Primary sleep disorders in people with epilepsy: clinical questions and answers

Duration of N1 sleep is a factor for excessive daytime sleepiness in epilepsy patients with interictal epileptiform discharges: A polysomnographic study

Purpose

This study aimed to identify the occurrence of excessive daytime sleepiness (EDS) in epilepsy patients with interictal epileptiform discharges and to explore the impact of interictal sleep architecture and sleep-related events on EDS.

Methods

This study included 101 epilepsy patients with interictal epileptiform discharges (IED) and 100 control patients who underwent simultaneous polysomnography and video ambulatory electroencephalography for >7 h throughout a single night. Multiple sleep latency tests were used to assess EDS. Comorbid EDS was present in 25 and 11 patients in the IED epilepsy and control groups, respectively. In addition, univariate and multivariate logistic regression analyses were performed to explore the factors influencing EDS.

Results

The epilepsy group had a higher prevalence of comorbid EDS and shorter R sleep duration. Univariate logistic regression analysis indicated that an increased risk of EDS may be associated with prolonged N1 sleep duration, higher arousal index, lower mean saturation (mSaO2), higher oxygen desaturation index (ODI), and duration of wake after sleep onset (WASO). Multivariate logistic regression analysis revealed that N1 sleep duration was significantly correlated with EDS.

Conclusion

In epilepsy patients with IED, the arousal index, mSaO2, ODI, and duration of WASO were weakly correlated with EDS, and the duration of N1 sleep demonstrated a significant positive correlation with EDS, which requires further research.

The course of sleep habits in newly diagnosed epilepsy in children: A prospective study

BACKGROUND

Epilepsy and sleep have a close, complex, and reciprocal relationship. Sleep may also be adversely affected by epilepsy and anti-seizure medication (ASM). This study sought to determine sleep-related problems before and after six months of treatment with ASMs follow-up in children with epilepsy, to reveal changes in sleep habits, and to determine the effect of ASMs on sleep in different types of epilepsy.

METHODS

This is a prospective study that included 61 children, aged 4-18 years with newly diagnosed epilepsy, who regularly had follow-up checks and used ASM for six months, and completed the Children's Sleep Habits Questionnaire (CSHQ). Children's Sleep Habits Questionnaire was completed before and after six months of ASM, allowing for assessments based on treatment group and type of epilepsy.

RESULTS

The mean ages of 61 children were 10.6 ± 3.9 years. The participants' post-treatment total scores on the CSHQ decreased by 2.9 ± 7.8 units on average compared to their pretreatment scores (p = 0.008; p < 0.01). In the levetiracetam group, post-treatment CSHQ subscale scores showed a mean decrease for bedtime resistance (p = 0.001), sleep duration (p = 0.005), sleep anxiety (p = 0.030), and total scores (p = 0.012) (p < 0.05). In the valproic acid group, post-treatment CSHQ subscale scores showed a mean decrease in sleep duration (p = 0.007) and a mean increase in daytime sleepiness (p = 0.03) (p < 0.05).

CONCLUSION

Our study found that children diagnosed with epilepsy had significantly higher rates of pretreatment sleep problems, which significantly decreased in patients who regularly attended follow-up examinations and received treatment. Except for the daytime sleepiness factor, our study found that sleep-related problems improved with treatment. It was observed that the initiation of epilepsy treatment had a positive effect on the patient's sleep, regardless of the type of treatment or epilepsy.

Sleep Characteristics Among Children with Idiopathic Generalized Epilepsy: A Polysomnography-Based Study

This study was designed to describe the sleep profile in a cohort of children 5-15 y with idiopathic generalized epilepsy (IGE) using polysomnography (PSG) and Children's Sleep Habits Questionnaire (CSHQ) and Pittsburg Sleep Quality Index (PSQI). The controls included age- and gender-matched healthy controls. A total of 30 cases of IGE and matched 30 controls were enrolled in study. The global CSHQ score [58.8 (10.8) vs. 32.3 (4.1); p < 0.01] and PSQI score [2.4 (1.6) vs. 0.9(0.3); p < 0.01] was significantly higher among children with IGE as compared to controls. REM sleep duration was significantly lower and other parameters including AHI [2.8 (1.9, 4.6) vs. 2.6 (1.3, 2.9); p = 0.04], frequency of arousals [51.5 (36.7, 71.5) vs. 27 (24, 43); p < 0.01], percentage of oxygen desaturation > 4% [23.5 (8, 36.5) vs. 4 (2, 8); p < 0.01], were significantly higher among children with IGE when compared to controls. Children with IGE have sleep disturbances and alteration in sleep architecture. They should be assessed   and screened for sleep characteristics.

Invasive Electrophysiology for Circuit Discovery and Study of Comorbid Psychiatric Disorders in Patients With Epilepsy: Challenges, Opportunities, and Novel Technologies

Intracranial electroencephalographic (iEEG) recordings from patients with epilepsy provide distinct opportunities and novel data for the study of co-occurring psychiatric disorders. Comorbid psychiatric disorders are very common in drug-resistant epilepsy and their added complexity warrants careful consideration. In this review, we first discuss psychiatric comorbidities and symptoms in patients with epilepsy. We describe how epilepsy can potentially impact patient presentation and how these factors can be addressed in the experimental designs of studies focused on the electrophysiologic correlates of mood. Second, we review emerging technologies to integrate long-term iEEG recording with dense behavioral tracking in naturalistic environments. Third, we explore questions on how best to address the intersection between epilepsy and psychiatric comorbidities. Advances in ambulatory iEEG and long-term behavioral monitoring technologies will be instrumental in studying the intersection of seizures, epilepsy, psychiatric comorbidities, and their underlying circuitry.

Prevalence of periodic limb movement in sleep in people with epilepsy: A semi-structured literature review

OBJECTIVES

Epilepsy is a prevalent health problem worldwide in all ages, and it is essential to identify disease markers for diagnosis and treatment. Periodic limb movements in sleep (PLMS) are a common finding in polysomnography (PSG). Still, its clinical relevance in people with epilepsy (PWE) is unknown. The aim of this review was to compare PLMS frequency in PWE and controls.

METHODS

A semi-structured literature review was conducted using PubMed in search of relevant studies in English on August 23, 2019, with the search terms "sleep," "epilepsy," or "seizure," and "polysomnography" in the title and/or abstract. The research was complemented with citation analysis and manual search using Google Scholar. Studies involved PWE and comparative controls using PSG with reported PLMS index (PLMI).

RESULTS

Seven studies were identified. Only two showed a statistically significant difference in PLMI between cases and controls, and in another study, cases had uncontrolled seizures. In general, studies did not adjust for potential confounders including demographics, apnea-hypopnea index, or medication use.

CONCLUSIONS

We found few studies exploring the prevalence of PLMS in PWE. In the majority, PLMI did not differ from controls. Further studies are warranted given the prevalence of sleep disturbances in epilepsy.

Parasomnias, sleep-related movement disorders and physiological sleep variants in focal epilepsy: A polysomnographic study

PURPOSE

The link existing between epilepsy and sleep is widely recognized. However, little is known about the prevalence and the clinical consequences of the comorbidity between focal epilepsy and sleep disorders, especially those sleep phenomena classified as isolated symptoms or normal variants. Objective of the study was to evaluate the frequency of sleep disorders and physiological sleep variants in a group of adult patients with focal epilepsy as compared to healthy controls by means of nocturnal polysomnography.

METHODS

We performed a retrospective observational study in the Neurological Clinic of the University of Catania in adult patients with a diagnosis of focal epilepsy and in a group of control subjects. All subjects underwent an overnight polysomnography. The following sleep disorders were considered: NREM-related parasomnias; REM-related parasomnias; sleep-related movement disorders; isolated symptoms or normal variants.

RESULTS

100 patients [mean age 30.3 ± 14.7 years, 40 men] and 62 controls [mean age 36.4 ± 15.9, 20 men] were studied. A significant higher percentage of sleep disorders was recorded in patients as compared to controls (73 % vs 48.4 %; p = 0.002). In particular, we found a higher frequency of periodic limb movements (PLM) (20 % vs 4.8 %; p = 0.007), bruxism (20 % vs 4.8 %; p = 0.007) and neck myoclonus (22 % vs 4.8 %; p = 0.003). Moreover, alternating limb muscle activation was associated with sleep-related hypermotor epilepsy (OR = 7.9; p = 0.01).

CONCLUSION

Sleep disorders and physiological sleep variants are common in adult patients with focal epilepsy.

More daytime sleepiness and worse quality of sleep in patients with Dravet Syndrome compared to other epilepsy patients

AIM

Sleep problems are often reported in patients with a Dravet Syndrome (DS). In this study we explored the sleep behavior in DS and compared the prevalence of sleep problems with other epilepsy patients.

METHODS

An online questionnaire based on the 'Sleep Behavior Questionnaire by Simonds & Parraga (SQ-SP)' was distributed amongst DS parents and a control group (parents from children with epilepsy). Completed questionnaires were evaluated by factor scores and Composite Sleep Index (CSI).

RESULTS

Fifty-six responses were recorded in the DS group (42 were ≤18 year). Caregivers reported an overall frequency of sleep problems in 42.3% (22/52). Severe sleep problems, measured by CSI, were found in 28.3% (13/46) mainly related to night waking or daytime sleepiness. In the control group (n = 66, 62 were ≤18 year), sleep problems were reported by 21.2% (14/52) of the parents. Comparison analysis between pediatric DS and epilepsy patients revealed no significant differences between the prevalence of different types of sleep disorders, except for daytime sleepiness (p = 0.042). However, the parent (or caregiver)-reported quality of sleep was significantly lower in the DS group (p = 0.011).

INTERPRETATION

Sleep problems are frequent in DS patients and are mainly related to daytime sleepiness and night waking. Compared with other epilepsy patients, severe sleep problems are not more common in patients with a DS. However DS patients tend to have more mild night waking problems, which may explain the worse parental-reported sleep quality in DS patients.

Adult-Onset Sleepwalking Secondary to Hyperthyroidism: Polygraphic Evidence

ABSTRACT

Sleepwalking is a disorder characterized by complex motor behaviors arising from slow wave sleep usually occurring in children. The adult onset of sleepwalking suggests the presence of an external precipitating factor leading to the occurrence of the disorder. Hyperthyroidism has been reported to be the possible cause of sleepwalking in a few cases. We present the case of a 36-year-old man who reported a sudden appearance of nocturnal episodes of sleepwalking. He underwent a complete video polysomnography (VPSG), which showed a polygraphic pattern arising from stage N3 sleep related to the presence of simple motor behaviors. Routine blood tests showed a mild hyperthyroidism. After 4 months of thyrostatic treatment, the patient reported no more sleepwalking events. A VPSG performed at the last follow-up showed the absence of pathological electroclinical events arising from stage N3 sleep. Therefore, we hypothesize that there is a link between sleepwalking and thyroid dysfunction in our patient.

Sleep Disorders in Childhood Neurological Diseases

Sleep problems are frequently addressed as a primary or secondary concern during the visit to the pediatric neurology clinic. Sleep disorders can mimic other neurologic diseases (e.g., epilepsy and movement disorders), and this adds challenges to the diagnostic process. Sleep disorders can significantly affect the quality of life and functionality of children in general and those with comorbid neurological diseases in particular. Understanding the pathophysiology of sleep disorders, recognizing the implications of sleep disorder in children with neurologic diseases and behavioral difficulties, and early intervention continue to evolve resulting in better neurocognitive outcomes.

Insomnia, parasomnias, and narcolepsy in children: clinical features, diagnosis, and management

Sleep problems are frequently encountered as presenting complaints in child neurology clinical practice. They can affect the functioning and quality of life of children, particularly those with primary neurological and neurodevelopmental disorders, since coexisting sleep problems can add substantially to neurocognitive and behavioural comorbidities. Additionally, symptoms of some sleep disorders such as parasomnias and narcolepsy can be confused with those of other neurological disorders (eg, epilepsy), posing diagnostic challenges for paediatric neurologists. The understanding of the neurophysiology of sleep disorders such as insomnia, parasomnias, and narcolepsy is still evolving. There is a complex relation between the sleeping brain and its waking function. The interplay among genetic factors, alterations in neurotransmitters, electrophysiological changes, and environmental factors potentially contribute to the genesis of these sleep disorders.

Comparing sleep profiles between patients with juvenile myoclonic epilepsy and symptomatic partial epilepsy: Sleep questionnaire-based study

OBJECTIVES

Patients with epilepsy commonly report excessive daytime sleepiness and daytime fatigue, which may be attributed to the direct effect of seizures, a side effect of antiepileptic drugs or a combination of the two. The aim of the study was to compare sleep profiles in patients with juvenile myoclonic epilepsy (JME) and symptomatic partial epilepsy (PE) in drug naïve and treated patients using standardized sleep questionnaires.

METHODS

Three study groups: - 1) juvenile myoclonic epilepsy (N=40) [drug naïve (N=20); On sodium valproate (SVA) (N=20)]; 2) symptomatic partial epilepsy (N=40) [drug naïve (N=20); On carbamazepine (CBZ) (N=20)]; 3) healthy controls (N=40) completed 3 standardized sleep questionnaires - Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and NIMHANS Comprehensive Sleep Disorders Questionnaire. Scores were compared using t-test and Chi-squared tests (P≤0.005).

RESULTS

The mean PSQI scores as well as the proportion of subjects with abnormal PSQI scores were higher in patients with JME and PE compared to controls. Although the mean ESS scores were comparable between patients with epilepsy and controls, the percentage of patients with partial epilepsy having abnormal ESS scores was higher. No significant differences were present between drug naïve and treatment monotherapy groups. Excessive daytime somnolence was reported more often by patients with JME compared to patients with partial epilepsy and controls.

CONCLUSION

This study found that patients with epilepsy have a higher prevalence of poor sleep quality compared to controls. Moreover, a significantly higher percentage of patients with partial epilepsy had higher ESS scores compared to healthy controls. However, there was no difference between ESS and PSQI scores between drug naïve and treated patients with JME or PE.

SIGNIFICANCE

Poor sleep quality is more prevalent in patients with epilepsy irrespective of the use of antiepileptic medications. Excessive daytime somnolence is more commonly seen in patients with partial epilepsy when compared to the general population.