Francesca Ingravallo

Injurious REM sleep behaviour disorder in narcolepsy with cataplexy contributing to criminal proceedings and divorce.

We present a case of violent sleep-related behaviour in a patient with narcolepsy with cataplexy (NC) and REM sleep behaviour disorder (RBD), causing injuries to his wife that resulted in charge of assault, followed by a divorce case. This observation pinpoints that RBD in NC can arise early in a patients life and that it can be violent, that pharmacological treatment for RBD has to be considered in this case, that lack (or delay) of RBD diagnoses may further exacerbate the psychosocial burden of NC, and that a general awareness of the nature of sleep related violence may avoid unfortunate legal and personal consequences for patients, their partners and families.

Medico-legal assessment of disability in narcolepsy: an interobserver reliability study

Impairment because of narcolepsy strongly limits job performance, but there are no standard criteria to assess disability in people with narcolepsy and a scale of disease severity is still lacking. We explored: (1) the interobserver reliability among Italian Medical Commissions making disability and handicap benefit decisions for people with narcolepsy, searching for correlations between the recognized disability degree and patients’ features; (2) the willingness to report patients to the driving licence authority and (3) possible sources of variance in judgement. Fifteen narcoleptic patients were examined by four Medical Commissions in simulated sessions. Raw agreement and interobserver reliability among Commissions were calculated for disability and handicap benefit decisions and for driving licence decisions. Levels of judgement differed on percentage of disability (Pu2003<u20030.001), severity of handicap (Pu2003=u20030.0007) and the need to inform the driving licence authority (Pu2003=u20030.032). Interobserver reliability ranged from Kappau2003=u2003−0.10 to 0.35 for disability benefit decision and from Kappau2003=u2003−0.26 to 0.36 for handicap benefit decision. The raw agreement on driving licence decision ranged from 73% to 100% (Kappa not calculable). Spearman’s correlation between percentages of disability and patients’ features showed correlations with age, daytime naps, sleepiness, cataplexy and quality of life. This first interobserver reliability study on social benefit decisions for narcolepsy shows the difficulty of reaching an agreement in this field, mainly because of variance in interpretation of the assessment criteria. The minimum set of indicators of disease severity correlating with patients’ self assessments encourages a disability classification of narcolepsy.

Medico-Legal Aspects of Disability in Narcolepsy

Narcolepsy is a severe, chronic, disabling disease affecting almost all personal and social activities. Sleep disorder specialists deal with the disabling burden of narcolepsy since their first approach to the patient. The disease continues to be a burden throughout the patient’s life as pharmacological and behavioral treatments only seldom control the variety of symptoms. Empirical data showed that from one fourth to half of people with narcolepsy are forced to modify or leave a job due to the disease, which may also cause higher absenteeism due to disability and accidents, as well as being more likely subjected to unemployment and early retirement with high social and economic costs. Excessive daytime sleepiness seems to be the main symptom associated with work disability, but cataplexy may be even more disabling in cases with many cataplectic attacks. Since people with narcolepsy experience a wide range of occupational problems, both clinicians and researchers are interested in how to help their patients to hold down a job, return to work, and, if necessary, receive benefits for work disability.