OBJECTIVE:Understanding respiratory control during sleep is fundamental to understanding the approach to the diagnosis and management of central sleep apnea (CSA). LATEST DEVELOPMENTS:CSA is not one disease but rather a syndrome resulting from a heterogeneous group of etiologies. There are complex chemical, metabolic, mechanical, and neural contributions that can cause dysregulation in loop gain, decreased central respiratory drive, or both. The traditional dichotomy between obstructive versus central sleep apnea is overly simplistic. Conventional CSA is the extreme end along a continuum between obstructive and central phenotypes of sleep apnea. In addition to assessing CSA severity from sleep study data, new approaches, including computational analytics and the use of wearable technologies, are increasingly aimed at extrapolating additional information to characterize CSA etiology. Various positive airway pressure modalities are available to treat CSA, but residual disease is common. There is a better understanding of drugs as causes and as treatments of CSA. Phrenic nerve stimulation is a new treatment option. Multimodal therapy is the likely future of CSA therapy. ESSENTIAL POINTS:CSA can be mechanistically divided into hypercapnic and hypocapnic CSA, with the six CSA syndromes in the International Classification of Sleep Disorders (Third Edition, Text Revision) falling under one or both of these categories depending on their etiology. Understanding the obstructive-central continuum of sleep apnea, in which the degree of contribution from each underlying sleep apnea driver, known as endotypes, predicts the relative central disease of a given patient on this continuum, can enhance comprehensive management.
OBJECTIVE:This article reviews the growing field of inpatient sleep medicine, addressing the importance of inpatient sleep quality and the evaluation and treatment of sleep disorders during and shortly after hospitalization. LATEST DEVELOPMENTS:Sleep disruption and sleep disorders in the inpatient setting are associated with worse outcomes. Improving sleep quality and duration in the hospital and treating sleep disorders such as obstructive sleep apnea may improve in-hospital and short-term outcomes, such as mortality, stroke recurrence, and recovery. The 2025 American Academy of Sleep Medicine guidelines conditionally recommend the availability of inpatient sleep medicine services. Screening questionnaires can be used to prioritize objective testing for obstructive sleep apnea or empiric treatment in inpatients, but atypical symptoms in patients with stroke and congestive heart failure make them less sensitive. Objective screening tools such as high-resolution pulse oximetry may help prioritize resources but do not qualify patients for therapy such as CPAP; portable or in-laboratory sleep testing may be needed. ESSENTIAL POINTS:Inpatient sleep medicine may be delivered by a multidisciplinary team based on available resources. Even if diagnosis or treatment cannot occur in the inpatient setting, recognizing sleep disorders during inpatient admissions increases the chances for successful outpatient treatment and can facilitate timely outpatient workup.
OBJECTIVE:The purpose of this article is to provide an overview of how to evaluate, diagnose, and manage patients with hypersomnia disorders. LATEST DEVELOPMENTS:The extended-release formulation of sodium oxybate to treat narcolepsy with a dosage of once a night, rather than twice a night, was approved in 2023 for adults and in 2024 for pediatric patients aged 7 years and older by the US Food and Drug Administration (FDA). The novel pharmacokinetics of this formulation may improve medication adherence and reduce nighttime disruptions and sleep fragmentation for patients and their bed partners. Orexin receptor 2 agonists are also being investigated for the treatment of narcolepsy and idiopathic hypersomnia. CSF orexin testing can be used to diagnose narcolepsy type 1. ESSENTIAL POINTS:Patients with hypersomnia have excessive daytime sleepiness, which can be due to an underlying sleep disorder or can be secondary to another condition. Diagnostic tools are useful but imperfect. It is essential to obtain a detailed sleep history to understand how patient symptoms are affecting daily life.
OBJECTIVE:This article reviews sleep basics, including stages, need, changes with aging, sleep drive, and circadian rhythm, to provide a normative framework and to reveal potential opportunities for insomnia intervention. In addition, it elucidates the symptoms, causes, consequences, diagnosis, and treatment of insomnia, including the role of sleep aids and cognitive behavioral therapy (CBT) for insomnia. LATEST DEVELOPMENTS:The wide-ranging consequences of insomnia are increasingly appreciated, with research highlighting its detrimental effects on health. Newer medication options include three orexin receptor antagonists. Home-based sleep tracking may allow screening to identify contributing factors, including sleep disorders that require treatment, and assessment of the environment for early intervention to optimize sleep. Existing and emerging wearable technology and software as digital therapy will increase access to CBT for insomnia through increasingly individualized programs. ESSENTIAL POINTS:Insomnia is the most common sleep disorder, with significant effects on quality of life and long-term health. Optimizing the sleep drive and circadian rhythm, addressing underlying causes, reducing hyperarousal, and enhancing conditioning are key components of improving the disorder. Over-the-counter and prescription sleep aids may have a limited role because of modest benefits and the potential for side effects. CBT for insomnia remains the preferred treatment, with a growing number of novel modes of access.
OBJECTIVE:Obstructive sleep apnea (OSA) is a common disorder that can have a significant negative impact on quality of life and health, including many neurologic disorders. This article discusses the updates in the diagnosis, implications, and treatment of OSA. LATEST DEVELOPMENTS:New recommended criteria for diagnosing OSA increase the recognition of the disorder. Although the apnea-hypopnea index has been the metric used to diagnose, stratify severity, and monitor treatment, it has limitations. A growing number of other metrics, including hypoxic burden, sleep quality, arousal index, respiratory event duration, and daytime sleepiness, are important to consider for comprehensive assessment and risk stratification. Various endotypes and phenotypes of OSA may have certain risks and respond differently to treatment. Treatment of OSA may improve several neurologic symptoms and reduce the risk of neurologic comorbidities. Although positive airway pressure therapy remains the most efficacious treatment of OSA, several alternatives are available, and the list is rapidly expanding, including hypoglossal nerve stimulation and medications. ESSENTIAL POINTS:Neurologists should screen for signs and symptoms of OSA as well as consider testing in patients at high risk who are asymptomatic. Treatment should be tailored based on the severity of OSA, objective data such as the arousal index and hypoxic burden, symptoms, comorbidities, and several patient factors, including morphologic characteristics and personal preferences. OSA is a treatable condition that, when well-managed, may lead to improvement of many neurologic conditions and quality of life.
Wearable sensing offers the opportunity to create 21st-century approaches to assessing neurologic function in multiple environments and to augment the examination from the 19th century. Commonly used sensors in neurology include accelerometers, gyroscopes, surface electromyogram, mobile electroencephalogram, electrodermal sensors, and photoplethysmography. These are applied in various form factors to capture physical activity, upper or lower extremity movement, changes in skin conductance, and changes in blood volumes. For sleep monitoring, many types of sensors have been used, but electroencephalogram and photoplethysmography are the most commonly used. Consumer-grade sleep technologies have become very popular and present opportunities for screening, but also present challenges for providers because they have limitations in sensitivity for diagnosis and can increase orthosomnia (sleep-related anxiety). Rich sensor datasets should be rigorously analyzed to create usable, scalar variables for clinical actions, but these new tools need to be ethical and support, not worsen, health care equity.
OBJECTIVE:This article describes the diagnostic criteria of restless legs syndrome (RLS) and periodic limb movements. The pathophysiology of RLS and its management are discussed. The approach to address RLS augmentation is also reviewed. LATEST DEVELOPMENTS:In the 2025 American Academy of Sleep Medicine RLS treatment guidelines, long-term dopamine agonist therapy for RLS was downgraded because of the accumulating evidence of augmentation. In this context, it is important to optimally use IV iron therapy in patients with RLS. Ferric carboxymaltose is more likely to cause hypophosphatemia compared with other IV iron therapy formulations. Bilateral peroneal nerve stimulation demonstrated efficacy and safety, and it can be used as adjunct therapy in patients with refractory RLS. Data from the National RLS Opioid Registry demonstrated reassuring findings, reiterating the role of opioids in the treatment of patients with RLS. An increased periodic limb movement index can often be seen in patients with RLS. ESSENTIAL POINTS:Dopamine agonists are no longer considered first-line pharmacologic therapy in patients with RLS. The mainstay of treatment is α2δ calcium channel ligands.
OBJECTIVE:This article describes the variability of sleep needs throughout infancy and adolescence and the impact that primary or secondary changes in sleep architecture and sleep quality can have on children. It also reviews the changes in sleep as a child develops as well as the bidirectional relationship of sleep and pediatric neurodevelopmental disorders, epilepsy, and psychosocial health. LATEST DEVELOPMENTS:Pediatric sleep has historically been understudied. Advances have made the quantitative study of pediatric sleep more feasible, although significant gaps remain. As early as prenatal life, sleep can affect a child's development, psychological health, and long-term sleep health. Genetic influences on circadian rhythm and brain development place many children at greater risk of sleep disorders and may one day be used to proactively screen for sleep disorders in children. ESSENTIAL POINTS:Knowledge of common pediatric sleep disorders and the influence of sleep health on the impact of neurologic conditions is essential. Every child seen in a neurology clinic should be screened for sleep disorders, especially children with neurodevelopmental differences, epilepsy, or a history of structural brain abnormalities.
OBJECTIVE:Circadian rhythms describe the near 24-hour oscillations observed across almost all biological processes on Earth. These rhythms serve to coordinate our behavior and physiology with the 24-hour light-dark environment in which we live. This article highlights normal circadian physiology and the disorders that can develop when those processes are disrupted. LATEST DEVELOPMENTS:Although historically circadian dysfunction has been viewed in terms of sleep-wake disorders, there is growing recognition that circadian disruption can contribute to or result from many other disorders frequently encountered within neurology. ESSENTIAL POINTS:When caring for patients, it is important to recognize time as a variable in disease presentation and as a potential treatment that can be harnessed to optimize patient outcomes.
OBJECTIVE:This article helps neurologists understand modern approaches to diagnosing obstructive sleep apnea, including the clinical role and limitations of home sleep apnea testing, and learn how they can integrate wearable and noncontact technologies into patient care to improve diagnostic efficiency, monitor treatment, and reduce health disparities. LATEST DEVELOPMENTS:Advances in home sleep apnea testing have expanded beyond traditional type III monitors to include wearable devices such as wrist sensors and smart rings and noncontact "nearable" systems that use radar or acoustic signals. Since 2019, the US Food and Drug Administration (FDA) has cleared numerous software-as-a-medical-device platforms that leverage artificial intelligence and multisignal integration to estimate sleep parameters. These tools improve accessibility, particularly for patients who are unable or unwilling to undergo in-laboratory polysomnography. However, awareness of racial bias in pulse oximetry, regulatory gaps, variable accuracy, and privacy concerns highlight the need for further validation to ensure equitable and reliable clinical use. ESSENTIAL POINTS:Obstructive sleep apnea is common and underdiagnosed, particularly in patients with neurologic conditions. In-laboratory polysomnography remains the gold standard for the diagnosis of obstructive sleep apnea but is limited by cost and access, whereas home sleep apnea testing offers a validated alternative for appropriate patients. Wearable and nearable technologies expand diagnostic options, improving usability and scalability, although their accuracy and validation vary. Neurologists play a key role in identifying patients at high risk, selecting the appropriate test, and interpreting results with awareness of limitations such as pulse oximetry bias. Consumer devices can raise awareness but should not replace clinical evaluation, and modern continuous positive airway pressure (CPAP) platforms enhance remote monitoring and management.
OBJECTIVE:Sleep-disordered breathing is a major contributor to morbidity and mortality in individuals with neuromuscular disorders, significantly affecting quality of life. This article provides a comprehensive review of respiratory physiology in the context of neuromuscular disorders, highlights essential components of a sleep-focused clinical history, and outlines evidence-based strategies for the diagnosis and management of sleep-disordered breathing as neuromuscular conditions progress over time. LATEST DEVELOPMENTS:Sleep-disordered breathing testing can be accomplished in various settings to limit barriers to the identification of disease and treatment. Noninvasive ventilation technology has progressed to be more patient centric, with variable settings to ensure patient comfort and support. ESSENTIAL POINTS:Early identification and treatment of sleep-disordered breathing in patients with neuromuscular disease can significantly improve quality of life and represent a readily modifiable factor in patient care. Noninvasive ventilation should be tailored to the individual patient's needs and comfort, with ongoing monitoring and adjustments based on specific neuromuscular diagnosis and disease progression.
OBJECTIVE:This article discusses the relationship between sleep and neurodegenerative disorders. LATEST DEVELOPMENTS:Sleep disorders disrupt neurotransmitters, facilitating the progression of neurodegenerative changes. Sleep impairment promotes amyloid-β aggregation, propagating memory impairment in neurodegenerative disorders. The use of biomarkers for early diagnosis of neurodegenerative disorders may include sleep features. Sleep apnea is associated with an increased risk of Parkinson disease. ESSENTIAL POINTS:Sleep disorders, such as obstructive sleep apnea, are five times more likely in people with Alzheimer disease. Notably, individuals with genetic factors, including carriers of APOE4, are found to have decreased overall regulation of regions within the brain that control sleep. External factors that increase the risk of dementia include long-term use of antihistamines. The risk of mild cognitive impairment is reduced with the intake of 200 mg/d of caffeine, which aligns the circadian activity of suprachiasmatic nucleus cells. People diagnosed with idiopathic rapid eye movement (REM) sleep behavior disorders have more than a 90% risk of developing an α-synucleinopathy at 14 years follow-up.
OBJECTIVE:This article reviews the epidemiology, pathophysiology, clinical management, and prevention strategies for pregnancy-related stroke, with a focus on recognizing risk factors, guiding acute treatment, and counseling for future pregnancies. LATEST DEVELOPMENTS:Recent data highlight rising rates of pregnancy-related strokes, particularly among older maternal age groups, with increasing contributions from ischemic strokes and cerebral venous thrombosis. Advances in imaging safety, thrombolysis, and endovascular therapy now support their use in selected pregnant and postpartum patients. Low-dose aspirin, tighter blood pressure control, and preconception counseling have emerged as key strategies for stroke prevention, especially in women with hypertensive disorders of pregnancy or thrombophilia. ESSENTIAL POINTS:Stroke affects approximately 30 per 100,000 pregnancies, with risk peaking in the peripartum and postpartum periods. Physiologic changes during pregnancy, including hypercoagulability, venous stasis, and vascular injury, contribute to increased risk. Acute stroke therapies, including thrombolysis and endovascular thrombectomy, can be used safely in pregnant patients. Prevention efforts should focus on optimizing blood pressure, screening for thrombophilia, encouraging healthy lifestyle behaviors, and using low-dose aspirin in women at high risk.
