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Maski KP, Amos LB, Carter JC, Koch EE, Kazmi U, Rosen CL. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med 2024; 20:631-641. [PMID: 38149645 PMCID: PMC10985297 DOI: 10.5664/jcsm.10974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 12/26/2023] [Indexed: 12/28/2023]
Abstract
The American Academy of Sleep Medicine commissioned a task force of clinical experts in pediatric sleep medicine to review published literature on performing the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test for diagnosis and management of central disorders of hypersomnolence among children and adolescents. This paper follows a format similar to that of the paper "Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine" that was published in 2021. Since there is insufficient evidence to specify a recommended protocol for the Maintenance of Wakefulness Test in children and adolescents, this paper focuses only on the MSLT protocol. This protocol paper provides guidance to health care providers who order, sleep specialists who interpret, and technical staff who administer the MSLT to pediatric patients. Similar to the adult protocol paper, this document provides guidance based on pediatric expert consensus and evidence-based data when available. Topics include patient preparation, evaluation of medication and substance use, sleep needs before testing, scheduling considerations, optimal test conditions for youth, and documentation. Specific changes recommended for pediatric MSLT protocols include (1) provision of a minimum of 7 hours of sleep (with a minimum 8-hour recording time) on polysomnography the night before the MSLT, ideally meeting age-based needs; (2) use of clinical judgment to guide the need for sleep-disordered breathing treatments before polysomnography-MSLT testing; and (3) shared patient-health care provider decision-making regarding modifications in the protocol for children and adolescents with neurodevelopmental/neurological disorders, young age, and/or delayed sleep phase. CITATION Maski KP, Amos LB, Carter JC, Koch EE, Kazmi U, Rosen CL. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in children: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2024;20(4):631-641.
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Affiliation(s)
- Kiran P. Maski
- Department of Neurology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Louella B. Amos
- Pediatric Pulmonology and Sleep Medicine, Children’s Wisconsin, Milwaukee, Wisconsin
- Department of Pediatrics, Division of Pulmonary and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John C. Carter
- Department of Medicine, MetroHealth Medical Center, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ellen E. Koch
- American Academy of Sleep Medicine, Darien, Illinois
| | - Uzma Kazmi
- American Academy of Sleep Medicine, Darien, Illinois
| | - Carol L. Rosen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- American Academy of Sleep Medicine, Darien, Illinois
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Blattner M, Maski K. Narcolepsy and Idiopathic Hypersomnia. Sleep Med Clin 2023; 18:183-199. [PMID: 37120161 DOI: 10.1016/j.jsmc.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Narcolepsy types 1 and 2 and idiopathic hypersomnia are primary Central Nervous System (CNS) disorders of hypersomnolence characterized by profound daytime sleepiness and/or excessive sleep need. Onset of symptoms begins typically in childhood or adolescence, and children can have unique presentations compared with adults. Narcolepsy type 1 is likely caused by immune-mediated loss of orexin (hypocretin) neurons in the hypothalamus; however, the causes of narcolepsy type 2 and idiopathic hypersomnia are unknown. Existing treatments improve daytime sleepiness and cataplexy but there is no cure for these disorders.
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Affiliation(s)
- Margaret Blattner
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Kiran Maski
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, BCH3443, Boston, MA 02115, USA.
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Hartmayer LT, Hoffmann F, Bachmann CJ, Jobski K. Characteristics and outcomes of cases with methylphenidate abuse, dependence or withdrawal: an analysis of spontaneous reports in EudraVigilance. Int Clin Psychopharmacol 2023; 38:169-178. [PMID: 36728576 DOI: 10.1097/yic.0000000000000451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Methylphenidate (MPH) is a central nervous stimulant, which is mainly used in attention deficit hyperactivity disorder (ADHD) and narcolepsy. In recent years, rising MPH prescription volumes have drawn attention to possible misuse. We analyzed data on suspected MPH abuse, dependence or withdrawal reported to the EudraVigilance database (1996-2019), comparing case characteristics (e.g. age, indications and outcome). In 1531 cases from 35 countries (median: 29 years, 57.6% male), 42.3% had been diagnosed with ADHD and 8.0% with narcolepsy. Narcolepsy cases were older than ADHD cases (mean age: 47 vs. 22 years), and used co-medications more frequently (79.4 vs. 47.8%). Intravenous MPH administration was most common among individuals not diagnosed with ADHD or narcolepsy. A history of abuse, dependence or withdrawal of any substance was more often documented in fatal than in nonfatal cases (49.0 vs. 22.5%), whereas differences regarding the route of administration were less pronounced. Minors, who presumably received MPH for ADHD treatment, presented less frequently with serious outcomes than older cases or those without an approved indication. Prescribers should exercise caution in adult MPH users and should make a thorough co-medication assessment. Finally, more research on substance abuse in narcolepsy patients is required, which should include comorbidities and co-medication.
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Affiliation(s)
- Lara T Hartmayer
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg
| | - Falk Hoffmann
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg
| | - Christian J Bachmann
- Department of Child and Adolescent Psychiatry, University Hospital Ulm, Ulm, Germany
| | - Kathrin Jobski
- Department of Health Services Research, Carl von Ossietzky University Oldenburg, Oldenburg
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Dworetz A, Trotti LM, Sharma S. Novel Objective Measures of Hypersomnolence. CURRENT SLEEP MEDICINE REPORTS 2023; 9:45-55. [PMID: 37193087 PMCID: PMC10168608 DOI: 10.1007/s40675-022-00245-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/11/2023]
Abstract
Purpose of review To provide a brief overview of current objective measures of hypersomnolence, discuss proposed measure modifications, and review emerging measures. Recent findings There is potential to optimize current tools using novel metrics. High-density and quantitative EEG-based measures may provide discriminative informative. Cognitive testing may quantify cognitive dysfunction common to hypersomnia disorders, particularly in attention, and objectively measure pathologic sleep inertia. Structural and functional neuroimaging studies in narcolepsy type 1 have shown considerable variability but so far implicate both hypothalamic and extra-hypothalamic regions; fewer studies of other CDH have been performed. There is recent renewed interest in pupillometry as a measure of alertness in the evaluation of hypersomnolence. Summary No single test captures the full spectrum of disorders and use of multiple measures will likely improve diagnostic precision. Research is needed to identify novel measures and disease-specific biomarkers, and to define combinations of measures optimal for CDH diagnosis.
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Affiliation(s)
- Alex Dworetz
- Sleep Disorders Center, Atlanta Veterans Affairs Medical Center, Atlanta, GA
| | - Lynn Marie Trotti
- Sleep Center, Emory Healthcare, Atlanta, GA
- Department of Neurology, Emory University School of Medicine, Atlanta, GA
| | - Surina Sharma
- Sleep Center, Emory Healthcare, Atlanta, GA
- Deparment of Medicine, Emory University School of Medicine, Atlanta, GA
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Krahn LE, Arand DL, Avidan AY, Davila DG, DeBassio WA, Ruoff CM, Harrod CG. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med 2021; 17:2489-2498. [PMID: 34423768 DOI: 10.5664/jcsm.9620] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
This article updates the American Academy of Sleep Medicine protocols for the administration of the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. The American Academy of Sleep Medicine commissioned a task force of clinical experts in sleep medicine to review published literature on the performance of these tests since the publication of the 2005 American Academy of Sleep Medicine practice parameter paper. Although no evidence-based changes to the protocols were warranted, the task force made several changes based on consensus. These changes included guidance on patient preparation, medication and substance use, sleep before testing, test scheduling, optimum test conditions, and documentation. This article provides guidance to providers who order and administer the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test. CITATION Krahn LE, Arand DL, Avidan AY, et al. Recommended protocols for the Multiple Sleep Latency Test and the Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med. 2021;17(12):2489-2498.
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Affiliation(s)
| | - Donna L Arand
- Wright State University Boonshoft School of Medicine, Dayton, Ohio
| | - Alon Y Avidan
- David Geffen School of Medicine at UCLA, University of California, Los Angeles, Los Angeles, California
| | - David G Davila
- Central Arkansas Veterans Healthcare System, Little Rock, Arkansas
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Abstract
The measurement of daytime sleepiness is important in the evaluation of patients with excessive sleepiness. The multiple sleep latency test (MSLT) is an objective test that measures the tendency to fall asleep under controlled conditions. It is based on the notion that sleep latency reflects underlying physiological sleepiness. The MSLT consists of four to five naps given 2h apart during the day, following a standardized procedure. The mean sleep latency from all naps is used as the measure of sleepiness. The test has been shown to be valid and reliable and is part of the diagnostic criteria for narcolepsy and idiopathic hypersomnia. However, the MSLT is affected by numerous variables including insufficient sleep, drugs, activity, and arousal level. Adherence to the established protocol is necessary to limit the effect of these extraneous factors on the MSLT. While the test is a valuable and widely used diagnostic tool for narcolepsy and idiopathic hypersomnia, the use of MSLT in other sleep disorders is not well established.
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Affiliation(s)
- Donna L Arand
- Kettering Medical Center and Wright State University Boonshoft School of Medicine, Dayton, OH, United States.
| | - Michael H Bonnet
- Kettering Medical Center and Wright State University Boonshoft School of Medicine, Dayton, OH, United States
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Furer T, Nayak K, Shatkin JP. Exploring Interventions for Sleep Disorders in Adolescent Cannabis Users. Med Sci (Basel) 2018; 6:E11. [PMID: 29419734 PMCID: PMC5872168 DOI: 10.3390/medsci6010011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 02/02/2018] [Accepted: 02/05/2018] [Indexed: 11/17/2022] Open
Abstract
This review summarizes the available literature on the intersection of adolescent cannabis use and sleep disturbances, along with interventions for adolescent cannabis users who suffer sleep impairments. Adolescents are susceptible to various sleep disorders, which are often exacerbated by the use of substances such as cannabis. The relationship between cannabis and sleep is bidirectional. Interventions to improve sleep impairments among adolescent cannabis users to date have demonstrated limited efficacy, although few studies indicating the benefits of behavioral interventions-such as Cognitive Behavior Therapy for Insomnia or Mindfulness Based Stress Reduction-appear promising in the treatment of sleep disorders, which are present for users of cannabis. Further research is necessary to elucidate the precise mechanisms by which cannabis use coexists with sleep impairments, along with effective interventions for those users who suffer sleep difficulties.
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Affiliation(s)
- Tzvi Furer
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
| | - Komal Nayak
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
| | - Jess P Shatkin
- Department of Child and Adolescent Psychiatry, Child Study Center at Hassenfeld Children's Hospital of New York at NYU Langone, One Park Avenue, 7th Floor, New York, NY 10016, USA.
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Abstract
Excessive daytime sleepiness is defined as the inability to maintain wakefulness during waking hours, resulting in unintended lapses into sleep. It is important to distinguish sleepiness from fatigue. The evaluation of a sleep patient begins with a careful clinical assessment that includes a detailed sleep history, medical and psychiatric history, a review of medications, as well as a social and family history. Physical examination should include a general medical examination with careful attention to the upper airway and the neurologic examination. Appropriate objective testing with a polysomnogram and a multiple sleep latency test if needed will help confirm the diagnosis and direct the appropriate treatment plan.
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Affiliation(s)
- Renee Monderer
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA.
| | - Imran M Ahmed
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA
| | - Michael Thorpy
- Sleep-Wake Disorders Center, Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210(th) Street, Bronx, NY 10467, USA
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Abstract
PURPOSE OF REVIEW The current review aims to summarize the state of research on cannabis and sleep up to 2014 and to review in detail the literature on cannabis and specific sleep disorders from 2014 to the time of publication. RECENT FINDINGS Preliminary research into cannabis and insomnia suggests that cannabidiol (CBD) may have therapeutic potential for the treatment of insomnia. Delta-9 tetrahydrocannabinol (THC) may decrease sleep latency but could impair sleep quality long-term. Novel studies investigating cannabinoids and obstructive sleep apnea suggest that synthetic cannabinoids such as nabilone and dronabinol may have short-term benefit for sleep apnea due to their modulatory effects on serotonin-mediated apneas. CBD may hold promise for REM sleep behavior disorder and excessive daytime sleepiness, while nabilone may reduce nightmares associated with PTSD and may improve sleep among patients with chronic pain. Research on cannabis and sleep is in its infancy and has yielded mixed results. Additional controlled and longitudinal research is critical to advance our understanding of research and clinical implications.
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Affiliation(s)
- Kimberly A Babson
- National Center for PTSD-Dissemination & Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA.
| | | | - Danielle Morabito
- National Center for PTSD-Dissemination & Training Division, VA Palo Alto Health Care System, 795 Willow Road, Menlo Park, CA, 94025, USA
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Anniss AM, Young A, O'Driscoll DM. Importance of Urinary Drug Screening in the Multiple Sleep Latency Test and Maintenance of Wakefulness Test. J Clin Sleep Med 2016; 12:1633-1640. [PMID: 27655451 DOI: 10.5664/jcsm.6348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 07/29/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Multiple sleep latency testing (MSLT) and the maintenance of wakefulness test (MWT) are gold-standard objective tests of daytime sleepiness and alertness; however, there is marked variability in their interpretation and practice. This study aimed to determine the incidence of positive drug screens and their influence on MSLT, MWT, and polysomnographic variables. METHODS All patients attending Eastern Health Sleep Laboratory for MSLT or MWT over a 21-mo period were included in the study. Urinary drug screening for amphetamines, barbiturates, benzodiazepines, cannabinoids, cocaine, methadone, and opiates was performed following overnight polysomnography (PSG). Demographics and PSG variables were compared. RESULTS Of 69 studies, MSLT (43) and MWT (26), 16% of patients had positive urinary drug screening (7 MSLT; 4 MWT). Drugs detected included amphetamines, cannabinoids, opiates, and benzodiazepines. No patient self-reported use of these medications prior to testing. No demographic, MSLT or MWT PSG data or overnight PSG data showed any statistical differences between positive and negative drug screen groups. Of seven MSLT patients testing positive for drug use, one met criteria for the diagnosis of narcolepsy and five for idiopathic hypersomnia. On MWT, three of the four drug-positive patients had a history of a motor vehicle accident and two patients were occupational drivers. CONCLUSIONS These findings indicate drug use is present in patients attending for daytime testing of objective sleepiness and wakefulness. These data support routine urinary drug screening in all patients undergoing MSLT or MWT studies to ensure accurate interpretation in the context of illicit and prescription drug use.
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Affiliation(s)
- Angela M Anniss
- Department of Respiratory and Sleep Medicine, Eastern Health, Victoria, Australia
| | - Alan Young
- Department of Respiratory and Sleep Medicine, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Monash University, Victoria, Australia
| | - Denise M O'Driscoll
- Department of Respiratory and Sleep Medicine, Eastern Health, Victoria, Australia.,Eastern Health Clinical School, Monash University, Victoria, Australia
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Kosky CA, Bonakis A, Yogendran A, Hettiarachchi G, Dargan PI, Williams AJ. Urine Toxicology in Adults Evaluated for a Central Hypersomnia and How the Results Modify the Physician's Diagnosis. J Clin Sleep Med 2016; 12:1499-1505. [PMID: 27568897 DOI: 10.5664/jcsm.6276] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 07/08/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Drugs and psychoactive substances can cause sleepiness and when undetected, may lead to over diagnosis of central hypersomnias. We performed urine drug testing using gas chromatography-mass spectrometry in adults undergoing multiple sleep latency testing (MSLT) for a suspected central hypersomnia. We examined how the drug test results modified the treating physician's diagnosis. METHODS One hundred eighty-six consecutive patients with a suspected central hypersomnia who underwent clinical assessment, MSLT and urine drug testing by gas chromatography-mass spectrometry were retrospectively studied. Physicians made a diagnosis after clinical assessment and MSLT and were initially blinded to the urine drug test results. RESULTS A third of patients assessed for subjective hypersomnia had a positive urine drug test for a substance affecting sleep. Opioids, cannabis, and amphetamines were the commonest drugs detected. Using MSLT, 35 (18.8%) of 186 patients had objective hypersomnia that may have been due to a drug or substance. Drugs or substances may have confounded the MSLT in 11 (20.1%) of 53 patients who fulfilled diagnostic criteria for idiopathic hypersomnia, and 12 (52%) of 23 of those who fulfilled diagnostic criteria for narcolepsy without cataplexy. Of the 75 positive urine drug samples, 61 (81%) were substances or medications not revealed in the physician interview. The treating physician had not suspected drugs or substances as a possible cause of objective hypersomnia in 34 (97%) of the 35 patients. CONCLUSIONS Drugs and psychoactive substances can confound the results of the MSLT and when undetected could lead to over diagnosis of central hypersomnias.
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Affiliation(s)
- Christopher A Kosky
- West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Perth, Western Australia.,Sleep Disorders Centre Guys' Hospital, London, UK
| | - Anastasios Bonakis
- Sleep Disorders Centre Guys' Hospital, London, UK.,National and Kapodistrian University of Athens, 2nd Neurological Unit, Attiko Hospital, Greece
| | - Arthee Yogendran
- West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Perth, Western Australia.,Sleep Disorders Centre Guys' Hospital, London, UK
| | - Gihan Hettiarachchi
- Sleep Disorders Centre Guys' Hospital, London, UK.,Medway Maritime Hospital, Gillingham, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, United Kingdom
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Dunne L, Patel P, Maschauer EL, Morrison I, Riha RL. Misdiagnosis of narcolepsy. Sleep Breath 2016; 20:1277-1284. [PMID: 27339629 PMCID: PMC5155023 DOI: 10.1007/s11325-016-1365-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 05/16/2016] [Accepted: 05/23/2016] [Indexed: 10/29/2022]
Abstract
BACKGROUND Narcolepsy is a chronic primary sleep disorder, characterized by excessive daytime sleepiness and sleep dysfunction with or without cataplexy. Narcolepsy is uncommon, with a low prevalence rate which makes it difficult to diagnose definitively without a complex series of tests and a detailed history. The aim of this study was to review patients referred to a tertiary sleep centre who had been labelled with a diagnosis of narcolepsy prior to referral in order to assess if the diagnosis was accurate, and if not, to determine the cause of diagnostic misattribution. METHODS All patients seen at a sleep centre from 2007-2013 (n = 551) who underwent detailed objective testing including an MSLT PSG, as well as wearing an actigraphy watch and completing a sleep diary for 2 weeks, were assessed for a pre-referral and final diagnosis of narcolepsy. RESULTS Of the 41 directly referred patients with a diagnostic label of narcolepsy, 19 (46 %) were subsequently confirmed to have narcolepsy on objective testing and assessment by a sleep physician using ICSD-2 criteria. CONCLUSIONS The diagnosis of narcolepsy was incorrectly attributed to almost 50 % of patients labelled with a diagnosis of narcolepsy who were referred for further opinion by a variety of specialists and generalists. Accurate diagnosis of narcolepsy is critical for many reasons, such as the impact it has on quality of life, driving, employment, insurance and pregnancy in women as well as medication management.
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Affiliation(s)
- Laura Dunne
- Sleep Research Unit, Department of Sleep Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Pallavi Patel
- Department of Neurology, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Emily L Maschauer
- Sleep Research Unit, Department of Sleep Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - Ian Morrison
- Sleep Research Unit, Department of Sleep Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.,Department of Neurology, University of Dundee, Ninewells Hospital, Dundee, DD1 9SY, UK
| | - Renata L Riha
- Sleep Research Unit, Department of Sleep Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
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