Sleep disorders and management in Multiple system atrophy

Chun-Feng Liu

Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou

Institute of Neuroscience, Soochow University, Suzhou

Sleep disorders is one of the commonly reported non-motor symptoms in patients with Parkinson's disease (PD) as well as in multiple system atrophy (MSA). A wide range of sleep disorders that include insomnia, excessive daytime sleepiness, rapid eye movement sleep behaviour disorder (RBD), periodic limb movement disorder, and sleep-disordered breathing (SDB). The onset of RBD may predate synucleinopathies (PD and MSA). 88% of patients with MSA had polysomnography(PSG)-confirmed RBD. The proportion is higher than that of PD. Patients with MSA may develop SDB which include obstructive sleep apnea (OSA) and central sleep apnea (CSA). Patients with MSA usually have nocturnal stridor. SDB was associated with a shorter duration of survival in patients with MSA. Continuous positive airway pressure (CPAP) is the gold standard treatment option of OSA and stridor. Bilevel positive airway pressure (BiPAP) may be an appropriate therapy for CSA.However, there is a lack of guidance and consensus on sleep disturbances in MSA. PSG is essential for a confirmatory diagnosis of sleep disturbances in MSA. We should pay attention to PSG examination to determine the optimal solution.

The good sleep states of being are conventionally defined by the simultaneous occurrence of behavioral, neurophysiological and autonomic descriptors. Although conventional/classical sleep classification have contained more than 90 sleep disorders, it is no longer able to define complex clinical syndromes and sleep associated events. So, some scholars suggest that the importance of state dissociation disorders, which are due to the intrusion of features typical of a different state into an ongoing state. Furthermore, status dissociatus also should be taken seriously. In this forum, the speaker will focus on definition, classification and clinical differential diagnosis of state dissociation, status dissociatus and related diseases.

Several lines of evidence support a relationship between disrupted  circadian behavior and neurodegenerative disease. Pathological and imaging studies in Parkinson disease（PD） and Alzheimer disease (AD) have shown abnormalities in brain regions known to regulate circadian rhythms and  circadian abnormalities feature prominently in these disorders. 

Work in rodent models suggests that the relationship between circadian behavior and neurodegeneration may be complex. Transgenic rodent models of PD  and AD show prominent abnormalities of circadian behavior, suggesting that the underlying neurodegenerative processes themselves can cause circadian abnormalities. Conversely, in similar models, it has also been shown that environmental or pharmacological manipulation of sleep and circadian behavior can modify disease progression, suggesting that the relationship may go both ways.

Background and objectives: Early and accurate diagnosis of fatal familial insomnia (FFI) is critical for effective screening, however, this rare disease remains difficult to recognize. This work aimed to propose a new diagnostic criterion for fatal familial insomnia (FFI) with optimal sensitivity, specificity and likelihood ratio.

Methods: An international group of experts was established and 128 genetically confirmed FFI cases and 281 non-FFI prion disease controls are enrolled in the validation process. The new criteria were proposed based on the following steps with 2-round expert consultation: 1) Validation of the 2018 FFI criteria. 2) Diagnostic item selection according to statistical analysis and expert consensus. 3) Validation of the new criteria.

Results: The 2018 criteria for possible FFI had a sensitivity of 90.6%, specificity of 83.3%, the positive likelihood ratio (PLR) of 5.43, and negative likelihood ratio (NLR) of 0.11; the probable FFI criteria had a sensitivity of 83.6%, specificity of 92.9%, the PLR of 11.77, and NLR of 0.18. The new criteria included more specific and/or common clinical features, 2 exclusion items, and summarized a precise and flexible diagnostic hierarchy. The new criteria for possible FFI had a sensitivity of 92.2%, specificity of 96.1%, a PLR of 23.64, and NLR of 0.08, while the probable FFI criteria had a sensitivity of 90.6%, specificity of 98.2%, the PLR of 50.33, and NLR of 0.095. Discussion: A new clinical diagnostic criteria was proposed for FFI, which will be practical at the clinic for early recognition of FFI and differentiation from other prion diseases then help further referral and genetic test.

Narcolepsy is a rare sleep disorder characterized by the main symptom of excessive daytime sleepiness (EDS). The broad variety of medical and psychiatric comorbidities associated with narcolepsy, including sleep-related hallucinations, sleep paralysis, dyssomnia, nightmares, REM sleep behavior disorder, atypical eating disorders, obesity, attention-deficit/hyperactivity disorder (ADHD), psychiatric illnesses such as depression and anxiety. These symptoms may be confused with other diseases and present diagnostic and therapeutic challenges in narcolepsy. Narcolepsy has a significant impact on the quality of life. Currently, the available treatment methods include pharmacotherapy and nonpharmacological strategies. And the behavioral strategies play an important role in the clinical management of narcolepsy.

Insomnia is the most common sleep disorder. About 40% of short-term insomnia disorder develops into chronic insomnia disorder, which has a long-term impact on physical and mental health. Online sleep monitoring and self-help intervention systems have been developed. In addition, several artificial intelligence (AI) programmes have been put in use as interventions for insomnia during recent decades. In this session, we will discuss their advantages and disadvantages, as well as their application experience in The Chinese population.

Adolescence is a critical period for the development of insomnia and many mood problems. Adolescent insomnia seems to have distinct clinical presentation and etiology when compared with that in children and adults. In this presentation, Dr. Jihui Zhang will be presenting the updates in the diagnosis and treatment of adolescent insomnia from his experiences in clinical practice and research. He will also discuss the challenges and directions in this field. 

Our study found that the LED spectrum and sunshine spectrum of the visible light energy treatment system are more than 90% similar, with the sunshine spectrum at different time points as the standard, through the deployment of 7 phosphor materials, to achieve the closest distribution of sunshine spectrum.The first high precision microoptical system converts the LED lattice light source into a large area of parallel beam.To achieve a large area of sky, from top down, into the indoor scene can reflect the consistent effect with the outdoor sunshine environment.

Sleep is one of the most important biorhythms. Sleep is the result of the co-regulation of circadian rhythm and sleep homeostasis. Disruption of circadian rhythms can cause sleep disturbances; Insomnia is a risk factor of depression, which predicts more serious depression and seriously affects the social function of depressed patients. Depression is an independent risk factor for insomnia. The core symptoms of depression are closely related to biorhythm. The higher the severity of biorhythm disorder, the higher the severity of depression. Rhythm sleep and depression are closely correlated with each other. Restoring biorhythm provides a new treatment approach for patients with insomnia and depression, and is expected to bring better clinical treatment outcomes for patients.

Title :Clinical application and latest research progress of Brief Behavioral Treatment for Insomnia(BBT-I)

BBT-I is a short-term, easy-to-operate, evidence-based psychobehavioral treatment for Insomnia. The clinical operation guidelines for BBTI were formally put forward in 2012.

At present, The clinical efficacy of BBTI for insomnia disorders has been proven on improving insomnia related physical discomfort, changing false sleep beliefs and other aspects.

In this report, Professor Gao will introduce the latest clinical application of BBT-I and his team's achievements in the application of BBTI, and share the notes and standardization of using BBT-I technology in clinical practice.

Not all adults with chronic insomnia respond to the recommended therapeutic options of cognitive behavioral therapy and approved hypnotic drugs. Transcranial alternating current stimulation (tACS) may offer a novel potential treatment modality for insomnia. The primary outcome was response rate measured by the Pittsburgh Sleep Quality Index (PSQI) at week 8. Our study showed that the tACS, 20 daily 40-min, 77.5-Hz, 15-mA sessions of active tACS targeting the forehead and both mastoid areas, applied in the present study has potential as an effective and safe intervention for chronic insomnia within 8 weeks.