NARCOLEPSY

WITH CATAPLEXY
CASE STUDY
POLYSOMNOGRAPHY II

-Sudeep, Vibhuti
Definition:
Narcolepsy:
It is a chronic neurological disorder characterized by
excessive daytime sleepiness (EDS) despite a restful
night of sleep and sudden and uncontrollable attacks of
sleep accompanied by hallucinations and paralysis.[1]
It effects approximately 1 in 2000 people.[1]
No known cure for Narcolepsy but with aid of
medication, behavior modification, scheduled naps and
other treatments, symptoms can be managed to lead a
relatively normal life.[1]
Definition:
Cataplexy:
It is one of the symptoms of Narcolepsy.
It is a partial or complete loss of muscle tone in response
to strong emotion.[2]
Loss in muscle tone could be mild or severe.
Can cause head dropping, impaired speech, clumsiness
and in severe cases complete collapse of the body to
ground.[2]
Usually triggered by laughter, anger, fear or surprise, but
unusual things such as a particular odor can also
precipitate an episode.[2]
Symptoms of Narcolepsy:
Excessive Daytime Sleepiness
Cataplexy
Hypnagogic Hallucinations
Sleep Paralysis
Automatic Behavior
Disrupted Nocturnal Sleep
Case Study
A 43 yr old presented to the sleep lab with complains
of :
Loud snoring.
Cessation of breathing during sleep.
Difficulty falling asleep and maintaining sleep.
Crawling sensations in his legs at sleep onset, leg
kicking during sleep.
Excessive daytime sleepiness and fatigue.
Sudden weakness and difficulty breathing when angry
and laughing.
Case Study Cont…
Sleep is described as restless and he awakens in the
morning unrefreshed.
Wakes up in night gasping for air and has trouble
falling asleep.
He usually takes one nap on weekdays and two naps
on weekends for about 2 hours each.
The Epworth-Sleepiness Scale was 14.
Patient’s father has been diagnosed with Narcolepsy
Medications:
Ritalin:
Using it for 10 yrs, for ADHD.
This drug suppresses REM.

Pristiq:
Antidepressant in a group of drugs called selective
serotonin and norepinephrine reuptake inhibitors
(SNRIs).[3]
Causes Insomnia.
Has been using it for a month.
PSG:
An overnight PSG was performed, pt had trouble
falling asleep and staying asleep.
Sleep Latency was 58 min and REM Latency was 263
minutes.
Sleep efficiency was 61.7%.
The sleep stage percentages were 3.8% stage 1, 51.3%
stage 2, 35.5% stages 3 and 9.7% REM sleep.
Pt had a very fragmented sleep and would wake up
almost every hour.
PSG Cont..
Mild snoring was noted. There were 11 respiratory
events consisting of 3 apneas (3 obstructive, 0 mixed,
and 0 central) and 8 hypopneas. The apnea-hypopnea
index was 2.8. The mean oxygen saturation during the
study was 92%, with a minimum oxygen saturation of
88%.
There were 10 periodic limb movements during sleep,
resulting in a PLM-index of 3.3. 0 of these movements
was associated with arousals, resulting in a PLM-
arousal index of 0.
MSLT:
Due to patients questionable symptoms of cataplexy
and family history of Narcolepsy, the pt was advised to
undergo an MSLT.
After an overnight sleep study, MSLT was initiated and
the pt was provided with 5 nap opportunities to asses
his sleepiness during the day.
Pt fell asleep in all naps, usually reaching upto Stage II
of sleep, but would take progressively less time to fall
asleep.
MSLT Results:
The pt was diagnosed with Narcolepsy with Cataplexy
even though there were no REM sleep in naps.
The medical director of the lab felt that use of Ritalin
for a long period of time had suppressed REM.
The muscle tone in chin leads were almost at Atonia
during 3 naps.
Treatment:
Medications used in the treatment of Narcolepsy and
Cataplexy are symptom related.
Excessive Daytime Sleepiness:
All meds used for treatment for EDS suppress REM[4]
Meds include Ritalin, Dexedrine, Desoxyn. [4]
Cataplexy
All meds used for treatment of Cataplexy, suppress REM
and increase Sleep Latencies.[4]
Meds include, Vivactil, Clomipramine, Desipramine.[4]
References
1. Butkov et.al: Fundamentals of Sleep Medicine. 1st
Edition, Philadelphia: Williams & Wilkins, 2007: 159-
160.
2. Butkov et.al: Fundamentals of Sleep Medicine. 1st
Edition, Philadelphia: Williams & Wilkins, 2007: 162-163
3. http://www.drugs.com/pristiq.html

4. Butkov et.al: Fundamentals of Sleep Medicine. 1st

Edition, Philadelphia: Williams & Wilkins, 2007: 165-166