1140 Multiple Sleep Related Disorders and Their Interplay in a Complicated Case

Abstract

Abstract The diagnosis and management of sleep related disorders can be challenging. Continued vigilance is necessary in these patients, to help identify other comorbid conditions which can develop over time and to ensure adequate treatment. A 79 year old gentleman, with a history of atrial fibrillation (AF) on anticoagulation and heart failure with reduced ejection fraction, initially presented to the Sleep clinic with daytime sleepiness. His history was negative for sleep disruptions, limb movements or parasomnias. Nocturnal oximetry suggested moderate sleep disordered breathing. A baseline polysomnogram confirmed mild obstructive sleep apnea. The patient was initiated on Bi-level PAP therapy with subsequent improvement in daytime symptoms. He was followed up for 5 years with no significant changes in management, but lost to follow up thereafter. Two years later, the patient presented to Neurology with a traumatic subdural hematoma requiring emergent hemi-craniotomy for surgical evacuation. He had suffered a fall out of bed one day prior to presentation during a vivid nightmare. Recent history was notable for dream enactment described as "fighting someone" in his sleep. Neurological exam revealed cognitive impairment. He was referred to the Sleep clinic for re-evaluation of REM sleep behavior disorder (RBD), which likely resulted in his traumatic subdural hematoma in the setting of anticoagulation for AF. Our case provides a stark reminder that continued and repeated inquiry to identify potential dangerous parasomnias during routine follow up for sleep disordered breathing remains essential. The implications of an unfound diagnosis can be tremendous. Furthermore, a diagnosis of RBD can affect the risk and benefit counseling regarding anti-coagulation decisions in patient's with atrial fibrillation and should be strongly considered as a potential complicating factor that requires appropriate treatment. Adequate control of sleep disordered breathing is a therapeutic goal in these patients, as it improves sleep quality and thereby impacts parasomnia phenomena.