![]() Bogan, MD, FCCP, FAASM: I think that’s a good point. Then at that point, I would feel more confident saying this is most likely a type 2 narcolepsy and then tackling those REM-related phenomena that are disturbing to him. ![]() But my suspicion is his persistent sleepiness, those persistent REM phenomena, may not disappear just by treating the OSA. I would lean toward treating his mild sleep apnea, whether it’s PAP therapy or an oral appliance to manage that component. He’s on metoprolol, so it might be suppressing his blood pressure already, and that’s slightly elevated. In scenarios like this, he may have some blood pressure issues. But putting it all together, I still have a high suspicion there’s probably type 2 narcolepsy going on with underlying mild sleep apnea. That may have suppressed a second REM phenomenon, a SOREMP, potentially. And then that 1 SOREMP, to me, again, he’s on an antidepressant, and I’m assuming it was left on board during the test. But again, the profoundness of how often it’s happening and how intense they are, it’s hard for me to blame it on a mild degree of sleep apnea, but it’s possible. Again, you can have REM dissociation, REM-related phenomenon with sleep apnea in normal individuals as well. Bogan, MD, FCCP, FAASM: He did have a bit of mild sleep apnea, with an AHI of 6, and he had mild intermittent snoring.Īsim Roy, MD: He had mild sleep apnea, I don’t think that by itself explains the degree of sleepiness. ![]() But for me, the PSG, I don’t think there was any mention of the results on the PSG on this case? There was some description of that, it seemed like, potentially we need to dive deeper. In narcolepsy though, you can have REM behavior disorder at a younger age, and it can be part of that REM phenomena. It’s a whole different meaning, potential neurodegenerative disease implications with a synucleinopathy world like Parkinson disease or Parkinson-like syndromes. Normally, we think about this in individuals in their 50s, 60s, and 70s if they develop REM behavior. What do you think?Īsim Roy, MD: There’s another REM dissociation we didn’t get into, which I forgot to mention, but REM behavior disorder might be a feature in narcolepsy as well, where people act out their dreams. I will go ahead and tell you his MSLT was 6 minutes, and he only had 1 sleep onset REM episode. So we have a fellow who is a little overweight, with elevated blood pressure and an anxiety disorder, with those symptoms. He is actually on metoprolol for tachycardia and anxiety. His BMI is 32, and his blood pressure is 129 over 89 mm Hg, so his blood pressure is a little high. He’s diagnosed with having an anxiety disorder and placed on escitalopram. He has not had any episodes of muscle weakness with strong emotions. His clinical course has been somewhat problematic because he does have anxiety, some performance anxiety, and the methylphenidate makes his heart rate go up and makes him more nervous. He can still doze off in the afternoon and has trouble with projects during the day, dozing off when he is not adequately stimulated. He is diagnosed with having adult ADD and is placed on extended-release methylphenidate, which helped his sleepiness, interestingly enough, but he is still aggravated by the sleepiness. His bed partner says he talks a lot, kicks and yells, and sometimes when he wakes up, he sees these images or hears somebody outside trying to break into the house. He feels short of breath and panics during that. He also has vivid dreams and episodes of awakening in the night feeling as though he is paralyzed and can’t move. ![]() We’ve got a 29-year-old male project manager who presents with excessive sleepiness. Bogan, MD, FCCP, FAASM: I’m going to throw another case at you.
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