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PITFALLS IN THE DIAGNOSIS OF NON-REM PARASONIAS IN THE ELDERLY:AN INVESTIGATIVE SEQUENCE BASED ON A CASE REPORT
Non-REM(NREM) parasomnias include arousal disorders (confusional arousals,sleepwalking and night terrors) in addition to sleep-related eating disorder and some variants.They are especially prevalent in children and adults under 35 years of age, being rare in the elderly.However, in this population, sleep fragmentation or factors that increase sleep pressure, including polymedication, OSA, and sleep-related movement disorders can precipitate this condition.
To propose an investigative sequence for the diagnostic of NREM Parasomnias in the elderly, based on a case seen at the HCFMUSP Sleep Disorders Clinic.
Anamnesis, clinical evaluation and complementary exams.
A.A.S, 69 years old, housewife, began investigation in August 2020 for headaches and excessive snoring during 4 years.She brought polysomnography(PSG) with AHI: 38.2 events/hour and 3 abrupt awakenings from N3.She reported an episode of abnormal behavior during sleep, with stereotyped movements.Comorbidities:hypertension and dyslipidemia in treatment.We prescribed continuous positive airway pressure (CPAP) therapy and we requested additional tests (RM and EEG).She adapted to CPAP, with a residual AHI of 0.8 events/hour. In the clinical follow-up (April/2021) she reported typical episodes of sleepwalking and confusional awakenings in which she reproduced daily routine activities, with no memory of the events on the following day. In June/2021,she brought PSG with CPAP(maintaining the abrupt awakenings of N3 and presented a periodic limb movement index of 65.2/h) and extended EEG with normal results.After 2 weeks, she developed an episode of tonic-clonic movement during the day, characterizing a seizure.Based on the reported clinical case, we propose an investigative sequence in NREM Parasomnias on the elderly: 1)Clinical history:number of episodes, frequency and duration, personal and family history.2)To investigate using medications and abrupt withdrawal (hypnotics, antidepressants, antipsychotics).3)Current and past routine, checking triggers for sleep changes.4)PSG as a way to exclude TCSREM, to diagnose other disorders such as OSA and movement disorders.5)Complementary exams: imaging exams and electroencephalographic investigation if necessary.
Considering the low prevalence of NREM parasomnias and the high prevalence of comorbidities in the elderly, it is necessary to standardize the clinical investigation to avoid misdiagnosis and improve treatment of these parasomnias.
Relato de Caso
HOSPITAL DAS CLÍNICAS DA FACULDADE DE MEDICINA DA USP - São Paulo - Brasil
FLÁVIA ZUCCOLOTTO REIS REQUENA, CAMILA MUNARO MONTEIRO, EDDY ALBERTO BETANCOURT FLORES, GRACIELLY PORTE DE OLIVEIRA, HUGO GUSTAVO VEGA ALCIVAR, JOÃO VICTOR VALINHO DE MORAES, THAINÁ ROCHA BRAGA MACHADO, ROSA HASAN, ANDREA CECILIA TOSCANINI, ÁLVARO PENTAGNA