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General Commentary

published: 08 October 2013

doi: 10.3389/fneur.2013.00152

Narcolepsy or sleep apnea?: Not everything is what

it appears to be!
Seithikurippu R. Pandi-Perumal 1*, Ravi Gupta 2 and Jaime M. Monti 3
Somnogen Canada Inc., Toronto, ON, Canada
Department of Psychiatry and Sleep Clinic, Himalayan Institute of Medical Sciences, Dehradun, India
Department of Pharmacology and Therapeutics, School of Medicine, Clinics Hospital, Montevideo, Uruguay
Edited by:
Oscar Prospéro-García, Universidad Nacional Autónoma de México, Mexico
Reviewed by:
Michael J Thorpy, Albert Einstein College of Medicine of Yeshiva University, USA

Keywords: excessive daytime sleepiness, elderly, narcolepsy, rapid eye movement, multiple sleep latency test, sleep apnea, sleep onset REM periods,
epworth sleepiness scale

A commentary on (REM)‑related, but not positional. Although Fourth, was the quality and duration
not impossible, the inference that the apneas of nighttime sleep sufficient to justify per-
An 84-year-old woman with long-standing
were almost exclusively a REM sleep phe- forming an MSLT? (2). The inadequate
excessive daytime sleepiness
nomenon appears ­ improbable. The first sleep that the patient had the night before
by Carlucci M, Prasad B. (2013). Ann Am
question is – was the observed low AHI could also have resulted in daytime sleepi-
Thorac Soc 10:400–2.
related to the poor quality of sleep on the ness and SOREMPs (3).
testing nights (sleep efficiency 64 and 71%). Fifth, as per self-reports of the patient,
The world is seldom what it seems; to
man, who dimly sees, realities appear as
Second, this lady was not described the authors mentioned that she main-
dreams, and dreams realities. ­having any other symptoms that had sup- tained a regular schedule (although no
–Samuel Johnson ported the diagnosis of narcolepsy viz., hyp- mention was made with regards to her
nagogic or hypnopompic hallucination. If usual bed time). Considering her age, is it
We are reluctant to intrude in a discussion they were present, their presence should possible that her habitual time of retiring
in this case report. Based on their clinical be considered in presence of poor quality was much earlier than the sleep time fol-
observations of the patient (an 84-year- sleep in night, as recorded by two overnight lowed in ­laboratory (11:02 p.m. as per the
old woman with long-standing history of polysomnograms. study record); this could have produced an
excessive daytime sleepiness (EDS), the Third, the patient was described as early onset of REM during the overnight
study authors’ most likely diagnosis was late excessively sleepy (ESS score: 11/24). The polysomnogram.
onset narcolepsy. However, we believe that cut-off ESS score is an arbitrary one and Sixth, as per the hypnogram, the patient
some of the inferences made by Carlucci based upon the population norm. Our had long period of self-awakenings from all
and Prasad (1) merit further comments. concern is can a patient be categorized as of her REM periods. The interesting ques-
We see this as an interesting and impor- excessively sleepy because she scored just tion is – would this have produced early
tant case report and professionally reported. 1 point more than the population norm, REMs in her MSLT, especially during first
However, we view the number of atypical i.e., 10. We think, an important issue to MSLT session during the subsequent day-
symptoms and their significance from a consider is the compromise in daytime time study? For example, REM sleep onset
perspective that is somewhat different from functioning because of sleepiness, espe- latency (REMOL) in the first REM period
those of the authors. We believe that there cially when we are dealing with a single in the MSLT was markedly reduced (3 min)
are several fundamental questions that need case. Moreover, the authors state that at while subsequent MSLT tests showed some-
to be addressed here. In areas where we do the time of the study she was on multiple what delayed REMOL. Another possibility
not agree with the authors, we have stated medicines including cyclobenzaprine, and when we see this data in association with
them with the rationale for our disagree- hydrocodone, which were taken as needed. poor sleep efficiency is that the patient
ment. We address our comments point by Hydrocodone and cyclobenzaprine both might have been almost, if not already sleep-
point as follows: can produce drowsiness. Hence, ingestion ing during the hookup of the first MSLT.
The patient was reported to be morbidly of these medications should also have been Only a clear video recording review would
obese (BMI = 36), and to have a large neck taken into c­ onsideration while inferring the prove this. It should be considered also that
circumference (NC = 17), and a Mallampatti information about EDS. The report men- severe or complex psychiatric, neurological,
Gr III airway. Nevertheless the patient had tions that patient had goiter. The question or medical disorders, and the use of anti-
a normal AHI which was just 0.9 with is, whether the thyroid profile was within cataplectic or stimulants can compromise
normal overnight oximetry. Further, the normal limits? Moreover, was the toxicol- the validity of the MSLT. In addition, sleep
overnight hypnogram reveals that most, ogy screening done to find out the reason latency on MSLT and number of SOREMPs
if not all, apneas are rapid eye ­movement for excessive daytime sleepiness? usually decreases as a function of age (4). October 2013  |  Volume 4  |  Article 152  |  1

Pandi-Perumal et al. Narcolepsy or sleep apnea?

Seventh, after 7 h on the study night, Lastly, in clinical practice, narcolepsy all other c­ onfounding variables were also
the patient was awakened during her REM occurrence is rare in old age. So we have to considered. Further investigations to update
period. We suggest that brief notations from be cautious in making a diagnosis of nar- these strategies are required for an efficient
the patient’s sleep diary would have been colepsy in the elderly (11, 4). management of this patient for a better
helpful for confirming the validity of the In short, based on the presence of exces- therapeutic response.
authors’ conclusions, i.e., what was her typi- sive daytime ­sleepiness (EDS), sleep paral- We wish the authors take our views as a
cal bedtime routine, e.g., time to bed, total ysis, and sleep onset rapid eye movement ­constructive criticism of their report.
time in bed, subjective measure of how long periods (SOREMPs) as evident from the
she took to fall asleep, how long she slept, MSLT tests, one could persuasively argue Disclosure Statement
subjective feeling of how she felt about her that the patient in question might have a late The authors have read the journal’s policy
night sleep, i.e., of whether she felt feel- onset narcolepsy. Additional support also and have the following potential conflicts:
ing refreshed or not) and so on. There is could come from the increased incidence of S.R. Pandi-Perumal is a stockholder and
insufficient data to rule out chronic sleep sleep disordered breathing among narcolep- the President and Chief Executive Officer
deprivation in this patient and hence, MSLT tics. The prevalence of sleepiness is rather of Somnogen Canada Inc., a Canadian
alone cannot be relied to make a diagnosis not uncommon in a number of medical Corporation. He declares that he has no
of narcolepsy (5, 6). illnesses including primary and co-morbid competing interests that might be perceived
Eighth, an N3 of 24% at the age of sleep disorders. In clinical practice, whether to influence the content of this article. This
84 years appears atypical (7). it is a co-morbid condition or a second- does not alter the authors’ adherence to all
Ninth, we also found some strik- ary symptom is often misdiagnosed (12). the journal policies. All remaining authors
ing abnormalities in the cardiorespira- Excessive daytime sleepiness (EDS) can also declare that they have no proprietary, finan-
tory events during the second REM cycle exist as an independent disorder despite its cial, professional, nor any other personal
(between 12:46 and 1:46 a.m.). Our visual co-occurrence with other illnesses such as interest of any nature or kind in any prod-
analysis shows a surge in the heart rate narcolepsy, sleep apnea. Although sleep uct or services and/or company that could
dynamics as well as changes in the snor- onset REM periods (SOREMPs) in two or be construed or considered to be a potential
ing pattern. These changes in presence of more of naps based on MSLT findings is conflict of interest that might have influ-
snoring suggest presence of sleep related highly suggestive of a diagnosis of narco- enced the views expressed in this manuscript.
breathing disorder. lepsy; one could also speculate that there are
Tenth, can the falls described in this other medical conditions, which can mimic References
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Frontiers in Neurology | Sleep and Chronobiology October 2013  |  Volume 4  |  Article 152  |  2

Pandi-Perumal et al. Narcolepsy or sleep apnea?

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International Classification of Sleep Disorders – 15. Singh M, Drake CL, Roth T. The prevalence of multi- Creative Commons Attribution License (CC BY). The use,
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gist. Brain (2001) 124:1482–91. published online: 08 October 2013. duction is permitted which does not comply with these terms. October 2013  |  Volume 4  |  Article 152  |  3