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Other conditions that are commonly associated with narcolepsy include obesity while they're not directly related. It makes sense. Then when we feel very exhausted, very tired during the day that we tend to reach for foods that contain sugar and fats and even caffeine. So people with narcolepsy kind of self-treat with sugar to give themselves a boost of energy. Unfortunately, if your diet is made up of soda and candy bars, this tends to lead to obesity and frequently obesity can lead to other problems like hypertension, diabetes, and even obstructive sleep apnea, another common sleep disorder, which can cause daytime fatigue as well. Another thing that may occur is that patients with narcolepsy may develop depression. There's a higher incidence of that, partly because of their disease state itself, but also some of those alerting neuro-transmitters in the head also give us energy. And if we don't have enough energy, our mood may be low and depression is a common side effect.
Other conditions that are commonly associated with narcolepsy include obesity while they're not directly related. It makes sense. Then when we feel very exhausted, very tired during the day that we tend to reach for foods that contain sugar and fats and even caffeine. So people with narcolepsy kind of self-treat with sugar to give themselves a boost of energy. Unfortunately, if your diet is made up of soda and candy bars, this tends to lead to obesity and frequently obesity can lead to other problems like hypertension, diabetes, and even obstructive sleep apnea, another common sleep disorder, which can cause daytime fatigue as well. Another thing that may occur is that patients with narcolepsy may develop depression. There's a higher incidence of that, partly because of their disease state itself, but also some of those alerting neuro-transmitters in the head also give us energy. And if we don't have enough energy, our mood may be low and depression is a common side effect.
"In addition to excessive daytime sleepiness people with narcolepsy dream very frequently, and a lot more than the average person would, they also may be associated with symptoms that are kind of unusual. Like cataplexy which is a transient loss of muscle function. It's precipitated by a strong emotion. So if there's a funny joke or surprise or fear or terror, all of a sudden that person may lose some of their muscle function. It may last for moments or even minutes. Most of the time it affects the head and the neck and the shoulders. So it could be something very subtle, such as the face becoming Slack or the inability to speak clearly, or the eyes shutting. But sometimes the whole body can be affected and somebody can actually fall to the ground with loss of muscle function of their legs. Their knees may buckle. They may actually collapse. They can feel it coming, but they can't do anything about it. And they're completely conscious while this happens. They're aware of everything going on, but sometimes they may have double vision and they can't talk, but they know what's going on around them. It's just out of control. Sometimes narcoleptics actually avoid comedy clubs or surprise parties because they don't want that sudden emotion. They may avoid scary movies because they know they'll have a fright and they'll lose control. Cataplexy is not prevalent in everybody with narcolepsy, but it's certainly a very distinctive thing. And if one has that aspect of cataplexy, the diagnosis of dark narcolepsy can be made. So excessive daytime sleepiness is the most common symptom and cataplexy is the most interesting and exotic symptom."
"There are several diagnostic tests that we use to make the diagnosis of narcolepsy. The first is simply a clinical history hearing the patient's story and seeing what symptoms they have. After that, we look at the Epworth sleepiness scale score. What that is is a simple quiz. And the patient's asked a few questions. How sleepy are they if they're sitting in reading or after lunch or on a drive as a passenger for an hour without a break. So they have several clinical scenarios and they score themselves. I'm not sleeping at all. I'm a little sleepy, I'm moderately sleepy. I'm very sleepy. We add up the score and the higher the score, the more likely they are to be excessively sleepy or abnormally sleepy. So what we'd like is a nice low score, meaning that we're well rested, but a score above 10 out of 24 is already abnormal. Narcoleptics on average, have high scores like 17 or 18 out of 24. And they may answer positively to falling asleep at a stoplight or sitting and talking to some someone. So the first thing, the Epworth sleepiness scale score gives us a sense quantifies how sleepy they are during the day and how they function as a result. The next thing that we do is order a polysomnogram. This is a sleep study, which measures four things. We look at the brain waves to make sure there's no seizure activity going on, but it also tells us when the patient's awake during the night and what stage one, two, three, or REM sleep they're in. We know that patients with narcolepsy have extra REM density. They dream more than the average person and that their dream has come very early into the night cycle. Not just 90 minutes after falling asleep, but even a few minutes or a few moments after falling asleep. We also look at their heart rate and rhythm their muscle activities and their breathing. But the biggest thing about that sleep study is their sleep cycles and how much dreams they have."
There's sleep paralysis. So when we all normally dream at night, our brains are very active and of course her eyes are rapidly moving. Our lungs are breathing in our diaphragm and our heart is beating, but our large skeletal muscles, the arms, the legs, the chest, and the back are actually paralyzed. This is a good thing because if you're dreaming and you're dreaming that you're running, you would literally run in your bed. And so while the rest of us dream, we are pretty much paralyzed when narcoleptics dream they're paralyzed too, but there may be a difficulty stopping the paralysis. So they're actually awake, but they can't move. They can breathe. Their eyes can move and their hearts of course will continue to beat, but they cannot move their arms and legs. So they're awake, but stuck in this paralysis. Again, certainly it could be frightening. It may last for just a few moments or a few minutes, but it's another hallmark part of narcolepsy.
Sleep paralysis can actually occur in any one of us, especially if we're sleep deprived enough. I had the experience of sleep paralysis once in my life, and it was very frightening and I'll never forget it. I was a medical resident and I was on call and I was on a 36 hour shifts. And I didn't get much sleep that night, but there was a lull in activity and I was able to go back to the call room and lie down within a few moments. I was asleep and within a few minutes, my pager went off, but I'd already fallen into a dream, which is very unusual. And as the pager went off, I could certainly hear it and I reached to get it, but I was stuck. I was unable to move my own self. A few moments went by and the messages from my brain to my muscles occurred properly and I was able to move again. But sleep paralysis is something that's very common in narcoleptics and less common in the rest of us. There are a few people who get this on a regular basis and it can actually run in families. That's called isolated recurring sleep paralysis, but it could happen to any of us if we're sleep deprived enough.
"The next morning after we know they've gotten at least six hours of sleep. So we think they're adequately rested from an average viewpoint. We do an MSLT a mean sleep latency test. It's normal to take five to 20 minutes to fall asleep, but we asked narcoleptics well, people we think might be narcoleptic to take this test the night after their polysomnogram. And we give them an opportunity to sleep and nap opportunity. Once at eight o'clock in the morning, 10 o'clock in the morning, noon, 2:00 PM and 4:00 PM, five different opportunity to sleep and in between their naps or opportunities to sleep, they're allowed to get up, roam around, eat breakfast, take a shower, have lunch, but they're not allowed to jump up and down and be too stimulated with exercise. They're not allowed to have caffeine or any stimulating drug, and then they're invited to sleep. And what would be average is to maybe take a snooze in the middle of the afternoon at a sleepy time of day, such as a two o'clock or four o'clock nap, but we see how quickly they fall asleep. Often narcoleptics can fall asleep within minutes, less than three minutes of being given this 20 minute nap opportunity. What clinches the diagnosis is not just falling asleep during an app, how, but how quickly they do so. And if they fall into a REM period for the rest of us, unless we're grossly sleep deprived, we'd never have a dream in a 20 minute nap, but patients who fall asleep and go into a dream, a sleep onset REM period, go right into a dream with their nap, at least two out of those five times, clinches the diagnosis for narcolepsy. That's very unusual after that. If there is a confusion, because sometimes other things get in the way and we still can't quite interpret our results. We may consider even checking for hypocretin levels in the cerebral spinal fluid. This would require a spinal tap. So that's an invasive procedure. We try not to do that too often, but it can be done. And there's certain specialized labs across the country who measure these things. We would know a very low hypocretin level would be very, very suspicious for narcolepsy because this is the primary problem in this disease. We sometimes do genetic testing for patients with narcolepsy and cataplexy who have a high relationship with certain genetic markers. But those people who have narcolepsy without cataplexy, it's hard to tell. And it probably wouldn't wouldn't be worth it because those genes are kind of common in society. Anyway. So we have several tests that we look at for narcolepsy, but we put them together to make a diagnosis. And while nothing's perfect, we get a lot of information. And very few things give us all the symptoms of narcolepsy. Although all of us can have some of them at some time of our lives, but put together with these diagnostic tests, we can have a pretty good clear understanding to make this diagnosis."