From the Research
Confusional arousals occur due to incomplete transitions between sleep and wakefulness, primarily involving dysfunction in the brain's arousal systems, as evidenced by the most recent study in 2022 1. The pathophysiology centers on abnormal activation of the thalamocortical networks responsible for consciousness, resulting in a mixed state where aspects of sleep and wakefulness coexist. During normal sleep transitions, the ascending reticular activating system (ARAS) in the brainstem coordinates with the thalamus and cerebral cortex to ensure complete state transitions. In confusional arousals, this coordination fails, particularly during arousals from deep non-REM sleep (stages N3 and N4), as supported by a study in 2018 that used intracerebral recordings to investigate the temporo-spatial dynamics of EEG changes in cortical areas during confusional arousals 2. The prefrontal cortex, which governs executive function and decision-making, remains partially deactivated while motor and limbic systems become active, explaining the confused behavior and amnesia for the events. This dissociated brain state is more common in children due to their stronger sleep drive and immature neural networks. Precipitating factors include:
- Sleep deprivation
- Irregular sleep schedules
- Stress
- Fever
- Alcohol consumption
- Certain medications that affect sleep architecture, as discussed in a study from 1992 that highlights the importance of considering various factors in the diagnosis and management of sleep disorders 3. Some individuals may have genetic predispositions that lower the threshold for these events. Management focuses on:
- Improving sleep hygiene
- Maintaining regular sleep schedules
- Treating underlying sleep disorders like sleep apnea
- Ensuring safety during episodes, with the goal of reducing morbidity, mortality, and improving quality of life. A study from 1968 provides early insights into the nature of sleep disorders, including confusional arousals, and their relationship to arousal from slow-wave sleep 4. However, the most recent and highest quality evidence from 2022 1 and 2018 2 provides the most relevant and up-to-date information for guiding clinical practice and decision-making.