Journal of Geriatric Mental Health

CASE REPORT
Year
: 2020  |  Volume : 7  |  Issue : 1  |  Page : 60--61

Sleep paralysis in a 76-year-old male


Avinash Desousa, Sagar Karia 
 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Correspondence Address:
Dr. Avinash Desousa
Carmel, 18, St. Francis Road, Off SV Road, Santacruz West, Mumbai - 400 054, Maharashtra
India

Abstract

We present herewith a case of sleep paralysis (SP) which entails a transient, generalized inability to move or speak and that usually seen during the patient's transitions between sleep and wakefulness. We report a case of a 76-year-old man with recurrent SP in the absence of any other psychiatric disorder. The patient sought help after over 2 years of symptoms as he thought that the symptoms were part of dreaming during sleep. SP is seen in conjunction with multiple psychiatric disorders, and the symptoms may mimic them, thereby confounding the diagnosis. SP with onset in old age is rare and is the highlight of this case report.



How to cite this article:
Desousa A, Karia S. Sleep paralysis in a 76-year-old male.J Geriatr Ment Health 2020;7:60-61


How to cite this URL:
Desousa A, Karia S. Sleep paralysis in a 76-year-old male. J Geriatr Ment Health [serial online] 2020 [cited 2020 Sep 29 ];7:60-61
Available from: http://www.jgmh.org/text.asp?2020/7/1/60/288243


Full Text



 Introduction



Sleep paralysis (SP) is a condition characterized by a transient, generalized inability to move or speak that usually seen during the patient's transitions between sleep and wakefulness.[1] It has been noted as the symptom of narcolepsy and may be seen with excessive daytime sleepiness, cataplexy, and hypnagogic hallucinations as per the DSM-5 criteria.[2] SP is a rapid eye movement sleep parasomnia and is a recurrent phenomenon that may often occur every day in sleep.[3] SP is rare in the general population and may be seen as an isolated occurrence or a comorbidity with multiple psychiatric disorders.[4] Although literature is abound with multiple case reports on SP, its onset after the age of 65 is rare.[5] We report herewith a case of a 76-year-old patient with SP where help was not sought for over 2 years.

 Case Report



A 76-year-old man, who was a retired engineer, presented to the psychiatry outpatient department with chief complaints of multiple episodes of inability to move his limbs at night during his sleep since a little over the past 2 years. The patient had these episodes during his sleep at night, and each of these events lasted 15–20 min, wherein he was unable to move his limbs completely or turn in bed or even call for help, all of which he would desperately want to do each time but was unable to do so. These attacks were often accompanied with a dream that some alien-like creatures were trying to abduct him and he had been seeing dreams of being kidnapped by people or aliens recurrently over the past 2 years. He thought that these episodes were part of his dreaming and had done nothing about them. Only when he started realizing that he was in fact conscious and these episodes occurred during consciousness did, he decided to seek help. These episodes had him feeling extremely fearful, and he would sometimes cry during the episode. Even though things returned to normal in 20–25 min, he would be worried for 1 h after these episodes. He could very clearly hear his spouse and son calling out to him and speaking to him but was never able to respond to them or say anything. The episodes would usually occur early morning between 5 am and 6 am when he was about to get up from sleep. He reported the first such episode a little over 2 years from the time of presentation, and they had progressed from one attack a month to 2–3 attacks weekly at the time of presentation. On evaluation and history, he did not have symptoms suggestive of narcolepsy and slept on an average 6 h a night. He described his sleep quality as fine, but the episodes would disturb him immensely. He denied symptoms suggestive of other parasomnias and other major psychiatric disorders. No family history suggestive of any psychiatric or sleep disorders existed. On speaking to family members who slept with him, there was no history suggestive of apnea episodes. There was no history of any form of substance use ever by the patient. His general and systemic examination was within normal limits, and on mental state examination, he was absolutely normal. His body mass index was normal for his age. All routine blood tests done by the patient a week before presentation were normal. The patient was not cooperative for sleep studies; hence, we did not go ahead with the same. Using the International Criteria of Sleep Disorders criteria,[6] we reached a diagnosis of chronic SP. We psychoeducated the patient and his family members and also spoke to him about regular sleep hygiene. We started the patient on escitalopram 5 mg at night and increased the dose to 10 mg in 7 days as episodes continued at 5 mg. In a week of starting 10 mg, he reported no attacks and he is currently symptom-free on the same dose of medication for a month. We plan to keep him on the same dose for 6 months and then evaluate further.

 Discussion



Our patient had symptoms of recurrent attacks of SP occurring in the absence of any symptoms of narcolepsy and in the absence of any other psychiatric disorder. The episodes in SP are more likely to occur during awakening from sleep (hypnopompic) as in our case.[7] Hallucinatory experiences have been noted SP, but our case had no such features. Most case reports mention that patients are aware of other people present in the room and can hear their voices and other noises around them, but they usually complain of complete inability to move any part of their bodies, including an inability to speak out as in our case.[8] It is prudent that cases of SP be diagnosed accurately as these attacks may, at times, be misdiagnosed as panic attacks.[9] Selective Serotonin Reuptake Inhibitors (SSRIs) have been used widely for treating SP, and our case also responded to escitalopram when the dose was increased.[10],[11] It is important for psychiatrists to be aware of SP as a diagnostic entity even in the elderly, and this must be a part of the differential diagnosis when considering such episodes in the elderly.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Denis D, French CC, Gregory AM. A systematic review of variables associated with sleep paralysis. Sleep Med Rev 2018;38:141-57.
2Sharpless BA. A clinician's guide to recurrent isolated sleep paralysis. Neuropsychiatr Dis Treat 2016;12:1761-7.
3Sharpless BA, Kliková M. Clinical features of isolated sleep paralysis. Sleep Med 2019;58:102-6.
4Munezawa T, Kaneita Y, Yokoyama E, Suzuki H, Ohida T. Epidemiological study of nightmare and sleep paralysis among Japanese adolescents. Sleep Biol Rhythms 2009;7:201-10.
5Wing YK, Chiu H, Leung T, Ng J. Sleep paralysis in the elderly. J Sleep Res 1999;8:151-5.
6International Classification of Sleep Disorders, Revised. Diagnostic and Coding Manual. Chicago, Illinois: American Academy of Sleep Medicine; 2014.
7de Jong JT. Cultural variation in the clinical presentation of sleep paralysis. Transcult Psychiatry 2005;42:78-92.
8Cheyne JA, Girard TA. Paranoid delusions and threatening hallucinations: A prospective study of sleep paralysis experiences. Conscious Cogn 2007;16:959-74.
9Panossian LA, Avidan AY. Review of sleep disorders. Med Clin North Am 2009;93:407-25, ix.
10Sharpless BA, Doghramji K. Sleep Paralysis: Historical, Psychological, and Medical Perspectives. Oxford University Press; 2015.
11Hintze JP, Gault D. Escitalopram for recurrent isolated sleep paralysis. J Sleep Res 20200; e13027.