Objectively measured sleep-wake patterns in patients with drug-resistant epilepsy - Interaction with quality of life and antiepileptic treatment

Caregiver-reported outcomes with real-world use of cannabidiol in Lennox-Gastaut syndrome and Dravet syndrome from the BECOME survey

PURPOSE

Plant-derived highly purified cannabidiol (CBD) reduced the frequency of seizures associated with Lennox-Gastaut syndrome (LGS) and Dravet syndrome (DS) and improved the overall condition of patients in placebo-controlled phase 3 clinical trials. Anecdotal reports also suggest a positive effect on nonseizure outcomes. In this study, we aimed to identify, through a caregiver survey which nonseizure outcomes were most likely to change in these patients.

METHODS

The BEhavior, COgnition, and More with Epidiolex® (BECOME) was a 20-minute, cross-sectional, online survey that was developed with extensive input from caregivers, healthcare professionals, and epilepsy researchers, and was based on questions from validated measures and previously published caregiver reports. US-based caregivers (from Jazz Pharmaceuticals patient/caregiver database) of people with LGS or DS who were treated with CBD (Epidiolex®, 100 mg/mL oral solution) for ≥3 months were asked to compare the past month to the period before CBD initiation and rate their impression of changes using symmetrical Likert scales.

RESULTS

A total of 498 caregivers (97% parents) of patients with LGS (80%) or DS (20%) completed the survey. Mean (range) age of patients was 16 (1-73) years, and 52% were male. Patients were taking a median CBD dose of 14 mg/kg/d and median 4 concomitant antiseizure medications. A large proportion of respondents reported improvements in ≥1 survey question for all nonseizure-related domains: alertness, cognition, and executive function (85%); emotional functioning (82%); language and communication (79% in nonverbal patients and 74% in verbal); activities of daily living (51%); sleep (51%); and physical functioning (46%). Respondents reported improvements in seizure-related domains, including overall seizure frequency (85%), overall seizure severity (76%), seizure-free days per week for ≥1 seizure type (67%), and seizure freedom during the past month (16%). The majority of respondents who reported reduction in seizure frequency also reported improvements in nonseizure outcomes domains (51-80%). However, improvements in nonseizure outcomes (18-56%) were also reported in patients who either had no change or worsening of seizure frequency.

CONCLUSIONS

This survey characterized and quantified caregiver impression of changes in the seizure and nonseizure outcomes in patients taking add-on CBD treatment. Overall, 93% of caregivers reported planning to continue CBD treatment, primarily because of reduced seizure burden but also because of improvements in nonseizure-related outcomes. Despite the limitations that are associated with a retrospective survey-based study design, these results support further evaluation of the effect of CBD treatment on nonseizure outcomes among patients with LGS or DS.

Long time polysomnographic sleep and breathing evaluations in children with CDKL5 deficiency disorder

STUDY OBJECTIVES

CDKL5 deficiency disorder (CDD) is a rare developmental and epileptic encephalopathy, developing in the first months of life, caused by a mutation in the cyclin-dependent kinase-like 5 (CDKL5) gene. Children with CDD often have sleep (90%) and breathing disorders in wake (50%). Sleep disorders may have a significant impact emotional wellbeing and quality of life of caregivers of children with CDD and are challenging to treat. The outcomes of these features are unknown in children with CDD.

METHODS

We retrospectively evaluated sleep and respiratory function changes over 5-10 years in a small cohort of Dutch children with CDD, using video-EEG and/or polysomnography (3 × 24 h) and a parental questionnaire, the Sleep Disturbance Scale for Children (SDSC). The present study is a follow-up sleep and PSG study to evaluate if sleep and breathing disturbances persist in children with CDD previously studied.

RESULTS

Sleep disturbances persisted during the study period (5.5-10 years). All five individuals had long sleep latency (SL, range 32-174.5 min) and frequent arousals and awakenings (14-50/night), unrelated to apneas/seizures, corresponding to the SDSC findings. Low sleep efficiency (SE, 41-80%) was present and did not improve. In our participants, total sleep time (TST, 3h52min-7h52min) was short and remained so. Time in bed (TIB) was typical for children aged 2-8 years, but did not adjust with ageing. Low duration (4.8-17.4%) or even absent REM sleep persisted over time. No sleep apneas were noted. Central apneas due to episodic hyperventilation were reported during wakefulness in two of the five.

CONCLUSION

Sleep disturbances were present and persisted in all. The decreased REM sleep and sporadic breathing disturbances in wake may indicate failure of brainstem nuclei. Sleep disturbances can severely affect the emotional wellbeing and quality of life of the caregivers and the individuals with CDD and are challenging to treat. Hopefully our polysomnographic sleep data contribute to find the optimal treatment of the sleep problems in CDD patients.

Circannual incidence of seizure evacuations from the Canadian Arctic

OBJECTIVES

Emerging evidence suggests that circadian rhythms affect seizure propensity in addition to, and possibly independent of, sleep-wake states. Subject to extreme seasonal changes in light and dark, the northerly Arctic can serve as a "natural experiment" to assess the real-life impact of environmental influences on seizure severity. Therefore, we evaluated the timing of seizure evacuations over 11.25 years in a well-defined region of the Canadian Arctic.

METHODS

Retrospective review of EEG database and patient records at the single "bottleneck" hospital to which all patients from the Kivalliq Region in Nunavut, Canada are evacuated for seizure emergencies. We calculated the mean resultant length (MRL) of circular data for circannual analysis, and conducted Rayleigh's test to assess for a statistical departure from circular uniformity.

RESULTS

Screening 40,392 EEGs, we found 117 medical evacuations from 99 distinct individuals from September 2009 to November 2020. Most evacuations occurred month-wise in May (19%); week-wise within a 7-day period in February (5%), June (5%), or November (5%); and day-wise within a 24-hour period in June (3%) or November (3%). Maximal MRL clustering occurred in April no matter if analyzed by day (0.16333, p = 0.04), week (0.16296, p = 0.04), or month (0.1736, p = 0.03).

CONCLUSIONS

A relative circannual increase in seizure evacuations between the winter and summer solstices may be related to increasing sleep loss when day length grows. Fewer evacuations between the summer and winter solstices may be related to decreased daylight and "catching up" on sleep when night length grows. Additional factors likely also play a role in circannual variation of seizure evacuations in the Arctic, which warrants further research.

More than sleep and wake disturbances: An actigraphic study showing the sleep-wake pattern dysregulation in epilepsy

OBJECTIVE

This study aimed to assess the sleep-wake pattern in patients with epilepsy compared to controls.

METHODS

Patients with epilepsy and controls underwent a 14-day actigraphic recording to evaluate the rest-activity cycle. A sleep medicine interview was performed to exclude conditions interfering with the sleep-wake cycle in both patients and controls. Patients presenting seizures during the actigraphic recording were excluded. Daytime activity, nocturnal sleep, and non-parametric circadian rhythm activity (NPCRA) were analysed.

RESULTS

Twenty-two patients (mean age 49.5 ± 19.84 years; 50% female) and 17 controls were included. Patients showed lower sleep efficiency and longer sleep latency than controls. NPCRA analysis showed lower inter-daily stability and higher intra-daily variability in patients, who also presented lower daytime activity and a longer central phase measure (CPM) than controls.

CONCLUSIONS

Patients showed a significant alteration of the sleep-wake pattern, featured by lower synchronization and higher fragmentation of the rest-activity rhythm. Moreover, patients showed a delayed CPM compared with controls, corresponding to an evening chronotype tendency. Nocturnal sleep alteration and lower daytime activity were also evident. Therefore, patients with epilepsy present an alteration of the sleep-wake pattern and clinicians should increase their awareness about circadian rhythmicity dysregulation in epilepsy.

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.

Expert Opinion: Managing sleep disturbances in people with epilepsy

Poor sleep and daytime sleepiness are common in people with epilepsy. Sleep disorders can disrupt seizure control and in turn sleep and vigilance problems can be exacerbated by seizures and by antiepileptic treatments. Nevertheless, these aspects are frequently overlooked in clinical practice and a clear agreement on the evidence-based guidelines for managing common sleep disorders in people with epilepsy is lacking. Recently, recommendations to standardize the diagnostic pathway for evaluating patients with sleep-related epilepsies and comorbid sleep disorders have been presented. To build on these, we adopted the Delphi method to establish a consensus within a group of experts and we provide practical recommendations for identifying and managing poor night-time sleep and daytime sleepiness in people with epilepsy. We recommend that a comprehensive clinical history of sleep habits and sleep hygiene should be always obtained from all people with epilepsy and their bed partners. A psychoeducational approach to inform patients about habits or practices that may negatively influence their sleep or their vigilance levels should be used, and strategies for avoiding these should be applied. In case of a suspected comorbid sleep disorder an appropriate diagnostic investigation should be performed. Moreover, the possible presence of sleep fragmentation induced by sleep-related seizures should be ruled out. Finally, the dose and timing of antiepileptic medications and other co-medications should be optimized to improve nocturnal sleep and avoid daytime sedation.

The Quality of Life in Patients with Epilepsy in the Context of Sleep Problems and Sexual Satisfaction

Epilepsy influences the quality of patient functioning in almost all aspects of life. This study aimed to assess the quality of difficulties with sleep initiation and those concerning sexual function, and to assess whether sleep disorders are associated with selected aspects of sexual function and quality of life. The study involved completing a quality-of-life questionnaire for persons with epilepsy: a QOLIE-31 questionnaire, and the present authors' questionnaire, including 20 questions. A total of 170 questionnaires were completed by 89 men and 81 women. Sleep problems of various frequency were reported by 98 participants (57.6%). Only 41% of patients were definitely satisfied with their sex life. The respondents who declared dissatisfaction with their sex life more often reported difficulties with sleep initiation (χ2 = 10.20; p ≤ 0.001). Moreover, those who claimed that epilepsy might contribute to sex life problems more commonly declared dissatisfaction with their sex life (χ2 = 20.01; p ≤ 0.001) and more frequently, reported difficulties with sleep initiation (χ2 = 6.30; p ≤ 0.012). The issues should constitute the constant element of medical history taking, as improvement in these areas of functioning may promote better quality of life in patients with epilepsy.