Neurological Examination

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Cerebral. The neurological examination focuses on the general state of alertness. Patients may appear sleepy or even nod off during the examination if EDS is severe. Cognitive and psychological functioning is assessed for evidence of dementia or depression, both of which are associated with sleep pattern disruption. Excessive anxiety, fears, and concerns are frequent causes for insomnia, and clues to these problems may reveal themselves during cerebral assessments of memory, concentration, and attention.

Cranial Nerves. Cranial nerve lesions indicate brain stem pathology. Disorders of REM sleep, including narcolepsy and RBD, may reflect focal pathology in the pons, so

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TABLE 2-1 -- ACTIVITY OF SUBPOPU

LATIONS OF CELL GROUPS DURING WALKING, SLOW-WAVE SLEEP AND REM SLEEP

Nucleus

Primary Neurotransmitter

Waking Activity

Slow-Wave Sleep

REM Sleep

Pedunceulopontine nucleus (PPN)

Acetyleholine

Inereased

Decreased

Increased

Locus coeruleus

Norepinephnne

Increased

Increased

Decreased

Raphe nueleus

Serotonin

Increased

Increased

Decreased

Substantia nigra

Dopamine

Increased

Decreased

Increased

Reprinted from Garcia-Rill E The pedunculopontine nucleus Prog Neulrobiol 1991;36; 363-389,with permission of Elsevier Science.

Reprinted from Garcia-Rill E The pedunculopontine nucleus Prog Neulrobiol 1991;36; 363-389,with permission of Elsevier Science.

specific attention to pontine cranial nerve function (trigeminal, abducens, facial, and vestibulocochlear) are essential. Bulbar dysfunction in the form of dysphagia, hoarseness, and dyspnea can occur in neuromuscular disorders and myopathies. In checking for the gag reflex, the upper airway can be examined, and a reddened palate and uvula are suggestive of snoring.

Motor/Reflexes/Cerebellar/Gait. Several disorders of the motor system are associated with sleep alterations. Strength should be examined, specifically the strength of the neck and respiratory muscles. Patients with myopathies, neuropathies, and neuromuscular junction disease can have significant chest wall weakness. In acute or chronic demyelinating polyneuropathy (Guillain-Barre(c) syndrome), tendon reflexes are lost and there may be additional bulbar cranial nerve weakness. In patients with myasthenia gravis, initial inspiration and expiration volumes may be normal, but repeated testing demonstrates rapid fatigability and poor aeration. In the condition multiple system atrophy, a diffuse degenerative condition with numerous areas of the nervous system affected, typical signs include parkinsonism in the form of bradykinesia and rigidity and gait dysfunction, along with cerebellar dysfunction-like dysmetria, ataxia, or tremors. Spinocerebellar atrophies are also associated with sleep disruption, and their motor signs are predominantly limb, trunk, and gait ataxia, along with sensory neuropathies. Whereas most movement disorders resolve during sleep, patients with tics may have significant sleep disruption from continuing tics, and patients with Parkinson's disease have difficulty going to sleep because of stiffness and shaking as well as further difficulty staying asleep. In addition, they have a frequent problem with vivid dreams and sleep fragmentation, and they may have RBD associated with injurious behaviors.

Sensory. A number of neuropathies are associated with sleep alterations, and hence the sensory examination, including both position and vibration testing for myelinated fiber function and pain and temperature testing for unmyelinated fiber function should be performed. RLS can be frequently exacerbated by neuropathy, and diabetes mellitus and spinocerebellar atrophies have characteristic neuropathic findings.

Autonomic Nervous System. Central sleep apnea is the loss of respiratory airflow associated with a loss of respiratory muscle effort. It is thought to arise from alterations in the functioning of chemoreceptors monitoring hypoxic and hypercapnic influences on respiration. Patients should be examined for waking respiratory difficulties and cardiac functioning, in particular for congestive heart failure. Neuromuscular diseases likewise may predispose to episodes of sleep apnea, as can autonomic nervous system instability. Patients should be assessed for evidence of orthostatic hypotension and examined for those disorders with autonomic nervous system involvement, including multiple system atrophy, Guillain-Barre(c) syndrome, and diabetes.

Neurovascular System. A general cardiac and vascular examination reveals signs of cardiac failure and blood pressure, specifically signs of pulmonary hypertension that is frequently associated with obstructive sleep apnea.

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