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Background: The COVID-19 pandemic has led to significant changes in daily routines and lifestyle worldwide and mental health issues have emerged as a consequence. We aimed to assess the presence of sleep disturbances during the lockdown in the general population. Methods: Cross-sectional, online survey-based study on adults living through the COVID-19 pandemic. The questionnaire included demographics and specific questions assessing the impact of the pandemic/ lockdown on sleep, daytime functioning and mental health in the general population. Identification of sleep pattern changes and specific sleep-related symptoms was the primary outcome, and secondary outcomes involved identifying sleep disturbances for predefined cohorts (participants reporting impact on mental health, self-isolation, keyworker status, suspected COVID-19 or ongoing COVID-19 symptoms). Results: In total, 843 participants were included in the analysis. The majority were female (67.4%), middle aged [52 years (40–63 years)], white (92.2%) and overweight to obese [BMI 29.4 kg/m2 (24.1–35.5 kg/m2)]; 69.4% reported a change in their sleep pattern, less than half (44.7%) had refreshing sleep, and 45.6% were sleepier than before the lockdown; 33.9% had to self-isolate, 65.2% reported an impact on their mental health and 25.9% were drinking more alcohol during the lockdown. More frequently reported observations specific to sleep were ‘disrupted sleep’ (42.3%), ‘falling asleep unintentionally’ (35.2%), ‘difficulties falling’/‘staying asleep’ (30.9% and 30.8%, respectively) and ‘later bedtimes’ (30.0%). Respondents with suspected COVID-19 had more nightmares and abnormal sleep rhythms. An impact on mental health was strongly associated with sleep-related alterations. Conclusions: Sleep disturbances have affected a substantial proportion of the general population during the COVID-19 pandemic lockdown. These are significantly associated with a self-assessed impact on mental health, but may also be related to suspected COVID-19 status, changes in habits and self-isolation.

Sleep disorders, such as sleep-disordered breathing (SDB), insomnia or restless legs syndrome (RLS), are common in the general population and after stroke. In some cases, sleep disturbances are pre-existing, but can also appear de novo as a direct consequence of brain damage or due to stroke-related complications. Furthermore, some sleep conditions may act as a risk factor of stroke. This review explores the available evidence of the two-way relationship between sleep and stroke. Cardiovascular physiological changes during sleep are described, as well as the evidence on the relationship between stroke and sleep duration, SDB, RLS, insomnia, excessive daytime sleepiness (EDS), and circadian rhythm alterations. Potential changes on sleep architecture, and the links that may exist between sleep and functional outcomes after stroke are also discussed. Importantly, sleep-related disturbances may be associated with worse stroke recovery outcomes and increased cerebrovascular morbidity. It is therefore relevant that the bidirectional association between stroke and sleep is taken into consideration by clinicians taking care of these patients. Future research may focus on this mutual relationship for a better understanding of the impact of stroke on sleep, the importance of sleep in stroke incidence and recovery, and have further evidence on treatment strategies that may improve functional outcome after stroke.

Unpleasant dreamlike mentation can occur during non-rapid eye movement parasomnias, leading to associated panic attacks. The mentations are rarely remembered and are likely underreported. However, they may lead to significant personal distress and, if not addressed, may contribute to poorer clinical outcomes. Cotard le délire de negation are very rare nihilistic delusions, historically described with psychotic disorders. Their association with a variety of neurologic disorders, including migraine and cluster-headache, has also been reported. Here we present three cases of Cotard parasomnia during which distinct states of consciousness defined by nihilistic ideation occurred. Patients described believing they are dead or dying, while unable to perceive or experience their bodies in whole, or in part, as their own. A source analysis of the electroencephalographic fingerprint of these mentations suggests right-hemispheric hypoactivity subsequent to confusional arousals. Mechanistically, an aberrant activation of two major intrinsic brain networks of wakefulness, the salience network and the default mode network, is argued. CITATION: Gnoni V, Higgins S, Nesbitt AD, et al. Cotard parasomnia: le délire de negation that occur during the sleep-wake dissociation? J Clin Sleep Med. 2020;16(6):971–976.

The central hypersomnias encompass a range of conditions causing persisting or intermittent excessive daytime sleepiness (EDS). These conditions therefore present not infrequently in general clinical sleep practice, and remain in the differential for patients presenting with sleepiness. Our understanding of the pathophysiology, diagnosis and management of these conditions has progressed significantly over recent years, and in this article we review this group of disorders, focussing in particular on recent changes in classification and diagnosis, pathophysiological advances, and novel treatment options.

The correct spelling of the author should be listed as Laura Perez-Carbonell, MD as shown above.

The aim of this review is to discuss and summarize the main therapeutic strategies for the management of excessive daytime sleepiness (EDS) in patients with narcolepsy. An overview of novel therapies and potential future options are covered as well. First line treatments for EDS in narcolepsy patients include modafinil/armodafinil and sodium oxybate. Other options with a stimulant effect, such as methylphenidate and amphetamines are considered if the former do not control the symptoms. More recently, pitolisant (H3 receptor inverse agonist) was approved by the European Medicines Agency, and solriamfetol (dopamine and norepinephrine reuptake inhibitor) by the Food and Drug Administration, for the treatment of EDS in adult narcolepsy patients. Sodium oxybate was recently approved for EDS management in paediatric patients from the age of seven. Further studies involving the paediatric population are warranted to have solid evidence in the management of children with narcolepsy. Ongoing research of new molecules is based on several mechanisms of action (histamine antagonists/inverse agonists, GABA receptor modulators), and potential future strategies involve immunologic treatment and hypocretin-based therapies. Additionally to the wakefulness-promoting agents and stimulants classically used, other pharmacologic options have been recently approved for the treatment of EDS in Europe (pitolisant) and the US (solriamfetol). Emerging treatments are under development; newly developed wakefulness-promoting agents act via different mechanisms of action, whereas other forms of therapy are focused in the underlying hypocretin deficiency that characterizes narcolepsy type 1.

Introduction Excessive daytime sleepiness (EDS) is disabling and it’s control is usually contingent on ongoing pharmacological therapy including: modafinil, methylphenidate, dexamfetamine, pitolisant, and sodium oxybate. Irrespective of the medication used, all pharmacological options must be taken to have an effect and while assessment of treatment adherence is standard clinical practice in many chronic conditions, in sleep medicine, evidence regarding adherence to prescribed medications is strikingly limited. The aim of this study was to assess degree and predictors of adherence to prescribed treatment in patients with narcolepsy attending a tertiary Sleep Disorders Centre. Methods We examined adherence to treatment in consecutive adult patients with a final diagnosis of narcolepsy by comparing prescription collection rates with prescribed therapy over a one-year period. Three levels of adherence were defined depending on the medication supplied in the last year in proportion to the total prescribed: poor (≤50%), intermediate (51–79%), and good (≥80%) adherence. Patients with adherence Results Demographic and clinical characteristics 162 patients were identified, from which 123 subjects with accurate information regarding current treatment regimen and adherence were included (see table 1). Good adherence was seen in 52.8% of patients, whilst 12.2% were intermediately and 35% poorly adherent. No difference was seen in proportion of good adherence between patients with refractory vs non-refractory symptoms (41.5% vs 58.5%; p=0.68). The proportion of refractory patients with suboptimal adherence was 44.9%. Patients with NT1 were less likely than those with NT2 to have suboptimal adherence (40.4% vs 75%; p=0.002). Discussion Our findings suggest that poor adherence is observed in a high proportion of patients with narcolepsy, and that a diagnosis of NT2 seems to be associated with non-adherence to prescribed treatment. Adherence to treatment should be routinely assessed in narcolepsy, particularly prior to initiating any step-up in therapy.

Idiopathic rapid eye movement (REM) sleep behavior disorder (iRBD) is characterized by unpleasant dreams, dream-enacting behaviors, loss of REM sleep atonia, lack of waking motor and cognitive complaints, and the absence of a detectable underlying condition. iRBD typically occurs in people aged 50 years or older, mainly in men, with an estimated prevalence of 0.3–1%. Content of dreams is usually of frightening situations where patients are attacked or chased, and they often have to defend themselves with aggressive behaviors. The most common RBD behaviors are limb and body jerks, but elaborated and aggressive behaviors are also typical, with consequent sleep-related injuries. Despite the ongoing motor-behavioral activity during REM sleep with RBD, it is surprising that patients usually report a good night’s sleep and feel rested upon arising in the morning. Since about 50% of patients are completely unaware of their sleep behaviors, interviews with bed partners are essential to obtain a full clinical description. Clonazepam and melatonin typically have a beneficial effect in treating both RBD nightmares and vigorous behaviors. iRBD patients show markers of neurodegeneration (hyposmia, depression, constipation, substantia nigra hyperechogenicity, abnormal executive, and visuospatial functions) and the neuropathological substrate of Parkinson disease (deposits of abnormal synuclein in the peripheral autonomous nervous system, microglial activation in substantia nigra, and decreased dopamine activity in the striatum). In the majority of cases, there is a progression from iRBD to Parkinson disease, dementia with Lewy bodies, mild cognitive impairment, and multiple system atrophy. iRBD constitutes an excellent target population to test neuroprotective agents to halt or delay the occurrence of parkinsonism and dementia.