Frank M. Ralls

Roles of gender, age, race/ethnicity, and residential socioeconomics in obstructive sleep apnea syndromes.

Purpose of review Review recent research on the roles of gender, race/ethnicity, residential socioeconomics and age in obstructive sleep apnea syndromes (OSA) and their treatment. Recent findings Men have a higher prevalence of OSA than women and require higher continuous positive airway pressure (CPAP) pressures for treatment, given similar severity of OSA. When comparing age, women have less severe apnea at all ages. Menopause, pregnancy and polycystic ovarian syndrome increase the risk for OSA in women. Neck fat and BMI influence apnea–hypopnea index (AHI) severity in women; abdominal fat and neck-to-waist ratio do so in men. Obesity, craniofacial structure, lower socioeconomic status and neighborhood disadvantage may better explain ethnic/racial differences in the prevalence and severity of OSA. Ethnicity was no longer significantly associated with OSA severity when WHO criteria for obesity were used. Summary OSA has a male predominance; women have a lower AHI than men during certain stages of sleep; women require less CPAP pressure for treatment of similar severity of OSA, and there are ethnic/racial differences in the prevalence and severity of OSA but these may be due to environmental factors, such as living in disadvantaged neighborhoods.

Cognitive dysfunction and obstructive sleep apnea: from cradle to tomb.

Purpose of review To understand clinical characteristics and risk factors for cognitive impairment in patients with obstructive sleep apnea (OSA) syndromes. Recent findings Primary snoring increases the risk of neurocognitive impairment and lower intelligence quotients in infants and children. Middle-aged adults with severe OSA are at greater risk for cognitive impairment than young adults with apnea of equal severity. Older women with OSA are at increased risk for minimal cognitive impairment or dementia, 5 years later. Summary Certain age groups (younger and older) are particularly susceptible to the negative effects of OSA on cognition. Other influences that increase the risk for cognitive dysfunction in OSA include premature birth, apolipoprotein e4 allele status and other genetic polymorphisms, lower socioeconomic status, fewer years of education, and ethnicity.

Treatment strategies for complex behavioral insomnia in children with neurodevelopmental disorders.

Purpose of review This review describes recent research in pediatric behavioral insomnias in neurodevelopmental disorders and their treatment. Recent findings Insomnia in children with autism spectrum disorder (ASD) and other neurodevelopmental disorders (NDDs) is typically complex, chronic, and difficult to adequately control. Abnormalities in genetic and/or epigenetic regulation of sleep/wakefulness and its timing predispose patients with NDD to insomnia, although poor sleep hygiene, maladaptive associations, and limit-setting are likely to contribute. Parents are agents for change in problematic sleep behaviors in patients with NDD. We review the benefits of behavioral therapies and melatonin to treat sleep problems in children with NDD. Problematic sleep is so prevalent in some neurodevelopmental syndromes (Rett, Angelman, Williams, and Smith–Magenis) that it is part of their diagnostic criteria. Summary Children and adolescents with neurological disorders frequently have complex sleep disorders that require treatment. Understanding the basic pathology and treatment strategies provides an opportunity to improve well being and quality of life in those affected by NDD and their families.

Sleep disorders in adults with epilepsy: past, present, and future directions.

Purpose of review To summarize recent studies on the complex relationships between sleep disorders, sleep, and epilepsy. Recent findings Insomnia in adults with epilepsy (AWE) warrants consideration of depression, anxiety, and suicidal ideation. Daytime sleepiness in AWE is more often due to undiagnosed sleep disorders. Sleep deprivation is an important provoker of seizures in juvenile myoclonic epilepsy. Abnormalities in frontal lobe executive function with difficulties making advantageous decisions may explain failure of juvenile myoclonic epilepsy patients to adhere to treatment recommendations and regulate their sleep habits. Sleep architecture in AWE is more likely to be abnormal if seizures are poorly controlled or occur during sleep. Obstructive sleep apnea is much more common in AWE who are man, older, heavier, or whose seizures are poorly controlled. Chronobiology and chronopharmacology of epilepsy is an emerging field worthy of future research and clinical applications. Summary Identifying and treating unrecognized sleep disorders and understanding the impact of circadian rhythms on epilepsy can improve quality of life and seizure control in AWE.

Primary Sleep Disorders and Paroxysmal Nocturnal Nonepileptic Events in Adults With Epilepsy From the Perspective of Sleep Specialists

Sleep specialists are frequently referred adults with epilepsy to evaluate their sleep/wake complaints, sometimes to determine whether their paroxysmal nocturnal behaviors are epileptic or not. Many patients with epilepsy have at least one parasomnia (some more than one), and the sleep specialists are often asked to differentiate and treat these. Sleep specialists review which primary sleep disorders are more common in adults with epilepsy and how to evaluate and best treat these. The authors summarize (1) how to evaluate and differentiate parasomnias using video-polysomnography; (2) the value of sleep deprivation and loud auditory stimuli to increase the likelihood of provoking a non-rapid eye movement arousal parasomnia with a single night of video-polysomnography; and (3) how to score excessive muscle activity during rapid eye movement sleep to confirm a diagnosis of rapid eye movement sleep behavior disorder. The clinical semiology and video-polysomnography features of simple and complex sleep-related movement disorders and parasomnias are reviewed.

Sleep, Pregnancy, and Nutrition

Sleep both influences and is influenced by nutritional choices. The quality and quantity of sleep, as well as the presence of sleep disorders, can have major impacts on pregnancy and its outcomes. Obstructive sleep apnea and restless legs syndrome are two common sleep disorders that occur during pregnancy. Both are influenced by diet and nutrition.

Sleepwalking and Its Variants in Adults

Nocturnal wanderings, especially when they occur in adults, have provided endless fascination, fear, perplexity, and occasional bemusement. Most often, nocturnal wanderings in adults are sleepwalking (SW) episodes. Frequent, chronic, and/or potentially injurious SW in adults is a parasomnia that usually begins as an incomplete arousal from non-rapid eye movement (NREM) 3 sleep. SW occurs at a peak age of 8–12 years, only a quarter continue beyond age 13 years. Epidemiological studies suggest that 2–4 % of adults sleepwalk at least once a year, but less than 0.5 % walk frequently. Most have a history of SW as children. Complex motor behaviors during sleep (such as eating, driving a motor vehicle, or sexual behavior) may be a variant of SW, but must be distinguished from other causes (e.g., rapid eye movement (REM) sleep behavior disorder, parasomnia overlap syndrome, drug impairment, dissociation, and even malingering). SW in adults tends to be chronic, often a persistence or recurrence of childhood SW, but then precipitated, primed, and/or triggered by a host of factors that impair arousal and deepen and fragment NREM 3 sleep. Other primary sleep disorders (especially obstructive sleep apnea, restless legs, or a circadian rhythm disorder) can precipitate or exacerbate SW, especially in individuals with a familial or genetic susceptibility for it. Video-polysomnography (PSG) is usually indicated. Treatment of SW consists of reassurance, education of the patient and family, setting up a safe sleep environment, identifying and treating other sleep disorders, and reducing or avoiding priming or precipitating factors. Video-PSG findings and indications for pharmacotherapy are reviewed.

Epidemiology and Risk Factors for Parasomnias

Parasomnias are undesirable movements, emotions, and behaviors that occur during sleep. Parasomnias are most prevalent in children and decrease in frequency with increasing age. REM behavioral disorder (RBD) is a parasomnia that often occurs after the age of 50, affects mostly men, and is often associated with neurodegenerative disorders.