Sleep disorders and COVID-19.

This chapter summarizes the known associations between COVID-19 and sleep dysfunction, including insomnia, excessive daytime sleepiness, restless legs syndrome and nightmares, and touches upon pandemic-related considerations for obstructive sleep apnea and continuous positive airway pressure treatment. Treatment strategies and management approaches are also briefly discussed.

Bilateral Martin-Gruber and Marinacci Anastomoses in the Same Patient: A Case Report.

Anomalous innervations are commonly encountered on electrodiagnostic testing and may be mistaken for a pathological process, especially if seen in multiple nerves. While crossover of median-to-ulnar fibers in the forearm (Martin-Gruber anastomosis) has been frequently described, the corresponding ulnar-to-median crossover (Marinacci anastomosis) is much less commonly seen. There have been no reported cases of both of these anomalous innervations occurring together. We describe a novel case of bilateral Martin-Gruber and Marinacci anastomoses in the same patient. The importance of the case lies in the fact that the multiple pseudo-conduction blocks that result from these crossovers could potentially be misinterpreted as being pathological in nature, illustrating the need for electromyographers to be familiar with common anomalous innervations in the upper extremity and with techniques to identify them.

Treatment of vagus nerve stimulator-induced sleep-disordered breathing: A case series.

OBJECTIVE: Vagus nerve stimulation (VNS) is a treatment option for patients with drug-resistant seizures, but it is also associated with sleep-disordered breathing (SDB). We present four patients with VNS who underwent polysomnography (PSG) concurrently with VNS stimulation monitoring and adjustment, and positive airway pressure (PAP) treatment. We demonstrate the importance of sleep apnea screening prior to VNS placement and the dilemma of optimizing VNS settings. BACKGROUND: VNS is a common adjunct therapy for refractory epilepsy. Despite its low side effect profile, complications of VNS include delayed arrhythmias, laryngopharyngeal dysfunction, obstructive sleep apnea, and tonsillar pain mimicking glossopharyngeal neuralgia. Risk of developing or exacerbating existing obstructive sleep apnea (OSA) limits the VNS settings, as there appears to be a dose dependent effect. OSA can further cause sleep fragmentation and cause hypoxia, potentially worsening seizures. METHODS: Four patients with drug-resistant epilepsy with VNS underwent PSG with concurrent VNS leads to monitor correlation of SDB and VNS. AHI was calculated to quantify SDB, and it was scored as non-VNS related when the VNS was off, and VNS-induced when the onset of SDB corresponded to VNS activation. Subsequent PAP and VNS adjustment was performed to treat the SDB episodes. RESULTS: Three out of four patients had non-VNS associated SDB, which improved with PAP treatment. All four patients had VNS-induced SDB episodes but none improved with PAP. The VNS-induced SDB events decreased in a dose dependent manner, when VNS was adjusted down and disappeared when turned off completely. CONCLUSION: Our case series provides further evidence of VNS-induced SDB secondary to VNS. PAP treatment alone is ineffective for VNS-induced SDB. Screening for OSA before VNS implant is crucial; further research is needed to establish optimal VNS parameters for prevention andminimization of VNS-induced SDB along with other possible treatments.

The relationships between improvements in daytime sleepiness, fatigue and depression and psychomotor vigilance task testing with CPAP use in patients with obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine if the subjective improvements in daytime sleepiness, fatigue and depression experienced by patients with obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) therapy predict an objective improvement in vigilance, and whether patients with mild-to-moderate OSA differ from patients with severe OSA in this regard. METHODS: A total of 182 patients underwent psychomotor vigilance task (PVT) testing and measurements of subjective daytime sleepiness, fatigue and depression at baseline and after a minimum of one month of adherent CPAP use at an adequate pressure. RESULTS: Patients with both mild-to-moderate (n = 92) and severe (n = 90) OSA experienced improvements in subjective daytime sleepiness, fatigue and depression, but objective improvement in vigilance was only seen in patients with severe OSA. In patients with severe OSA, while a correlation was found between improvements in daytime sleepiness and some PVT parameters, changes in subjective daytime sleepiness, fatigue and depression scores were not predictive of objective improvement in vigilance while controlling for all these subjective symptoms and for age, gender, body mass index, apnea-hypopnea index/respiratory event index and total sleep time/total recording time with pulse oximetry below 90%. CONCLUSIONS: We found no predictive relationship between subjective improvements in daytime sleepiness, fatigue and depression and objective vigilance with CPAP use in patients with OSA. These results suggest that subjective complaints of daytime impairment and objective measures of vigilance in patients with OSA should be assessed separately while evaluating the efficacy of CPAP therapy on daytime functioning.

Melatonin-Responsive Complex Nocturnal Visual Hallucinations.

ABSTRACT: Complex nocturnal visual hallucinations are vivid, dramatic, intricate visual hallucinations occurring during sleep onset or awakenings at night, generally lasting for a few minutes at most and disappearing with increased levels of light. They may occur in a number of neurological conditions, as well as in normal individuals. The optimal treatment for this condition remains unclear. We describe three patients with complex nocturnal visual hallucinations in whom melatonin brought about a dramatic improvement in symptoms. Our report suggests that melatonin may be a safe, effective treatment for this rare but often distressing and anxiety-provoking condition.

"To sleep, perchance to tweet": in-bed electronic social media use and its associations with insomnia, daytime sleepiness, mood, and sleep duration in adults.

OBJECTIVES: The use of mobile device-based electronic social media (ESM) in bed is rapidly becoming commonplace, with potentially adverse impacts on sleep and daytime functioning. The purpose of this study was to determine the extent to which in-bed ESM use is associated with insomnia, daytime sleepiness, mood, and sleep duration in adults. METHODS: This was a cross-sectional observational study conducted among 855 hospital employees and university students (mean age, 43.6years; 85% female) via an online questionnaire. RESULTS: Nearly 70% of participants indulged in in-bed ESM use, with nearly 15% spending an hour or more a night doing so. The degree of in-bed ESM use did not vary by gender, but higher levels of in-bed ESM use were seen in younger and middle-aged than elderly participants. Compared with participants with no in-bed ESM use and controlling for age, gender, and ethnicity, participants with high in-bed ESM use were more likely to have insomnia, anxiety, and short sleep duration on weeknights, but not depression or daytime sleepiness; low in-bed ESM use only increased the likelihood of short sleep duration on weeknights. In-bed ESM use by a bed partner did not have an adverse association with sleep or mood. CONCLUSIONS: In-bed ESM use is associated with sleep and mood dysfunction in adults. These findings are of relevance to clinicians, therapists, and the public at large, as they suggest that limitation of in-bed ESM use is a potential interventional strategy in the overall management of sleep hygiene and mental health.

Hypersomnia in Neurodegenerative Diseases.

Hypersomnia is a common complaint in many patients with neurodegenerative diseases and a major cause of decreased quality of life. This article discusses the prevalence and factors associated with hypersomnia in patients with a variety of neurodegenerative diseases affecting the central nervous system, including tauopathies, synucleinopathies, and other conditions. Common nocturnal sleep problems that may result in daytime hypersomnia are delineated. A clinical approach to hypersomnia in patients with neurodegenerative diseases, recommended diagnostic testing, and available treatment options are also discussed.

The utility of patient-completed and partner-completed Epworth Sleepiness Scale scores in the evaluation of obstructive sleep apnea.

PURPOSE: Excessive daytime sleepiness in obstructive sleep apnea (OSA) is often rated differently by patients and their partners. This cross-sectional study compared the utility of patient-completed and partner-completed Epworth Sleepiness Scale (ESS) scores in the evaluation of suspected OSA. METHODS: Eighty-five patient-partner pairs were enrolled, and 75 patients completed diagnostic sleep studies. The individual and combined utilities of patient-completed and partner-completed ESS scores in identifying OSA and predicting various sleep study-derived indicators of disease severity were determined. RESULTS: Mean partner-completed ESS scores were higher than patient-completed ESS scores (12.3 ± 4.2 vs. 9.4 ± 4.8, p < 0.0001); Bland-Altman plot showed significant bias (partner-completed ESS scores 33.5 % higher, SD ±55.2 %). Partner-completed and combined (but not patient-completed) ESS scores correlated weakly with the apnea-hypopnea index (AHI; partner-completed ESS score r s  = 0.25, p = 0.029; combined ESS score r s  = 0.29, p = 0.013) and oxygen desaturation index (partner-completed ESS score r s  = 0.26, p = 0.025; combined ESS score r s  = 0.23, p = 0.047). None of the ESS scores correlated with body mass index, arousal index, or other parameters of nocturnal oxygen desaturation. In OSA (AHI > 15/h) detection, partner-completed ESS scores had greater sensitivity than patient-completed ESS scores (76.9 vs. 46.2 %) but poorer specificity (39.1 vs. 65.2 %); sensitivity was greatest (82.7 %) when either patient-completed or partner-completed ESS score was 10 or higher, and specificity was greatest (80.8 %) when both scores were 10 or higher. CONCLUSIONS: Neither patient-completed nor partner-completed ESS scores by themselves have great utility in identifying OSA or predicting its severity. However, taking both scores into consideration together improves the sensitivity and specificity of the screening process.

The therapeutic dilemma of vagus nerve stimulator-induced sleep disordered breathing.

Intermittent vagus nerve stimulation (VNS) can reduce the frequency of seizures in patients with refractory epilepsy, but can affect respiration in sleep. Untreated obstructive sleep apnea (OSA) can worsen seizure frequency. Unfortunately, OSA and VNS-induced sleep disordered breathing (SDB) may occur in the same patient, leading to a therapeutic dilemma. We report a pediatric patient in whom OSA improved after tonsillectomy, but coexistent VNS-induced SDB persisted. With decrease in VNS output current, patient's SDB improved, but seizure activity exacerbated, which required a return to the original settings. Continuous positive airway pressure titration was attempted, which showed only a partial improvement in apnea-hypopnea index. This case illustrates the need for clinicians to balance seizure control and SDB in patients with VNS.

The impact of Sleep Time-Related Information and Communication Technology (STRICT) on sleep patterns and daytime functioning in American adolescents.

This cross-sectional study explored the extent and impact of mobile device-based Sleep Time-Related Information and Communication Technology (STRICT) use among American adolescents (N = 3139, 49.3% female, mean age = 13.3 years). Nearly 62% used STRICT after bedtime, 56.7% texted/tweeted/messaged in bed, and 20.8% awoke to texts. STRICT use was associated with insomnia, daytime sleepiness, eveningness, academic underperformance, later bedtimes and shorter sleep duration. Moderation analysis demonstrated that the association between STRICT use and insomnia increased with age, the association between STRICT use and daytime sleepiness decreased with age, and the association between STRICT use and shorter sleep duration decreased with age and was stronger in girls. Insomnia and daytime sleepiness partially mediated the relationship between STRICT use and academic underperformance. Our results illustrate the adverse interactions between adolescent STRICT use and sleep, with deleterious effects on daytime functioning. These worrisome findings suggest that placing reasonable limitations on adolescent STRICT use may be appropriate.

Fasciculations masquerading as minipolymyoclonus in bulbospinal muscular atrophy.

Minipolymyoclonus has been described in both anterior horn cell disorders and central nervous system degenerative conditions. While its etiology remains unclear and speculative, a central generator has been previously proposed. We describe a case of bulbospinal muscular atrophy (Kennedy's disease), where minipolymyoclonus-like movements corresponded to fasciculations in neurophysiological studies. Our novel finding suggests that the etiologies of minipolymyoclonus in central and peripheral nervous system disorders are distinct, despite outward clinical similarity. The term "minipolyfasciculations" may be more reflective of the underlying process causing minipolymyoclonus-like movements in lower motor neuron disorders.

Is There a Clinical Role For Smartphone Sleep Apps? Comparison of Sleep Cycle Detection by a Smartphone Application to Polysomnography.

STUDY OBJECTIVES: Several inexpensive, readily available smartphone apps that claim to monitor sleep are popular among patients. However, their accuracy is unknown, which limits their widespread clinical use. We therefore conducted this study to evaluate the validity of parameters reported by one such app, the Sleep Time app (Azumio, Inc., Palo Alto, CA, USA) for iPhones. METHODS: Twenty volunteers with no previously diagnosed sleep disorders underwent in-laboratory polysomnography (PSG) while simultaneously using the app. Parameters reported by the app were then compared to those obtained by PSG. In addition, an epoch-by-epoch analysis was performed by dividing the PSG and app graph into 15-min epochs. RESULTS: There was no correlation between PSG and app sleep efficiency (r = -0.127, p = 0.592), light sleep percentage (r = 0.024, p = 0.921), deep sleep percentage (r = 0.181, p = 0.444) or sleep latency (rs = 0.384, p = 0.094). The app slightly and nonsignificantly overestimated sleep efficiency by 0.12% (95% confidence interval [CI] -4.9 to 5.1%, p = 0.962), significantly underestimated light sleep by 27.9% (95% CI 19.4-36.4%, p < 0.0001), significantly overestimated deep sleep by 11.1% (CI 4.7-17.4%, p = 0.008) and significantly overestimated sleep latency by 15.6 min (CI 9.7-21.6, p < 0.0001). Epochwise comparison showed low overall accuracy (45.9%) due to poor interstage discrimination, but high accuracy in sleep-wake detection (85.9%). The app had high sensitivity but poor specificity in detecting sleep (89.9% and 50%, respectively). CONCLUSIONS: Our study shows that the absolute parameters and sleep staging reported by the Sleep Time app (Azumio, Inc.) for iPhones correlate poorly with PSG. Further studies comparing app sleep-wake detection to actigraphy may help elucidate its potential clinical utility. COMMENTARY: A commentary on this article appears in this issue on page 695.

The efficacy of a chinstrap in treating sleep disordered breathing and snoring.

STUDY OBJECTIVES: A previously published case report suggested that a chinstrap alone might improve obstructive sleep apnea (OSA). We conducted this study to determine whether a chinstrap was a feasible alternative to continuous positive airway pressure (CPAP) in patients with OSA. METHODS: 26 adult patients with OSA (apnea-hypopnea index [AHI] > 5/h on diagnostic polysomnogram [PSG]) underwent a modified split-night PSG, using only a chinstrap for the first 2 hours of sleep, followed by CPAP titration for the remainder of the night. Improvements in AHI, arterial oxygen saturation (SpO2), and snoring with chinstrap use were compared to results with optimal CPAP pressures. RESULTS: There was no significant difference between the diagnostic PSG and the chinstrap portion of the split-night PSG in the following parameters: general AHI (median [IQR] 16.0/h [9.7-26.0] vs. 25.9/h [10.7-42.7]), SpO2 nadir (84.0% [80.5-87.5] vs. 87.0 [84.0-88.5]), AHI in REM sleep (26.7/h [16.8-43.7] vs. 42.4/h [21.3-57.7]), AHI in supine sleep (24.9/h [11.9-51.5] vs. 29.8/h [11.7-55.5]), snoring index (253.2/h [147.5-353.1] vs. 180.0/h [9.8-393.3]) or subjective snoring scale (3.0 [0.8-3.0] vs. 2.5 [0.4-3.0]). The AHI and SpO2 nadir in the 13 patients with mild OSA also did not improve with chinstrap use (9.6/h [8.1-12.2] vs. 10.6/h [6.8-35.4] and 87.0% [83.0-90.0] vs. 88.0% [87.0-89.0]). All these parameters showed significant improvement with optimal CPAP titration (p < 0.05). CONCLUSIONS: A chinstrap alone is not an effective treatment for OSA. It does not improve sleep disordered breathing, even in mild OSA, nor does it improve the AHI in REM sleep or supine sleep. It is also ineffective in improving snoring.