Tests
1st tests to order
polysomnography (PSG) (in rapid eye movement sleep behavior disorder [RBD])
Test
PSG should be requested if RBD is suspected.[53]
PSG may also be considered when the patient's bed partner reports leg kicking.[58]
Result
evidence of increased electromyographic tone during rapid eye movement sleep and abnormal behavior documented on video (e.g., shouting and swearing, kicking, punching, and even jumping out of bed)
Tests to consider
PSG (in confusional arousals)
Test
PSG is not required for the diagnosis of confusional arousals and should be ordered only if there is some uncertainty about the history or physical exam.
Result
arousal from slow-wave sleep on EEG; delta or theta activity may be noted
PSG (in sleepwalking)
Test
PSG can be helpful if the differential diagnosis includes sleepwalking precipitated by sleep-disordered breathing (obstructive sleep apnea), other parasomnias causing sleepwalking, or rapid eye movement sleep behavior disorder mimicking sleepwalking.
However, PSG is not required for diagnosis of sleepwalking.
Result
arousal from slow-wave sleep on EEG, with video recording showing aimless ambulation occurring during sleep and often preceded by sitting up in bed
PSG (in nightmare disorder)
Test
PSG is not required unless nightmare disorder must be differentiated from other parasomnias.
Result
an arousal from rapid eye movement sleep noted on EEG
PSG (in sleep terrors)
Test
PSG can be helpful if the differential diagnosis includes sleep terrors precipitated by sleep-disordered breathing (obstructive sleep apnea), or other parasomnias causing sleep terrors.
However, PSG is not required for diagnosis of sleep terrors.
Result
arousal from slow-wave sleep on EEG with video recording demonstrating patient fear, agitation, and confusion
PSG (in all other parasomnias)
Test
Indicated whenever the diagnosis is not obvious from the history.
Also indicated if there is a suspicion of a primary sleep disorder such as obstructive sleep apnea or periodic limb movement disorder.
PSG may also be considered when the patient's bed partner reports leg kicking.
Result
normal or may demonstrate evidence of other primary sleep disorder
electroencephalogram (EEG)
Test
Performed if nocturnal seizures are suspected in the differential diagnosis of confusional arousals, sleepwalking, sleep terrors, and rapid eye movement sleep behavior disorder.
Result
normal; epileptiform spikes may be noted or clinical seizure activity during EEG monitoring may be accompanied by an electrographic seizure if nocturnal epilepsy present; in sleepwalking episodes, EEG shows increased slow-wave activity and slow oscillation density
urine drug screen
Test
A urine drug screen is also indicated if drug misuse is suspected.
Result
normal; drugs of misuse may be present
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