Excessive nocturnal

Sleep-wake state alterations in PD can be broadly classified into disturbances of (1) thalamocortical arousal state and (2) excessive nocturnal movement (Rye and Bliwise 2004 Rye and Iranzo 2005). The former includes the loss of sleep spindles and SWS, daytime sleepiness, and intrusion of REM sleep into daytime naps (i.e. sleep onset REM periods, or SOREMs), and the latter encompass periodic leg movements of sleep (PLMs) and REM sleep behavior disorder (RBD). The pathophysiological basis of sleepiness and SOREMs appears to be dopaminergic cell loss in PD, though excessive nocturnal movements are not as clearly related to dopaminergic deficits. 

FIGURE 38-1. Primary assessment and initial treatment for complaint of excessive daytime sleepiness. RLS, restless-legs syndrome NPSG, nocturnal polysomnography OSA, obstructive sleep apnea DA, dopamine agonist MSLT, multiple sleep latency test BZDRA, benzodiazepine receptor agonist SNRI, serotonin and norepinephrine reuptake inhibitor TCA, tricyclic antidepressant CPAP, continuous positive airway pressure. 

The efficacy of diuretic treatment is evaluated by disappearance of the signs and symptoms of excess fluid retention. Physical examination should focus on body weight, extent of jugular venous distension, presence of hepatojugular reflux, and presence and severity of pulmonary congestion (rales, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea) and peripheral edema. 

Inhaled salmeterol has a pharmacological half-life in excess of 12 hours, much longer than either albuterol or terbutaline. The likely basis for this long half-hfe is that the long lipophilic tail of salmeterol promotes retention of the molecule in the cell membrane. Its long duration of action makes salmeterol particularly suitable for prophylactic use, such as in preventing nocturnal symptoms of asthma. Because of its relatively slow onset of action, salmeterol should not be used to treat acute symptoms. 

Because it is stable, desmopressin is preferred for treatments especially if pressor effects are not desired. The primary indication for therapy is central diabetes insipidus, a disorder that results when ADH secretion is reduced and that is characterized by polydipsia, polyuria, and dehydration. Desmopressin is also used to reduce primary nocturnal enuresis, or bedwetting, in children. It is useful in people with mild hemophilia A or with some types of von Willebrand s disease, in which von Willebrand s factor is present at low levels. In these cases, desmopressin is given when excessive bleeding occurs or before surgery to help reduce bleeding indirectly by increasing the amounts of coagulation factors. 

The word narcolepsy refers to a syndrome of unknown origin that is characterized by abnormal sleep tendencies, including excessive daytime sleepiness and often disturbed nocturnal sleep and pathological manifestations of REM sleep. The REM sleep abnormalities include sleep onset REM periods and the dissociated REM sleep inhibitory processes, cataplexy and sleep paralysis. Excessive daytime sleepiness, cataplexy, and less often sleep paralysis and hypnagogic hallucinations are the major symptoms of the disease [12]. 

In short, the studies reviewed here indicate that neither typical nocturnal sleep pattern of major depression, nor objective excessive daytime sleepiness could be evidenced in depressed patients with subjective hypersomnia. This suggests that the appearance of objective signs of sleep dysregulation is limited to depressed patients with insomnia complaints. The few studies of manic patients show a same pattern of sleep dysregulation than in insomniac depressed patients. 

Excessive dose of insulin leads to overeating and obesity it also leads to hypoglycaemia (especially nocturnal), that may be followed by reboimd morning hyperglycaemia that is mistakenly treated by increased insulin, thus establishing a vicious cycle (Somogyi effect). 

Psychogenic or Primary Polydipsia. A chronic, excessive intalce of water suppresses AVP secretion and produces hypotonic polyuria. The polyuria and polydipsia are usually not as sustained as in HDI or NDI nocturnal polyuria also is less frequent. Psychogenic factors are most commonly associated with this disorder, but hypothalamic disease affecting the thirst center may be a cause. Drugs also can affect the thirst center and result in primary polydipsia. 

Desmopressin, as its acetate salt, is a synthetic analogue of vasopressin in which the N-terminal Cys is devoid of its a-amino function (1-Deamino) and where Arg is present as its D-isomer (D-Arg ), thus the commercial acronym DDAVP (Fig. 7.15). The presence of D-Arg and the absence of the N-terminal amine in the desmopressin structure have increased its half-life such that it is available for oral, parenteral, or nasal use. It is used by all three of these routes of administration to prevent or control polydipsia (excessive thirst), polyuria, and dehydration of patients with diabetes insipidus caused by a deficiency of vasopressin. It also has been approved for the treatment of nocturnal enuresis (bed-wetting), which is believed to be caused by an absence of the normal night time rise in vasopressin levels. 

Anxiety can be defined as a sense of apprehensive expectation. In reasonable amounts and at appropriate times, anxiety is helpful (e.g., anxiety before an examination may cause a student to initiate an appropriate study plan). Too much anxiety, however, can be deleterious. Anxiety can be considered pathological when it is either completely inappropriate to the situation or is in excess of what the situation normally should call for. An example of the former is nocturnal panic attacks—episodes of extreme anxiety that arise out of one of the most physiologically quiet times of the day, stage lll/IV sleep (64). An example of the latter is specific phobias—for example, an irrational fear to venture outside of one s home. 

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