Q. Why do I fall out of bed with sleep apnea?

Answered by
Dr. Hitesh Kumar
and medically reviewed by Dr. Sneha Kannan
This is a premium question & answer published on Apr 12, 2021

Hi doctor,

I have been diagnosed with rapid eye movement sleep behavior disorder, and I am worried about the link with Parkinson’s and, even worse, and Lewy body dementia. While the Fluoxetine may be a cause, it has been noticed there is a marked lack of swing in my right arm while walking. I am not sure whether to work with my doctor on stopping Fluoxetine temporarily. I am under a sleep specialist.

#

Hello,

Welcome to icliniq.com.

I would like to know some further details about your symptoms. Since when you started problems in sleep? What symptoms used to happen in sleep. Please describe in detail (please tell what you yourself felt in sleep and also tell what your family or bed partner described it during sleep). Since when and what dosage of Fluoxetine (Prozac) are you taking? For what symptoms or diagnosis are you on Fluoxetine? Since when lack of right arm swings during the walk was noticed? Was your observation or your family members or your doctor noticed it? Do you have tremulousness of any hand or leg? Have you or your family noticed that there been a change in walking style or slowness in daily activities (wearing clothes or eating food or speaking etc.) If yes, since when? Do you have any other associated medical problems? If yes, please tell details. Are you on some other medications too? If yes, please tell their names and dosage. How is your sleep routine? Do you get sleepy soon after lying in bed, or it takes a long time? Once got sleepy, do you have frequent awakenings during sleep? - Do you feel fresh on awakening from sleep in the morning? How is your usual mood in day-to-day activities? Happy or toward the sad side (thinking about past events) or toward the worried side (thinking about future things or irritable or something else)? How is your appetite?


Treatment plan:

RBD (REM behavior disorder) has an association with Parkinson's disease or Lewy body dementia. But it is not mandatory that every patient of RBD will develop these diseases. Fluoxetine is not well known to cause RBD, there may be some case reports of augmentation of REM disorder (from subclinical to clinical). But difficult to be sure. Parkinson's or Lewy body dementia are better judged clinically. In early stage, investigations are not much helpful to make diagnosis, they are only supportive or required to rule out some other things. Depression patients also have some slowing in daily activities.

Regarding follow up:

Revert with the above-mentioned information and also send your till now investigation reports or psychiatrist assessment sheet. Also, it would be better to consult neurologist physically so that clinical examination can be performed.

Thank you doctor,

My sleep problems started ten years back when I had a violent dream and acted out the dream content by hitting out to defend myself. I have hit my wife while acting out dreams and have fallen out of bed or kicked the radiator. I can usually recall the content of the dream upon awakening. Melatonin reduces the number of episodes. I am also using an APAP (automatic positive airway pressure) machine for obstructive sleep apnea. The medications I take are:

  1. Tablet Fluoxetine 40mg for OCD (Obsessive Compulsive Disorder).
  2. Tablet Concerta 45 mg (Methylphenidate Hydrochloride) for ADHD (attention deficit hyperactivity disorder).
  3. Tablet Amlodipine 5 mg for Hypertension.
  4. Tablet Propranolol for fast pulse (occurred following hospitalization with COVID-19).
  5. Tablet Melatonin 4 mg for REM (rapid eye movement) sleep behavior disorder.

It was noticed by my wife when walking that my right arm swings a lot less than my left, and my wife thinks I walk slower now. I have seen how my right arm does not swing on watching videos of myself walking. This was also picked up by my sleep specialist. I have a slight tremor to the fingers or thumb on my right hand, but the sleep specialist seemed to think that was linked to Concerta. However, it happens even if I do not take the Concerta. The only other symptom I have is some lightheadedness on standing. I often go to bed late due to my stimulant medication. My mood is not too bad, and I feel anxious at times. Please let me know if you need to know anything else. I can forward hospital letters to you soon.

#

Hello,

Welcome back to icliniq.com.

As per your description, it is difficult to conclude about having Parkinson's. Some slowing in daily activity is very common in patients having OSA (obstructive sleep apnea) and depression. But as you mention that there is tremulousness in the right hand and decreased right arm swing, there may be the possibility of some signs of Parkinson's. If it has been due to medication, that might be present in both hands. Suppose there is doubt about it being medication-induced. In that case, we can try to observe after withholding Concerta for few weeks as Concerta is a minimal effect on OSA over the use of right pressures in CPAP (continuous positive airway pressure)or BiPAP (bilevel positive airway pressure). But Parkinson's or parkinsonism is a clinical diagnosis that may need support by responding to medications. It also needs detailed clinical examination and follow-ups to make some conclusion. Other effective options for RBD (REM behavior disorder) can be tablet Pramipexole and tablet Clonazepam. I would suggest you consult a neurologist and psychiatrist physically for detailed clinical assessment and decide about further medications and follow-up (also need to see the effect of medicines regularly and accordingly modifications in dosage or medication).


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