.1 to 3.1), and restless legs syndrome (OR 4.7; 1.7 to 13.2) associated with the presence of RBD. CONCLUSION: Parkinson patients with RBD have often also other parasomnias and/or isolated sleep symptoms.

Sleepwalking, REM sleep behaviour disorder and overlap parasomnia in patients with Parkinson's disease.

BACKGROUND/AIMS: In a questionnaire survey, we identified 36 (9%) of 417 Parkinson's disease (PD) patients with sleepwalking (SW); 72% of them also had a history of REM sleep behaviour disorder (RBD). We aimed to assess the clinical and polysomnographic characteristics of SW in PD and to compare them to patients with PD with and without a history of RBD. METHODS: We performed video-polysomnography and detailed clinical examination in 30 PD patients from the above-mentioned survey: 10 patients with a history of SW, 10 patients with a history of RBD, and 10 patients with no history of either SW or RBD. RESULTS: PD patients with SW had higher depression, anxiety and Hoehn & Yahr scores and lower activities of daily living scores than patients without a history of RBD but did not differ from patients with RBD. Patients with SW and RBD also had more often dyskinesia and hallucinations. By polysomnography, RBD was observed in 8 patients with SW and in all patients with a history of RBD. A total of 5 patients without a history of either SW or RBD had REM sleep without atonia without behavioural peculiarities. CONCLUSION: SW in PD is associated with depression, higher disease severity and functional disability. The simultaneous occurrence of SW and RBD (overlap parasomnia) in most patients suggests a common underlying disturbance of motor control during sleep in PD, with variable manifestations in different sleep stages.

Brain tumor presenting as somnambulism in an adolescent.

BACKGROUND: Sleepwalking is typically a benign and self-limited non-rapid eye movement parasomnia of childhood. PATIENT: We describe an unusual 15-year-old boy referred to our sleep center for new-onset sleepwalking. RESULTS: An overnight polysomnogram was normal from a respiratory standpoint, but a concurrent extended electroencephalogram montage showed frequent epileptiform discharges from the right parietal-temporal region and two electroclinical seizures arising from the right-frontal-central-temporal region during sleep. Magnetic resonance imaging scan revealed a right parasagittal parietal region lesion consistent with a low-grade neoplasm, and surgical resection of the lesion demonstrated a right parietal dysembryoplastic neuroepithelial tumor. Complex partial seizures and sleepwalking remitted completely with anticonvulsant therapy following surgery. CONCLUSIONS: This patient highlights the differential diagnosis of nocturnal events appearing to be typical parasomnias, especially when they arise abruptly at an older age.

Somnambulism: clinical aspects and pathophysiological hypotheses.

Somnambulism, or sleepwalking, can give rise to a wide range of adverse consequences and is one of the leading causes of sleep-related injury. Accurate diagnosis is crucial for proper management and imperative in an ever-increasing number of medicolegal cases implicating sleep-related violence. Unfortunately, several widely held views of sleepwalking are characterised by key misconceptions, and some established diagnostic criteria are inconsistent with research findings. The traditional idea of somnambulism as a disorder of arousal might be too restrictive and a comprehensive view should include the idea of simultaneous interplay between states of sleep and wakefulness. Abnormal sleep physiology, state dissociation, and genetic factors might explain the pathophysiology of the disorder.

Sleepwalking in Parkinson's disease: a questionnaire-based survey.

Sleepwalking (SW) corresponds to a complex sleep-associated behavior that includes locomotion, mental confusion, and amnesia. SW is present in about 10% of children and 2-3% of adults. In a retrospective series of 165 patients with Parkinson's disease (PD), we found adult-onset ("de novo") SW "de novo" in six (4%) of them. The aim of this study was to assess prospectively and systematically the frequency and characteristics of SW in PD patients. A questionnaire including items on sleep quality, sleep disorders, and specifically also SW and REM sleep behavior disorder (RBD), PD characteristics and severity, was sent to the members of the national PD patients organization in Switzerland. In the study, 36/417 patients (9%) reported SW, of which 22 (5%) had adult-onset SW. Patients with SW had significantly longer disease duration (p = 0.035), they reported more often hallucinations (p = 0.004) and nightmares (p = 0.003), and they had higher scores, suggestive for RBD in a validated questionnaire (p = 0.001). Patients with SW were also sleepier (trend to a higher Epworth Sleepiness Scale score, p = 0.055). Our data suggest that SW in PD patients is (1) more common than in the general population, and (2) is associated with RBD, nightmares, and hallucinations. Further studies including polysomnographic recordings are needed to confirm the results of this questionnaire-based analysis, to understand the relationship between SW and other nighttime wandering behaviors in PD, and to clarify the underlying mechanisms.

Sleep disorders in kidney disease.

Sleep disorders are common in patients with end stage renal disease receiving hemodialysis or peritoneal dialysis. However also a well functioning renal graft does not cure the poor sleep pattern which now emerges as a problem even in early chronic kidney disease (CKD). When patients are made aware for the first time of a disease such as CKD, which may brink to dialysis or at the best to a renal transplant patients begin to experience a disordered sleep. Sleeping disorders include insomnia (I), sleep apnoea (SAS), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), excessive daily sleeping (EDS), sleepwalking, nightmares, and narcolepsy. Disordered sleep did not meet the clinical and scientific interest it deserves, in addition and we do not have a well defined solution for sleeping complaints. However, awareness that a poor sleep is associated with poor quality of life and carries an increase in mortality risk has recently stimulated interest in the field. There are many putative causes for a disordered sleep in chronic kidney disease and in end-stage renal disease. For a unifying hypothesis demographic factors, lifestyles, disease related factors, psychological factors, treatment related factors, and social factor must be taken into consideration.

Abnormal talk by a 14-year-old boy with hypersomnolence after a long-haul flight.

This case alerts readers to the occurrence of grammatical, nonsensical speech in a 14-year-old boy, an alarming symptom. Speech of this sort may be caused by serious medical conditions such as cerebral irritation and acute confusional states, but in this case it was most probably part of a sleepwalking episode associated with jetlag. Abnormal speech during sleepwalking has been described, but it is not well characterised. This report of somniloquy offers some descriptive phenomenology for such speech.

Brain germinoma in a young adult man with suspicion of fatal neglect.

We report a forensic autopsy case of brain germinoma in a 26-year-old man who was severely wasted and initially suspected of fatal neglect. He had a history of nocturnal wandering and was confined by his parents. Neuropathological examination showed germinoma in the hypothalamus and neurohypophysis. The cause of death was certified as hypothalamo-hypophyseal insufficiency due to germinoma. Because hypothalamic lesions may dysregulate feeding behavior and sleeping rhythms, germinoma was considered the causative lesion of the anorexic wasting and nocturnal wandering. Confinement was a preventive measure of the patient's wandering. The findings in this case indicated that hypothalamic tumors should be recognized as a cause of wasting in autopsies suspected of fatal neglect.

A brainstem inflammatory lesion causing REM sleep behavior disorder and sleepwalking (parasomnia overlap disorder).

A 40-year-old woman with no prior parasomnia developed an acute inflammatory rhombencephalitis with multiple cranial nerve palsies and cerebellar ataxia, followed by myelitis 6 months later, and by an intracranial thrombophlebitis 1 month after. Between and after these episodes, she had a persistent, mild right internuclear ophtalmoplegia, a mild cerebellar ataxia, and a severe REM sleep behavior disorder (RBD) lasting for 2 years. She talked, sang and moved nightly while asleep, and injured her son (cosleeping with her) while asleep. In addition, she walked asleep nightly. During video-polysomnography, there were two arousals during slow wave sleep without abnormal behavior, while 44% of REM sleep was without chin muscle atonia with bilateral arm and leg movements. There were small hypointensities in the right pontine tegmentum and in the right dorsal medulla on T1-weighted magnetic resonance imaging, suggesting post-inflammatory lesions that persisted between acute episodes. The RBD and sleepwalking did not improve with clonazepam, but improved with melatonin 9 mg/d. The unilateral small lesion of the pontine tegmentum could be responsible for the parasomnia overlap disorder as in other rare lesional cases.