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1 REM REM sleep without atonia RWA REM RBDREM REM REM sleep without atonia, RWA RWA RWA AASM manual for scoring sleep 2007 RBD 13 REM, RWA tonic activity type RWA REM RWA tonic activity type RWA RWA, tonic activity type RWA REM rapid eye movement REM sleep behavior disorder, RBDREM 1 REM RBD 2 RBD polysomnography, PSG REM REM REM sleep without atonia, RWA RBD 2 International Classification Sleep Disorder-2, ICSD-2 2 PSG RWA RWA REM tonic phasicrapid eye movements, REMs phasic activity 3 RWA tonic phasic activity RWA 4 RBD RWA RBD RWA AASM manual for scoring sleep RWA RBD RWA RWA

2 ,745 8,672 2,073 ICSD-2 RBD 2 1 PSG REM 2 PSG RWA 2 PSG PSG Rechtschaffen and Kales EEG 4 C3 A2, C4 A1, O1 A2, O2 A1EOG chin EMGEKG SpO 2 Fp1 C3, Fp2 C4, Fp1 T3, Fp2 T4 apnea hypopnea periodic leg movement during sleep, PLMS: 40 4 EEG arousal American Academy of Sleep Medicine, AASM Practice parameters PLMS index PLMI: 1 PLMS apnea hypopnea index, AHI RWA 1 ICSD-2 tonic phasic 50 RWA 2 2 RWA 1 Rechtschaffen & Kales REM REMs Spindle K-complex Low Voltage Mixed Frequency: LVMF REM REM 1 RWA Table 1 Scoring rules for RWA Rechtschaffsen & Kales AASM2007 REM Rechtschaffsen & Kales AASM2007 REMs Spindle K-complex REM REMs REMs LVMF K-complex, spindle, arousal 3 REMs REMs RWA REM 1 50 nonrem stagen1, N2, N tonic activity phasic activity 5 LVMF: Low Voltage Mixed Frequency.

2012. 171 終了 REMs 消失後 LVMF 出現中はオトガイ筋筋電図の上昇までまたは他の睡眠ステージの指標 Spindle K-complex などの出現までとする 2 オトガイ筋筋電図の筋活動の上昇が 30 秒エポッ 3 RWA 再解析方法 2007 年に

であるものを RWA とする REM 睡眠中の 1 エポックでの 50 以上筋電図の同種のデジタル機器 Somnostar Pro VIASIS で PSG を施行した 13 例について REM 睡眠 RWA につ振幅が nonrem stagen1, N2, N3

オトガイ筋筋電図が持続的な筋活動上昇を示す b オトガイ筋筋電図における群発放電 burst c と d.

1 Various patterns of increased EMG activity in REM sleep. a. Chin EMG shows continuous tonic EMG activity. b.

3 終了 REMs 消失後 LVMF 出現中はオトガイ筋筋電図の上昇までまたは他の睡眠ステージの指標 Spindle K-complex などの出現までとする 2 オトガイ筋筋電図の筋活動の上昇が 30 秒エポッ 3 RWA 再解析方法 2007 年に AASM manual for scoring sleep 2007 が発表され RWA に関して以前より詳しく解析方法が記 5 載されたクの 50 以上みられるがその他の特徴が REM 睡眠 1 Sustained tonic activity in REM sleep であるものを RWA とする REM 睡眠中の 1 エポックでの 50 以上筋電図の同種のデジタル機器 Somnostar Pro VIASIS で PSG を施行した 13 例について REM 睡眠 RWA につ振幅が nonrem stagen1, N2, N3 の最低振幅より大きい 2 Excessive burst phasic activity in REM sleep いて再解析を行った REM 睡眠中の 30 秒 1 エポックを 10 分割し最低図 1 a b c d REM 睡眠中における筋活動上昇の様々なパターン a オトガイ筋筋電図が持続的な筋活動上昇を示す b オトガイ筋筋電図における群発放電 burst c と d. オトガイ筋筋電図では持続性と相動性筋活動の両方が組み合わさってみられる略語 LOC 左眼球運動 ROC 右眼球運動 CHIN オトガイ筋筋電図 LLEG 左前脛骨筋筋電図 RLEG 右前脛骨筋筋電図 BPOS 体位 Fig. 1 Various patterns of increased EMG activity in REM sleep. a. Chin EMG shows continuous tonic EMG activity. b. Chin EMG shows bursts of EMG activity. c and d. Chin EMG shows the combination of both tonic and phasic activities. Abbreviations. LOC: outer canthus of the left eye, ROC: outer canthus of the right eye, CHIN: Chin EMG, LLEG: left leg tibialis anterior EMG, RLEG: right leg, BPOS: body position.

4 tonic muscle activity phasic muscle activity REM AASM manual for scoring sleep 2007 Lappiere & Montplaisir 11 1 REM REMs REM K-complex, spindle, arousal 3 REMs 2 RWA 1 a, b, c, d REM 1 50 nonrem stagen1, N2, N3 REM tonic activity phasic activity 5 3 REM RWA REM tonic type RWA tonic REM REM 3 REMs REM density 4 REM, RWA paired t test 10, RBD REM RWA Table 2 REM sleep and RWA in the 13 patients with RBD Reanalysed Reanalysed Sex Age REM RWA REM RWA Case 1 M Case 2 M Case 3 M Case 4 F Case 5 M Case 6 M Case 7 M Case 8 M Case 9 M Case 10 M Case 11 M Case 12 M Case 13 M Abbreviations; RWA REM sleep without atonia, RBD REM sleep behavior disorder. 3 REM RWA Table 3 Comparison of REM and RWA according to analyzed methods p REM n.s. RWA n.s. Results are presented as mean standard deviation, p: Paired t test. RBD RBD 67 PSG Parkison s disease, PD REM RWA 13 REM RWA 2 13 REM REM RWA RWA 2 RWA 3 13 REM tonic activity REM

2012. 173 4 REM Table 4 Tonic activity and REM density during REM sleep All RBD combined Idiopathic RBD RBD associated with PD Age at PSG 66.5 8.0 68.5 6.9 70.7 9.

5 REM Table 4 Tonic activity and REM density during REM sleep All RBD combined Idiopathic RBD RBD associated with PD Age at PSG Sex, M/F 12/1 9/1 3/0 tonic REM, REM density RWA RWA Fig. 2 The epoch is scored as not RWA by the original analysis, and as RWA by the reanalyzed analysis. REM density 4 PSG PD 3 PSG RBD 10 PD tonic REM REM density RWA RBD AASM manual for scoring sleep 2007 REM Sustained tonic activity burst phasic activity tonic phasic activity REM REMs RWA REMs REM REM RWA RWA REM sleep atonia REM 13 RWA REM tonic activity phasic activity RBD tonic sublaterodosal nicleus phasic locomortor generator inter mediate ventromedial medulla RBD PD multiple system atrophy, MSA dementia with Lewy body, DLB synucleinopathy RBD 22 PD PD I-MIBG 24 RBD RWA RWA 25 26

6 174 PSG tonic RBD PD 27 tonic REM RBD 51.9 PD REM tonic 60 PD PD PD RWA tonic REM RBD RWA RWA AASM2007 REM RWA tonic 50 RWA 50 phasic 3 RWA ICSD-2 RBD RWA tonic phasic RWA 4 28 RWA 30 REM RWA tonic type REM tonic REM REM 3 phasic activity RBD 40 4 phasic tonic 11 RWA tonic phasic REM RWA RWA PSG RWA RWA RBD 1 Schenck CH, Bundlie SR, Ettinger MG, et al: Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep 9: , American Academy of Sleep Medicine: International Classification of Sleep Disorders. 2nd ed.: Diagnostic and Coding Manual. Ameican Academy of Sleep Medicine, Westchester, Illinois, pp , Carskadon MA, Dement WC: Principles and practice of sleep medicine. In Kryger MH, Roth T, Dement WC eds. Normal Human Sleep. Ed5, Elsevier Sanders, Missonni, pp 16 26, REM sleep without atonia 35 4 : , Iber C: The AASM Manual for Scoring of Sleep and Associated Events. American Academy of Sleep Medicine, Westchester, Illinois, p 42, Rechtschaffen A, Kales A ed : A Manual of Standardized Terminology, Techniques, and Scoring System for Sleep Stages of Human Subjects. U.S. Department of Health, Education and Walfare, Public Health Service, American Sleep Disorders Association Atlas Task Force: EEG arousals: scoring rules and examples. Sleep 15: , American Sleep Disorders Association Atlas Task Force: Recoding and scoring leg movements. Sleep 16: , American Academy of Sleep Medicine Task Force: Sleeprelated breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 22: , 1999.

7 American Academy of Sleep Medicine: International Classification of Sleep Disorders. 2nd ed.: Diagnostic and Coding Manual. American Academy of Sleep Medicine, Westchester, Illinois, pp 51 55, Lapierre O, Montplaisir J: Polysomnographic features of REM sleep behavior disorder: development of a scoring method. Neurology 42: , : REM Brain and Nerve : , Vetrivelan R, Fuller PM, Tong Q, et al: Medullary circuitry regulating rapid eye movement sleep and motor atonia. J Neurosci : , Boeve BF, Silber MH, Saper CB, et al: Pathophysiology of REM sleep behaviour disorder and relevance to neuro degenerative disease. Brain 130: , : Brain and Nerve 61 5 : , Gjerstad MD, Boeve B, Wentzel-Larsen T, et al: Occurrence and clinical correlates of REM sleep behaviour disorder in patients with Parkinson s disease over time. J Neurol Neurosurg Psychiatry 79 4 : , Lu J, Sherman D, Devor M, et al: A putative flip-flop switch for control of REM sleep. Nature : , Fuller PM, Saper CB, Lu J: The pontine REM switch: past and present. J Physiol 584 Pt 3 : , Schenck CH, Bundlie SR, Mahowald MW: Delayed emergence of a parkinsonian disorder in 38 of 29 older men initially diagnosed with idiopathic rapid eye movement sleep behaviour disorder. Neurology 46: , Schenck CH, Bundlie SR, Mahowald MW: REM behaviour disorder RBD : delayed emergence of parkinsonism and/or dementia in 65 of older men initially diagnosed with 175 idiopathic RBD, and an analysis of the minimum & maximum tonic and/or phasic electromyographic abnormalities found during REM sleep. Sleep 26 S : A316, Iranzo A, Molinuevo JL, Santamaria J, et al: Rapid-eyemovement sleep behaviour disorder as an early marker for a neurodegenerative disorder: a descriptive study. Lancet Neurol 5: , Oguri T, Tachibana N, Mitake S, et al: Decrease in myocardial 123 I-MIBG radioactivity in REM sleep behavior disorder: two patients with different clinical progression. Sleep Med 9: , Stiasny-Kolster K, Doerr Y, Moller JC, et al: Combination of idiopathic REM sleep behaviour disorder and olfactory dysfunction as possible indicator for alpha-synucleinopathy demonstrated by dopamine transporter FP-CIT-SPECT. Brain : , Miyamoto T, Miyamoto M, Inoue Y, et al: Reduced cardiac 123 I-MIBG scintigraphy in idiopathic REM sleep behavior disorder. Neurology 67: , Tachibana N, Oka Y: Longitudinal change in REM sleep components in a patient with multiple system atrophy associated with REM sleep behavior disorder: paradoxical improvement of nocturnal behaviors in a progressive neurodegenerative disease. Sleep Med 5: , Iranzo A, Luca Ratti P, Casanova-Molla J, et al: Excessive muscle activity increases over time in idiopathic REM sleep behavior disorder. Sleep 32 9 : , Postuma RB, Gagnon JF, Rompré S, et al: Severity of REM atonia loss in idiopathic REM sleep behavior disorder predicts Parkinson disease. Neurology 74 3 : , Buskova J, Nevsimalova S, Kemlink D, et al: REM sleep without atonia in narcolepsy. Neuro Endocrinol Lett 30 6 : , 2009.

8 The scoring method for REM sleep without atonia in REM sleep behavior disorder HIDEKO SUGITA, MUTSUMI OKURA, MITSUTAKA TANIGUCHI, MOTOHARU OHI Sleep Medical Center, Osaka Kaisei Hospital REM sleep behavior disorder RBD is characterized by loss of normal REM sleep skeletal muscle atonia, resulting in complex motor behaviors associated with dream mentation. The polysonographical hallmarks of RBD include tonic/phasic loss of the skeletal muscle atonia of REM sleep REM sleep without atonia; RWA, and the International Classification of Sleep Disorders 2nd edition ICSDF-2 requires this finding of polysomnography PSG in the diagnosis of RBD. However, a scoring rule for RWA is not well established. We describe our methods of a scoring rule for RWA and some unsolved issues for RWA scoring were discussed. Methods: The subjects were 10,745 consecutive patients who presented with sleep and/ or wake problems at our sleep center between April 1998 and March Diagnosis of RBD was made based on ICSD-2 criteria. Our original analysis for RWA was that each page of REM sleep is marked either tonic or atonic tonic 50 of the page or more is occupied by EMG activity. In our new RWA scoring, increased EMG activity was counted separately according to EMG activity patterns; tonic EMG, phasic pattern, and combined EMG activities. Date of 13 patients who underwent PSG with the same digital polygraph among patients with RBD were used for analyze according to new scoring methods, and we also calculated tonic REM and REM density in 13 patients. Results: Sixty-seven patients 0.6 were diagnosed as having RBD. There was a strong male predominancy In 13 of 67 patients, there were no differences between the original and the new methods in REM and RWA. Patients with Parkinson disease had increased tonic chin EMG activity during REM sleep vs and REM density vs compared to idiopathic RBD patients, however it was not statically significant. Conclusions: The pathogenesis of RBD is still unclear; therefore, detailed analysis of RWA give hints for finding predictors for the development of neurodegerative disease and for establishing its diagnostic classification. Key Words REM sleep behavior disorder, REM sleep without atonia, polysom no g- raphy, Parkinson disease, synucleinopathy

REM Rapid Eye Movement REM Zzz Non-REM

Sleep and sleep-related disorders in the elderly 20051027 REM Rapid Eye Movement REM Zzz Non-REM 90 180 270 360 90 How old is the elderly in sleep? 40 In: Primer of Polysomnography Circadian rhythm 24