Subjective sleep disturbance in epilepsy patients at an outpatient clinic: A questionnaire-based study on prevalence

Insomnia in patients with MRI-negative epilepsy: The associated factors and 3D-pCASL cerebral blood flow perfusion changes

OBJECTIVE

This study aimed to identify the factors associated with insomnia in MRI-negative epilepsy and uncover the underlying pathological mechanism driving insomnia within the context of epilepsy.

METHODS

We conducted a retrospective study of patients with MRI-negative epilepsy recruited consecutively from December 2021 to December 2022. All subjects completed the Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS). Additionally, some subjects underwent the three-dimensional pseudo continuous arterial spin labeling(3D-pCASL) imaging examination. Bilateral frontal lobe, temporal lobe, hippocampus, thalamus, amygdala, caudate nucleus and lenticular nucleus were selected as regions of interest(ROI) and cerebral blood flow(CBF) values were measured in these regions. Subjects were classified into insomnia (ISI ≥ 10) or non-insomnia (ISI < 10) groups, and univariate and stepwise logistic regression analyses were employed to identify the factors associated with insomnia. Furthermore, CBF values in each ROI were compared between the two groups to identify the brain regions potentially related to the underlying pathological mechanism of insomnia in epilepsy.

RESULTS

A total of 73 patients with MRI-negative epilepsy were recruited in this study(men, 49.3 %). Among them, 14 patients(19.2 %) had insomnia. Univariate regression revealed that nocturnal seizures, number of anti-seizure medication(ASM), anxiety, use of valproic acid(VPA), depression, and excessive daytime sleepiness(EDS) may be associated with insomnia in MRI-negative epilepsy (all p＜0.05). Stepwise regression demonstrated that nocturnal seizures, anxiety, and EDS were independently associated with insomnia in MRI-negative epilepsy (OR[95 %CI]P: 14.64[2.02-106.27]0.008,49.35[3.06-796.61]0.006, 13.28[1.25-140.66]0.032, respectively). Furthermore, CBF values in the left amygdala were significantly lower in patients with MRI- negative epilepsy who had insomnia.

CONCLUSION

The prevalence of insomnia in MRI-negative epilepsy is 19.2%. Nocturnal seizures, anxiety, and EDS were independently associated with insomnia in MRI-negative epilepsy. The noteworthy decrease in CBF values in the left amygdala might be connected to the underlying pathological mechanism of insomnia in epilepsy.

Differences in factors associated with insomnia symptoms between patients with epilepsy with and without depressive symptoms

OBJECTIVE

To determine if insomnia-related factors differ depending on the presence of depression in patients with epilepsy.

METHODS

This cross-sectional multicenter study collected data on depressive symptoms, insomnia symptoms, and excessive daytime sleepiness, which were defined as a Patient Health Questionnaire-9 (PHQ-9) score of ≥ 10, an Insomnia Severity Index (ISI) score of ≥ 15, and an Epworth Sleepiness Scale (ESS) of ≥ 11, respectively. Further, uncontrolled seizures were defined as one or more seizures per month during antiseizure medications treatment. A stepwise logistic regression analysis was conducted, with a logistic regression with interaction terms performed to identify differences in insomnia-related factors depending on depressive symptoms.

RESULTS

Of 282 adults with epilepsy (men, 58 %; mean age, 40.4 ± 13.9 years), a PHQ-9 score ≥ 10, an ISI score ≥ 15, an ESS score ≥ 11 were noted in 23.4 % (n = 66), 20.2 % (n = 57), and 12.8 % (n = 36), respectively. More patients with depressive symptoms had an ISI score ≥ 15 (56.1 % vs. 9.3 %; p < 0.001) than those without. In multiple logistic regression, uncontrolled seizures (odds ratio [OR], 4.896; p < 0.01), daytime sleepiness (OR, 5.369; p < 0.05), and a history of psychiatric disorders (OR, 3.971; p < 0.05) were identified as significant factors that were more likely to be associated with an ISI score ≥ 15; however, this was only true in patients without depressive symptoms. In contrast, use of perampanel (OR, 0.282; p < 0.05) was less likely associated, while female sex (OR, 3.178; p < 0.05) was more likely associated with an ISI score ≥ 15 only in patients with depressive symptoms.

CONCLUSIONS

Insomnia-related factors in patients with epilepsy may differ between patients with and without depression. Our findings of different insomnia-related factors based on the presence of depression may facilitate the management of patients with epilepsy.

Prevalence of restless legs syndrome in adults with epilepsy: A systematic review and meta-analysis of observational studies

INTRODUCTION

Epilepsy is a common neurological disorder that significantly contributes to the worldwide disease burden. Restless legs syndrome is sleep-related movement disorder that causes uncomfortable sensations in the legs with an irresistible urge to move them. The aim of this study is to comprehensively assess the current evidence to estimate the prevalence of restless legs syndrome (RLS) in adults with epilepsy (AWE) and to compare it to healthy controls.

METHODS

PubMed, Medline, Scopus, and Web of Science databases were searched for observational studies reporting the prevalence of RLS in AWE. The modified Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the studies. Comprehensive Meta-Analysis software (version 3.0) was used to perform data analysis. The heterogeneity of the studies was assessed using the I2 index. The pooled prevalence of RLS in AWE and the odds ratio were calculated based on the random-effect model. Sensitivity analysis was assessed. A funnel plot and Egger's test were used to investigate publication bias. Subgroup analysis and univariate meta-regression analysis were done.

RESULTS

Based on the analysis of 17 studies (2262 AWE patients), the prevalence of RLS was 14.9 % (95%CI, 10.4%-21 %). This rate was highest in the Americas (35.3 %; 95 % CI: 19.7-54.9 %) and lowest in Asian countries (11.6 %). The risk of RLS was significantly higher in AWE patients compared to health controls (12 studies, OR = 2.09; 95 % CI: 1.53-2.85, I2 = 91.69 %, P < 0.001). subgroup analysis showed Variations in RLS rates between studies depending on quality scores, methodology, and diagnostic criteria. The funnel plot and Egger's test suggest there was publication bias. Sensitivity analysis showed that none of the studies on their own significantly affected the results.

CONCLUSIONS

This meta-analysis provides the first pooled estimate of RLS prevalence in AWE. RLS occurs in 15 out of every 100 AWE patients, and the risk is high compared to healthy controls. However, the findings need to be confirmed in future studies owing to limitations in the analysis and study design.

Sleep profiles in epilepsy patients undergoing monotherapy and polytherapy: A comparative cross-sectional study

OBJECTIVE

Sleep disturbances commonly reported among epilepsy patients have a reciprocal relationship with the condition; While epilepsy and anti-seizure medications (ASMs) can disrupt sleep structure, disturbed sleep can also exacerbate the frequency of seizures. This study explored subjective sleep disturbances and compared sleep profiles in patients who underwent ASM monotherapy and polytherapy.

METHODS

We enrolled 176 epilepsy patients who completed a structured questionnaire containing demographic and clinical information and the Persian versions of the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Patient Health Questionnaire-9 (PHQ-9) to evaluate sleep quality, insomnia, excessive daytime sleepiness (EDS), and depressive symptoms, respectively. Chi-square and Mann-Whitney U tests were employed to analyze the association between variables, and logistic regression analysis was conducted to identify factors predicting sleep disturbances.

RESULTS

Comparative analysis of mono/polytherapy groups revealed a significantly higher prevalence of insomnia and EDS among patients on polytherapy compared to monotherapy. However, no significant difference was found in sleep quality between the two groups. Logistic regression analysis revealed that a depressive mood serves as a robust predictor for sleep issues, whereas treatment type did not emerge as an independent predictor of sleep disturbances.

CONCLUSION

Our findings suggest that an increased number of ASMs does not inherently result in a higher incidence of sleep issues. Therefore, multiple ASMs may be prescribed when necessary to achieve improved seizure control. Furthermore, this study underscores the importance of comprehensive management that addresses seizure control and treating affective symptoms in individuals with epilepsy.

Sleep physiology in patients with epilepsy: Influence of seizures on rapid eye movement (REM) latency and REM duration

OBJECTIVE

A well-established bidirectional relationship exists between sleep and epilepsy. Patients with epilepsy tend to have less efficient sleep and shorter rapid eye movement (REM) sleep. Seizures are far more likely to arise from sleep transitions and non-REM sleep compared to REM sleep. Delay in REM onset or reduction in REM duration may have reciprocal interactions with seizure occurrence. Greater insight into the relationship between REM sleep and seizure occurrence is essential to our understanding of circadian patterns and predictability of seizure activity. We assessed a cohort of adults undergoing evaluation of drug-resistant epilepsy to examine whether REM sleep prior to or following seizures is delayed in latency or reduced in quantity.

METHODS

We used a spectrogram-guided approach to review the video-electroencephalograms of patients' epilepsy monitoring unit admissions for sleep scoring to determine sleep variables.

RESULTS

In our cohort of patients, we found group- and individual-level delay of REM latency and reduced REM duration when patients experienced a seizure before the primary sleep period (PSP) of interest or during the PSP of interest. A significant increase in REM latency and decrease in REM quantity were observed on nights where a seizure occurred within 4 h of sleep onset. No change in REM variables was found when investigating seizures that occurred the day after the PSP of interest. Our study is the first to provide insight about a perisleep period, which we defined as 4-h periods before and after the PSP.

SIGNIFICANCE

Our results demonstrate a significant relationship between seizures occurring prior to the PSP, during the PSP, and in the 4-h perisleep period and a delay in REM latency. These findings have implications for developing a biomarker of seizure detection as well as longer term seizure risk monitoring.

Influence of sleep disturbance, depression, anxiety, and stress on quality of life in people with epilepsy

OBJECTIVES

We assessed the quality of life, sleep, depression, anxiety, and stress in people with pharmacoresistant epilepsy (PRE) and newly diagnosed epilepsy (NDE). We also assessed the influence of sleep, depression, anxiety, and stress on the quality of life (QOL) and the complex association between these factors.

METHODS

We recruited 80 PRE and 70 NDE people attending the epilepsy clinic. We assessed QOL, sleep quality, daytime sleepiness, and mood using the quality of life in epilepsy-31 inventory (QOLIE-31), Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and depression anxiety stress scale (DASS-21). We compared the results between the two groups of epilepsy populations. We performed univariate and multivariate linear regression to determine the factors affecting the QOLIE-31 total score. We applied Spearman's rank correlation to find the interrelationship between variables influencing QOL.

RESULTS

We found significantly lower QOLIE-31 total scores (p = .001) in PRE compared to NDE. The PSQI and ESS did not differ significantly between the PRE and NDE groups. Anxiety (p = .002) and stress (p = .003) scores were significantly higher in PRE than in NDE. QOLIE-31 total scores showed a negative correlation with PSQI as well as symptoms of depression, anxiety, and stress scores in both groups. Multiple linear regression analysis revealed depression as a major factor influencing the QOLIE-31 total score in PRE (p = .001) and NDE (p = .003). We found significant complex associations between PSQI, depression, anxiety, stress, and QOLIE total scores in both groups.

SIGNIFICANCE

The QOL is poorer for people with PRE than for those with NDE. Depression is a major determinant of QOL in PWE. These factors need to be considered to improve the QOL in epilepsy.

Expert opinion on diagnosis and management of epilepsy-associated comorbidities

Apart from seizure freedom, the presence of comorbidities related to neurological, cardiovascular, or psychiatric disorders is the largest determinant of a reduced health-related quality of life in people with epilepsy (PwE). However, comorbidities are often underrecognized and undertreated, and clinical management of comorbid conditions can be challenging. The focus of a comprehensive treatment regimen should maximize seizure control while optimizing clinical management of treatable comorbidities to improve a person's quality of life and overall health. A panel of four European epileptologists with expertise in their respective fields of epilepsy-related comorbidities combined the latest available scientific evidence with clinical expertise and collaborated to provide consensus practical advice to improve the identification and management of comorbidities in PwE. This review provides a critical evaluation for the diagnosis and management of sleep-wake disorders, cardiovascular diseases, cognitive dysfunction, and depression in PwE. Whenever possible, clinical data have been provided. The PubMed database was the main search source for the literature review. The deleterious pathophysiological processes underlying neurological, cardiovascular, or psychiatric comorbidities in PwE interact with the processes responsible for generating seizures to increase cerebral and physiological dysfunction. This can increase the likelihood of developing drug-resistant epilepsy; therefore, early identification of comorbidities and intervention is imperative. The practical evidence-based advice presented in this article may help clinical neurologists and other specialist physicians responsible for the care and management of PwE.

Insomnia in epilepsy is associated with nocturnal seizures and anxiety

PURPOSE

The purpose of this study was to identify the factors associated with insomnia in patients with epilepsy (PWE) and provide evidence for clinical prevention and treatment.

METHODS

PWE who visited our epilepsy clinic from December 2021 to December 2022 were enrolled in our study. All participants completed the Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Self-rating Anxiety Scale (SAS), and Self-rating Depression Scale (SDS). Based on their ISI scores, they were categorized into two groups: PWE with insomnia (ISI score ≥ 10) and PWE without insomnia (ISI score < 10). Univariate analysis and stepwise logistic regression analysis were conducted to identify the factors associated with insomnia in PWE.

RESULTS

A total of 196 Chinese PWE were recruited in this study(men, 39.8 %). Of these, 39 PWE(19.9 %) had insomnia.The incidence of nocturnal seizures (43.6 %vs19.7 %), depression (46.2 %vs9.6 %), anxiety (59.0 %vs11.5 %), and excessive daytime sleepiness(EDS,28.2 %vs5.7 %) in PWE with insomnia were significantly higher than in those without insomnia(all p＜0.01). Univariate regression analysis showed that seizures greater than or equal to once per month, nocturnal seizures, anxiety, depression, and EDS may associate with insomnia in PWE(all p＜0.05). Stepwise logistic regression analysis demonstrated that nocturnal seizures (OR = 2.611,95 % CI 1.040-6.478, P = 0.038) and anxiety (mild OR = 4.830,95 %CI 1.741-13.186, P = 0.002;moderate OR = 24.239,95 %CI 4.719-183.935, P＜0.001; severe OR = 37.653,95 %CI 4.931-782.741, P = 0.002) were independently associated with insomnia in PWE.

CONCLUSION

PWE with insomnia are more likely to experience depression and EDS. Nocturnal seizures and anxiety are identified as independent factors associated with insomnia in PWE. Furthermore, Anxiety has a greater impact on insomnia in PWE and the likelihood of insomnia has increased significantly with the aggravation of anxiety levels.

The effect of sleep disorders on quality of life in patients with epilepsy: A multicenter study from Turkey

OBJECTIVE

We aimed to investigate sleep disorders in patients with epilepsy (PWE) and to investigate the effects of sleep disorders on quality of life.

METHODS

In our multicenter study conducted in Turkey, 1358 PWE were evaluated. The demographic and clinical data of the patients were recorded. The Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and Quality of Life in Epilepsy Inventory-10 (QOLIE-10) were administered.

RESULTS

The mean age of 1358 patients was 35.92 ± 14.11 (range, 18-89) years. Seven hundred fifty-one (55.30 %) were women. Some 12.7 % of the patients had insomnia (ISI > 14), 9.6 % had excessive daytime sleepiness (ESS > 10), 46.5 % had poor sleep quality (PSQI > 5), and 354 patients (26.1 %) had depressive symptoms (BDI > 16). The mean QOLIE-10 score was 22.82 ± 8.14 (10-48). Resistant epilepsy was evaluated as the parameter with the highest risk affecting quality of life Adjusted odds ratio (AOR = 3.714; 95 % confidence interval (CI): [2.440-5.652] < 0.001)). ISI (AOR = 1.184; 95 % CI: [1.128-1.243]; p < 0.001), ESS (AOR = 1.081; 95 % CI: [1.034-1.130]; p < 0.001), PSQI (AOR = 0.928; 95 % CI: [0.867 - 0.994]; p = 0.034), BDI (AOR = 1.106; 95 % CI: [1.084-1.129]; p < 0.001), epilepsy duration (AOR = 1.023; 95 % CI: [1.004-1.041]; p = 0.014), were determined as factors affecting quality of life.

SIGNIFICANCE

Sleep disorders are common in PWE and impair their quality of life. Quality of life can be improved by controlling the factors that may cause sleep disorders such as good seizure control, avoiding polypharmacy, and correcting the underlying mood disorders in patients with epilepsy.

The impact of epilepsy and antiseizure medications on sleep: Findings from a large European survey in adults with epilepsy and matched controls

OBJECTIVE

To assess the impact of epilepsy and antiseizure medications (ASMs) on sleep quality in people with epilepsy (PWE).

METHODS

An online survey was conducted in France, Germany, Italy, Spain and the UK among PWE taking >1 ASM and matched controls. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI). Associations between sleep quality (global PSQI) and overall quality of life (QoL; assessed using the 12-Item Short Form Survey [SF-12]) and sleep quality and depressive symptoms (assessed using the Neurological Disorders Depression Inventory for Epilepsy [NDDI-E]) were also evaluated.

RESULTS

Overall, 500 PWE and 500 matched controls were included. PWE had significantly greater mean global PSQI scores than controls (9.32 vs 7.56; p < 0.0001), with 80% reporting a score >5 versus 66% of controls (p < 0.001). PWE experienced significantly more problems with most PSQI components than controls. Mean global PSQI scores in PWE receiving 2 versus ≥3 ASMs were 9.03 and 10.18, respectively (p < 0.004); global PSQI scores >5 were reported in 76% versus 90%, respectively (p = 0.001). Regimens containing lamotrigine or phenobarbital were associated with poorer sleep quality than those without these ASMs. In PWE, negative correlations were identified between global PSQI scores and both the SF-12 physical and mental components (Pearson's correlation coefficient [PCC], -0.61 and -0.40, respectively); NDDI-E and global PSQI scores were positively correlated (PCC, 0.6).

CONCLUSIONS

PWE experience significantly worse sleep quality than people without epilepsy, with some ASMs contributing to poorer sleep. QoL and physical and mental health were all affected by sleep quality in PWE.

Abnormal Topological Organization of Structural Covariance Networks in Patients with Temporal Lobe Epilepsy Comorbid Sleep Disorder

OBJECTIVE

The structural covariance network (SCN) alterations in patients with temporal lobe epilepsy and comorbid sleep disorder (PWSD) remain poorly understood. This study aimed to investigate changes in SCNs using structural magnetic resonance imaging.

METHODS

Thirty-four PWSD patients, thirty-three patients with temporal lobe epilepsy without sleep disorder (PWoSD), and seventeen healthy controls underwent high-resolution structural MRI imaging. Subsequently, SCNs were constructed based on gray matter volume and analyzed via graph-theoretical approaches.

RESULTS

PWSD exhibited significantly increased clustering coefficients, shortest path lengths, transitivity, and local efficiency. In addition, various distributions and numbers of SCN hubs were identified in PWSD. Furthermore, PWSD networks were less robust to random and target attacks than those of healthy controls and PWoSD patients.

CONCLUSION

This study identifies aberrant SCN changes in PWSD that may be related to the susceptibility of patients with epilepsy to sleep disorders.

Insomnia in neurological disorders: Prevalence, mechanisms, impact and treatment approaches

Insomnia is more prevalent in neurological disorders compared to the general population, with rates ranging from 11 to 74.2% in neurodegenerative disorders, 20 to 37% in vascular diseases, 13.3 to 50% in inflammatory diseases, 28.9 to 74.4% in epilepsy, and nearly 70% in migraines. Insomnia in neurological disorders stems from a variety of factors, encompassing physical and neuropsychiatric factors, behavioral patterns, and disruptions in the biological clock and circadian rhythm. There are bidirectional connections between neurological disorders and insomnia. Insomnia in neurological disorders worsens symptoms, resulting in heightened depressive symptoms, elevated mortality rates, reduced quality of life, and intensified acute symptoms. Managing comorbid sleep disorders, especially in the presence of psychiatric comorbidities, is crucial. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommendation for insomnia management in neurological disorders. Other treatments are second-line strategies. Melatonin may demonstrate effectiveness in addressing insomnia, with soporific and chronobiotic effects. Furthermore, it has the potential to alleviate "sundowning" and behavioral disturbances, while generally being well-tolerated. Other treatment options that may be of interest include morning bright light therapy, sedative antidepressants, new orexin dual antagonists and levodopa specifically indicated for Parkinson's disease. Benzodiazepines and z-drugs can be used primarily during acute phases to prevent pharmacotolerance and minimize side effects. However, they should be avoided in patients with neurological disorders and not used in patients over 75 years old due to the risk of falls and confusion. In neurological disorders, insomnia has a profound impact on daytime functioning, making its management crucial. Effective treatment can result in improved outcomes, and additional research is necessary to investigate alternative therapeutic options and enhance patient care.

Neurologic Disorders in Women and Sleep

Sleep disorders in women remain underrecognized and underdiagnosed mainly because of gender bias in researching and characterizing sleep disorders in women. Symptoms of common sleep disorders are frequently missed in the general female population and are expected to be further overlooked because of overlapping symptoms in women with neurologic disorders. Given the bidirectional relationship with sleep and neurologic disorders, it remains critical to be aware of the presentation and impact of sleep disorders in this patient population. This article reviews available data on sleep disorders in women with neurologic disorders and discusses their distinctive features.

Fear of sleep in people with epilepsy

More than one third of people with epilepsy (PWE) report experiencing insomnia. This is highly concerning given that sleep loss both triggers and exacerbates seizures. It is therefore paramount that we understand the underlying mechanisms of insomnia in PWE. Nevertheless, research in this area remains limited, with little understanding of the emerging or maintaining factors of insomnia in PWE. Therefore, the current study sought to explore fear of sleep as a novel explanation for the increased rate of insomnia in PWE, and whether fear of sleep was related to post-seizure trauma. We recruited 184 PWE and 197 healthy controls via social media and collected data using a series of online questionnaires. We found that fear of sleep did not significantly differ between the epilepsy and control group. In the epilepsy group, fear of sleep seemed to be largely driven by trauma, especially post-seizure trauma but also non-seizure related trauma, along with anxiety and higher seizure frequency. Fear of sleep in the control group was also largely driven by trauma, but also anxiety and depression. Finally, we found more severe and prevalent insomnia in PWE relative to controls, and in both groups, fear of sleep was the most significant contributor to insomnia. Our novel findings carry important clinical implications. First, they point to the central role of trauma in fear of sleep not only in PWE but also in the general population. Our findings also indicate that fear of sleep is an important maintaining factor of insomnia. Ultimately, these results suggest that all individuals with insomnia may benefit from insomnia interventions targeted at trauma, depression, anxiety, and fear of sleep. PWE are likely to benefit from additional treatment components for seizure-related trauma and seizure management. To better understand the reliability and generalisability of our novel findings, future research should further assess fear of sleep and its role in maintaining insomnia in the epilepsy population.

Sleep architecture in drug-naïve adult patients with epilepsy: Comparison between focal and generalized epilepsy

OBJECTIVE

Sleep impairment is one of the most common comorbidities affecting people with epilepsy (PWE). The bidirectional relation between epilepsy and sleep has been widely established. Several studies investigated subjective sleep quality and daytime vigilance in PWE, highlighting frequent complaints of sleep fragmentation, difficulties in falling asleep, and daytime sleepiness. The present study aimed to evaluate sleep structure in drug-naive PWE, distributed on the basis of epilepsy type, and compared with controls.

METHODS

This observational study included adult patients newly diagnosed with epilepsy and drug-naive as well as a control group of healthy subjects. All PWE and controls underwent a dynamic 24-h EEG with signals for sleep recording to evaluate sleep architecture, structure, continuity, and fragmentation.

RESULTS

Twenty-four PWE were included and distributed in two groups based on epilepsy type. Eleven patients were included in the generalized epilepsy group (63.6% male; 34.91 ± 9.80 years) and 13 patients in the focal epilepsy group (53.8% male; 38.69 ± 12.74 years). The control group included 16 subjects (56.3% male; 32.75 ± 12.19 years). Patients with generalized or focal epilepsy had a significantly lower sleep efficiency than controls. Moreover, both patient groups presented the alteration of markers of sleep fragmentation and loss of continuity, with higher indices of sleep stage transitions and arousal. Finally, the two patient groups presented less REM sleep than controls.

SIGNIFICANCE

This study highlighted the alteration of sleep quality, continuity, and stability in both patients with focal or generalized epilepsy compared with controls, also in the absence of ictal events. This sleep impairment resulted in the reduction of REM sleep. Therefore, these findings may be explained by the increase in awakenings and sleep stage shifts, which may be attributed to both sleep networks impairment and neurotransmission dysfunction in PWE, and also possibly triggered by paroxysmal interictal abnormalities.

Effect of an intervention of exercise on sleep and seizure frequency in idiopathic epileptic dogs

OBJECTIVE

The goal of this study was to compare sleep and seizure frequency between epileptic dogs prescribed a 20% activity increase and epileptic dogs not prescribed an activity increase.

METHODS

Sixty-nine dogs receiving anti-epileptic drug therapy were enrolled in a 6-month prospective, randomised, placebo-controlled clinical trial with an intention-to-treat analysis. A canine activity monitoring device was used to measure activity levels and sleep scores.

RESULTS

Using an intention-to-treat analysis, the treatment group had an average of 0.381 more seizures per month (95% CI: 0.09 to 0.68) compared with the control group, although the difference in seizure days per month was not statistically significant. In a subgroup analysis of dogs whose activity increased by at least 10%, partial compliers had 0.719 more seizures per month (95% CI: 0.22 to 1.22) and 0.581 seizure days per month (95% CI: 0.001 to 1.16) compared with the control group. Sleep scores increased by 1.2% in the treatment compared with the control group (95% CI: 0.2 to 2.3%).

CONCLUSIONS

Seizure frequency and sleep score increased slightly, but significantly, in dogs with idiopathic epilepsy prescribed an increase in activity, compared with a control group.

Restless leg syndrome prevalence in epilepsy patients and its impact on quality of sleep

This study aimed to determine the frequency of restless leg syndrome (RLS) and other sleep-related movement disorders and their effects on sleep quality in epilepsy patients. One hundred and twenty-seven epilepsy patients were compared with 115 age-and gender-matched healthy controls. RLS was determined from the clinical characteristics of the patients according to the International RLS Study Group's (IRLSSG) diagnostic criteria. Sleep bruxism was diagnosed based on the International Classification of Sleep Disorders, Third Edition (ICSD-3) criteria. Subjective sleep quality was evaluated with the Pittsburgh Sleep Quality Index (PSQI). Poor sleep quality was more common in the epilepsy group than in the control group (42.5% versus 26.1%; p = 0.007). The epilepsy group had significantly higher PSQI total scores than the control group (p = 0.003). The frequency of RLS was higher in epileptic patients than in the control group (13.4% versus 5.2%; p = 0.024). There were no significant differences between the patient group and the control group regarding limb movement and bruxism frequency during sleep. The PSQI scores were high in epilepsy patients with RLS compared to those without RLS (p = 0.009). The frequency of habitual snoring, bruxism, and repetitive leg movement in sleep was also high in epilepsy patients with RLS compared to those without RLS (p < 0.05). The prevalence of poor sleep quality and RLS in epilepsy patients is higher than in healthy controls. Our results also show the negative impact of RLS on sleep quality in epilepsy patients. Further confirmatory studies using objective sleep tests are needed to identify the mechanisms underlying the current findings.

Gender differences in prevalence and risk factors of sleep disturbances in patients with epilepsy

Background

Sleep disturbances are frequently observed in patients with epilepsy (PWE), with adversely effects on life quality and seizure control. The study aimed to assess the gender differences in incidence and factors of sleep disturbances in PWE.

Methods

PWE confirmed the diagnosis of epilepsy were consecutively enrolled in this cross-sectional study, with detailed information recorded. A group of healthy participants were recruited as the control. Sleep and mood disorders were evaluated with the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI) and Beck Anxiety Inventory (BAI).

Results

One hundred and thirty-three patients (age: 30.2 ± 10.6 years, men: 51%) and 150 healthy subjects were recruited in this study. Compared with healthy controls, PWE had higher mean scores of the ISI and BDI (p < 0.001 and p = 0.01). There were no significant gender differences in the prevalence and scores of sleep disturbances in PWE. In the overall PWE, nocturnal seizures and focal epilepsy were respectively related to insomnia and poor sleep quality (OR = 3.35, p = 0.024; OR = 3.08, p = 0.013), and mood disorders were also important factors in sleep disturbances (p < 0.05). In the analysis by gender, depression, anxiety, nocturnal seizures and focal epilepsy were associated with insomnia and poor sleep quality in men. For women, however, depression mood was the only factor of sleep disturbances.

Conclusions

Though no gender difference was observed in the incidence of sleep disturbances, factors contributing to insomnia and sleep quality were different by gender. The factors and gender differences of sleep disturbances should be taken into account in the clinical treatment.

Effects of Obstructive Sleep Apnea on Epilepsy, and Continuous Positive Airway Pressure as a Treatment Option

Purpose: To compare the characteristics of obstructive sleep apnea (OSA) between patients with epilepsy and patients without epilepsy and to investigate CPAP (Continuous Positive Airway Pressure) effect on seizures. Methods: Medical and polysomnography (PSG) data from 235 adult OSA patients with epilepsy (OE; 183 males; mean age, 49.8 years) and 268 age- and sex-matched OSA patients without epilepsy (OSE; 216 males; mean age, 51.3 years), obtained between March 2014 and May 2020 and housed in a database in a university-affiliated hospital, were retrospectively reviewed. All subjects completed surveys addressing comorbidities and medications, and sleep-related questionnaires including the Insomnia Severity Index, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, and Beck Depression Inventory-II. Results: Compared with the OSE group, the OE group reported fewer sleep-related complaints and less severe OSA-related PSG parameters, with a lower apnea-hypopnea index (24.9 vs. 33.4 events/h; p < 0.003), arousal index (23.3 vs. 30.8 events/h; p < 0.001), and oxygen desaturation index (19.6 vs. 28.8; p < 0.002). The OE group had fewer smokers and lower alcohol consumption but a higher body mass index (27.0 vs. 25.9 kg/m2; p < 0.001). No correlations were observed between OSA-related PSG parameters and epilepsy-related factors, such as age at seizure onset, seizure type, frequency of seizures, presence of nocturnal seizures, and number of antiseizure medications, in the OE group. Patients with OE who demonstrated good compliance with CPAP therapy exhibited a decrease in seizure frequency. Conclusions: The OE group exhibited less severe disease characteristics than their age- and sex-matched OSE counterparts. Nevertheless, because the coexistence of OSA and epilepsy is high, CPAP therapy can reduce the frequency of seizures. Therefore, it is important to evaluate the presence of OSA in patients with epilepsy and to treat the conditions concurrently.

High prevalence of pathological alertness and wakefulness on maintenance of wakefulness test in adults with focal-onset epilepsy

BACKGROUND

Excessive daytime sleepiness (EDS) is a common complaint in adults with epilepsy (AWE), but objective evaluation is lacking. We used the maintenance of wakefulness test (MWT) to objectively measure the ability of adults with focal-onset epilepsy to maintain wakefulness in soporific conditions.

METHODS

Adults with epilepsy participating in a study investigating the effects of lacosamide on sleep and wakefulness underwent baseline ambulatory polysomnography (PSG)/EEG followed by MWT. Mean sleep latency (MSL) and mean percent sleep time (MST, mean percentage of non-wake EEG scored in 3-sec bins from lights out to sleep onset averaged over the 4 MWT trials) were quantified. Subjective sleepiness was assessed by the Epworth Sleepiness Scale (ESS). Spearman correlation and linear regression assessed relationships between MWT parameters, ESS and relevant sleep and epilepsy-related variables.

RESULTS

Maintenance of wakefulness test MSL in 51 AWE (mean age 43.5 ± 13 years, 69% female, mean BMI 24.6 ± 11.2 kg/m²) was 21.7 ± 11.9 min; 45.1% had an abnormally short MSL <19.4 min and 15.7% <8 min. MST was 9.3% [3.3, 19.1]. Mean ESS score was 8.8 ± 5.7; 39% had elevated ESS (>10). No correlation between subjective ESS and objective MSL (p = 0.67) or MST (p = 0.61) was found. MSL was significantly shorter in subjects with focal to bilateral tonic-clonic seizures (FBTCS; 7.9 min [13.6, 22.3]) compared to those without (27.4 min [21.2, 33.6], p = 0.013). Younger subjects had shorter MSL; MSL increased 3.2 min for every 10-year increase in age.

CONCLUSION

We found a high prevalence of objective sleepiness/difficulty maintaining wakefulness on the MWT and subjective sleepiness using the ESS in AWE without a correlation between the two. More severe objective sleepiness was found in subjects with a history of FBTCS and younger age. Further research is needed to determine mechanistic underpinnings and optimal measurements of pathological sleepiness in people with epilepsy given the burden of it on quality of life.

Relationship between sleep quality and cognitive performance in patients with epilepsy

PURPOSE

To investigate the relationship between self-reported sleep quality and cognitive function in patients with epilepsy (PWE), as well as anxiety and depressive symptoms and patient quality of life (QoL).

METHODS

This multicenter cross-sectional study included PWE aged ≥12 years who were receiving ≥1 anti-seizure medication (ASM) and had not been diagnosed with a sleep disorder. Patients completed the Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Montreal Cognitive Assessment test (MoCA), the Hospital Anxiety and Depression Scale (HADS), and the Quality of Life in Epilepsy Inventory-10 (QOLIE-10).

RESULTS

The study enrolled 150 patients aged 16-83 years, mean age (standard deviation [SD]) 40.6 (15.2) years; 58.7% were female and 75.3% had focal epilepsy. Mean (SD) PSQI score was 4.71 (3.08), 44.4% of patients had impaired sleep quality (PSQI score ≥5), 19.9% had pathologic excessive daytime sleepiness (ESS score >12), and 32.7% had mild cognitive impairment (MoCA score <26). Within the PSQI, sleep disturbance (P = 0.036) and use of sleep medication (P = 0.006) scores were significantly higher in patients with mild cognitive impairment. Multiple regression analysis showed older age (regression coefficient [B], -0.086; 95% confidence interval [CI], -0.127, -0.045; P < 0.001) and the use of sleep medication component of the PSQI [B, -1.157; 95% CI, -2.064, -0.220; P = 0.013) were independently associated with lower MoCA score. Poor sleep quality was associated with probable anxiety and depression symptoms, and directly correlated with reduced QoL.

CONCLUSIONS

In PWE, sleep quality was not significantly independently associated with mild cognitive impairment, although poor sleep quality had a negative effect on mood and QoL.

Sleep duration and quality among U.S. adults with epilepsy: National Health Interview Survey 2013, 2015, and 2017

BACKGROUND

Epilepsy is associated with a high prevalence of sleep disturbance. However, population-based studies on the burden of sleep disturbance in people with epilepsy are limited. This study assessed sleep duration and sleep quality by epilepsy status in the general U.S. adult population aged ≥ 18 years.

METHODS

We pooled data of cross-sectional National Health Interview Surveys in 2013, 2015, and 2017 to compare the prevalence of sleep duration and quality among those without epilepsy (N = 93,126) with those with any epilepsy (a history of physician-diagnosed epilepsy) (N = 1774), those with active epilepsy (those with a history of physician-diagnosed epilepsy who were currently taking medication to control it, had one or more seizures in the past year, or both) (N = 1101), and those with inactive epilepsy (those with a history of physician-diagnosed epilepsy who were neither taking medication for epilepsy nor had had a seizure in the past year) (N = 673). We also compared these measures between those with active and those with inactive epilepsy. The prevalences were adjusted for sociodemographics, behaviors, and health covariates, with multivariable logistic regression. We used Z-tests to compare prevalences of sleep duration and quality at the statistical significance level of 0.05.

RESULTS

Adults with any epilepsy reported significantly higher adjusted prevalences of short sleep duration (<7 h) (36.0% vs. 31.8%) and long sleep duration (>9 h per day) (6.7% vs. 3.7%) but a lower prevalence of healthy sleep duration (7-9 h per day) (57.4% vs.64.6%) than those without epilepsy. In the past week, adults with any epilepsy reported significantly higher adjusted prevalences than adults without epilepsy of having trouble falling asleep (25.0% vs. 20.3%), staying asleep (34.4% vs. 26.3%), nonrestorative sleep (adults did not wake up feeling well rested) (≥3days) (50.3% vs. 44.3%), and taking medication to help themselves fall asleep or stay asleep (≥1 times) (20.9% vs. 13.5%). However, adults with active epilepsy did not differ from adults with inactive epilepsy with respect to these sleep duration and quality measures.

CONCLUSIONS

Adults with epilepsy reported more short or long sleep duration and worse sleep quality than those without epilepsy. Neither seizure occurrence nor antiepileptic drug use accounted for these differences in sleep duration and quality. Careful screening for sleep complaints as well as identifying and intervening on the modifiable risk factors associated with sleep disturbances among people with epilepsy could improve epilepsy outcomes and quality of life.

Risk Factors for Epilepsy: A National Cross-Sectional Study from National Health and Nutrition Examination Survey 2013 to 2018

Objective

The purpose of this study is to investigate the risk factors of epilepsy based on the National Health and Nutrition Examination Survey (NHANES).

Methods

The data in this study was obtained from the NHANES database between 2013 and 2018. It included 14,290 participants aged between 20 and 80. We defined people with epilepsy (PWE) when they self-reported took at least one treatment medication for seizures or epilepsy. Analysis of risk factors for epilepsy mainly includes Student’s t-test, chi-square test, univariate and multivariate logistic regression analysis.

Results

People aged 40–59 shared 1.8 times the risk of epilepsy than those who aged 20–39, P=0.034. People who never married had a 2.8-fold higher risk of epilepsy than those who married/living with partner, P<0.001. The risk of epilepsy in subjects with very good/good general health was 0.4 times than that of subjects with fair/poor general health, P<0.001. Moreover, subjects without sleep disorders had a 0.4-fold higher risk of epilepsy than those who had sleep disorders, P=0.042.

Conclusion

People who are older, unmarried, and have sleep disorders are at higher risk of epilepsy. In addition, good/good general health condition is associated with a lower risk of epilepsy.

The Epworth Sleepiness Scale in epilepsy: Internal consistency and disease-related associations

BACKGROUND

The Epworth Sleepiness Scale (ESS) is the most common instrument for measuring subjective sleep propensity in people with epilepsy but has not yet been validated in this population.

STUDY OBJECTIVES

We aimed to systematically assess the validity, performance, and internal consistency of the ESS, as well as correlations between the ESS and disease-specific variables and patient-reported outcome measures in a cohort of adults with epilepsy (AWE).

METHODS

Ninety-five AWE completed sleep and seizure diaries, in-laboratory polysomnography (PSG) and patient-reported outcome measures, including the ESS, Insomnia Severity Index (ISI), and the Beck Depression Inventory (BDI). Demographic information and data from 95 matched controls referred for PSG for suspected obstructive sleep apnea (OSA) was taken from the electronic medical record. Frequencies of high ESS item ratings (item score ≥2) were calculated for each group. Cronbach's α and factor analysis were performed to assess the internal consistency and validity of the ESS within cases and controls. Multivariable linear models were used to assess the association between ESS and predictors of interest, adjusting for demographic and disease-specific variables, including seizure type, frequency, and anti-seizure medication (ASM) therapy.

RESULTS

While suspected OSA controls had significantly greater mean ESS total scores (9.9 vs 7.9, p = 0.004) and proportion with ESS >10 (42% vs 25%, p = 0.014), there were no significant differences in the severity of item responses, with the exception of "lying down to rest in the afternoon when circumstances permit," for which more controls rated as likely/very likely (79% vs 64%), p = 0.024). AWE with ESS >10 had higher mean standardized ASM dose (2.5 vs 1.7, p = 0.026). All ESS items were significantly correlated with the total score within each group. Cronbach's α was 0.75 for cases and 0.85 for controls, indicating good internal consistency of the ESS for both groups. After adjusting for demographic and sleep characteristics, higher ESS scores were associated with greater insomnia scores on the ISI (p = 0.024) and depressive symptoms on the BDI (p = 0.018).

CONCLUSIONS

This study provides validity for the use of the ESS in adult populations with epilepsy.

Quantitative evaluation of the microstructure of rapid eye movement sleep in refractory epilepsy: a preliminary study using electroencephalography and heart rate variability analysis

INTRODUCTION

Patients with epilepsy have a disturbed sleep architecture. Polysomnographic studies have shown that patients with refractory epilepsy have decreased rapid eye movement (REM) sleep and longer REM latency than those with medically controlled epilepsy. However, little is known about the differences in the REM sleep microstructure between these patient groups.

METHODS

We conducted a retrospective case-control study of 20 patients with refractory epilepsy (refractory group) and 28 patients with medically controlled epilepsy (medically controlled group). All patients completed sleep questionnaires and underwent overnight in-lab polysomnography. Five-minute electroencephalogram recordings at the C3 and C4 electrodes from each REM sleep were selected for spectral analysis, and 5-min electrocardiogram segments recorded during REM sleep were used for heart rate variability analysis. The groups' scores on the sleep questionnaires, polysomnographic sleep parameters, indices of sleep-related breathing disorders, and REM sleep electroencephalogram spectra were compared.

RESULTS

The refractory group had decreased REM sleep (p < 0.001) and longer REM latency (p = 0.0357) than those of the medically controlled group. Moreover, electroencephalogram spectral analysis revealed that the refractory group had decreased absolute beta power (p = 0.0039) and relative beta power (p = 0.0035) as well as increased relative delta power (p = 0.0015) compared with the medically controlled group.

CONCLUSIONS

Differences in the polysomnographic macrostructure and REM sleep microstructure between the study groups suggest REM sleep dysregulation in patients with refractory epilepsy.

Daytime and nocturnal activity in treated dogs with idiopathic epilepsy compared to matched unaffected controls

BACKGROUND

In dogs, antiepileptic drugs (AED) cause lethargy but quantitative data regarding the effects of AED on activity levels are not available, and little is known about how AEDs affect sleep quality.

OBJECTIVE

To quantitatively compare activity levels and nocturnal activity in dogs previously diagnosed with idiopathic epilepsy (IE) receiving AEDs compared to age- and breed-matched control dogs.

ANIMALS

Sixty-two dogs with IE and 310 control dogs.

METHODS

This is a 3-month prospective parallel observational study. An activity monitoring device for dogs was used to measure daily activity levels and sleep scores in all dogs.

RESULTS

Dogs with IE treated with AEDs had an 18% average lower baseline activity level compared to control dogs (P = .005; point estimate = 0.82, 95% confidence interval [CI], 0.75-0.90). The combination of phenobarbital and potassium bromide (KBr) was associated with an average 28% decrease in activity in dogs with IE compared to control dogs (P = .03; point estimate = 0.72; CI, 0.62-0.82). Mean sleep scores were not significantly different in dogs with IE receiving AEDs compared to control dogs (P = .43). However, higher dosages of KBr were associated with lower sleep scores (P = .01).

CONCLUSIONS

Dogs with IE receiving AEDs have lower activity levels, but no difference in sleep scores, compared to controls. The combination of phenobarbital and KBr had the largest decrease in activity between groups. Higher doses of KBr may affect nocturnal activity in epileptic dogs.

Sleep quality and daytime sleepiness in epilepsy: Systematic review and meta-analysis of 25 studies including 8,196 individuals

We sought to gain a better understanding of the relationship between epilepsy and sleep quality and daytime sleepiness by performing a literature search of PubMed for case-control studies that compared patients with epilepsy to controls and reported the Pittsburgh sleep quality index (PSQI) and/or the Epworth sleepiness scale (ESS). Study-specific mean differences in the PSQI and ESS between cases and controls were extracted from the publications and pooled using random-effects meta-analysis. Twenty-five studies (2964 cases, 5232 controls) were included. Fifteen studies reported the PSQI and 24 the ESS. Mean age was 40 years; 50.4% were women. When comparing cases to controls, the pooled mean differences in the PSQI and ESS were 1.27 (95% confidence interval (CI): 0.76, 1.78; P < 0.001; I²: 81.4%) and 0.38 (95% CI: -0.07, 0.84; P = 0.099; I²: 81.0%). Subgroup analyses revealed that mean differences in the ESS were significantly lower in studies with a higher proportion of patients with focal epilepsy (P = 0.004). In this large-scale meta-analysis patients with epilepsy had a higher PSQI, close to the pathological cut-off, compared to controls, but a similar and unremarkable ESS. Further studies are needed to investigate potential effect modifiers, such as specific antiepileptic drugs or seizure frequency.

Insomnia in neurological diseases

Insomnia is defined as difficulties of initiating and maintaining sleep, early awakening and poor subjective sleep quality despite adequate opportunity and circumstances for sleep with impairment of daytime performance. These components of insomnia - namely persistent sleep difficulties despite of adequate sleep opportunity resulting in daytime dysfunction - appear secondary or co-morbid to neurological diseases. Comorbid insomnia originates from neurodegenerative, inflammatory, traumatic or ischemic changes in sleep regulating brainstem and hypothalamic nuclei with consecutive changes of neurotransmitters. Symptoms of neurological disorders (i.e motor deficits), co-morbidities (i.e. pain, depression, anxiety) and some disease-specific pharmaceuticals may cause insomnia and/or other sleep problems.This guideline focuses on insomnias in headaches, neurodegenerative movement disorders, multiple sclerosis, traumatic brain injury, epilepsies, stroke, neuromuscular disease and dementia.The most important new recommendations are: Cognitive behavioral therapy (CBTi) is recommended to treat acute and chronic insomnia in headache patients. Insomnia is one of the most frequent sleep complaints in neurodegenerative movement disorders. Patients may benefit from CBTi, antidepressants (trazodone, doxepin), melatonin and gaba-agonists. Insomnia is a frequent precursor of MS symptoms by up to 10 years. CBTi is recommended in patients with MS, traumatic brain injury and. Melatonin may improve insomnia symptoms in children with epilepsies. Patients with insomnia after stroke can be treated with benzodiazepine receptor agonists and sedating antidepressants. For patients with dementia suffering from insomnia trazodone, light therapy and physical exercise are recommended.

Rapid eye movement sleep disturbance in patients with refractory epilepsy: A polysomnographic study

OBJECTIVE/BACKGROUND

Patients with epilepsy have disrupted sleep architecture and a higher prevalence of sleep disturbance. Moreover, obstructive sleep apnea (OSA) is more common among patients with refractory epilepsy. Few studies have compared subjective sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and those with medically controlled epilepsy. Therefore, this study aimed to evaluate the differences in sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and patients with medically controlled epilepsy.

PATIENTS

This retrospective case-control study included 38 patients with refractory epilepsy and 96 patients with medically controlled epilepsy. Sleep parameters and indices of sleep-related breathing disorders were recorded by standard in-laboratory polysomnography. The scores from sleep questionnaires on sleep quality and daytime sleepiness were compared between the two groups.

RESULTS

Patients with refractory epilepsy versus medically controlled epilepsy had statistically significantly decreased rapid eye movement (REM) sleep (13.5 ± 6.1% vs. 16.2 ± 6.1%) and longer REM latency (152.2 ± 84.1 min vs. 117.2 ± 61.9 min). Further, no differences were found in the prevalence of sleep-related breathing disorders, subjective sleep quality, prevalence of daytime sleepiness, and quality of life. Although not statistically significant, patients with refractory epilepsy have a lower rate of OSA compared with those with medically controlled epilepsy (21.1% vs. 30.2%).

CONCLUSIONS

Patients with refractory epilepsy had more disrupted REM sleep regulation than those with medically controlled epilepsy. Although patients with epilepsy have a higher risk of OSA, in this study patients with refractory epilepsy were not susceptible to OSA.

Depression is a major determinant of sleep abnormalities in patients with epilepsy

ABSTRACT Introduction: We aimed to identify sleep disorders in patients with epilepsy and compare this group with a healthy population. We also analyzed the features of sleep disorders in patients with epilepsy to demonstrate the effect of seizures and seizure types on sleep. Methods: Our study assessed 43 patients with epilepsy and 53 age- and gender-matched healthy controls. The demographic and clinical data of all participants were recorded. The Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index (PSQI), International Restless Legs Syndrome Study Group Rating Scale, Berlin Questionnaire, and Beck Depression Inventory (BDI) were administered to all study subjects. The interview used to evaluate insomnia is based on the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition - DSM-5 diagnostic criteria. Results: Twenty-four patients (55.8%) and 26 controls (49.1%) are women. The mean age of patients and controls was 34.2±11.37 (16-71) and 34.6±11.28 (16-77), respectively. Patients with epilepsy had depression more often than controls, a result that was statistically significant (p<0.0001). We found no statistically significant difference between sleep parameters of patients and controls with normal BDI scores (p>0.05). Patients with depression had worse results on the Berlin Questionnaire and PSQI total score, with statistical significance (p=0.002). Nocturnal seizures, seizure type, and drug treatment had no effect on sleep (p>0.05). Conclusion: We concluded that depression rather than epilepsy negatively affects sleep, suggesting that all patients should be asked about their mood and sleep complaints.

Deep-Seated Interictal Epileptiform Activity: Another Reason to Lose Sleep

Sleep Disruption in Epilepsy: Ictal and Interictal Epileptic Activity Matter

Peter-Derex L, Klimes P, Latreille V, et al. Ann Neurol. 2020;88(5):907-920. doi:10.1002/ana.25884. PMID: 32833279.

Objective:

Disturbed sleep is common in epilepsy. The direct influence of nocturnal epileptic activity on sleep fragmentation remains poorly understood. Stereo-electroencephalography paired with polysomnography is the ideal tool to study this relationship. We investigated whether sleep-related epileptic activity is associated with sleep disruption.

Methods:

We visually marked sleep stages, arousals, seizures, and epileptic bursts in 36 patients with focal drug resistant epilepsy who underwent combined stereo-electroencephalography/polysomnography during presurgical evaluation. Epileptic spikes were detected automatically. Spike and burst indices (n/sec/channel) were computed across four 3-second time windows (baseline sleep, prearousal, arousal, and postarousal). Sleep stage and anatomic localization were tested as modulating factors. We assessed the intra-arousal dynamics of spikes and their relationship with the slow-wave component of nonrapid eye movement sleep (NR) arousals.

Results:

The vast majority of sleep-related seizures (82.4%; 76.5% asymptomatic) were followed by awakenings or arousals. The epileptic burst index increased significantly before arousals as compared to baseline and postarousal, irrespective of sleep stage or brain area. A similar prearousal increase was observed for the spike index in NR stage 2 and rapid eye movement sleep. In addition, the spike index increased during the arousal itself in neocortical channels and was strongly correlated with the slow-wave component of NR arousals (r = 0.99, P < .0001).

Interpretation:

Sleep fragmentation in focal drug-resistant epilepsy is associated with ictal and interictal epileptic activity. The increase in interictal epileptic activity before arousals suggests its participation in sleep disruption. An additional increase in the spike rate during arousals may result from a sleep–wake boundary instability, suggesting a bidirectional relationship.

[Sleep and wake disorders in epilepsy]

OBJECTIVE

To summarize published data on the prevalence, characteristics and diagnostic criteria of sleep disorders in epilepsy.

MATERIAL AND METHODS

A search of published articles was performed in Medline (Pubmed), Scopus, Web of Science and e-library databases.

RESULTS

Epidemiologic, clinical and diagnostic aspects of excessive daytime sleepiness, obstructive sleep apnea and central apnea, restless leg syndrome and parasomnias related to slow-wave and REM-sleep in patients with epilepsy were analyzed.

CONCLUSIONS

Further studies are needed to gain an insight into the complex associations of sleep disorders in epilepsy to optimize diagnostic and treatment approaches and to improve the quality of life in that patient population.

Course and impact of sleep disturbance in newly diagnosed epilepsy: A prospective registry study

OBJECTIVE

To determine the course of sleep distrurbance (insomnia symptoms and short sleep duration) after a diagnosis of epilepsy and their associations with seizure control, mood, disability, and quality of life.

PATIENTS AND METHODS

One hundred and sixty-nine adults were drawn from the Sydney Epilepsy Incidence Study to Measure Illness Consequences (SEISMIC), a prospective, multicenter, community-wide study in Sydney, Australia. Socio-demographic, psychosocial, clinical characteristics, and information on sleep disturbance were obtained early (median 48 [IQR15-113] days) after a diagnosis of epilepsy, and at 12 months. Logistic regression models were used to determine associations between patterns of sleep disturbance with outcomes at 12 months.

RESULTS

Insomnia symptoms and/or short sleep duration were present in 18-23% of participants at both time points, with over half (54-61%) showing a chronic pattern. There was no association of sleep disturbance pattern with recurrent seizures, medication use or disability. Chronic insomnia symptoms and short sleep duration were strongly associated with worse mental health (aOR 3.76, 95% CI 1.28-11.06; and aOR 5.41, 95% CI 1.86-15.79) and poorer quality of life at 12 months (aOR 3.02, 95% CI 1.03-8.84; and aOR 3.11, 95% CI 1.10-8.82), after adjusting for clinical features of epilepsy and comorbidity. Those whose sleep disturbance remitted had no adverse outcomes.

CONCLUSIONS

Insomnia symptoms and short sleep duration are less common in people with recently-diagnosed than chronic epilepsy. The temporal association with poor psycholosocial outcomes supports specific interventions addressing sleep disturbance.

Subjective and objective hypersomnia highly prevalent in adults with epilepsy

INTRODUCTION

Sleepiness is among the most common complaints of people with epilepsy, but objective documentation is lacking. We systematically investigated subjective and objective sleepiness in an observational cross-sectional cohort of adults with epilepsy (AWE).

METHODS

This is a prospective study of AWE consecutively recruited without foreknowledge of sleep/wake complaints. Polysomnography (PSG) with 18-channel electroencephalography (EEG) followed by multiple sleep latency testing (MSLT) was performed. Patients completed the Epworth Sleepiness Scale (ESS), a single-item question assessing excessive daytime sleepiness (EDS), and a 7-day sleep and seizure diary. Multivariable linear models were used to assess the association between MSLT mean sleep latency (MSL) and interests with adjustment of covariates of interest. Receiver operating characteristics (ROC) analysis was performed to evaluate the discrimination capability of ESS on MSL < 8 min and <5 min and investigate the optimal cutpoints.

RESULTS

Among 127 AWE (mean age: 38.7 ± 13.7 years), abnormal MSL (<8 min) was observed in 49.6% and MSL <5 min in 31.5%. While 78% reported feeling sleepy during the day on a single-item question, only 24% had elevated scores on the ESS (>10/24). The ESS score was associated with MSL even after adjusting for seizure frequency, antiseizure medication (ASM) standardized dose and number, age, gender, depression and insomnia symptom severity, and apnea-hypopnea index (HPI) and total sleep time on PSG (coefficients [95% confidence interval (CI)]: -0.26 [-0.48, -0.05], p = 0.018). The area under the curve (AUC) of the ESS ROC predicting MSL < 8 min and MSL < 5 min were similar: 0.62 (95%CI: 0.52-0.72) and 0.62 (95%CI: 0.51-0.74).

CONCLUSIONS

This is the largest prospective cross-sectional observational study to date using MSLT in AWE. We found subjective and objective daytime sleepiness highly prevalent in AWE and not explained by seizure frequency, ASM burden, symptoms of insomnia/depression, or PSG findings although those with MSL < 5 min were more likely to have obstructive sleep apnea (OSA). Pathologic sleepiness with MSL < 8 min was present in half of AWE. Nearly one-third of AWE unselected for sleep/wake complaints had MSL < 5 min, a range typical of narcolepsy.

Sex differences in factors associated with daytime sleepiness and insomnia symptoms in persons with epilepsy

Clinical factors associated with daytime sleepiness and insomnia in persons with epilepsy (PWE) were examined in this cross-sectional study of 126 participants (men, 50.8%). Excessive daytime sleepiness (EDS; score of ≥11 on the Epworth Sleepiness Scale (ESS)) was noted in 17.5% of participants (mean score, 6.1 ± 4.2), and moderate-to-severe insomnia (Insomnia Severity Index (ISI) scores of ≥15) was noted in 20.6% (mean score, 7.8 ± 6.4). Linear regression analyses revealed that ESS scores were independently associated with obstructive sleep apnea (OSA; snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, and gender (STOP-Bang) score of ≥3), an antiepileptic drug (AED) load of >3, depression (Patient Health Questionnaire-9 (PHQ-9) score of ≥10), female sex, and nocturnal seizures. Insomnia Severity Indices were independently associated with depression and anxiety (Generalized Anxiety Disorder-7 (GAD-7) score of ≥7). Notably, significant sex differences were found. Epworth Sleepiness Scale scores were associated with OSA in men but were associated with depression in women. In addition, anxiety was associated with insomnia in women only. Overall, OSA and depression were the most important significant clinical factors associated with daytime sleepiness and insomnia, respectively. However, there were sex differences for the associations between individual factors and sleep disturbances.

Group-based cognitive behavioral therapy program for improving poor sleep quality and quality of life in people with epilepsy: A pilot study

Sleep difficulties are commonly reported by patients with epilepsy and can have a detrimental impact on overall quality of life. The purpose of this pilot study was to assess the efficacy of a psychotherapeutic approach, namely Cognitive Behavioral Therapy for Insomnia (CBT-I), in improving sleep quality in patients with epilepsy. Twenty outpatients with epilepsy who reported poor sleep quality were randomized to either a control or CBT-I treatment group, which involved four group-based CBT-I sessions, delivered on a weekly basis. In addition to completing a range of standardized measures related to sleep quality and quality of life, participants also monitored their sleep with a self-completed sleep diary over a two-week period, on two separate occasions. Following CBT-I treatment, no between-group difference was found on any sleep or quality of life measure. However, both the treatment and control groups improved on measures of sleep quality, quality of life, sleep hygiene behaviors, and dysfunctional beliefs about sleep. These findings suggest that sleep monitoring alone may have the potential for prompting healthy behavior change in this clinical population.

Perampanel effect on sleep architecture in patients with epilepsy

PURPOSE

Among patients with epilepsy, sleep disturbances can worsen seizure control. This prospective open-label study determined the effect of the antiepileptic drug perampanel on sleep architecture in patients with refractory epilepsy.

METHODS

Adult patients with refractory epilepsy received add-on perampanel, starting at 2 mg/day at bedtime, increased by 2 mg after 2 weeks and then monthly until the target dose of 4-8 mg/day was reached. The median dose of perampanel used was 6 mg (SD 1.2). Polysomnographic (PSG) recordings were scheduled 1 week before starting perampanel and the control PSG after 12 weeks under perampanel treatment and at least 4 weeks on stable perampanel dose; patients completed the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI) questionnaires. The main endpoints were change from baseline in the ESS and PSQI scores, and PSG variables.

RESULTS

Of 25 patients included (aged 18-65 years, 56 % female) only 17 completed the study. Perampanel caused a modest decrease from baseline in mean ESS score (n = 13 patients; p = 0.126) and PSQI score (n = 12 patients; p = 0.127). Treatment significantly improved sleep parameters (n = 17 patients) including total sleep time (p = 0.037), sleep latency (p = 0.022), sleep efficiency (p = 0.015), sleep maintenance index (p = 0.005), wake time after sleep onset (p = 0.015), and duration of N3 sleep stage (p = 0.026). Patients with altered sleep efficiency parameters at baseline showed a significant increase in sleep maintenance index (p = 0.015), and 77.8 % achieved sleep efficiency >85 % (p = 0.016 vs baseline).

CONCLUSION

Perampanel improved sleep architecture in patients with focal refractory epilepsy without worsening daytime sleepiness.

Co-morbid sleep disorders and epilepsy: A narrative review and case examples

Co-morbid sleep disorders, including sleep apnea, insomnia, restless legs syndrome, and the parasomnias, occur frequently in people with epilepsy. This article reviews the cardinal presenting symptoms and diagnostic features of each of these disorders to enable epileptologists to readily screen and identify sleep co-morbidities in their patients. It summarizes current evidence concerning the reciprocal relationship between sleep disturbances and epilepsy and available treatment options for common sleep disorders in people with epilepsy. Several illustrative cases demonstrate the practical consequences of co-morbid sleep disorders in epilepsy patients and suggest diagnostic and treatment approaches that may improve daytime functioning, alertness, quality of life, and seizure burden.

Wake up to sleep: The effects of lacosamide on daytime sleepiness in adults with epilepsy

OBJECTIVE

The objective of the study was to investigate the effects of lacosamide (LCM) on daytime sleepiness ascertained by the Epworth Sleepiness Scale (ESS) in adults with focal epilepsy in a randomized, controlled design.

METHODS

Subjects taking ≤2 AEDs for ≥4weeks underwent polysomnography with EEG followed by the maintenance of wakefulness test (MWT) and completed the ESS and other patient-reported outcomes (PROs) at baseline, LCM 200mg/day, and LCM 400mg/day (Visit 4; V4). Primary endpoint was ESS change (V4 to baseline) between LCM and placebo. Noninferiority test on ESS used a one-sided t-test based on a hypothesized difference of 4-point change between groups. Superiority test used a two-sided t-test to investigate the difference in change in PROs and MWT mean sleep latency (MSL) between groups. Fifty-five subjects provided 80% power to show noninferiority of LCM assuming 10% dropout.

RESULTS

Fifty-two subjects (mean age: 43.5±13.2years, 69% female, median monthly seizure frequency: 1 [0, 4.0]) participated. Baseline group characteristics including age, sex, ethnicity, standardized AED dose, seizure frequency, and ESS were similar. Abnormal baseline ESS scores were found in 35% of subjects. Noninferiority test found a ≤4-point increase in ESS (mean [95% CI]) in LCM subjects vs. placebo (-1.2 [-2.9, 0.53] vs. -1.1 [-5.2, 3.0], p=0.027) at V4. No significant difference in change in PROs, MSL, seizure frequency, or AED standardized dose was observed between groups.

SIGNIFICANCE

Our interventional trial found that LCM is not a major contributor to daytime sleepiness based on subjective and objective measures. Inclusion of sleepiness measures in AED trials is warranted given the high prevalence of sleep-wake complaints in people with epilepsy.