Things that go bang in the night

The Clinical Spectrum of the Parasomnias

Parasomnias are defined as abnormal movements or behaviors that occur in sleep or during arousals from sleep. Parasomnias vary in frequency from episodic events that arise from incomplete sleep state transition. The framework by which parasomnias are categorized and diagnosed is based on the International Classification of Sleep Disorders-Third Edition, Text Revision (ICSD-3-TR), published by the American Academy of Sleep Medicine. The recent Third Edition, Text Revision (ICSD-3-TR) of the ICSD provides an expert consensus of the diagnostic requirements for sleep disorders, including parasomnias, based on an extensive review of the current literature.

Phantom shocks in implantable cardioverter-defibrillator recipients: impact of education level, anxiety, and depression

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are designed to deliver shocks in the event of ventricular arrhythmias. Some ICD recipients experience the sensation of ICD discharge in the absence of an actual discharge (phantom shock, PS).

OBJECTIVES

The aim of this study was to evaluate the incidence, predictors, and consequences of PS in ICD recipients.

MATERIALS AND METHODS

Consecutive ICD recipients were examined during a routine outpatient follow-up (FU) visit. Subjects completed a written survey; their level of depression and anxiety was assessed with the hospital anxiety and depression scale (HADS). Quality of life (QOL) was assessed using the Minnesota living with heart failure questionnaire.

RESULTS

Of 434 patients invited to the study, 423 (97.5%) ICD recipients agreed to and completed the survey; 349 (83%) had a primary prevention indication and 339 (80%) ischemic cardiomyopathy. A total of 27 patients (6.4%) reported a PS during a mean FU of 64 ± 44 months (5.4% in the primary prevention group and 10.8% in the secondary prevention group; p = 0.11). PS were related to higher education (≥bachelor's degree 41% versus 20%; p = 0.03), and more frequent in patients receiving adequate shocks during FU (34% versus 0.5%; p < 0.001). HADS score levels were higher following PS (15 ± 6 versus 8.8 ± 7.4; p < 0.001). The majority of patients reporting PS felt that the information provided to them prior to ICD placement was insufficient (22.2% versus 5.0%), that they needed psychological support after ICD implantation (26% versus 3%), and considered ICD deactivation in near end-of-life situations (59% versus 29%; p < 0.001 for all).

CONCLUSIONS

PS occur in 6.4% of all ICD recipients and are related to higher education and to patients that experienced adequate shocks during FU.

Nocturnal phantom shock cessation with zolpidem

A 77 year old man with a biventricular ICD-pacemaker complained of painful, electric jolts disturbing him nightly from sleep. Extensive work-up including device interrogation revealed no defibrillations or arrhythmia, and he was subsequently diagnosed with phantom shocks (PS). His nightly PS symptoms terminated after starting zolpidem 10 mg each night. To date, literature review reveals fifteen articles reporting 163 phantom shock (PS) cases. PS affects 5-9% of ICD recipients. Risk factors include psychiatric disease, atrial fibrillation, NYHA functional status III or greater, prior shock storm, and intraoperative awareness during ICD placement, with defibrillation threshold testing. This report describes a successful PS intervention, and reviews the current knowledge available in the pathophysiology and treatment of PS.

Perceptions and experiences of patients living with implantable cardioverter defibrillators: a systematic review and meta-synthesis

Background

Sudden cardiac deaths have become a growing major public health concern that affects the world. Despite the various etiologies, life-threatening cardiac arrhythmias attribute the main cause of sudden cardiac deaths. Therefore in certain groups of high-risk patients, the Implantable Cardioverter Defibrillator (ICD) has been recommended as either a secondary or primary prophylactic method of prevention.

Objective

To summarise the perceptions of ICD recipients and provide an overview of their experiences with regards to the quality of life, coping strategies, and learning needs.

Methods

A systematic search was conducted using CINAHL, MEDLINE, PsycINFO, Scopus, Cochrane Library, and Web of Science. Primary research articles published from January 2005 to January 2016 that met the inclusion criteria were selected and assessed for methodological quality.

Results

Thirty-nine articles consisting of 16 qualitative studies, 22 quantitative studies, and 1 mixed methods study were included for the meta-synthesis. Findings extracted from these studies were grouped into eight subthemes with ‘living the ICD experience: a constant process of redefining oneself’ emerging as an over-arching theme.

Conclusion

This review provides insight into the perspectives and experiences of ICD recipients. Current evidence highlights the need for healthcare professionals to improve future care standards and develop a patient-centric holistic program that meets the specific needs of ICD recipients. Moreover, future studies are required to address the research gaps identified and also explore the perceptions of patients living with ICD in the Asian context.

Incidence and predictors of phantom shocks in implantable cardioverter defibrillator recipients

BACKGROUND

Implantable cardioverter defibrillators (ICDs) are designed to deliver shocks or antitachycardia pacing (ATP) in the event of ventricular arrhythmias. During follow-up, some ICD recipients experience the sensation of ICD discharge in the absence of an actual discharge (phantom shock). The aim of this study was to evaluate the incidence and predictors of phantom shocks in ICD recipients.

METHODS

Medical records of 629 consecutive patients with ischaemic or dilated cardiomyopathy and prior ICD implantation were studied.

RESULTS

With a median follow-up of 35 months, phantom shocks were reported by 5.1 % of ICD recipients (5.7 % in the primary prevention group and 3.7 % for the secondary prevention group; p=NS). In the combined group of primary and secondary prevention, there were no significant predictors of the occurrence of phantom shocks. However, in the primary prevention group, phantom shocks were related to a history of atrial fibrillation (p=0.03) and NYHA class <III (p=0.05). In the secondary prevention group, there were no significant predictors for phantom shocks.

CONCLUSION

Phantom shocks occur in approximately 5 % of all ICD recipients. In primary prevention patients, a relation with a history of atrial fibrillation and NYHA class <III were significant predictors for the occurrence of phantom shocks. In the secondary prevention patients, no significant predictors were found.

Phantom shocks unmasked: clinical data and proposed mechanism of memory reactivation of past traumatic shocks in patients with implantable cardioverter defibrillators

BACKGROUND

Implantable cardioverter defibrillators (ICD), despite an unequivocal clinical benefit, are known to have a complex psychosocial impact on the patients. ICD shocks and the resultant psychobiological changes are known to contribute to increased levels of anxiety, depression, and post-shock stress symptoms in these patients. Phantom shock is a patient-reported perception of an ICD shock in the absence of any actual shock; however, its pathophysiological understanding is poor.

METHODS

A retrospective chart review of the University hospital ICD patients' database from June 2006 to April 2010 was conducted. A total of 38 patients with documented phantom shocks as cases and 76 age- and sex-matched patients with no phantom shocks as controls were selected from the database. Patient characteristics were analyzed for their potential association with the occurrence of phantom shocks.

RESULTS

Phantom shock patients had higher prevalence of documented depression (31.6%), anxiety (23.7%), and cocaine use (42.1%). Additionally, patients who had previous ICD shock storms were more likely to have phantom shocks (39.5%; p = 0.001). More importantly, no phantom shocks were reported in patients who did not receive defibrillation threshold testing or past ICD shock storms.

CONCLUSIONS

Phantom shocks are primarily observed in ICD patients who had prior exposure to traumatic device shocks and are more common in patients with a history of depression, anxiety, or substance abuse. A pathophysiological mechanism is proposed as a guide to potential prevention.

Phantom shocks in patients with an implantable cardioverter defibrillator

Phantom shock is the sensation of shock in the absence of an actual implantable cardioverter-defibrillator (ICD) discharge. The ICD is now the first-line therapy for patients with ventricular tachycardia and fibrillation. There has been a significant increase in the number of patients with an ICD and patients presenting to the Emergency Department (ED) after a shock for evaluation and device interrogation. Phantom shock is more likely to be nocturnal in the first 6 months after implantation, and patients are more likely to be clinically depressed and have higher levels of anxiety. There is no specific treatment. We report 3 patients who presented to the ED with the sensation of ICD discharges, however, on device interrogation had no shocks and no dysrhythmias.

Non-rapid eye movement sleep parasomnias

Parasomnias are unpleasant or undesirable behavioral or experiential phenomena that occur during sleep. Once believed unitary phenomena related to psychiatric disorders, it is now clear that parasomnias result from several different phenomena and usually are not related to psychiatric conditions. Parasomnias are categorized as primary (disorders of the sleep states) and secondary (disorders of other organ systems that manifest themselves during sleep). Primary sleep parasomnias can be classified according to the sleep state of origin: rapid eye movement sleep, non-rapid eye movement sleep, and miscellaneous (those not respecting sleep state). Secondary sleep parasomnias are classified by the organ system involved.

Development of the implanted devices adjustment scale

Advances in microelectronics have resulted in exponential growth in the number of implanted medical devices. Most people do well adjusting to their devices, but others show signs of depression and/or anxiety. The Implanted Device Adjustment Scale (IDAS) was developed to measure how well a person is adjusting to an implanted device. First, a pool of items was generated and reviewed by 2 panels of clinicians and psychometricians for content validity. The revised version was then administered to a small sample that provided information about problematic items. Finally, a convenience sample of 45 persons (66% males) with implanted devices (18 pacemakers only, 37 cardioverter/defibrillators) completed the revised IDAS twice. After deleting weak items, the Cronbach alpha was 0.90. No age, gender, or device differences were found. Test-retest reliability was 0.92. The IDAS may be useful to evaluate how well a person is adjusting to her/his device. This may lead to more timely and appropriate interventions to improve outcomes.

Sleep Disorders in the Older Patient

Sleep changes dramatically with old age. Subjective and objective measures demonstrate an increase in sleep and wake disturbances with advancing age. The older person has a more fragmented sleep, sleeps less deeply, and tends to experience early morning awakenings. When older patients have sleep disorders, they often present with excessive daytime sleepiness, insomnia, or abnormal motor activity. In making the appropriate diagnosis, the role of the provider is to review the patient's medical history,psychiatric history, medications, underlying medical illnesses, and sleep-wake pattern. The aging process itself does not cause sleep problems and sleep requirements do not decrease with advanced age. The prevalence of insomnia, sleep-related breathing disorder, PLMS, and RLS increases with age and may lead to poor sleep quality. Because many sleep disorders are potentially reversible, it is the responsibility of the primary care provider to screen for these problems. A carefully planned clinical decision-making process when encountering a sleep disturbance in the older patient can greatly enhance quality of life and daytime function.

Focused life stories of women with cardiac pacemakers

Biotechnical devices such as cardiac pacemakers are implanted into people to manage a range of disorders, yet comparatively little is known about the emotional impact of this experience. Women may have a unique response to implanted devices due to cultural messages about the masculinity of technology. In this qualitative study using Hall's focused life stories design, 11 women from teenagers to elders with permanent cardiac pacemakers were asked to describe their experiences using semistructured interviews. The themes that emerged are relinquishing care, owning the device, experiencing fears and/or resistance, imaging the body, normalizing, positioning as caretaker, finding resilience, and sensing omnipotence. Understanding what it means for women to live with an implanted biotechnical device may facilitate planning interventions to support their psychological and physiological health. Effective pacemaker function may depend, in part, on recipients' successful emotional attachment to the device.

NREM sleep parasomnias

The three states of mammalian being--wakefulness, REM sleep, and NREM sleep--are not mutually exclusive and may occur simultaneously, oscillate rapidly, or appear in dissociated or incomplete form to produce primary sleep parasomnias. Dysfunctions of a wide variety of organ systems may take advantage of the sleeping state to declare themselves, resulting in the secondary sleep parasomnias. Contrary to popular opinion, most of these often bizarre and frightening experiences are not the manifestation of underlying psychological or psychiatric conditions. Formal study in an experienced sleep disorders center usually reveals a diagnosable and treatable condition. Various parasomnias may result in injurious or violent behavior. The forensic science implications are beyond the scope of this article but have been reviewed extensively elsewhere. Continued study of unusual sleep-related events undoubtedly will reveal more fascinating conditions, expanding our knowledge of sleep physiology and strengthening the bonds between clinicians and basic science sleep researchers.