Abnormal nocturnal behavior due to hypoglycemia: A case report

RATIONALE

Hypoglycemia, which is characterized mainly by palpitations, dizziness, and sweating, is common and easy to identify. However, some other symptoms, such as mental disorder or abnormal behavior, are atypical, which may lead to a misdiagnosis of epilepsy, sleepwalking, infarction, or mental disorder, among others.

PATIENT CONCERNS

We report a case of a patient with type 2 diabetes who presented with abnormal nocturnal behavior due to hypoglycemia.

DIAGNOSIS

Hypoglycemia was diagnosed based on a blood glucose level of 2.1 mmol/L when the patient turned up disoriented unresponsive, unable to understand what was said to him, and producing nonsensical speech. After the patient ate a piece of chocolate, his consciousness returned to normal and all mental symptoms disappeared. Polysomnography (PSG) was synchronously performed. The results of the PSG did not show any signs of abnormality during nonrapid eye movement (NREM) or rapid eye movement (REM) sleep.

INTERVENTIONS

We regulated his dose of insulin.

OUTCOMES

No additional episodes occurred during the 3-month follow-up. Therefore, the abnormal nocturnal behavior of this patient was determined to be due to hypoglycemia, while the cause of the hypoglycemia was insulin overuse.

LESSONS

For physicians, if the cause of abnormal behavior cannot be detected, hypoglycemia should be suspected. Long-term persistent hypoglycemia may cause brain dysfunction and even result in permanent brain damage.

Evaluation of quality of sleep in women with stress urinary incontinence before and after surgical correction

OBJECTIVE

To evaluate the quality of sleep in women with urinary incontinence before and after sling surgery.

METHODS

A prospective study of case series of women with urodynamic diagnosis of stress urinary incontinence. To evaluate the subjective quality of sleep, two specific questionnaires were used and validated for the Portuguese Language: Epworth Sleepiness Scale and Pittsburgh Sleep Quality Index. The questionnaires were applied before and 6 months after surgical repair.

RESULTS

When analyzing the Epworth Sleepiness Scale, there was an improvement in sleep quality (p=0.0401). For the Pittsburgh Sleep Quality Index, only for sleep disorder there was improvement in quality of sleep after surgery (p=0.0127).

CONCLUSION

Women with urinary incontinence, submitted to surgery with sling, showed improvement in both quality of sleep and sleep disorder.

Correlation between allopregnanolone levels and depressive symptoms during late menopausal transition and early postmenopause

OBJECTIVES

This observational, cross-sectional study included 140 women with climacteric symptoms. The aim of the study was to evaluate the correlation between the presence and severity of depressive symptoms and allopregnanolone levels in women during late menopausal transition and early postmenopause.

METHODS

The study group was divided into two groups: 45 women in late menopausal transition and 95 early postmenopausal women. We evaluated Kupperman index, Hamilton scale and serum follicle-stimulating hormone, luteinizing hormone, 17β-estradiol, prolactin, total testosterone, dehydroepiandrosterone sulfate and allopregnanolone levels.

RESULTS

We found that serum allopregnanolone concentration was lower in early postmenopausal women compared to women in late menopausal transition; that there was a correlation between serum allopregnanolone levels in early postmenopausal women and time since last menstruation, intensity of climacteric symptoms, and intensity of depression symptoms and that there was a correlation between serum allopregnanolone levels and several depression symptoms presence (shallow sleep and symptoms of the digestive tract in women during late menopause transition; feelings of guilt, sleep disorders and general somatic symptoms in early postmenopausal women).

CONCLUSION

We concluded that reproductive aging is characterized by a reduction of allopregnanolone circulating levels that correlate to Hamilton depression index in early postmenopause and presence of specific depressive symptoms during late menopausal transition and early postmenopause.

[Depressive phenomenology at the outset of neuropaediatric diseases]

INTRODUCTION

Depressive phenomenology, in its diverse nosological forms, affects 8-10% of children and adolescents of general population. Most frequently mood disorders have a primary origin, following poligenic multifactorial model. Moreover there is a non negligible proportion of cases in which depressive symptoms accompany neurological illnesses or they even constitute a part of predominant manifestations at the clinical start of neurologic disease, or mark a point of inflexion in its course. The aim of the present article is to review relevant literature dealing with this topic.

DEVELOPMENT

A significative higher frequency of depressive phenomenology, not explainable by hazard, can be an early manifestation in children and adolescents with: epileptic syndromes, sleep disorders, chronic recurrent cephalalgias, several neurometabolic diseases, and intracranial tumors. Points of coincidence have been shown in dysequilibrium of brain neurotransmitters (serotonine, noradrenaline, hyperglutamatergic states) which could not be hypothesized as maintaining both neurological and mood conditions.

CONCLUSIONS

The suspiction of a neurological disease should be adopted in cases of mood disorder not easily explainable by familial antecedents or clear biographical stressors. The search for a brain disorder by means of a meticulous anamnesis and neurological clinical and ancillary exams makes possible to discover the brain disorder at a very early stage and ameliorate the chances of accurately manage both the neurological and mood disorders. The simultaneous treatment of both dimension of the illness helps to improve the patients' quality of life.

[Sleep disorders and quality of life in refractory partial epilepsy: results of the SLEEP study]

INTRODUCTION

Sleep disorders are frequent among patients with epilepsy and are correlated with a poorer quality of life.

AIMS

To evaluate the prevalence of sleep disorders in patients with refractory and non-refractory focal epilepsy, and to explore the influence of these alterations on the quality of life of these patients.

PATIENTS AND METHODS

An epidemiological, controlled, cross-sectional study was conducted in 150 outpatient neurology services. Patients who had been treated with two antiepileptic drugs since the onset of the disease (18-55 years) were recruited for the study.

RESULTS

The sample included 237 patients with non-refractory focal epilepsy and 264 patients with refractory focal epilepsy. Twenty-two per cent of the non-refractory epilepsy group and 45% of the group with refractory epilepsy (p < 0.0001) suffered from some sleep disorder. The patients with refractory epilepsy had a poorer quality of life (p < 0.001) as measured with the quality of life questionnaire QOLIE-10. A positive significant correlation was observed between quality of life and quality of sleep, in both chronic insomnia (r = 0.65; p < 0.0001) and excessive daytime sleepiness (r = 0.43; p < 0.0001).

CONCLUSIONS

Sleep disorders are more frequent in refractory than in non-refractory epilepsy, and affect the patients' quality of life.

Nonmotor symptoms of Parkinson's disease revealed in an animal model with reduced monoamine storage capacity

Parkinson's disease (PD) is a progressive neurodegenerative disorder that is characterized by the loss of dopamine neurons in the substantia nigra pars compacta, culminating in severe motor symptoms, including resting tremor, rigidity, bradykinesia, and postural instability. In addition to motor deficits, there are a variety of nonmotor symptoms associated with PD. These symptoms generally precede the onset of motor symptoms, sometimes by years, and include anosmia, problems with gastrointestinal motility, sleep disturbances, sympathetic denervation, anxiety, and depression. Previously, we have shown that mice with a 95% genetic reduction in vesicular monoamine transporter expression (VMAT2-deficient, VMAT2 LO) display progressive loss of striatal dopamine, L-DOPA-responsive motor deficits, alpha-synuclein accumulation, and nigral dopaminergic cell loss. We hypothesized that since these animals exhibit deficits in other monoamine systems (norepinephrine and serotonin), which are known to regulate some of these behaviors, the VMAT2-deficient mice may display some of the nonmotor symptoms associated with PD. Here we report that the VMAT2-deficient mice demonstrate progressive deficits in olfactory discrimination, delayed gastric emptying, altered sleep latency, anxiety-like behavior, and age-dependent depressive behavior. These results suggest that the VMAT2-deficient mice may be a useful model of the nonmotor symptoms of PD. Furthermore, monoamine dysfunction may contribute to many of the nonmotor symptoms of PD, and interventions aimed at restoring monoamine function may be beneficial in treating the disease.

Sleep complaints in elderly tinnitus patients: a controlled study

OBJECTIVES

Sleep difficulties are among the most frequent complaints associated with tinnitus. Yet most studies reporting on this problem are rather succinct, and all of them lack proper age- and health-matched control subjects.

DESIGN

The present study reports on 102 participants (51 with and 51 without tinnitus), assessed with the Pittsburgh Sleep Quality Index (PSQI), the Beck-II depression inventory, a hyperacusis questionnaire, and a tinnitus-reaction questionnaire (tinnitus group only). Participants were matched for health and relevant socioeconomic factors.

RESULTS

Results show that tinnitus patients have greater self-reported sleep difficulties compared with control subjects, specifically sleep efficiency and sleep quality, and that high tinnitus-related distress is associated with greater sleep disturbance.

CONCLUSIONS

Rather than hearing loss, sleep complaints in this population are mainly explained by hyperacusis, a hallmark of tinnitus, and to a lesser extent by subclinical depressive symptoms.

Quality of life in nonorganic and organic sleep disorders: II. Correlation with objective and subjective quality of sleep and awakening

OBJECTIVE

The purpose of this study of 100 patients suffering from sleep-disorders was to determine correlations between their subjective health-related quality of life (HRQoL) and objective variables in sleep initiation and maintenance, sleep architecture, objective quality of awakening, psychophysiological parameters and subjective quality of sleep and awakening.

METHODS

Objective measurements were obtained from overnight diagnostic polysomnography. Subjective HRQoL was determined from the Quality of Life Index (QLI, Mezzich and Cohen) completed prior to the adaptation night. Other measurements included subjective and objective quality of sleep and awakening (psychometry) the evening before and morning after polysomnographic investigations.

RESULTS

63% of the patients were suffering from nonorganic and 37% from organic sleep disorders (SDs). Within the first group, nonorganic insomnia predominated; within the second, sleep apnea. Subjective HRQoL correlated well with subjective sleep and awakening quality, especially in nonorganic SDs. There were only a few correlations of objective measurements with subjective HRQoL: in the total group of SD patients HRQoL correlated with sleep stage S2, and in nonorganic SDs with attention scores and psychophysiological measurements (mainly the pulse rate in the evening and morning).

CONCLUSION

Our findings suggest only a weak relationship between objective sleep variables and subjective HRQoL in both organic and nonorganic SDs. However, we found various significant correlations of HRQoL with subjective measurements of sleep, especially in nonorganic SDs.

Quality of life in nonorganic and organic sleep disorders: I. Comparison with normative data

Subjective health-related quality of life (HRQoL) was investigated in 100 patients with disturbed sleep (39 women aged 52 +/- 13 years and 61 men aged 53 +/- 10 years) referred to the sleep laboratory and compared with HRQoL in 100 normal healthy adults. Measurements included the Quality of Life Index (QLI) (Mezzich and Cohen), and objective (polysomnographic) and subjective (psychometric) quality of sleep and awakening. Statistical analysis (Mann-Whitney U-test) showed HRQoL to be significantly reduced in sleep disorders (SDs), with a more pronounced reduction in nonorganic than in organic SDs. Patients with nonorganic hypersomnia were more disturbed than those with nonorganic insomnia. Within organic SDs, patients with apnea were more disturbed than those with obstructive snoring. Out of ten elementary HRQoL components, seven were disturbed in SDs: physical well-being, psychological well-being, self-care and independent functioning, occupational functioning, interpersonal functioning, personal fulfillment, and overall quality of life. No differences between patients and normal healthy subjects where found in the components social support, community and services support or spiritual fulfillment. Patients suffering from nonorganic SDs had significantly worse scores in physical and psychological well-being and overall quality of life than those with organic SDs. Patients with both SDs and additional diagnoses of affective disorders had more profoundly reduced HRQoL than those with anxiety disorders. Follow-up of 51 patients (31 with nonorganic SDs and 20 with organic SDs) one year after sleep laboratory investigation and subsequent treatment found significantly improved HRQoL compared with pre-treatment. Moreover, patients diagnosed and treated in the sleep laboratory showed lower re-hospitalization rats.

Are all older adults with persistent pain created equal? Preliminary evidence for a multiaxial taxonomy

BACKGROUND

Persistent pain is grossly undertreated in older adult sufferers, despite its high prevalence in this age group. Because of its multidimensional impacts, including depression, sleep disruption and physical disability, patients with persistent pain often benefit from interdisciplinary pain clinic treatment. This treatment is expensive, however, and may not be required by all patients. The Multiaxial Assessment of Pain (MAP) has demonstrated value in predicting response to treatment in younger adults with persistent pain.

OBJECTIVE

To examine the feasibility of a MAP taxonomy for community-dwelling adults age 65 years or older. PARTICIPANTS AND PROCEDURES: One hundred eight subjects with persistent pain (mean age 73.8 years, SD=8.4 years) were interviewed and data collected on demographics, pain intensity, depressive symptoms, sleep disruption, pain interference with performance of basic and instrumental activities of daily living, frequency of engagement in advanced activities of daily living, cognitive function and comorbidity. A subset of these subjects underwent physical capacities testing, including maximal isometric lift strength, dynamic lifting endurance, timed chair rise and balance.

RESULTS

Analyses derived three primary clusters of patients. Cluster 1 (24%) reported less intense pain, less depression and sleep disruption, and higher activity levels. Cluster 3 (30%) suffered from more pain and were more functionally disabled. Cluster 2 (46%) had characteristics of cluster 1 and cluster 3, but with some characteristics that were clearly unique.

CONCLUSIONS

While these results are preliminary and require further validation, they indicate that older adults are heterogeneous in their response to persistent pain. Future studies should be performed to examine whether the MAP taxonomy is applicable to older adults regardless of medical diagnosis. Ultimately, this information may have meaning with regard to both treatment prescribing, and the design and interpretation of intervention studies.

Prednisone as initial treatment of analgesic-induced daily headache

The majority of the patients who seek medical care in tertiary headache centres present with transformed migraine, and convert to daily headache, as a result of excessive intake of symptomatic medications (SM). This study aimed to analyse the possibility of using a short course of oral prednisone for detoxifying patients with chronic daily headache due to medication overuse in an out-patient setting. Four hundred patients with headache occurring more than 28 days per month for longer than 6 months were studied (mean baseline frequency of 0.96). Symptomatic medications were stopped suddenly and prednisone was initiated in tapering doses during 6 days, followed by the introduction of preventive treatment. Withdrawal symptoms and the frequency, intensity and duration of the headache, as well as the consumption of rescue medications, were analysed during the first 16 and 30 days of withdrawal. Eighty-five percent of the patients experienced a reduction in headache frequency and no patients presented severe attacks during the first 6 days. With regard to the following 10 days, 46% of the patients experienced at least 2 days without headache and 58% less intense attacks. Most of the patients noticed attacks with longer duration. After the 30-day period there was a significant decrease in headache frequency (mean 0.83, P<0.001), and no patients returned to overuse of SM. This study demonstrates that it is possible to detoxify patients suffering from rebound headaches, using oral prednisone during the first days of withdrawal, in an out-patient setting.