Elsevier

Sleep Medicine

Volume 5, Issue 1, January 2004, Pages 21-30
Sleep Medicine

Original article
Sleep disorders in multiple system atrophy: a correlative video-polysomnographic study

https://doi.org/10.1016/j.sleep.2003.07.002Get rights and content

Abstract

Objective: The reciprocal relation between breathing, heart and motor system abnormalities during sleep was studied in multiple system atrophy (MSA) by means of video-polysomnographic recordings (VPSG).

Patients and Methods: Nineteen consecutive MSA patients underwent VPSG with scoring for sleep, respiratory abnormalities, heart (HR) and breathing (BR) rates, and abnormal motor activities. A comparative analysis was performed versus 10 patients with obstructive sleep apnoea syndrome (OSAS).

Results: All MSA patients displayed snoring, 42% stridor, and 37% OSAS. Mean sleep SaO2 was 92.7%, and lowest SaO2 86%. Patients with stridor had a significant increase in BR from Wake to NREM and REM sleep, and higher HR during sleep. Respiratory muscles and tibialis anterior EMG tonic activity was frequently found, more often in patients with stridor. All patients had REM sleep behaviour disorders (RBD) and 88% periodic limb movements during sleep (PLMS). No OSAS patient had RBD or respiratory muscles and tibialis anterior tonic activity.

Conclusions: MSA patients, especially those with associated stridor, commonly display impaired breathing and abnormal control of respiratory and limb muscles during sleep. Breathing and motor abnormalities are often concomitant in the same patient, indicating a diffuse impairment of sleep homeostatic integration that should be included within the diagnostic features of MSA.

Introduction

Several sleep-related respiratory and motor disturbances have been reported in multiple system atrophy (MSA). Subjective sleep complaints reported by patients or relatives include insomnia, excessive daytime sleepiness (EDS), snoring or other respiratory noises, and motor restlessness while asleep, sleep talking or overt violent behaviours [1]. Video-polysomnographic recordings (VPSG) demonstrate abnormal sleep architecture, respiratory disturbances such as nocturnal alveolar hypoventilation [2], [3], [4], obstructive and central sleep apnoeas [5], [6], [7], [8] and nocturnal stridor [9], [10], [11], [12], [13] and motor abnormalities including periodic limb movements during sleep (PLMS) [14] and REM sleep behaviour disorder (RBD), the latter often forerunning the disease [15], [16], [17], [18], [19].

The relation between abnormal motor control and sleep-related breathing abnormalities in MSA, and the occurrence in the same patient of sleep-related breathing and motor abnormalities have not been systematically analysed, except by questionnaire analysis [1], which may be open to criticism when not checked against VPSG recordings.

We performed VPSG recordings in 19 consecutive MSA patients, monitoring respiration, heart (HR) and breathing rate (BR) and limb muscular EMG activity, to define the extent and reciprocal relation of sleep-related autonomic and motor disturbances in MSA.

Section snippets

Patients

Nineteen consecutive patients (13 men and 6 women) fulfilling criteria for clinically probable MSA [20] were admitted for diagnostic purposes in our Neurological Department, which has an interest in sleep disorders. Patients were not selected on the basis of sleep, respiratory or motor problems. Thirteen of these patients had probable cerebellar type MSA (MSA-C) and six had probable parkinsonian type MSA (MSA-P) [20]. Nine patients died during follow-up with a median survival of 9.2 years

Methods

A history of sleep patterns and disorders was obtained from each patient according to a structured interview and checked with interviews of close relatives. Patients underwent VPSG including EEG (C3-A2, O2-A1, Cz-A1), right and left EOG, surface EMG from submental, intercostalis (electrodes placed at least 2 cm apart on the second anterior intercostal space lateral to the sternum), diaphragm (electrodes at the seventh/eighth intercostal space on the anterior axillary line, on the right to

MSA: subjective complaints and clinical findings

All patients complained of autonomic symptoms and 15 had mild–moderate symptomatic postural hypotension (dizziness, syncope and visual disturbances). The most frequent sleep-related subjective complaints were abnormal violent motor behaviours during sleep and respiratory noises.

Eight out of the 19 patients (42%), six with MSA-C (three men) and two with MSA-P (one man) complained of nocturnal stridor upon admission. Mean BMI was 25.9 (24.1 in patients without stridor). Remarkably, RBD was

Wake–sleep architecture and parameters

Our patients with MSA had abnormal sleep structure, with reduced NREM deep sleep and decreased sleep efficiency. Though these findings probably relate at least in part to a first night effect, the decreased sleep efficiency, striking in MSA compared to the OSAS patients who were subjected to the same procedures, seems to indicate that lack of sleep is characteristic of MSA, and cannot be attributed entirely to the disturbing effects of our investigational procedures.

Lack of sleep is also a

Acknowledgements

A. Laffi gave invaluable secretarial help, and A. Collins corrected the English manuscript. Supported by MURST ex-60% 2000, MURST ex-40% cofin 2000 prot. MM06244347_004 and MURST ex-40% cofin 1999 prot. 9906037938 grants.

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