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Polysomnographic Findings in Dementia With Lewy Bodies

Pao, Winnie C. MD*,†; Boeve, Bradley F. MD*,†; Ferman, Tanis J. PhD; Lin, Sioung-Chi MD; Smith, Glenn E. PhD; Knopman, David S. MD*; Graff-Radford, Neill R. MBChB*; Petersen, Ronald C. PhD, MD*; Parisi, Joseph E. MD*,§; Dickson, Dennis W. MD; Silber, Michael H. MBCbB*,†

doi: 10.1097/NRL.0b013e31827c6bdd
Invited Review Article

Introduction: The clinical features of dementia with Lewy bodies (DLB) during wakefulness are well known. Other than rapid eye movement (REM) sleep behavior disorder, only limited data exists on other sleep disturbances and disorders in DLB. We sought to characterize the polysomnographic (PSG) findings in a series of DLB patients with sleep-related complaints.

Methods: Retrospective study of patients with DLB who underwent clinical PSG at Mayo Clinic, Rochester or Mayo Clinic, Jacksonville over an almost 11-year span for evaluation of dream enactment behavior, excessive nocturnal movements, sleep apnea, hypersomnolence, or insomnia. The following variables were analyzed: respiratory disturbance index (RDI) in disordered breathing events/hour, periodic limb movement arousal index, arousals for no apparent reason (AFNAR), total arousal index, presence of REM sleep without atonia, and percent sleep efficiency.

Results: Data on 78 patients (71 male, 7 female) were analyzed. The mean age was 71±8 years. Seventy-five (96%) patients had histories of recurrent dream enactment during sleep with 83% showing confirmation of REM sleep without atonia±dream enactment during PSG. Mean RDI=11.9±5.8, periodic limb movement arousal index =5.9±8.5, arousals for no apparent reason index=10.7±12.0, and total arousal index=26.6±17.4. Sleep efficiency was <80% in 72% of the sample, <70% in 49%, and <60% in 24%. In patients who did not show evidence of significant disordered breathing (23 with RDI<5), 62% of arousals were AFNARs. In those patients who had significant disordered breathing (55 with RDI≥5), 36% of arousals were AFNARs. Six patients underwent evaluations with PSG plus multiple sleep latency test. Two patients had mean initial sleep latencies of <5 minutes, and both had RDI<5. No patient had any sleep onset REM periods. Nineteen patients have undergone neuropathologic examination, and 18 have had limbic-predominant or neocortical-predominant Lewy body pathology. One had progressive supranuclear palsy, but no REM sleep was recorded in prior PSG.

Conclusions: In patients with DLB and sleep-related complaints, several sleep disturbances in addition to REM sleep behavior disorder are frequently present. In this sample, about 3/4 had a significant number of arousals not accounted for by a movement or breathing disturbance, and the primary sleep disorders do not seem to entirely account for the poor sleep efficiency in DLB, especially in those without a significant breathing disorder. Further studies are warranted to better understand the relationship between disturbed sleep, arousal, and DLB; such characterization may provide insights into potential avenues of treatment of symptoms that could impact quality of life.

Departments of *Neurology

Center for Sleep Medicine

Psychology and Psychiatry

§Laboratory Medicine and Pathology

Neuroscience (Neuropathology Laboratory), Mayo Clinic College of Medicine; and Robert H. and Clarice Smith and Abigail Van Buren Alzheimer's Disease Research Program of the Mayo Foundation, Rochester, MN, and Jacksonville, FL

Supported by NIA grants AG015866, AG006786, AG016574, and the Mangurian Foundation.

B.F.B. has no relevant disclosures for this paper. He has served as an investigator for clinical trials sponsored by Cephalon, Inc., Allon Pharmaceuticals, and GE Healthcare. He receives royalties from the publication of a book entitled Behavioral Neurology of Dementia (Cambridge Medicine, 2009). He is on the Scientific Advisory Board of the Tau Consortium. He has received honoraria from the American Academy of Neurology. G.E.S. has no relevant disclosures for this paper. He is a consultant for Home Instead. D.S.K. has no relevant disclosures for this paper. He has been site PI on clinical trials sponsored by Janssen, Forest and Baxter. He is on the DSMB for a trial by Lilly Pharmaceuticals. He is on the editorial board of Neurology. N.R.G-R. has no relevant disclosures for this paper. He has been site PI on clinical trials sponsored by Janssen, Allon, Pfizer and Baxter. He is Chair of the DSMB for a trial by Baxter. He is on the Scientific Advisory Board of Codman. He receives royalties from UpToDate and is on the editorial board of The Neurologist. R.C.P. has no relevant disclosures for this paper. He is Chair of the DSMB for trials by Pfizer and Janssen Alzheimer Immunotherapy. He is a consultant to Elan Pharmaceuticals and GE Healthcare. He received compensation by Novartis for a CME presentation. M.H.S. has no relevant disclosures for this paper. He receives royalties from the publication of 2 books [Sleep Medicine in Clinical Practice 2nd Ed (Informa Healthcare, 2010), and Atlas of Sleep Medicine (Informa Healthcare, 2010)]. He has received honoraria from the American Academy of Neurology and American Academy of Sleep Medicine. The remaining authors declare no conflict of interest.

Reprints: Bradley F. Boeve, MD, Mayo Clinic, 200 First Street SW, Rochester, MN 55905. E-mail: bboeve@mayo.edu.

© 2013 by Lippincott Williams & Wilkins