These are exciting times for our Department of Neurology. I have recently returned as Chairman of Neurology and this coincided with the affiliation of LSU Health Shreveport with Ochsner Healthcare, which has a main campus in New Orleans, but is now a major presence in delivering quality healthcare to an increasing geographical environment.
Our Department is dedicated to high-quality patient care, resident and medical student education as well as our academic mission of research, presentations and publications.
We are very proud of our participation in a Primary Stroke Center with efforts moving toward a Comprehensive Stroke Center at our affiliated hospital. We also boast a certified Sleep Disorders Center with Sleep Fellowship as well as an Epilepsy Monitoring Unit as part of our Epilepsy Surgery program. We have specialty clinics in Headache, Movement Disorders, Stroke, Sleep disorders, Epilepsy, Pediatric Neurology, Multiple Sclerosis as well as an MDA Clinic and General Neurology. We are also expanding our efforts to provide clinical care in Neurodegenerative disease. Our catchment area includes much of northern Louisiana including what is termed the ARK-LA-TEX reflective of contiguous states.
We have effective collaboration in the basic science arena with a well extra-mural funded stroke research lab within our Department, under the direction of Dr. Kevin Lin, as well as ongoing collaborative cognitive neuroscience research with Elizabeth Disbrow, PhD and Steven Alexander, PhD. Our clinical research, including controlled clinical trials, is active and ongoing with Jeannie McGee, DHEd, CCRC serving as our Director of Clinical Trials. We have a Neurology Residency Training Program that is a continuing source of pride. Our residents traditionally excel with the Neurology in-service exam, board performance, publication and presentation productivity reflective of their research and in the quality of post-graduate fellowships that they enter.
We are in the process of expanding our faculty as we assume increasing responsibility in healthcare outreach with efforts to be increasingly available to both underserved as well as those with more ready access to healthcare. We have a very effective and collegial collaboration with Neurosurgery, Neuroradiology, Pediatrics and Psychiatry as well as other services within our medical center. There is a lot to be proud of with our accomplishments, to date, but we view this, to quote the group Chicago, as "only the beginning".
- Child Neurology
- Clinical Neurophysiology
- Multiple Sclerosis
- Neuromuscular Disease
- Parkinson's Disease
- Sleep Disorders Center
- Useful Links
Child Neurology is a sub-specialty of General Pediatrics which focuses on the care of children with disorders of both the central and peripheral nervous systems. Our department currently has one board certified child neurologist, Dr. Rosario Maria Riel-Romero. She has a special interest and expertise in areas of pediatric epilepsy for patients with refractory seizures being considered for surgery, neurogenetic disorders, neurocutaneous disorders, neonatal neurology, pediatric neuromuscular disease, movement disorders such as tics, developmental disabilities, cerebral palsy among others. In addition, with our colleagues in the department, we offer an array of neurodiagnostic services.
This includes the following:
- Intracranial EEG monitoring
- Pediatric Epilepsy Surgery
- Routine and video EEG
- Visual Evoked Potentials
- Neuroimaging studies including CT Scans, MRIs, MR Spectroscopy, PET scans and ictal SPECT
- Pediatric Sleep Studies
Our goal is to work with our patients' primary care providers to diagnose and treat neurological problems with the most advanced and state of the art care available.
We offer the following services as well:
- Eteplirsen for Duchenne Muscular Dystrophy
- Nusinersen for Spinal Muscular Atrophy
- ACTH Therapy for Infantile Spasms
- Dysport injections for Spasticity
- Intrathecal Baclofen Pump
The clinical neurophysiology laboratory at LSU Health Shreveport will serve as the resident's "training grounds" in learning to interpret of electroencephalograms, nerve conduction studies/electromyograms and evoked potentials. Currently the laboratory performs about 1,000 EEG's, 400-500 EMG's and about 20-30 EP's each calendar year. Instruction in basic neurophysiology and anatomical substrates of EEG, EMG and EP's and the indications for performance of these tests will form the core curriculum leading proper interpretation of these clinical studies. The resident will learn to recognize normal EEG patterns in infants, children and adults as well as to recognize abnormal patterns and their clinical significance. In the EMG lab, the resident will learn the normal parameters of nerve conduction studies and needle electrode exam of infants, children and adults. The trainee will learn to recognize abnormal patterns of nerve conduction and EMG and to correlate findings with clinical conditions affecting the neuromuscular and peripheral nervous systems. The trainee will learn the principles and techniques in recording and interpreting evoked potential studies.
This basic knowledge of clinical neurophysiology should be helpful in further diagnostic studies in sleep disorders and epilepsy and in intraoperative monitoring.
Our department performs routine EEG’s, nerve conduction studies, electromyographic studies and evoked potential testing (visual, auditory and somatosensory). Studies can be scheduled by calling (318) 626-1828.
EEG / Epilepsy
Our Epilepsy Center is accredited at the highest level, a level 4 Epilepsy Center. We are the only level 4 center in the Tri-State area.
The diagnosis and treatment of epilepsy is a major interest of the LSU Health Shreveport Neurology department. A specialty clinic designed to meet the needs of patients with epilepsy meets once a week. This clinic is especially suited for management of the patient with seizures that are not fully controlled. While medical management of epilepsy and seizures is the rule for most patients, other treatments such as surgery, vagus nerve stimulation and special diets may have to be considered. Our epilepsy monitoring unit is helpful in identifying persons who may respond to surgical intervention. Long-term video and electroencephalographic (EEG) monitoring in our epilepsy monitoring unit is essential in the initial evaluation of those with intractable epilepsy. Monitoring is also helpful in identifying patients whose clinical symptoms may not be related to epilepsy.
Our neurology residents must be able to diagnose and care for patients with epilepsy, including those with complications and diagnostic uncertainties. Instruction in the interpretation of EEG recordings and various epileptic syndromes helps in the management of seizure disorders.
The resident also is expected to understand the epidemiology, genetics, classification, prognosis and treatment of epilepsy. The trainee is expected to manage conditions such as convulsive and non-convulsive status epilepticus and refractory epilepsy. Further instruction in the pharmacology of various anti-epileptic drugs will enable the resident to choose medications that are appropriate for the type of seizure that an individual patient has. Our hospital has excellent neuro-imaging facilities, including computerized tomography (CT), magnetic resonance imaging (MRI), positron emission imaging (PET) and single photon emission computerized tomography (SPECT). Our clinical neurophysiology laboratories offer routine EEG as well as long-term video/EEG monitoring.
We also emphasize consideration of the quality of life in the epileptic patient. Problems such as employment, educational opportunities, driving, gender issues and medication side-effects must all be considered in successful management of patients with epilepsy.
The neurology epilepsy academic program has been built-up over last two decades. It has unconditionally supported the epilepsy care in this region assisted by local healthcare systems. Along with neurosurgeons Dr. Sun and Dr. Notarianni, the epilepsy surgery program has been certified as level IV center (NAEC), the highest level of epilepsy care nationwide. For pediatric epilepsy patient referral, please ask PCP or primary neurologist to contact at (318) 675-8182. or Fax request to (318) 675-7805. For adult epilepsy patient referral to Oschner, please ask PCP or primary neurologist to contact at (318) 675-4613, or Fax request to (318) 675-6382. For adult epilepsy patient referral to Tri-State Neurosurgery (Dr. Wilden's office, part of Willis-Knighton Physician Network), please ask PCP or primary neurologist to contact at (318) 675-8176, or Fax request to (318) 675-8186. For general question, please contact at (318) 675-2482, the neurology clinic.
The LSU Health Shreveport neurophysiology department operates Monday through Friday from 8:00 AM to 4:30 PM. The department offers routine EEG testing and long-term video monitoring on patients of all ages. Please contact Alena Stevens, R.EEG.T. at (318) 626-1833 or Fax request to (318) 626-3485.
Dr. Debra Elliott Davis is board certified in Neurology and Headache Medicine. She manages chronic migraine and other primary headache disorders in an outpatient setting with inpatient treatment available when necessary. Pharmacologic and non-pharmacologic state of the art therapeutic protocols are used in treating migraine, cluster headache and chronic daily headache, with emphasis on a non-opioid approach. Trigger point and Botox injections are utilized as well. Patients are encouraged to make lifestyle changes in order to achieve realistic goals and maximize activity and productivity for an improved quality of life.
Multiple sclerosis (or MS) is a chronic, often disabling disease that attacks the central nervous system (CNS), which is made up of the brain, spinal cord, and optic nerves. Symptoms may be mild, such as numbness in the limbs, or severe, such as paralysis or loss of vision. Multiple sclerosis (MS) involves an immune-mediated process in which an abnormal response of the body’s immune system is directed against the central nervous system (CNS). The CNS is made up of the brain, spinal cord and optic nerves. The progress, severity, and specific symptoms of MS are unpredictable and vary from one person to another. Today, new treatments and advances in research are giving new hope to people affected by the disease.
Although there is still no cure for MS, effective strategies are available to modify the disease course, treat exacerbations (also called attacks, relapses, or flare-ups), manage symptoms, improve function and safety, and provide emotional support. In combination, these treatments enhance the quality of life for people living with MS. Treatments for MS involve disease modifying therapies in the forms of oral medications, injectable medications and infusions.
For more information please visit the National Multiple Sclerosis Society website at www.nationalmssociety.org
Types of Multiple Sclerosis (MS):
Relapsing-Remitting Multiple Sclerosis: People with this type of MS experience clearly defined attacks of worsening neurologic function. These attacks—which are called relapses, flare-ups, or exacerbations —are followed by partial or complete recovery periods (remissions), during which no disease progression occurs. Approximately 85% of people are initially diagnosed with relapsing-remitting MS.
Secondary Progressive Multiple Sclerosis: Following an initial period of relapsing-remitting MS, many people develop a secondary-progressive disease course in which the disease worsens more steadily, with or without occasional flare-ups, minor recoveries (remissions), or plateaus. Before the disease-modifying medications became available, approximately 50% of people with relapsing-remitting MS developed this form of the disease within 10 years. Long-term data are not yet available to determine if treatment significantly delays this transition.
Primary Progressive Multiple Sclerosis: This disease course is characterized by slowly worsening neurologic function from the beginning—with no distinct relapses or remissions. The rate of progression may vary over time, with occasional plateaus and temporary minor improvements. Approximately 10% of people are diagnosed with primary-progressive MS.
Progressive Relapsing Multiple Sclerosis: In this relatively rare course of MS (5%), people experience steadily worsening disease from the beginning, but with clear attacks of worsening neurologic function along the way. They may or may not experience some recovery following these relapses, but the disease continues to progress without remissions.
The resident's exposure to neuromuscular disease and diseases of the peripheral nervous system will be, in part, through the local Muscular Dystrophy Association Clinic. This clinic currently meets weekly. Eight to twelve established and new patients are evaluated each week. Enrollment of patients includes not only those with muscular dystrophy but also patients with a variety of other conditions including other hereditary muscle diseases (congenital and mitochondrial myopathies), acquired neuromuscular problems (i.e. inflammatory myopathies), diseases of the neuromuscular junction, diseases of the motor neuron (ALS, spinal muscular atrophy), hereditary neuropathies and a number of other hereditary conditions (spinocerebellar ataxias). The resident will learn skills in performing the neuromuscular examination, in diagnosing and managing neuromuscular conditions, in genetic counseling of hereditary disorders and in utilizing allied health specialties (physical, occupational, speech/language therapy).
The resident will also receive instruction in the neuropathology of neuromuscular disease including indications for and interpretation of muscle and nerve biopsy.
The in-patient service and consultation service will also provide further experience in diagnosis and management of more acute neuromuscular diseases such as myasthenia/myasthenic crisis, Guillain-Barre syndrome, traumatic nerve and plexus injury, acute weakness in the critical care unit. The outpatient clinic service will provide exposure to a similar variety of subacute and chronic neuromuscular and peripheral nerve conditions.
Neurological Medical Ethics
Over the course of his/her training, the resident can expect to receive further instruction in neurological aspects of medical ethics. A case-based curriculum will likely be the format for this instruction. A few topics that will be considered include truth-telling, ethics of genetic testing and problems regarding persistent vegetative state, brain death and transplantation. There will be opportunities to participate in and interact with the hospital ethics committee, if desired.
"To assist in motivating individuals with Parkinson's disease, to maximize strengths, minimize impediments, and to achieve and maintain full potential."
About Parkinson's Disease
Parkinson's disease is a common, progressive disorder in which loss of nerve cells in certain areas of the brain result in characteristic symptoms. The classic triad includes tremor (primarily with limb at rest), rigidity (stiffness), and bradykinesia (slowness). Difficulty with balance, stooped posture, and small steps can make walking difficult. Slurred speech and a soft voice are also symptoms of Parkinson's. However, every affected person is different. For example, some individuals have tremor but few additional symptoms. Others have no tremor.
Most people are well, not sick, with Parkinson's. The symptoms are treatable. The commonly used medications for this disorder can improve symptoms in many patients for a number of years. It is important that the individual with Parkinson's and those involved with their care know the proper indications and side effects of the medications. Exercise programs, physical, occupational, and speech therapy are also beneficial.
- Provide information and resources to individuals with Parkinson's disease, their families, caregivers, medical professionals involved in their treatment, and other interested people.
- Provide educational and technical/administrative support to the local and regional PD support groups and facilitate the establishment of the satellite support groups in outlying communities.
- Enhance public education and awareness of the disease and its problems.
- Support Parkinson's disease basic science research (Eichler and Special Awards).
- Advocacy for national funding of Parkinson's research.
Parkinson's Disease Resource Team
Lola and Clif Eichler, Founders
Richard Zweig, MD, Medical Director
Jim & Louise Altick, PAN Advocates
A.C. Cowan, PAN Advocate
Phyllis Armstrong, Administrative Coordinator
Trudy Floyd, Volunteer
Pam Neff, Newsletter Columnist
Walt Robbins, Volunteer
Anna Vaughn, Volunteer
One of the goals of the Parkinson's Disease Resource is to promote Parkinson's disease-related basic science research at LSU Health Shreveport. To date we have provided pilot grants to five investigators who have initiated very promising, state-of-the-art research concerning Parkinson's disease. These investigators have presented their results at national meetings, several manuscripts have been published in the scientific literature acknowledging our support, and funding from the National Institute of Health and other organizations has been obtained by local researchers based on results generated from our pilot grants. Click on CLINICAL TRIALS for current studies available.
Local, State and National Organizations
American Parkinson Disease Association (APDA)
Parkinson's Disease Foundation (PDF)
National Parkinson Foundation (NPF)
National Family Caregivers Association (NFCA)
Parkinson's Action Network (PAN)
Young Onset Parkinson's Association
Michael J. Fox Foundation
Local and National Events
Annual Lola Eichler Memorial Parkinson's Symposium
Parkinson's Action Network (PAN); Washington, DC 800.850.4726
Community Support Groups and Resources
Shreveport Parkinson's Meeting & Continuing Education; Pam Neff 318.221.8979
CENLA Parkinson's Support Group; Becky Watkins 318.448.6938
Caregiver Support Group; Pat Hudnall 318.549.9744 or
Monroe Support Group; Louise Altick 318.388.3071
Exercise and Fitness Programs
Parkinson's Community Fitness Program
CHRISTUS Schumpert Out-Patient Rehab; 1500 Line Avenue-Shreveport
11:00 a.m. every Tuesday and Thursday; $30/month (318) 681-7530
CHRISTUS Schumpert Wellness Centers
2541 Viking, Bossier City (318) 848-2900
9425 Healthplex, Shreveport (318) 681-7800
Willis-Knighton Reconditioned Water Aerobics and Up & Able Exercise
Classes are offered at various times during the week at all four Wellness Centers.
Call for information (318) 212-4475
Willis-Knighton Health & Fitness
2600 Greenwood, Shreveport (318) 212-4475
2452 Hospital Dr., Bossier City 318) 752-7475
8001 Youree Dr., Shreveport (318) 212-3475
9130 Susan Dr., Shreveport (318) 212-5475
- Using a multidisciplinary and patient-centered approach to diagnose and treat the full spectrum of sleep disorders
- Providing sleep-disorders training and education of the highest quality to sleep fellows and medical staff
- Conducting innovative basic-science and clinical research that is directly relevant to the advancement of patient care and the discipline of sleep medicine
- Offering public education in sleep medicine and research
- Circadian Rhythm Disorders
- Restless Legs Syndrome
- Pediatric Disorders
- Snoring & Sleep Apnea
- Sleep Disorders
- Nighttime Sleep Behaviors
Insomnia is a common sleep disorder that affects about 10% of the adult population. The nighttime symptoms include persistent difficulty falling and/or staying asleep. Daytime symptoms include fatigue, and difficulties with concentration and/or memory. Insomnia may be diagnosed when symptoms persist for at least a month.
Insomnia sometimes occurs alone, with no other co-existing disease. But more often insomnia occurs in conjunction with other medical or psychiatric conditions, and may worsen them or hinder their treatment. For example, people with depression and insomnia do not respond as well to depression treatment as depressed people without insomnia.
Risks for Insomnia
The known risk factors include:
- Absence of a regular wake time
- Excessive worry
- Failure to unwind from the day’s stresses
- Other sleep disorders, including restless legs syndrome and sleep apnea
- Genetic predisposition
- Gender: Women are twice as likely as men to experience insomnia
- Age: Older adults are more likely to experience insomnia
An insomnia disorder is diagnosed when the disturbed sleep lasts more than a month and negatively impacts general well being, either because the difficulty in sleeping is particularly distressing or because it leads to an impairment in performance or mood. Part of the diagnosis involves a determination of whether the symptoms are better explained by other medical or psychiatric conditions.
Circadian Rhythm Disorders
The internal activity of the human body follows a cyclic pattern called a circadian rhythm. Chemical and electrical signals are generated during the cycle that tend to produce sleep at night and wakefulness during the day. The rhythm works best when a reasonable amount of exposure to sunlight is obtained and regular routines for going to bed in the evening and awakening in the morning are maintained. Disorders involving the rhythm occur when it becomes misaligned with a person’s chosen time for sleeping and waking. Various types of disorders are recognized, the most common of which are delayed sleep-phase, advanced sleep-phase, and a disruption of the rhythm that results from shift work.
Delayed sleep-phase occurs when the timing of the internal signal for sleep is delayed several hours relative to a person’s desired bedtime. People with this disorder have difficulty falling asleep because their internal clocks do not send the signal for sleep until late into the night. They also have difficulty waking up at what is generally considered a normal time because their natural awakening is delayed. Someone with delayed sleep-phase may sleep well but wakes up late, making it difficult to begin a typical daily routine of activity in a timely fashion. People are not considered to have delayed sleep-phase disorder unless they also experience impairment in social, occupational, or other areas of life as a consequence of the sleep problem.
Advanced sleep-phase disorder is produced when the sleep signal occurs several hours or more earlier than the desired bedtime. People with this disorder go to bed and awaken unusually early because their sleep and awakening signals are mis-timed relative to their desired schedules. The disorder makes it difficult to engage in social activities because of the need to go to sleep much earlier than what is generally considered normal. Advanced sleep-phase is particularly prevalent among older adults.
Shift-work sleep disorder is a problem that stems from the mismatch between a person’s circadian rhythm and the time interval for sleep that fits a particular work schedule. Symptoms produced by the mismatch may include difficulty in initiating and maintaining sleep, excessive sleepiness when awake, difficulty concentrating, headaches, and/or a general feeling of malaise. Rotating shifts are particularly a problem because they may lead to trouble staying alert while working, and to unrefreshing sleep.
Restless Legs Syndrome
Restless legs is a common syndrome in which a person has an urge to move the legs and, typically, experiences abnormal sensations including burning, tingling, or aching. The arms or other body areas may also be affected. The symptoms can range from mild to severe, and may occur occasionally or almost every evening. The disorder is about twice as common in women, and its prevalence increases with age.
The symptoms of restless legs syndrome (RLS) start or worsen during rest, especially in the evening and/or when lying down. The longer someone rests, the greater the chances the symptoms will occur and will be more severe. The symptoms improve as a result of movement. At least partial relief typically starts soon after beginning activities such as walking, and persists as long as the activity continues.
Most people with RLS also demonstrate periodic limb movements during sleep, which are abrupt leg movements that occur 20 to 30 seconds apart at various times during the night. The movements, which can also occur in other parts of the body, cause partial awakenings that disrupt sleep, resulting in poor sleep quality.
Low brain iron metabolism and abnormal levels of dopamine in the brain are probably important factors in causing RLS. The disorder commonly runs in families, especially when it is severe and starts early in life. Environmental factors and other medical problems are also associated with the disorder. RLS frequently begins or becomes worse during pregnancy, and is more frequent in people with damaged nerve endings, such as in those with diabetes. RLS may be associated with other conditions such as depression and heart disease.
The disorder may be difficult to diagnose in children because the symptoms overlap those of other pediatric disorders.
Sleep disorders can occur in infants, young children, and adolescents, resulting in developmental, behavioral, and social difficulties, and in other health problems. Children may suffer from problems falling or staying asleep, obstructive sleep apnea, restless legs syndrome, abnormal behaviors during sleep such as sleepwalking or other parasomnias, or from daytime sleepiness. Additionally, many medical or psychiatric conditions can contribute to sleep disorders. The symptoms shown by children may be quite different compared to those of adults with sleep disorders, because developmental aspects of childhood play an important role in pediatric sleep.
An arousal occurs when a child transitions from deep sleep to light sleep or partial wakefulness. During the arousal the child may appear to be alert, as evidenced by crying or walking, while simultaneously appearing to be disoriented and confused, as evidenced by unresponsiveness to parental directions or environmental challenges. A child who is awakened during an arousal typically does not recall the events that occurred during the episode.
Many kinds of behaviors may be exhibited ranging from mumbling or sitting up in bed during sleep to more elaborate behaviors including loud, distressful crying, ignoring parental directions and reassurances, and a dreamlike expression. The child may act aggressively and regard the parent as a threat. Sleepwalking and running into furniture can occur, which may appear either goal-oriented or without purpose.
Commonly only one episode occurs during the night, often within the first two hours of falling asleep, but multiple episodes are possible. There may be periods when multiple episodes occur each night followed by periods without a single episode. Overall, the timing frequency, intensity, and behavior exhibited are all quite variable.
In older teenagers, alcohol intake and sleep deprivation are possible triggers for arousals. Sometimes the aberrant behaviors are triggered by sleep-disordered-breathing, abnormal sleep-wake schedules, and/or stressful conditions.
Medical and Psychiatric Conditions
Sleep disturbances can occur as a consequence of many different conditions including:
- Attention deficit hyperactivity disorder
- Gastroesophageal reflux disease
- Developmental disorders
- Mental retardation
- Prader-Willi syndrome
- Tourette disorder
- Nocturnal asthma
- Depressive disorders
- Neuromuscular disorders
- Nocturnal seizures
- Kleine-Levin syndrome
- Chronic fatigue syndrome
Diagnosing Pediatric Sleep Disorders
If you suspect your child has a sleep disorder, you should schedule an appointment for an evaluation.
Hypersomnias are disorders that involve excessive sleep and difficulty in staying awake during the day. The core symptom is excessive daytime sleepiness that is not due to other identifiable causes. Persistent sleepiness lasting more than three months without abnormalities specifically related to REM sleep is called idiopathic hypersomnia. A pattern of periodic isolated episodes of sleepiness is called recurrent hypersomnia.
Persons with idiopathic hypersomnia sleep far more than normal, have difficulty waking up, and feel tired, sleepy, or groggy during the day, and experience these symptoms more or less continuously for three months or more with a resulting significant impact on daily life. A diagnosis of idiopathic hypersomnia requires exclusion of other causes of daytime sleepiness such as insufficient sleep, disturbed nocturnal sleep, insomnia, circadian rhythm disorder, sleep-related breathing disorders, or medical issues.
Idiopathic hypersomnia can have many causes including brain abnormalities, low-grade infections, or a brain imbalance associated with psychiatric conditions. The disorder may arise from an abnormal sleep schedule, or sedative or stimulant medications taken in excess or at the wrong time.
Recurrent hypersomnia is characterized by recurrent, reversible episodes of hypersomnia, often associated with other symptoms, that typically occur weeks or months apart. During the episodes the sufferers experience extreme sleepiness and have big sleep requirements, sometimes as much as 16 to 20 hours a day.
Snoring and sleep apnea are sleep-related breathing disorders that involve abnormal breathing during sleep.
When the airway becomes partially blocked, some of the inhaled air becomes redirected from the lungs to the mouth, producing a pressure that vibrates the soft tissue of the palate, resulting in snoring.
Snoring is associated with disrupted sleep, daytime fatigue and sleepiness, and low oxygen levels in the body. Snoring can also seriously disturb the bed partner’s sleep, resulting in difficulties in interpersonal relationships.
Obstructive Sleep Apnea
The soft tissues in the throat relax during sleep. Obstructive sleep apnea (OSA) occurs when the airway repeatedly collapses during the night, either completely or partially, thereby disrupting breathing. When the airway is blocked, the oxygen levels in the body drop, causing the person to awaken and begin breathing normally. The affected person often is unaware of the awakenings because they may last only a few seconds. Someone with severe sleep apnea may awaken hundreds of times during the night. The awakenings fragment and interrupt the sleep cycle, which causes the common symptoms of sleep apnea, daytime fatigue and sleepiness. OSA is a treatable disease, but if untreated it is associated with serious medical conditions.
Symptoms of OSA in adults include:
- Choking or gasping during sleep
- Observed pauses in breathing
- Daytime fatigue and/or sleepiness
- Dry and/or sore throat in the morning
- Morning headaches
- Night sweats
- Poor concentration and attention
- Memory problems
- Sleepwalking or night terrors
Symptoms of sleep apnea in children include:
- Daytime cognitive and behavioral problems including problems paying attention, easy distractibility, aggressive behavior, and hyperactivity
- Mouth breathing
- Enlarged tonsil and adenoids
- Problems sleeping and restless sleep
- Parasomnias such as sleepwalking or night terrors
- Failure to thrive
- Excessive daytime sleepiness
- Upper airway resistance syndrome is a condition in which the throat becomes blocked, resulting in periodic episodes of reduced air flow. Although the resulting disturbance of sleep is not as great as that associated with OSA, upper airway resistance syndrome can cause similar symptoms.
Other Sleep-Related Breathing Disorders
Other sleep-related breathing disorders include central sleep apnea (CSA) and sleep-related hypoventilation syndromes (SHS). CSA occurs when the brain fails to signal the body to breathe. Unlike obstructive sleep apnea, in CSA there is no breathing effort because there is no drive to breathe. SHS are the result of a decreased response to low oxygen or high carbon dioxide during wakefulness and sleep. The syndromes are characterized by frequent episodes of shallow breathing during sleep that last longer than 10 seconds.
A comprehensive history and physical examination by a sleep physician and an overnight sleep study is needed to diagnose sleep-related breathing disorders in children or adults.
Narcolepsy is a chronic neurological sleep disorder characterized by excessive daytime sleepiness, and abnormal REM sleep. A person with narcolepsy will experience a high level of fatigue and may fall asleep at odd and inappropriate times, such as during work or school. A brief nap may be refreshing, but the sleepiness can reoccur after a few hours.
Most patients with narcolepsy also experience cataplexy, which is a sudden feeling of paralysis or weakness in the head, legs or other body parts especially after excitement or laughing.
In most cases of narcolepsy without cataplexy, the cause of the symptoms is unclear and the diagnosis is based on the results of a sleep study.
Sleep is critically important for health and happiness, yet sleep is often neglected and its importance underappreciated in our busy society. About one of every four Americans has a sleep problem. If you are sleeping too much, experiencing excessive daytime sleepiness (falling asleep at inappropriate times), having difficulty falling or staying asleep, or experiencing abnormal behaviors associated with sleep, you may have a sleep disorder.
- Sleepwalking and/or Sleeptalking
- Sleep Terrors
- Confusion Arousals
- REM Behavior Disorder
- Sleep Paralysis
Sleepwalking and/or sleeptalking are conditions in which a sleeping person appears to be awake and exhibits behaviors associated with being awake, but is actually sleeping. During sleeptalking the person’s vocalizations may be anything from a few words to long conversations. Sleepwalking involves activities ranging from sitting up in bed or walking to the bathroom, to extreme behaviors such as getting in a car and driving. Persons who talk or walk in their sleep are rarely aggressive, but may become confused and combative when attempts are made to arouse them. The episodes usually occur in the first half of the night during the deepest stage of sleep, and the sleeper often has little or no memory of the events.
Sleepwalking can occur at any age, but is most common in children and usually diminishes as children grow older. Conditions such as fatigue, stress or anxiety, lack of sleep, illness, physiological stimuli such as a full bladder, or alcohol are often associated with sleepwalking episodes.
In persons who show regular, persistent, or alarming behavior, tests are needed to help evaluate the possible role of specific triggers, such as sleep-disordered breathing or nocturnal seizure disorder.
Sleep terrors are episodes characterized by extreme fright and a temporary inability to attain full consciousness. Affected persons may abruptly exhibit fear, panic, confusion, or a desire to escape, and remain unresponsive to soothing from others. Vocalizations including gasping, moaning or screaming may occur even though the person is not fully awake. Typically a person undergoing a sleep terror returns to normal sleep after the episode ends, without ever fully waking up, and with no recollection of the episode in the morning.
Terror episodes occur during deep sleep, usually during the first part of the night. The timing of the events helps differentiate the episodes from nightmares, which occur later in the sleep period. Sleep terrors can occur at any age, but are more common in children. Emotional stress during the day, fatigue or an irregular routine may trigger episodes, and a predisposition to sleep terrors may be hereditary.
A confusional arousal is an event in which a sleeping person appears to be awake but exhibits unusual or strange behavior. The person may be disoriented, unresponsive, and exhibit slow speech or confused thinking. Confusional arousals typically occur in the first two hours after falling asleep. The episodes may last only a few minutes, or they may last much longer. The next morning there is usually little or no recall of the events that occurred during the arousal.
Confusional arousals can occur at any age, but are more common in children. Sleep disruptions caused by fever or other health problems, travel, abrupt sleep loss, migraine, and irregular sleep-wake schedules may trigger an episode. Other disorders including sleep-disordered breathing and restless legs syndrome, or nocturnal asthma can occur in association with the confusional arousals.
Dreaming occurs during rapid eye movement (REM) sleep. Normally, in REM sleep, the tone in many of the body’s muscles becomes reduced. REM behavior disorder is a condition in which the brain fails to send the signals necessary to cause reduced muscle tone, thereby allowing sleeping persons to move and act out their dreams. The movements can be minor such as leg twitches, or complex behaviors that are manifestations of action-filled or violent dreams. A person may awaken and become quickly alert at the end of an episode and be able to provide a coherent description of the dream.
The prevalence of the disorder increases with age and may be associated with certain neurological disorders. Adverse reactions to certain drugs or drug withdrawal can sometimes appear as REM behavior disorder. Evaluation of REM behavior disorder requires appropriate tests including a sleep study to evaluate for other sleep disorders and the occurrence of abnormal muscle tone during REM sleep.
Loss of muscle tone is a normal part of REM sleep but is an abnormal condition, termed sleep paralysis, when it occurs outside of REM sleep. Sleep paralysis can occur in otherwise healthy people or as a presenting symptom in narcolepsy or other sleep disorders. Sleep paralysis commonly occurs when a person is either falling asleep or awakening. If an individual has awareness as the body enters or exits REM sleep, they may experience sleep paralysis, which can last from several seconds to several minutes. Episodes of longer duration are typically disconcerting and may even provoke a panic response. The paralysis may be accompanied by vivid hallucinations, which is often attributed to being part of dreams.
Sleep paralysis can occur in otherwise normal sleepers, and is relatively common in its occurrence and universality. It has also been linked to various conditions such as increased stress, excessive alcohol consumption, sleep deprivation, and narcolepsy.
Treatment of sleep paralysis is often limited to education about sleep phases and atonia that normally occur during sleep. If episodes persist, the person will be evaluated for narcolepsy, which is commonly present in those suffering from sleep paralysis.
ightmares are vivid dreams that contain frightening images or cause negative feelings such as fear, terror, and/or extreme anxiety. When awakened during a nightmare, the sleeper can usually provide a detailed description of the dream content. A nightmare can cause the sufferer to awaken in a heightened state of distress, resulting in perspiration and an elevated heart rate. Often it takes time to recover from the negative emotions provoked by the nightmare, leading to difficulty in returning to sleep.
Nightmares are distinguished from sleep terrors based on the timing of the episodes and on whether dream content can be recalled. Nightmares are more likely to occur during the last third of the night when there is a higher concentration of REM sleep.
Nightmares can have both psychological and physical causes. Factors including illness, anxiety, or even sleeping in an uncomfortable position can lead to bad dreams. Post-traumatic stress disorder can trigger frequent nightmares, as can side effects from various medications and narcotics including amphetamines and cocaine.
The Neurology residents who train within our Program will have the opportunity to see a large number of patients with various forms of stroke during their three year residency. Many of the stroke patients are admitted onto the Neurology Service and most of the rest are seen in consultation. There are a number of didactic presentations on the diagnostic evaluation and management of acute, subacute and chronic stroke. This includes a series of lectures on optimizing stroke prevention. There is outstanding neuroimaging available, when clinically appropriate, and this includes ready access to CT brain scan (with the availability of perfusion CT) for acute stroke, MRI including magnetic resonance spectroscopy as well as perfusion and diffusion-weighted imaging, along with formal instruction in the Department's Noninvasive Lab which includes color duplex scanning along with transcranial Doppler. The transcranial Doppler component is responsible for the reading of the transcranial Doppler studies of all patients with aneurysmal subarachnoid hemorrhage and Sickle Cell Disease at our medical center and from referring medical centers. It is expected that the Neurology residents will be quite comfortable with acute and chronic management of stroke by the time they complete their training. This is augmented by the neurorehabilitation rotation during the PGY-4 year. The Department of Neurology has an active Stroke Service which is involved in a number of stroke preventive and interventional studies. Residents are encouraged to participate in clinical trials in stroke as sub-investigators.
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