Sleep-wake habits and disorders in a series of 100 adult epilepsy patients--a prospective study

The effects of Reiki application on sleep and quality of life in patients with epilepsy

BACKGROUND

Patients with epilepsy face sleep problems due to disease-related effects and antiepileptic drugs and as a result, their quality of life decreases. Reiki is an energy therapy and a non-invasive, low-cost treatment that has gained a place in complementary-integrative medicine practices.

AIM

The present study aimed to find out the effects of Reiki Application on sleep and quality of life in patients with epilepsy.

METHOD

A total of 60 patients with epilepsy, 30 in the intervention group and 30 in the control group, who met the research criteria and volunteered to participate were included in this randomized experimental study with a pre-test-post-test control group. "Patient Information Form", "Pittsburgh Sleep Quality Index (PSQI)" and "Quality of Life in Epilepsy (QOLIE-31) Scale" were used to collect the research data. Frequencies, percentages, arithmetic mean, standard deviations, Chi-Square Test, Independent Groups t-Test, Dependent Groups t-Test, and regression analysis were used in the evaluation of the study data.

RESULTS

After the Reiki Application, when compared with the patients in the control group, the patients in the intervention group had significantly reduced PSQI total (t = -5.636, p = 0.001), subjective sleep quality (t = -2.868, p = 0.006), sleep latency (t = -4.261, p = 0.001), sleep duration (t = -3.073, p = 0.003), habitual sleep efficiency (t = -2.669, p = 0.010), sleep disturbances (t = -3.664, p = 0.001), sleeping medications (t = -4.368, p = 0.001), daytime dysfunction (t = -3.472, p = 0.001) scores. It was also found that the patients in the intervention group had significantly higher QOILE-31 total (t = 3.750, p = 0.001), concerns about seizure (t = 3.212, p = 0.002), overall quality of life (t = 3.050, p = 0.003), emotional well-being (t = 2.557, p = 0.013), energy/fatigue (t = 2.835, p = 0.006), cognitive functioning (t = 2.308, p = 0.025), medication effects (t = 2.524, p = 0.014), and social functioning (t = 2.126, p = 0.038) mean scores.

CONCLUSION

Reiki Application was found to improve sleep quality and increase quality of life in patients with epilepsy. The results suggest that the use of Reiki Application should be generalized in addition to basic nursing care practices during the care and treatment of patients with epilepsy.

Global Prevalence of Sleep Bruxism and Awake Bruxism in Pediatric and Adult Populations: A Systematic Review and Meta-Analysis

Background/Objectives: The purpose of this systematic review was to assess the global prevalence of sleep bruxism and awake bruxism in pediatric and adult populations. Methods: This systematic review was conducted by analyzing studies published from 2003 to 2023. The following keyword combination was utilized: prevalence, epidemiology, population, and bruxism. The PubMed database was analyzed, supplemented by manual searches using the Google search. Additionally, the snowballing procedure method was applied. A double assessment of the quality of publications was carried out to preserve the highest possible quality of evidence (e.g., Joanna Briggs Institute critical appraisal checklist). Analyses were conducted using the R statistical language. Results: The global bruxism (sleep and awake) prevalence is 22.22%. The global sleep bruxism prevalence is 21% and awake prevalence is 23%. The occurrence of sleep bruxism, based on polysomnography, was estimated at 43%. The highest prevalence of sleep bruxism was observed in North America at 31%, followed by South America at 23%, Europe at 21%, and Asia at 19%. The prevalence of awake bruxism was highest in South America at 30%, followed by Asia at 25% and Europe at 18%. Conclusions: One in four individuals may experience awake bruxism. Bruxism is a significant factor among women. It was observed that age is a significant factor for the occurrence of sleep bruxism in women. Among the limitations of the study is the lack of analysis of the prevalence of bruxism in Africa and Australia due to not collecting an adequate sample for analysis. The study was registered in the Open Science Framework (10.17605/OSF.IO/ZE786).

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.

Differences in health-related quality of life and somatic symptoms in employed and unemployed patients with epilepsy

This study compared overall and specific aspects of health-related quality of life (HRQOL) and self-report of somatic, anxiety, and depressive symptoms between employed (n = 71) and unemployed (n = 48) patients with epilepsy (PWE). The Quality of Life in Epilepsy (QOLIE-89) and the Personality Assessment Inventory (PAI) were examined. The unemployed group reported significantly worse overall HRQOL including aspects of HRQOL related to epilepsy, physical health, mental health, and cognitive function. Among these four, physical health related HRQOL revealed the most difference between groups. While there were no differences between the groups in the level of social support and social isolation, the unemployed group reported worse social function with respect to work and driving. The unemployed group reported significantly greater somatic symptoms, but not anxiety and depressive symptoms. When specifically examining the subscales of the Somatic Concerns scale, conversion and health concerns, but not somatization, were greater in the unemployed group. Among the Depression subscales, the unemployed group reported greater physiologically manifested depressive symptoms. These findings suggest that along with optimizing seizure control, identifying and addressing presence of physical limitations, dysfunction, and somatic symptoms are also of importance in the care of PWE, particularly for those who are unemployed.

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.

Sleep and Epilepsy

The relationship between sleep and epilepsy is both intimate and bidirectional. The molecular mechanisms which control circadian rhythm and the sleep/wake cycle are dysregulated in epileptogenic tissue and are themselves effected by molecular pathways for epilepsy. Sleep affects the frequency of interictal epileptiform discharges and recent research has raised new questions regarding the impact of discharges on sleep function and cognition. Epileptiform discharges themselves affect sleep architecture and increase the risk of sleep disorders. Several sleep-related epilepsy syndromes have undergone changes in their classification which highlights their intimate relationship to sleep and novel screening tools have been developed to help clinicians better differentiate epileptic seizures from sleep-related paroxysmal events. Improving sleep and addressing sleep disorders has been associated with improved seizure control and increased well-being in people with epilepsy. These interactions are discussed in detail in this review.

Sleep Disturbances in Neurological Disease: A Target for Intervention

Sleep is a biological function required for neurological and general health, but a significant and under-recognized proportion of the population has disturbed sleep. Here, we briefly overview the biology of sleep, sleep requirements over the lifespan, and common sleep disorders. We then turn our attention to five neurological diseases that significantly contribute to global disease burden and neurology practice makeup: epilepsy, headache, ischemic stroke, Parkinson's disease, and Alzheimer's disease. For each disease, we review evidence that sleep disturbances contribute to disease risk and severity and discuss existing data that addressing sleep disturbances may have disease-modifying effects. We provide recommendations derived from the literature and existing clinical guidelines to facilitate the evaluation and management of sleep disturbances within the context of each neurological disease. Finally, we synthesize identified needs and commonalities into future directions for the field and practical sleep-related recommendations for physicians caring for patients at risk for or currently suffering from neurological disease.

Sleep in children with refractory epilepsy and epileptic encephalopathies: A systematic review of literature

Children with epilepsy have more sleep disorders compared to healthy children. The bidirectional interaction between epilepsy and sleep is not completely understood. However, disruption of sleep architecture during childhood may have consequences for cognitive development. As children with drug-refractory epilepsy often have intellectual disability, sleep disruption could be an important contributing factor in severity of their cognitive impairment. To better understand these interactions, sleep architecture in children with drug-refractory epilepsy and epileptic encephalopathies should be investigated. In this review, we conducted a systematic literature search on this topic. Articles that investigated sleep macro- and/or microstructure by means of electroencephalogram/polysomnography were included, as well as articles that used validated questionnaires. Sixteen articles were reviewed, eight of which used polysomnography. Only 2 articles examined sleep in children with epileptic encephalopathies. Consistent findings on measures of sleep architecture were a reduction in REM percentage and an increase in sleep fragmentation when comparing drug-refractory patients with non-refractory and healthy subjects. The findings on slow wave sleep were less clear. Studies with questionnaires unambiguously confirmed subjectively more sleep problems in children with drug-refractory epilepsy. This is the first review of literature in this patient population. More good quality sleep studies in children with drug-refractory epilepsy are warranted. The use of wearables in the home setting together with automatic sleep staging could provide more insights.

Sleep and Temporal Lobe Epilepsy – Associations, Mechanisms and Treatment Implications

In this systematic review, we aim to describe the association between temporal lobe epilepsy (TLE) and sleep, with bidirectional links in mechanisms and therapeutic aspects. Sleep stages may variably impact seizure occurrence, secondary generalization and the development, frequency and distribution of interictal epileptiform discharges. Conversely, epilepsy affects sleep micro- and macroarchitecture. TLE, the most frequent form of drug resistant epilepsy (DRE), shares an enduring relationship with sleep, with some intriguing potential mechanisms specific to anatomic localization, linking the two. Sleep characteristics of TLE may also inform localizing properties in persons with DRE, since seizures arising from the temporal lobe seem to be more common during wakefulness, compared to seizures of extratemporal origin. Polysomnographic studies indicate that persons with TLE may experience excessive daytime somnolence, disrupted sleep architecture, increased wake after sleep onset, frequent shifts in sleep stages, lower sleep efficiency, decreased rapid eye movement (REM) sleep, and possibly, increased incidence of sleep apnea. Limited literature suggests that effective epilepsy surgery may remedy many of these objective and subjective sleep-related concerns, via multipronged effects, apart from reduced seizure frequency. Additionally, sleep abnormalities also seem to influence memory, language and cognitive-executive function in both medically controlled and refractory TLE. Another aspect of the relationship pertains to anti-seizure medications (ASMs), which may contribute significantly to sleep characteristics and abnormalities in persons with TLE. Literature focused on specific aspects of TLE and sleep is limited, and heterogeneous. Future investigations are essential to understand the pathogenetic mechanisms linking sleep abnormalities on epilepsy outcomes in the important sub-population of TLE.

Evaluation of Sleep Disturbances in Patients with Nocturnal Epileptic Seizures in a Romanian Cross-Sectional Study

(1) Background: Based on the premise that epilepsy is frequently associated with hypnopathies, in this study we aim to analyze the prevalence of sleep disturbances among patients with epilepsy, with exclusively or predominantly nocturnal seizures, in relation to demographic factors as well as clinical and electroencephalography (EEG) aspects. (2) Methods: 69 patients with nocturnal epilepsy were included in our study. Sleep disturbances were measured with the Pittsburgh Sleep Quality Index (PSQI) questionnaire, followed by a long-term video-EEG monitoring during sleep. We analyzed the PSQI results in relation to patients' gender and age and determined the correlations between the PSQI scores and the modifications on video-EEG recordings, in comparison to a control group of 25 patients with epilepsy but without nocturnal seizures. (3) Results: We found a statistically significant difference between the PSQI of patients with nocturnal seizures compared to those without nocturnal epileptic manifestations. In the experimental group, the mean PSQI score was 7.36 ± 3.91 versus 5.04 ± 2.56 in controls. In women, the average PSQI score was 8.26, whilst in men it only reached 6.41, highlighting a statistically significant difference between genders (p ˂ 0.01). By examining the relationships between the PSQI scores and certain sleep-related factors, evidenced on the nocturnal video-EEG, we found a statistically significant difference between PSQI values of patients who reached the N2 stage, and those who reached the N3 stage of nonrapid eye movement (NREM) sleep, highlighting that those with a more superficial nocturnal sleep also had higher PSQI scores. There were no statistically significant differences regarding the PSQI scores between patients with or without interictal epileptiform discharges, and also in the few patients with nocturnal seizures where we captured ictal activity. (4) Conclusions: we evidenced in this study a poor quality of sleep in patients with nocturnal epilepsy, mostly in women, independent of age. We observed that sleep disturbances were due to superficial and fragmented sleep with frequent microarousals, not necessarily caused by the electrical epileptiform activity.

Electrical brain stimulation and continuous behavioral state tracking in ambulatory humans

Objective.Electrical deep brain stimulation (DBS) is an established treatment for patients with drug-resistant epilepsy. Sleep disorders are common in people with epilepsy, and DBS may actually further disturb normal sleep patterns and sleep quality. Novel implantable devices capable of DBS and streaming of continuous intracranial electroencephalography (iEEG) signals enable detailed assessments of therapy efficacy and tracking of sleep related comorbidities. Here, we investigate the feasibility of automated sleep classification using continuous iEEG data recorded from Papez's circuit in four patients with drug resistant mesial temporal lobe epilepsy using an investigational implantable sensing and stimulation device with electrodes implanted in bilateral hippocampus (HPC) and anterior nucleus of thalamus (ANT).Approach.The iEEG recorded from HPC is used to classify sleep during concurrent DBS targeting ANT. Simultaneous polysomnography (PSG) and sensing from HPC were used to train, validate and test an automated classifier for a range of ANT DBS frequencies: no stimulation, 2 Hz, 7 Hz, and high frequency (>100 Hz).Main results.We show that it is possible to build a patient specific automated sleep staging classifier using power in band features extracted from one HPC iEEG sensing channel. The patient specific classifiers performed well under all thalamic DBS frequencies with an average F1-score 0.894, and provided viable classification into awake and major sleep categories, rapid eye movement (REM) and non-REM. We retrospectively analyzed classification performance with gold-standard PSG annotations, and then prospectively deployed the classifier on chronic continuous iEEG data spanning multiple months to characterize sleep patterns in ambulatory patients living in their home environment.Significance.The ability to continuously track behavioral state and fully characterize sleep should prove useful for optimizing DBS for epilepsy and associated sleep, cognitive and mood comorbidities.

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.

Sleep Disruption Worsens Seizures: Neuroinflammation as a Potential Mechanistic Link

Sleep disturbances, such as insomnia, obstructive sleep apnea, and daytime sleepiness, are common in people diagnosed with epilepsy. These disturbances can be attributed to nocturnal seizures, psychosocial factors, and/or the use of anti-epileptic drugs with sleep-modifying side effects. Epilepsy patients with poor sleep quality have intensified seizure frequency and disease progression compared to their well-rested counterparts. A better understanding of the complex relationship between sleep and epilepsy is needed, since approximately 20% of seizures and more than 90% of sudden unexpected deaths in epilepsy occur during sleep. Emerging studies suggest that neuroinflammation, (e.g., the CNS immune response characterized by the change in expression of inflammatory mediators and glial activation) may be a potential link between sleep deprivation and seizures. Here, we review the mechanisms by which sleep deprivation induces neuroinflammation and propose that neuroinflammation synergizes with seizure activity to worsen neurodegeneration in the epileptic brain. Additionally, we highlight the relevance of sleep interventions, often overlooked by physicians, to manage seizures, prevent epilepsy-related mortality, and improve quality of life.

Associations between sleep bruxism and other sleep-related disorders in adults: a systematic review

OBJECTIVE

Systematic reviews on sleep bruxism (SB) as a comorbid condition of other sleep-related disorders are lacking. Such reviews would contribute to the insight of sleep clinicians into the occurrence of SB in patients with other sleep-related disorders, and into the underlying mechanisms of such comorbid associations. This systematic review aimed: 1. to determine the prevalence of SB in adults with other sleep-related disorders; and 2. to determine the associations between SB and other sleep-related disorders, and to explain the underlying mechanisms of these associations.

METHODS

A systematic search on SB and sleep-related disorders was performed in PubMed, Embase, Cochrane Library, and Web of Science to identify eligible studies published until May 15, 2020. Quality assessment was performed using the Risk of Bias Assessment tool for Non-randomized Studies.

RESULTS

Of the 1539 unique retrieved studies, 37 articles were included in this systematic review. The prevalence of SB in adult patients with obstructive sleep apnea, restless leg syndrome, periodic limb movement during sleep, sleep-related gastroesophageal reflux disease, REM behavior disorder (RBD), and sleep-related epilepsy was higher than that in the general population. The specific mechanisms behind these positive associations could not be identified.

CONCLUSIONS

SB is more prevalent in patients with the previously mentioned disorders than in the general population. Sleep arousal may be a common factor with which all the identified disorders are associated, except RBD and Parkinson's disease. The associations between SB and these identified sleep-related disorders call for more SB screening in patients with the abovementioned sleep-related disorders.

Measuring Sleep, Wakefulness, and Circadian Functions in Neurologic Disorders

Neurologic disorders impact the ability of the brain to regulate sleep, wake, and circadian functions, including state generation, components of state (such as rapid eye movement sleep muscle atonia, state transitions) and electroencephalographic microarchitecture. At its most extreme, extensive brain damage may even prevent differentiation of sleep stages from wakefulness (eg, status dissociatus). Given that comorbid sleep-wake-circadian disorders are common and can adversely impact the occurrence, evolution, and management of underlying neurologic conditions, new technologies for long-term monitoring of neurologic patients may potentially usher in new diagnostic strategies and optimization of clinical management.

Relationship Between Epilepsy and Dreaming: Current Knowledge, Hypotheses, and Perspectives

The interactions between epilepsy and sleep are numerous and the impact of epilepsy on cognition is well documented. Epilepsy is therefore likely to influence dreaming as one sleep-related cognitive activity. The frequency of dream recall is indeed decreased in patients with epilepsy, especially in those with primary generalized seizures. The content of dreams is also disturbed in epilepsy patients, being more negative and with more familiar settings. While several confounding factors (anti-seizure medications, depression and anxiety disorders, cognitive impairment) may partly account for these changes, some observations suggest an effect of seizures themselves on dreams. Indeed, the incorporation of seizure symptoms in dream content has been described, concomitant or not with a focal epileptic discharge during sleep, suggesting that epilepsy might directly or indirectly interfere with dreaming. These observations, together with current knowledge on dream neurophysiology and the links between epilepsy and sleep, suggest that epilepsy may impact not only wake- but also sleep-related cognition.

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.

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.

Regulation of microRNA Expression in Sleep Disorders in Patients with Epilepsy

The effects of epilepsy on sleep and the activating effects of sleep on seizures are well documented in the literature. To date, many sleep-related and awake-associated epilepsy syndromes have been described. The relationship between sleep and epilepsy has led to the recognition of polysomnographic testing as an important diagnostic tool in the diagnosis of epilepsy. The authors analyzed the available medical database in search of other markers that assess correlations between epilepsy and sleep. Studies pointing to microRNAs, whose abnormal expression may be common to epilepsy and sleep disorders, are promising. In recent years, the role of microRNAs in the pathogenesis of epilepsy and sleep disorders has been increasingly emphasized. MicroRNAs are a family of single-stranded, non-coding, endogenous regulatory molecules formed from double-stranded precursors. They are typically composed of 21–23 nucleotides, and their main role involves post-transcriptional downregulation of expression of numerous genes. Learning more about the role of microRNAs in the pathogenesis of sleep disorder epilepsy may result in its use as a biomarker in these disorders and application in therapy.

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.

Bidirectional relationships of sleep and epilepsy in adults with epilepsy

This targeted review addresses the best accepted and most intriguing recent observations on the complex relationships between sleep and epilepsy. Ten to 15% of all epilepsies are sleep-related. Included in these is sleep-related hypermotor epilepsy, renamed from nocturnal frontal lobe epilepsy by a 2016 consensus conference since 30% of cases are extra-frontal, seizures are related to sleep rather than clock time, and the predominant semiology is hypermotor. Stereo-EEG is providing crucial insights into network activation in sleep-related epilepsies and definition of the epileptogenic zone. Pathologic high-frequency oscillations, a promising biomarker for identifying the epileptogenic zone, are most frequent in NREM sleep, lowest in wakefulness and REM sleep, similar to interictal epileptiform discharges (IEDs). Most sleep-related seizures are followed by awakening or arousal and IEDs cause arousals and increase after arousals, likely contributing to sleep/wake complaints. Sleep/wake disorders are 2-3 times more common in adults with epilepsy than the general population; these comorbidities are associated with poorer quality of life and may impact seizure control. Treatment of sleep apnea reduces seizures in many cases. An emerging area of research is in circadian biology and epilepsy. Over 90% of people with epilepsy have seizures with circadian periodicity, in part related to sleep itself, and the majority of SUDEP cases occur in sleep. Recognizing these bidirectional relationships is important for patient and caregiver education and counseling and optimizing epilepsy outcomes.

Prevalence of sleep disorders in patients with epilepsy: A questionnaire-based cross-sectional study

BACKGROUND

Sleep disturbance is a frequent finding in patients with epilepsy. As evaluation of sleep disorders and quality of sleep in patients with epilepsy may provide better management of these patients, we aimed to assess the prevalence of common sleep disorders in patients with epilepsy.

METHODS

Patients with epilepsy referred to an outpatient epilepsy clinic in Tehran during one year were included. Validated Persian questionnaires were used by an interviewer to assess Excessive daytime sleepiness (EDS), Restless leg syndrome (RLS), and insomnia. Also, patients' demographic features and clinical seizure-related characteristics were recorded.

RESULTS

Seventy patients (35 males) aged between 18 and 75 were enrolled. Among patients, 61.4, 35.7, and 28.6% suffered from insomnia, EDS, and RLS, respectively (mild to severe). When considering seizure characteristics, there was no significant correlation between either seizure frequency or its type and the prevalence of sleep disturbance (although sleep disturbance was more common among patients with higher seizure frequency and patients with generalized seizure). Interestingly, age had a positive correlation with EDS.

CONCLUSION

This study showed that sleep disturbance is a common finding in patients with epilepsy, which may become severe in some cases. Taking this into consideration, we suggest that routine evaluation of sleep disorders may help physicians to boost patients' sleep quality.

Insomnia is less prevalent and less severe, independent of depressive symptoms, in patients with epilepsy treated with perampanel as an adjuvant

PURPOSE

The potential benefit of perampanel for sleep disturbances is unknown. This study determined whether insomnia is less prevalent and less severe in patients with epilepsy (PWE) who take perampanel as an adjuvant.

METHODS

This cross-sectional study was conducted in adults with epilepsy. Insomnia in patients treated or not treated with perampanel was diagnosed according to the criteria of the International Classification of Sleep Disorders, the third edition (ICSD-3) and the Insomnia Severity Index (ISI). Patients were also scored on the Epworth Sleepiness Scale (ESS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7), and the groups were compared by stepwise linear or logistic regression analyses.

RESULTS

One hundred and twenty-six PWE were included in the study: 31 patients (24.6%) were taking perampanel. Insomnia was diagnosed in 15.9% and 20.6% of all patients according to the ICSD-3 and an ISI score of ≥15, respectively. Agreement between the two diagnostic methods was moderate (Cohen's kappa, 0.470). In a stepwise logistic regression model, insomnia diagnosed by either method was negatively associated with perampanel use (P<0.05) but positively correlated with depressive symptoms, anxiety, and duration of epilepsy. In a stepwise linear regression model, ISI scores correlated negatively with perampanel use (P=0.004) but positively with depressive symptoms (P<0.001) and anxiety (P=0.001).

CONCLUSIONS

Insomnia is less prevalent and less severe in PWE treated with perampanel independent of depressive symptoms, which will be helpful for treating PWE and comorbid sleep disturbances.

[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.

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.

Sleep-related movement disorders in a population of patients with epilepsy: prevalence and impact of restless legs syndrome and sleep bruxism

STUDY OBJECTIVES

Sleep disorders are frequent co-occurrences in patients with epilepsy (PWE), but sleep-disordered breathing and insomnia are better studied than others. Our aim was to study sleep-related movement disorders in epilepsy.

METHODS

We interviewed 175 PWE (age range 18-71 years, mean 35.4 years, 47.4% female) and 130 controls (age range 18-72 years, mean 33.6 years, 47.7% females). Restless legs syndrome (RLS) and sleep bruxism (SB) were diagnosed by International RLS Study Group's diagnostic criteria and International Classification of Sleep Disorders, Third Edition criteria respectively. We also used Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS) and Berlin Questionnaire (BQ).

RESULTS

Our findings suggest that RLS and SB are encountered more frequently in PWE than controls: 20.6% versus 6.1% for RLS, and 23.7% versus 5.4% for SB (P < .05). Insomnia was more prevalent in epilepsy (46.2% versus 24.6%, P < .05) while poor sleep hygiene occurred more frequently in controls (28.3% versus 53.8%), (P < .05). PWE had poorer sleep by PSQI 61.7% versus 41.5% (P < .05). Sleepiness (38.7% versus 39.2%) and snoring (42.8% versus 40.8%) were equally distributed in both groups, also ESS and BQ not showing significant differences (P > .05).

CONCLUSIONS

Our study demonstrates that sleep disorders comprise important part of epilepsy comorbidity. We demonstrated that unselected PWE had higher prevalence of RLS. For the first time we show higher prevalence of sleep bruxism in epilepsy population. Also complaints of insomnia are seen more in PWE, while snoring and poor sleep hygiene not.

Insomnia symptoms and obesity are associated with aggression independent of depression in patients with epilepsy

PURPOSE

There has been little research conducted into aggression in persons with epilepsy (PWE). We determine whether sleep disturbances and obesity are associated with aggression in PWE independent of psychological distress.

METHODS

This was a cross-sectional study. The Aggression Questionnaire (AQ-K), the Insomnia Severity Index (ISI), the Epworth Sleepiness Scale (ESS), the Patient Health Questionnaire-9 (PHQ-9), and the Generalized Anxiety Disorder-7 (GAD-7) were utilized in the study. A stepwise linear regression analysis was used.

RESULTS

A total of 104 participants (49% men) were included. Mean AQ-K score was 51.4 (SD 12.6). PHQ-9 scores ≥10 and GAD-7 scores ≥7 were noted in 26.9% and 24.0% of participants, respectively. In a stepwise linear regression model, AQ-K scores were positively associated with PHQ-9 scores ≥10 (p = 0.002), ISI scores (p = 0.007), body mass index (BMI) (p = 0.001), and composite scores of epilepsy severity (p = 0.013). This model explained 46.6% of the variance in the AQ-K. In the subscale analyses, different variables were identified as independent factors associated with different subscales of the AQ-K. For example, physical aggression was related to a PHQ-9 score ≥10, men, and perampanel usage, whereas hostility was related to a GAD-7 score ≥7, polytherapy, and BMI.

CONCLUSIONS

Insomnia symptoms and obesity were related to overall aggressive behavior in PWE independent of depressive symptoms. The individual subscales of the AQ were correlated differently with the various factors including male sex, obesity, depressive symptoms, anxiety, insomnia symptoms, epilepsy severity, polytherapy, and the use of perampanel.

Sleepwalking and Sleep Paralysis: Prevalence in Colombian Families With Genetic Generalized Epilepsy

BACKGROUND

Sleep deprivation commonly increases seizure frequency in patients with genetic generalized epilepsy, though it is unknown whether there is an increased prevalence of sleepwalking or sleep paralysis in genetic generalized epilepsy patients. Establishing this could provide insights into the bio-mechanisms or genetic architecture of both disorders. The aim of this study was to determine the prevalence of sleepwalking and sleep paralysis in a cohort of patients with genetic generalized epilepsy and their relatives in extended families.

METHODS

A structured interview based on International League Against Epilepsy (ILAE) and International Classification of Sleep Disorders (ICSD-3) criteria was applied to 67 index cases and their relatives to determine genetic generalized epilepsy subtypes and assess the occurrence of sleepwalking or sleep paralysis. Bivariate analysis was performed using chi-square and Fisher exact tests.

RESULTS

The prevalence of sleepwalking and sleep paralysis was 15.3% (95% confidence interval 12.1-18.9) and 11.7% (95% confidence interval 8.7-15.3), respectively. Unusually, no sleepwalkers were found among individuals displaying epilepsy with generalized tonic-clonic seizures. Approximately a quarter of the patients had either parasomnia or genetic generalized epilepsy. Over half the genetic generalized epilepsy families had at least 1 individual with sleepwalking, and more than 40% of the families had one individual with sleep paralysis.

CONCLUSION

The prevalence of sleepwalking or sleep paralysis is reported for individuals with genetic generalized epilepsy and their relatives. The co-existence of either parasomnia in the genetic generalized epilepsy patients and the co-aggregation within their families let suggest that shared heritability and pathophysiological mechanisms exist between these disorders. We hypothesize that sleepwalking/sleep paralysis and genetic generalized epilepsy could be variable expression of genes in shared pathways.

Evaluation of sleep quality in spouses of people with epilepsy

OBJECTIVE

The objective of this study was to evaluate the spouses of people with epilepsy with and without a history of seizures during sleep in terms of depression, anxiety, and sleep quality.

METHODS AND MATERIALS

This prospective, cross-sectional study was conducted in three groups of 18-55 year olds, who were at least primary school graduates. The 1st group consisted of healthy spouses of 30 healthy volunteers with age and sex matched with the other groups. The 2nd group comprised spouses of 30 people with epilepsy who had been married for at least one year and had no history of seizures during sleep. The 3rd group consisted of spouses of 30 people with epilepsy who had been married for at least one year and had a history of at least one seizure during sleep in the course of the previous year. The questionnaire including demographic data, Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI) was applied to all participants.

RESULTS

The mean age of the 1st group was 35.07 ± 8.33 years, that of the 2nd group was 36.47 ± 7.63 years, and that of the 3rd group was 35.33 ± 6.05 years. There was no significant age difference between the groups (p = 0.740). The depression scores of the 2nd and the 3rd groups were significantly higher than that of the 1st group (p < 0.001, for both). The anxiety scores of the 3rd group were significantly higher than those of the 1st and the 2nd groups (p < 0.001 and p = 0.001, respectively). Thirty percent (n = 9) of the 1st group, 40% (n = 12) of the 2nd group, and 70% (n = 21) of the 3rd group had poor sleep quality. The sleep disorder rate in the 3rd group was significantly higher than in the 1st and the 2nd groups (p = 0.002 and p = 0.020, respectively). When the PSQI subscales were examined, the sleep quality, sleep latency, usual sleep efficiency, daytime dysfunction, and the total sleep total score were significantly higher in the 3rd group than the 1st and the 2nd groups. The patients in the third group had significantly higher scores of sleep duration, sleep disturbance, and sleep medication use than those in the 1st group.

CONCLUSION

We found out that the PSQI score, which reflected the sleep quality, was poor in the spouses of people with epilepsy, who had seizures during sleep. To the best of our knowledge, these findings are the first in the literature on this subject.

Factors contributing to excessive daytime sleepiness in Korean adults with epilepsy: A sleep questionnaire-based study

OBJECTIVES

We determined factors contributing to excessive daytime sleepiness (EDS) in Korean adults with epilepsy (AWE).

METHODS

A total of 147 AWE who had been treated for >1 year were included. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Subjective sleep disturbances were assessed with the Sleep Apnea of Sleep Disorder Questionnaire (SA-SDQ) and questionnaires about insomnia and restless legs syndrome (RLS). The Hospital Anxiety and Depression Scale (HADS) was also used. An ESS score >10 was considered indicative of EDS. Multivariate logistic regression analyses using the backward elimination method were performed for variables with a p < 0.10 on univariate analysis.

RESULTS

The mean ESS score was 6.8 (standard deviation [SD]: 4.4). Among the 147 subjects, 36 (24.5%) had EDS. Multivariate logistic regression analysis showed that being employed (odds ratio [OR]: 4.469, p < 0.01), the presence of at least one sleep disturbance (OR: 3.626, p < 0.01), and antiepileptic drug (AED) polytherapy (OR: 2.663, p < 0.05) were independently associated with EDS in the overall group of AWE. In contrast, being employed (p < 0.05) and higher Hospital Anxiety and Depression Scale-Anxiety subscale (HADS-A) scores (p < 0.05) in a model for men with epilepsy, as well as having at least one sleep disturbance (p < 0.05) in a model for women with epilepsy, were identified as independent factors for EDS.

CONCLUSIONS

Excessive daytime sleepiness in AWE may have a multifactorial origin. Being employed, subjective sleep disturbances, and AED polytherapy are independent predictors of EDS. There may be sex differences in factors associated with EDS.

Value of combined video EEG and polysomnography in clinical management of children with epilepsy and daytime or nocturnal spells

PURPOSE

Sleep disorders are common in epilepsy. Additionally, events of staring, jerking, or nocturnal behaviors are common presentations in neurology or sleep practice. Moreover, sleepiness and nocturnal awakenings are common symptoms in children with epilepsy and differentiation form ongoing seizures and sleep disorders is needed. However, limited data exist for the best evaluation methods. This study evaluated the usefulness of combined video electroencephalography (EEG) and polysomnography (PSG) studies (vEEG/PSG).

METHODS

Polysomnography custom database was searched for combined vEEG/PSG studies, performed from July 2010 to April 2014, which identified 240 studies. From chart review, data were collected for presenting symptoms, sleep disorder and epilepsy/neurology diagnoses, and EEG and PSG results.

RESULTS

Most common indications for performing combined vEEG/PSG were correlating sleep events with seizure occurrence, evaluating sleepiness, nocturnal awakenings and nocturnal events. Sleep physician evaluation and/or PSG were abnormal in 94% of the studies. The EEG was abnormal in 53% and events or seizures were recorded in 40% of the studies. Hence, vEEG/PSG addressed the diagnostic questions. Additionally, as compared to children with epilepsy, a significantly larger number of children with spells/parasomnia had a normal sleep evaluation including a normal PSG (9 Vs 37%, p = 0.00003).

CONCLUSIONS

This study demonstrates that combined video EEG and polysomnography is useful in addressing the common management questions in children with epilepsy and suspicious nocturnal events. Additionally, sleep disorders are more common in children with epilepsy than parasomnia. Hence sleep evaluation is important in children with epilepsy. Further prospective studies are needed.

Sleep-disordered breathing, neuroendocrine function, and clinical SUDEP risk in patients with epilepsy

INTRODUCTION

Sudden unexpected death in epilepsy (SUDEP) is a major contributor to epilepsy-related mortality. It is associated with nocturnal seizures and centrally mediated postictal cardiorespiratory dysfunction (CRD), but mechanisms and contributors remain poorly understood.

METHODS

We performed a prospective, cross-sectional, observational pilot study in the Columbia University Medical Center (CUMC) adult epilepsy monitoring unit (EMU) to explore relationships between periictal CRD, sleep-disordered breathing (SDB), neuroendocrine function, and clinical SUDEP risk. Thirty patients (twenty women, ten men) underwent video-electroencephalogram (EEG) with electrocardiogram (EKG) and digital pulse oximetry, inpatient or outpatient polysomnography (PSG), and comprehensive laboratory evaluation of sex steroid hormones. Sudden unexpected death in epilepsy risk was defined as Low (0-2) or High (≥3) using the revised SUDEP-7 Inventory. Sleep-disordered breathing was defined using standard criteria. Neuroendocrine dysfunction was defined as ≥1 laboratory abnormality.

RESULTS

Cardiorespiratory dysfunction occurred more frequently in high-risk patients (60% vs. 27%, p = 0.018). Endocrine dysfunction was seen in 35% of patients, more in men (p = 0.018). Sleep-disordered breathing was found in 88% of fully scoreable PSGs.

CONCLUSIONS

There was no significant relationship between CRD, SDB, and neuroendocrine status, though all PSGs in those with high SUDEP risk or neuroendocrine dysfunction revealed SDB. Larger studies are needed to further elucidate relationships between CRD, SDB, neuroendocrine factors, and SUDEP.

Changes in sleep patterns after vagus nerve stimulation, deep brain stimulation or epilepsy surgery: Systematic review of the literature

PURPOSE

Perform a systematic review of the literature on the effects of vagus nerve stimulation (VNS), deep brain stimulation (DBS) and epilepsy surgery in subjective and objective sleep parameters.

METHODS

We performed a literature search in the main medical databases: Medline, Embase, Cochrane, DARE and LILACS, looking for studies that evaluated the effects of VNS, DBS or epilepsy surgery on sleep parameters. In all, 36 studies, coming from 11 countries, including reviews, cohort studies, case series and case reports were included.

RESULTS

VNS induces sleep apnoea dependent of the stimulation variables. This condition can be reverted modifying these settings. Surgical procedures for epilepsy cause an improvement in objective and subjective sleep parameters that depend on the success of the procedure evaluated through ictal frequency control. There is evidence that non-pharmacologic treatment of epilepsy has different effects on sleep patterns.

CONCLUSION

It is advisable to include objective and subjective sleep parameters in the initial evaluation and follow-up of patients considered for invasive procedures for epilepsy control, especially with VNS due to the risk of sleep apnoea. More high quality studies are needed.

[An effect of epilepsy on sleep structure]

In this review, the authors discuss the problem of management of the patient with epilepsy with regard an impact of epileptic seizures and syndromes on sleep structure. Sleep disorders can lead to worsening of seizure control and general medical condition of the patients. However, seizures themselves and types of epilepsy can affect the sleep architecture. One of the most frequent symptoms of disordered sleep in epilepsy patients is excessive daytime sleepiness, which can be a consequence of poor sleep quality due to frequent nocturnal seizures or excessive interictal epileptiform activity during sleep leading to frequent arousals. is frequently referred to antiepileptic drug side effects. In patients with frontal and temporal lobe epilepsies, which are more associated with sleep, the sleep architecture is significantly different from healthy individuals. They have more frequent arousals, disturbed relationship between sleep phases and stages, in particular inhibited REM-sleep phase. Most recent data on this problem are reviewed. Sleep patterns for different major epileptic syndromes are presented and some general recommendations for patient management, with a special consideration of sleep issues, are given.