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To investigate clinical and video-polysomnography (VPSG) findings of hallucinatory experiences in patients suffering from disorders of arousal (DOA) in the absence of other pathologies.The authors retrospectively reviewed the records of 370 adults with DOA. Thirty (8.1%) patients concomitantly reported complex nocturnal visual hallucinations. VPSG recordings were scrutinized, and motor behavioral and electroencephalogram (EEG) patterns were classified according to previous descriptions of DOA.Thirty DOA patients reported seeing images of objects, people, and animals; either distorted, static, or mobile. The images disappeared with increased illumination in 80% of patients, and 23.3% reported preceding dream imagery. In addition to the classical DOA patterns on VPSG, a distinct pattern of behavioral and EEG manifestation associated with complex hallucinatory episodes was identified in 16 (53.3%) DOA patients. This consisted of low-voltage mixed-frequency EEG activity before eye opening that persisted while patients were observed staring or visually tracking before the onset of motor behavior.A novel, distinct behavioral and EEG pattern in patients with DOA and history of reported complex nocturnal visual hallucinations was identified. This may represent a unique phenotype of dissociation between sleep states that merits further investigation.

Fatal insomnia (FI) is a rare prion disease severely affecting sleep architecture. Breathing during sleep has not been systematically assessed. Our aim was to characterize the sleep architecture, respiratory patterns, and neuropathologic findings in FI.Eleven consecutive FI patients (ten familial, one sporadic) were examined with video-polysomnography (vPSG) between 2002 and 2017. Wake/sleep stages and respiration were evaluated using a modified scoring system. Postmortem neuropathology was assessed in seven patients.Median age at onset was 48 years and survival after vPSG was 1 year. All patients had different combinations of breathing disturbances including increased respiratory rate variability (RRV; n = 7), stridor (n = 9), central sleep apnea (CSA) (n = 5), hiccup (n = 6), catathrenia (n = 7), and other expiratory sounds (n = 10). RRV in NREM sleep correlated with ambiguous and solitary nuclei degeneration (r = 0.9, p = 0.008) and reduced survival (r = -0.7, p = 0.037). Two new stages, Subwake1 and Subwake2, present in all patients, were characterized. NREM sleep (conventional or undifferentiated) was identifiable in ten patients but reduced in duration in eight. REM sleep occurred in short segments in nine patients, and their reduced duration correlated with medullary raphe nuclei degeneration (r = -0.9, p = 0.005). Seven patients had REM without atonia. Three vPSG patterns were identified: agitated, with aperiodic, manipulative, and finalistic movements (n = 4); quiet-apneic, with CSA (n = 4); and quiet-non-apneic (n = 3).FI patients show frequent breathing alterations, associated with respiratory nuclei damage, and, in addition to NREM sleep distortion, have severe impairment of REM sleep, related with raphe nuclei degeneration. Brainstem impairment is crucial in FI.

Parasomnias are undesirable physical events or experiences associated with sleep. Episodes are usually classified according the stage of sleep during or from which they occur. Non-rapid eye movement (NREM) parasomnias occur from deep NREM sleep and often involve complex behaviours that may appear purposeful but are not conscious or under deliberate control. There are a number of different types/presentations of NREM parasomnias. These may range from common manifestations such as sleeptalking, sleepwalking or night terrors, to the rarer sleep-related eating disorder or sexsomnia. Clinical features can facilitate the differential diagnosis, but polysomnography may be needed, particularly to assess potential concomitant sleep disorders that might represent precipitating factors. Medical treatment is often not indicated, but clonazepam or antidepressants may be used in more severe cases. Safety aspects, treating concomitant sleep disorders and avoiding trigger factors are key aspects of management.

BackgroundIdiopathic/isolated REM sleep behaviour disorder (iRBD) is characterised by vivid dreams with ‘acting-out’ behaviours due to REM sleep loss of atonia. It is associated with a risk of Parkinson’s disease (PD) and other synucleinopathies. There is uncertainty about what should be disclosed to iRBD patients in terms of future risk1.MethodsA survey was administered to patients with iRBD and participating in the PREDICT-PD study. They were invited to complete a 9-question survey exploring the information they would like to receive about the potential future implications of having iRBD.ResultsWe interviewed 31 patients (28 males, 70yo, SD 8.7y) with iRBD (mean 8.7-year disease duration, SD 6.4). A third had not received any information about the link of iRBD with other conditions by health- care professionals. More than half (61%) had searched for that information online. Most patients (87%) wanted to receive prognostic information to help them make informed decisions about their future. The preferred time for this was when a diagnosis of iRBD was made rather than when parkinsonism starts (61% vs 7%). Most wanted this information to come from their iRBD specialist (93%).ConclusionsPatients with iRBD mostly wished to receive information regarding the potential future impli- cations of having iRBD when the diagnosis of iRBD is made. Taking account of patients’ preferences is relevant to decide what, when and how to disclose prognostic information to patients with iRBD.