Effect of antiepileptic drugs on sleep

Irrational Use of Medications among Adults with Insomnia: An Observational Study at a Sleep Clinic in Mexico

BACKGROUND

To determine the patterns of irrational use of medications among a sample of adult patients with insomnia.

METHODS

We included 89 adult patients diagnosed with chronic insomnia who had consumed medications for this disorder during the 12 months prior to admission to a specialized Sleep Disorders Clinic (SDC) in Mexico City. With a 13-item survey, information was gathered on patterns of medication use and irrational use, considering therapeutic indications, dose, route of administration, and duration of treatment.

RESULTS

The participants had taken hypnotics (65%), antidepressants (21%), anticonvulsants (8%), and antipsychotics (6%), and 92% had irrational use of their medication. Irrational use was greatest with benzodiazepines and antipsychotics. There were two main types of irrational use: (1) 47% of participants had consumed a drug unsuitable for their condition, although it was almost always prescribed by a doctor, and (2) 43% had consumed a drug for longer than the maximum time recommended.

CONCLUSION

It is worrisome to find that the irrational use of medications to treat insomnia, especially benzodiazepines and antipsychotics is widespread. Although most participants had acquired their medication by prescription, for many the drug was inappropriate to treat their condition. It should be mandatory that patients with insomnia receive specialized medical attention in primary clinical care.

Effect of melatonin on sleep quality and EEG features in childhood epilepsy: a possible non-conventional treatment

Background

Sleep and epilepsy are characterized by a bidirectional relationship. Indeed, epilepsy predisposes to the development of sleep disorders, while sleep deprivation may exacerbate epilepsy. In addition, antiseizure medication can disrupt normal sleep architecture. Therefore, adequate sleep hygiene could lead to improvement in seizure control. The present study aimed to evaluate the effect of melatonin on seizure frequency, EEG tracing, and sleep in children with focal idiopathic epilepsy.

Methods

This observation study evaluated the effect of 4 mg oral melatonin in ameliorating sleep-wake cycle, seizure frequency, and EEG features in children with focal idiopathic epilepsy of infancy. Twenty children were enrolled from September 2020 to August 2021. The study consisted of serial controls at enrollment (t0), at 3 months (t1), and at 6 months (t2) including neurological examination, questionnaire about sleep disturbances (CSHQ), and EEG.

Results

A significant improvement in sleep quality and daytime sleepiness was observed after melatonin supplementation. Furthermore, we observed a noteworthy improvement in EEG tracing at t2 that exhibited a significant correlation with improvements in CSHQ scores.

Conclusion

The studies conducted so far to evaluate the effect of melatonin in persons with epilepsy do not lead to definitive conclusions. Despite the small population sample and the study design, we report sleep and EEG improvement after melatonin administration in our cohort. Larger studies are needed to further study the neuroprotective and anticonvulsant properties of melatonin.

The broad-spectrum activity of perampanel: state of the art and future perspective of AMPA antagonism beyond epilepsy

Glutamate is the brain's main excitatory neurotransmitter. Glutamatergic neurons primarily compose basic neuronal networks, especially in the cortex. An imbalance of excitatory and inhibitory activities may result in epilepsy or other neurological and psychiatric conditions. Among glutamate receptors, AMPA receptors are the predominant mediator of glutamate-induced excitatory neurotransmission and dictate synaptic efficiency and plasticity by their numbers and/or properties. Therefore, they appear to be a major drug target for modulating several brain functions. Perampanel (PER) is a highly selective, noncompetitive AMPA antagonist approved in several countries worldwide for treating different types of seizures in various epileptic conditions. However, recent data show that PER can potentially address many other conditions within epilepsy and beyond. From this perspective, this review aims to examine the new preclinical and clinical studies-especially those produced from 2017 onwards-on AMPA antagonism and PER in conditions such as mesial temporal lobe epilepsy, idiopathic and genetic generalized epilepsy, brain tumor-related epilepsy, status epilepticus, rare epileptic syndromes, stroke, sleep, epilepsy-related migraine, cognitive impairment, autism, dementia, and other neurodegenerative diseases, as well as provide suggestions on future research agenda aimed at probing the possibility of treating these conditions with PER and/or other AMPA receptor antagonists.

Sleep and seizure risk in epilepsy: bed and wake times are more important than sleep duration

Sleep duration, sleep deprivation and the sleep-wake cycle are thought to play an important role in the generation of epileptic activity and may also influence seizure risk. Hence, people diagnosed with epilepsy are commonly asked to maintain consistent sleep routines. However, emerging evidence paints a more nuanced picture of the relationship between seizures and sleep, with bidirectional effects between changes in sleep and seizure risk in addition to modulation by sleep stages and transitions between stages. We conducted a longitudinal study investigating sleep parameters and self-reported seizure occurrence in an ambulatory at-home setting using mobile and wearable monitoring. Sixty subjects wore a Fitbit smartwatch for at least 28 days while reporting their seizure activity in a mobile app. Multiple sleep features were investigated, including duration, oversleep and undersleep, and sleep onset and offset times. Sleep features in participants with epilepsy were compared to a large (n = 37 921) representative population of Fitbit users, each with 28 days of data. For participants with at least 10 seizure days (n = 34), sleep features were analysed for significant changes prior to seizure days. A total of 4956 reported seizures (mean = 83, standard deviation = 130) and 30 485 recorded sleep nights (mean = 508, standard deviation = 445) were included in the study. There was a trend for participants with epilepsy to sleep longer than the general population, although this difference was not significant. Just 5 of 34 participants showed a significant difference in sleep duration the night before seizure days compared to seizure-free days. However, 14 of 34 subjects showed significant differences between their sleep onset (bed) and/or offset (wake) times before seizure occurrence. In contrast to previous studies, the current study found undersleeping was associated with a marginal 2% decrease in seizure risk in the following 48 h (P < 0.01). Nocturnal seizures were associated with both significantly longer sleep durations and increased risk of a seizure occurring in the following 48 h. Overall, the presented results demonstrated that day-to-day changes in sleep duration had a minimal effect on reported seizures, while patient-specific changes in bed and wake times were more important for identifying seizure risk the following day. Nocturnal seizures were the only factor that significantly increased the risk of seizures in the following 48 h on a group level. Wearables can be used to identify these sleep-seizure relationships and guide clinical recommendations or improve seizure forecasting algorithms.

A meta-review of standard polysomnography parameters in Rett Syndrome

Rett Syndrome (RTT, OMIM 312750), a unique rare neurodevelopmental disorder, mostly affects females and causes severe multi-disabilities including poor sleep. This meta-analysis systematically reviewed the polysomnographic (PSG) data of individuals with RTT on both sleep macrostructure and sleep respiratory indexes and compared them to literature normative values. Studies were collected from PubMed, Web of Science, PsycINFO, Ebsco, Scopus, and Cochrane Library till 26 April 2022. Across 13 included studies, the 134 selected RTT cases were mostly females being MECP2 (n = 41) and CDKL5 (n = 4) positive. They were further stratified by gene, age, and clinical features. Findings of comparison with literature normative values suggested shorter total sleep time (TST) and sleep onset latency (SOL), twice as long wake after sleep onset (WASO) with lower sleep efficiency (SEI) in RTT, as well as increased non-rapid eye movement stage 3 (stage N3) and decreased rapid eye movement sleep. Based on limited data per stratifications, we found in RTT cases <5 years old lower stage N3, and in RTT cases >5 years old less WASO and more WASO in the epileptic strata. However, meta-results generated from studies designed with comparison groups only showed lower stage N1 in RTT than in healthy comparison, together with similar SEI and stage N3 to primary snoring subjects. For sleep respiratory indexes, severe disordered sleep breathing was confirmed across roughly all RTT strata. We are the first study to meta-analyze PSG data of subjects with RTT, illustrating shorter TST and aberrant sleep staging in RTT that may vary with age or the presence of epilepsy. Severe nocturnal hypoxemia with apneic events was also demonstrated. More studies are needed to explore and elucidate the pathophysiological mechanisms of these sleep findings in the future.

Sleep Disorders in Rett Syndrome and Rett-Related Disorders: A Narrative Review

Rett Syndrome (RTT) is a rare and severe X-linked developmental brain disorder that occurs primarily in females, with a ratio of 1:10.000. De novo mutations in the Methyl-CpG Binding protein 2 (MECP2) gene on the long arm of X chromosome are responsible for more than 95% cases of classical Rett. In the remaining cases (atypical Rett), other genes are involved such as the cyclin-dependent kinase-like 5 (CDKL5) and the forkhead box G1 (FOXG1). Duplications of the MECP2 locus cause MECP2 duplication syndrome (MDS) which concerns about 1% of male patients with intellectual disability. Sleep disorders are common in individuals with intellectual disability, while the prevalence in children is between 16 and 42%. Over 80% of individuals affected by RTT show sleep problems, with a higher prevalence in the first 7 years of life and some degree of variability in correlation to age and genotype. Abnormalities in circadian rhythm and loss of glutamate homeostasis play a key role in the development of these disorders. Sleep disorders, epilepsy, gastrointestinal problems characterize CDKL5 Deficiency Disorder (CDD). Sleep impairment is an area of overlap between RTT and MECP2 duplication syndrome along with epilepsy, regression and others. Sleep dysfunction and epilepsy are deeply linked. Sleep deprivation could be an aggravating factor of epilepsy and anti-comitial therapy could interfere in sleep structure. Epilepsy prevalence in atypical Rett syndrome with severe clinical phenotype is higher than in classical Rett syndrome. However, RTT present a significant lifetime risk of epilepsy too. Sleep disturbances impact on child's development and patients' families and the evidence for its management is still limited. The aim of this review is to analyze pathophysiology, clinical features, the impact on other comorbidities and the management of sleep disorders in Rett syndrome and Rett-related syndrome.

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.

Risk factors for dementia development, frailty, and mortality in older adults with epilepsy - A population-based analysis

OBJECTIVE

Although the prevalence of comorbid epilepsy and dementia is expected to increase, the impact is not well understood. Our objectives were to examine risk factors associated with incident dementia and the impact of frailty and dementia on mortality in older adults with epilepsy.

METHODS

The CALIBER scientific platform was used. People with incident epilepsy at or after age 65 were identified using Read codes and matched by age, sex, and general practitioner to a cohort without epilepsy (10:1). Baseline cohort characteristics were compared using conditional logistic regression models. Multivariate Cox proportional hazard regression models were used to examine the impact of frailty and dementia on mortality, and to assess risk factors for dementia development.

RESULTS

One thousand forty eight older adults with incident epilepsy were identified. The odds of having dementia at baseline were 7.39 [95% CI 5.21-10.50] times higher in older adults with epilepsy (n = 62, 5.92%) compared to older adults without epilepsy (n = 88, 0.86%). In the final multivariate Cox model (n = 326), age [HR: 1.20, 95% CI 1.09-1.32], Charlson comorbidity index score [HR: 1.26, 95% CI 1.10-1.44], and sleep disturbances [HR: 2.41, 95% CI 1.07-5.43] at baseline epilepsy diagnosis were significantly associated with an increased hazard of dementia development over the follow-up period. In a multivariate Cox model (n = 1047), age [HR: 1.07, 95% CI 1.03-1.11], baseline dementia [HR: 2.66, 95% CI 1.65-4.27] and baseline e-frailty index score [HR: 11.55, 95% CI 2.09-63.84] were significantly associated with a higher hazard of death among those with epilepsy. Female sex [HR: 0.77, 95% CI 0.59-0.99] was associated with a lower hazard of death.

SIGNIFICANCE

The odds of having dementia were higher in older adults with incident epilepsy. A higher comorbidity burden acts as a risk factor for dementia, while prevalent dementia and increasing frailty were associated with mortality.

Seizure likelihood varies with day-to-day variations in sleep duration in patients with refractory focal epilepsy: A longitudinal electroencephalography investigation

BACKGROUND

While the effects of prolonged sleep deprivation (≥24 h) on seizure occurrence has been thoroughly explored, little is known about the effects of day-to-day variations in the duration and quality of sleep on seizure probability. A better understanding of the interaction between sleep and seizures may help to improve seizure management.

METHODS

To explore how sleep and epileptic seizures are associated, we analysed continuous intracranial electroencephalography (EEG) recordings collected from 10 patients with refractory focal epilepsy undergoing ordinary life activities between 2010 and 2012 from three clinical centres (Austin Health, The Royal Melbourne Hospital, and St Vincent's Hospital of the Melbourne University Epilepsy Group). A total of 4340 days of sleep-wake data were analysed (average 434 days per patient). EEG data were sleep scored using a semi-automated machine learning approach into wake, stages one, two, and three non-rapid eye movement sleep, and rapid eye movement sleep categories.

FINDINGS

Seizure probability changes with day-to-day variations in sleep duration. Logistic regression models revealed that an increase in sleep duration, by 1·66 ± 0·52 h, lowered the odds of seizure by 27% in the following 48 h. Following a seizure, patients slept for longer durations and if a seizure occurred during sleep, then sleep quality was also reduced with increased time spent aroused from sleep and reduced rapid eye movement sleep.

INTERPRETATION

Our results suggest that day-to-day deviations from regular sleep duration correlates with changes in seizure probability. Sleeping longer, by 1·66 ± 0·52 h, may offer protective effects for patients with refractory focal epilepsy, reducing seizure risk. Furthermore, the occurrence of a seizure may disrupt sleep patterns by elongating sleep and, if the seizure occurs during sleep, reducing its quality.

Sleep profile and Polysomnography in patients with drug-resistant temporal lobe epilepsy (TLE) due to hippocampal sclerosis (HS) and the effect of epilepsy surgery on sleep-a prospective cohort study

OBJECTIVES

We analyzed changes in sleep profile and architecture of patients with drug-resistant TLE-HS using three validated sleep questionnaires- Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), NIMHANS Comprehensive Sleep Disorders, and polysomnography (PSG). We studied the effect of epilepsy surgery in a subset of patients.

METHODS

In this prospective observational cohort study, sleep profile of 40 patients with drug-resistant TLE-HS was compared to 40 healthy matched controls. Sleep architecture of 22 patients was studied by overnight PSG and compared to 22 matched controls. Sleep profile was reassessed in 20 patients after a minimum period of three months after epilepsy surgery.

RESULTS

The mean PSQI was higher among patients compared to controls(P=0.0004) while mean ESS showed no difference. NCSDQ showed fewer patients feeling refreshed after a night's sleep compared to controls (p=0.006). PSG revealed a higher time in bed (p=0.0001), longer total sleep time (p=0.006) and more time spent in NREM stage 1 (p=0.001) and stage 2 (p=0.005) while spending less time in stage 3 (p=0.039) among TLE patients. Sleep efficiency was worse in patients on ≥3 ASMs compared to those on 2 ASMs (p-0.044). There was no change in mean ESS (p=0.48) or PSQI (p=0.105) after surgery.

CONCLUSIONS

Patients with drug-resistant TLE-HS have an altered sleep profile and architecture. Patients on ≥3 ASMs have a lower sleep efficiency. Reassessment at short intervals after epilepsy surgery did not reveal significant changes in sleep profile.

Sleep disruption in children and adolescents with epilepsy: A systematic review and meta-analysis

This systematic review and meta-analysis aims to assess and quantify putative differences in sleep architecture, sleep efficiency, sleep timing and broadly-defined sleep difficulties between children with and without epilepsy. Databases were searched systematically, and studies identified in PubMed, EMBASE, PsychINFO and Medline. The meta-analysis included 19 studies comparing a total of 901 children with epilepsy to 1470 healthy children. Relative to healthy children, children with epilepsy experienced reduced sleep time, sleeping on average 34 mins less across self-report, actigraphy, 24-h video-EEG and polysomnography measures. They had more sleep difficulties specifically in the domains of night waking, parasomnias and sleep disordered breathing. The analysis also revealed a significantly increased percentage of N2 sleep and decreased sleep efficiency in children with epilepsy compared to healthy children. These results illustrate that children with epilepsy are vulnerable to more sleep difficulties compared to healthy children. This suggests that screening for sleep difficulties should be an integral part in a diagnosis of epilepsy to ensure that clinically relevant sleep difficulties are identified and treated. Such an approach may ultimately aid in the development of treatment strategies which can contribute to improvements in both developmental and diagnostic outcomes for children with epilepsy.

Overnight Video-Polysomnographic Studies in Children with Intractable Epileptic Encephalopathies

Background

The aim of this study was to assess sleep architecture and respiration during sleep in children with intractable epileptic encephalopathies using overnight video-polysomnography (V-PSG).

Material/Methods

Between 2015 to 2017 overnight V-PSG recordings were made for 31 children (22 boys and 9 girls) with intractable epileptic encephalopathy with a mean age of 6.78±3.61 years and a mean body mass index (BMI) of 15.83±3.16 kg/m³. Thirty-one healthy children were matched for sex, age, and BMI as the control group. The phases of sleep studied included rapid eye movement (REM) sleep, and non-REM (NREM) phases NREM 1, NREM 2, and NREM 3. Respiratory function during sleep was evaluated.

Results

Children with epileptic encephalopathies receiving antiepileptic treatment had significantly decreased total sleep time (TST) (p=0.038), significantly increased percentage of NREM1 (p=0.033), and a significantly lower percentage of total REM (p<0.0001), compared with the control group. All children 31/31 (100%) with epileptic encephalopathies had interictal epileptiform discharges, and 4/31 (12.9%) had ictal events. The number of respiratory events did not differ significantly between the two groups (p=0.118), but children in the epileptic encephalopathy group had a significantly shorter average duration (p=0.008) and longest duration (p=0.048) of respiratory events. Average (p=0.006) and least (p=0.0004) oxygen saturation (SatO₂) were significantly lower in children with epileptic encephalopathies compared with the control group.

Conclusions

Children with epileptic encephalopathies had altered sleep architecture and marked oxygen desaturation, which supports the need for referral of children with epileptic encephalopathy for overnight sleep evaluation.

Systematic integration of biomedical knowledge prioritizes drugs for repurposing

The ability to computationally predict whether a compound treats a disease would improve the economy and success rate of drug approval. This study describes Project Rephetio to systematically model drug efficacy based on 755 existing treatments. First, we constructed Hetionet (neo4j.het.io), an integrative network encoding knowledge from millions of biomedical studies. Hetionet v1.0 consists of 47,031 nodes of 11 types and 2,250,197 relationships of 24 types. Data were integrated from 29 public resources to connect compounds, diseases, genes, anatomies, pathways, biological processes, molecular functions, cellular components, pharmacologic classes, side effects, and symptoms. Next, we identified network patterns that distinguish treatments from non-treatments. Then, we predicted the probability of treatment for 209,168 compound-disease pairs (het.io/repurpose). Our predictions validated on two external sets of treatment and provided pharmacological insights on epilepsy, suggesting they will help prioritize drug repurposing candidates. This study was entirely open and received realtime feedback from 40 community members.

Sleep disturbances among patients with epilepsy

AIM

The aim of this study was to analyze the prevalence of sleep disorders among patients with epilepsy and to compare the incidence of sleep disorders between the clinical and demographics factors.

MATERIALS AND METHODS

The study was conducted among 302 patients with epilepsy. Sleep disturbances were measured with the Polish version of the Pittsburgh Sleep Quality Questionnaire (PSQI). The questionnaire prepared and applied by the authors contained questions relating to sociodemographic characteristics, clinical status, and sleep.

RESULTS AND CONCLUSION

Mean PSQI score in the study group was 9±2 points, with the range of 4-16 points. PSQI test results were analyzed with regard to clinical and demographic characteristics of those suffering from epilepsy: gender, age, profession, body mass index, illness duration, number of medicines taken, type of seizures, frequency of seizures, time which elapsed since last seizure, provocative factor of seizure attacks, occurrence of adverse effects of antiepileptic drugs (AEDs). Furthermore, the existence of a relationship between PSQI test result and particular sleep-related factors or particular sleep conditions was examined. However, the examination of a relationship between certain independent variables and the final PSQI test result did not prove the existence of a statistically relevant influence (in all cases P>0.05).

High incidence of obstructive sleep apnea syndrome in patients with late-onset epilepsy

OBJECTIVES

The objective of the present study was to evaluate the prevalence of obstructive sleep apnea (OSA) in patients with late-onset epilepsy (LOE) who were considered at higher risk of cardiovascular disease.

METHODS

Polysomnography was performed on 27 patients with LOE. Berlin questionnaires and Epworth sleepiness score were performed on all patients. We compared clinical, demographic and anthropometric characteristics, questionnaire scores on the patients with no or mild OSA (group 1) and the patients with moderate or severe OSA (group 2). Patients eligible for continuous positive airway pressure (CPAP) therapy were reviewed in consultation.

RESULTS

Twenty-four patients (88.9%) had OSA and 55.6% had moderate or severe OSA. Patients in group 2 (n=15) were older than patients in group 1 (n=12). The two groups were similar in terms of body mass index (BMI), neck circumference, nocturnal seizure frequency, vascular cardiovascular risk factors and excessive daytime sleepiness. Leukoaraiosis in MRI was highly prevalent in our patients (40.7%), especially in group 2 patients. Eighty percent of the patients who had begun CPAP therapy experienced decreased seizure frequency.

CONCLUSION

Patients with LOE should be screened for the presence of OSA and treated accordingly.

Association of Interictal Epileptiform Discharges with Sleep and Anti-Epileptic Drugs

BACKGROUND

The presence of interictal epileptiform discharges (IEDs) in electroencephalogram (EEG) is diagnostic of epilepsy. Latent IEDs are activated during sleep. Anti-epileptic drugs (AEDs) improve sleep. AEDs, sleep, and IEDs may interact and affect epilepsy management.

PURPOSE

To explore the occurrence of IEDs and its association with sleep and AED status in suspected patients of epilepsy.

METHODS

EEG records were collected of suspected patients of epilepsy who reported to the electrophysiology laboratory of a tertiary care hospital during 1 year. The anthropometric details, clinical presentations, and AED status of the patients were recorded from the EEG records. Patients were divided into 2 categories based on whether AEDs had been started prior to the EEG evaluation (category-I) or not (category-II). The occurrences of IEDs in EEG recordings in both categories were analyzed.

RESULTS

In 1 year, 138 patients were referred for diagnostic EEG evaluation. One-hundred-two patients fulfilled the inclusion criteria, of which 57 patients (53%) belonged to category-I and 45 patients (47%) belonged to category-II. Incidence of IEDs, suggestive of definite diagnosis of epilepsy in category-I was 88% and in category-II was 69%, and this difference was statistically significant (p = 0.02).

CONCLUSION

The increased proportion of IEDs in category-I patients may be due to high clinical suspicion or compounding interaction of AEDs and sleep. More extensive studies are required to delineate the complex interaction of AEDs, sleep, and IEDs so that judicious yet prompt management of epilepsy can be carried out.

The role of prescription medications in the association of self-reported sleep duration and obesity in U.S. adults, 2007-2012

OBJECTIVE

Previous research has not investigated the role of prescription medication in sleep-obesity associations despite the fact that 56% of U.S. adults take at least one prescription medication.

METHODS

Data from n = 16,622 adults in the National Health and Nutrition Examination Survey (2007-2012) were used to examine how the association between obesity and self-reported sleep duration varied by total number of prescription medications used in the past 30 days and by select classes of prescription medications including anxiolytics/sedatives/hypnotics, antidepressants, sleep aids, anticonvulsants, thyroid agents, and metabolic agents.

RESULTS

Logistic regression analyses showed a significant inverse linear association of sleep duration and obesity, regardless of the total number of prescription medications individuals were taking. Each additional hour of sleep was associated with a 10% decrease in the odds of obesity. Results suggest that increased sleep duration is associated with lower odds of having obesity overall, even for long-duration sleepers (≥9 h), and this association does not differ for those taking antidepressants, thyroid agents, metabolic agents, and multiple prescription medications.

CONCLUSIONS

The relationship between sleep duration and obesity was similar among all prescription medication users and nonusers. The potential for a nonlinear association between sleep duration and obesity may be important to examine in some specific prescription medication classes.

Sleep Neurobiology and Critical Care Illness

The intensive care unit (ICU) environment is not propitious for restoring sleep and many studies have reported that critically ill patients have severe sleep disruptions. However, sleep alterations in critically ill patients are specific and differ significantly from those in ambulatory patients. Polysomnographic patterns of normal sleep are frequently lacking in critically ill patients and the neurobiology of sleep is important to consider regarding alternative methods to quantify sleep in the ICU. This article discusses elements of sleep neurobiology affecting the specificity of sleep patterns and sleep alterations in patients admitted to the ICU.

Insomnia and its associations in patients with recurrent glial neoplasms

Background

Patient with neurological disorders and cancer can develop sleep disturbance, in particular insomnia. Etiology of insomnia is multi-factorial in primary brain tumour patients with possible causes including corticosteroids, psychoactive medications, co-morbid psychiatric/medical conditions, and damage to neuronal tissue.

Findings

To understand better insomnia in recurrent glioma patients, a single-center retrospective analysis was performed looking at recurrent glioma patients from January 2004 to May 2009. Data was extracted and included demographics, clinical factors, psychoactive medications, and co-morbid symptoms. Presence and absence of insomnia complaints was evaluated with other co-morbidities using Chi square and Wilcoxon analyses. Records from 340 recurrent glioma patients were evaluated and 46.8 % (n = 159) indicated presence of insomnia with 20 % (n = 66) actively using medications for sleep. Use of corticosteroids were significantly associated with insomnia (p = 0.0003). Age, gender, tumour location, use of stimulants, antipsychotics, and antidepressants were not significantly associated with insomnia in recurrent glioma patients. There was a trend towards a possible significant association with insomnia to fatigue complaints and use of anti-epileptics, p-values of 0.0501 and 0.0725 respectively.

Conclusions

In conclusion, insomnia is commonly encountered in patients with recurrent glial tumors. Corticosteroid use is associated with insomnia in this population. In light of the frequency of insomnia and its associations, future analysis is warranted into sleep complaints in recurrent glioma patients and its impact on quality of life.

Determinants of sleep disturbances in Rett syndrome: Novel findings in relation to genotype

Rett syndrome is a rare but severe neurological disorder associated with a mutation in the methyl CpG binding protein 2 (MECP2) gene. Sleep problems and epilepsy are two of many comorbidities associated with this disorder. This study investigated the prevalence and determinants of sleep problems in Rett syndrome using an international sample. Families with a child with a confirmed Rett syndrome diagnosis and a MECP2 mutation registered in the International Rett Syndrome Phenotype Database (InterRett) were invited to participate. Questionnaires were returned by 364/461 (78.9%) either in web-based or paper format. Families completed the Sleep Disturbance Scale for Children and provided information on the presence, nature, and frequency of their child's sleep problems. Multivariate multinomial regression was used to investigate the relationships between selected sleep problems, age group, and genotype and linear regression for the relationships between sleep disturbance scales and a range of covariates. Night waking was the most prevalent sleep problem affecting over 80% with nearly half (48.3%) currently waking often at night. Initiating and maintaining sleep was most disturbed for younger children and those with a p.Arg294* mutation. Severe seizure activity was associated with poor sleep after adjusting for age group, mutation type, and mobility. We were surprised to find associations between the p.Arg294* mutation and some sleep disturbances given that other aspects of its phenotype are milder. These findings highlight the complexities of aberrant MECP2 function in Rett syndrome and explain some of the variation in manifestation of sleep disturbances. © 2016 Wiley Periodicals, Inc.

Neuropsychological consequences of sleep disturbance in children with epilepsy

A growing body of research reveals strong relationships between sleep disturbance, sleep architecture, and neuropsychological functioning in children. Children with epilepsy experience numerous neuropsychological comorbidities, including cognitive deficiencies and emotional/behavioral difficulties; thus, it is reasonable to consider the moderating role of sleep in this population. This review summarizes findings involving the prevalence and characteristics of sleep problems often experienced by children with epilepsy. The complex and bidirectional relationship between sleep and seizure frequency is discussed. Research pertaining to the relationship between sleep disturbance and daytime cognition as well as behavior reveals a substantial association between these variables. Clinically relevant practices related to the assessment and treatment of sleep-related complications are reviewed, and directions for further research involving intervention and assessment are also reviewed.

Sleep neurobiology and critical care illness

The intensive care unit (ICU) environment is not propitious for restoring sleep and many studies have reported that critically ill patients have severe sleep disruptions. However, sleep alterations in critically ill patients are specific and differ significantly from those in ambulatory patients. Polysomnographic patterns of normal sleep are frequently lacking in critically ill patients and the neurobiology of sleep is important to consider regarding alternative methods to quantify sleep in the ICU. This article discusses elements of sleep neurobiology affecting the specificity of sleep patterns and sleep alterations in patients admitted to the ICU.

Cardiac phenomena during kainic-acid induced epilepsy and lamotrigine antiepileptic therapy

RATIONALE

Pathologic ECG events are known to accompany seizures and to persist in several chronic epilepsy syndromes. The contribution of antiepileptic drugs (AEDs) to these events and the implications in the etiology of sudden-unexpected death in epilepsy (SUDEP) continue to be a matter of debate. We therefore investigated cardiac parameters during kainic-acid (KA) induced experimental epilepsy and antiepileptic treatment with lamotrigine (LTG).

METHODS

Epilepsy was induced in seven C57Bl/6 mice by injections of KA (20 mg/kg) on days 1 and 5, which produced severe acute seizures and spontaneous seizures 10 days later. Treatment with LTG (30 mg/kg) was initiated on day 11 and repeated on day 12. Continuous ECGs and ECoGs were collected telemetrically from freely moving mice.

RESULTS

Mice displayed pre-ictal but not ictal tachycardia. The squared coefficient of variation (SCV) of R-R intervals was significantly elevated 30s before and during seizures compared to control conditions. LTG produced a significant reversible increase in SCV and LF/HF ratio during slow-wave sleep (SWS), potentially indicative of sympatho-vagal imbalance during this state of vigilance, in which epileptic patients are known to be particularly vulnerable to SUDEP.

SIGNIFICANCE

The KA model used in this study permits the investigation of cardiac phenomena during epilepsy, as it features many effects found in human epileptic patients. Increased LF/HF, a known risk factor for cardiac disease, which is often found in epileptic patients, was observed as a side-effect of LTG treatment during SWS, suggesting that LTG may promote imbalance of the autonomous nervous system in epileptic mice.

Epilepsy, antiseizure therapy, and sleep cycle parameters

A reciprocal relationship exists between sleep and epilepsy. The quality of sleep is affected by the presence and frequency of seizures, type of antiepileptic therapy utilized, and coexisting primary sleep disorders. Daytime somnolence is one of the most common adverse effects of antiepileptic therapy, with specific pharmacologic agents exhibiting a unique influence on components of sleep architecture. The newer generation of antiseizure drugs demonstrates improved sleep efficiency, greater stabilization of sleep architecture, prolongation of REM sleep duration, and increased quality of life measures. The emerging field of chronoepileptology explores the relationship between seizures and circadian rhythms, aiming for targeted use of antiseizure therapies to maximize therapeutic effects and minimize the adverse events experienced by the patients.

Effects of zonisamide as add-on therapy on sleep-wake cycle in focal epilepsy: a polysomnographic study

PURPOSE

The purpose of this study was to evaluate the effects of zonisamide (ZNS) as adjunctive therapy on sleep-wake cycle and daytime somnolence in adult patients affected by focal epilepsy.

METHODS

Thirteen patients affected by focal epilepsy were recruited to undergo a 24-hour ambulatory polysomnography, Multiple Sleep Latency Test (MSLT), and a subjective evaluation of nocturnal sleep by means of the Pittsburgh Sleep Quality Index (PSQI) and daytime somnolence by means of the Epworth Sleepiness Scale (ESS) before and after 3 months of treatment with ZNS as add-on therapy.

RESULTS

Twelve patients completed the study. Zonisamide therapy reduced seizures by >50% in 8 out of 12 patients. Zonisamide did not induce any significant changes in nocturnal polysomnographic variables and in PSQI scores. In addition, mean sleep latency and ESS score were unmodified after treatment.

CONCLUSION

Zonisamide seems to be effective and safe in focal epilepsy. Both subjective and objective sleep parameters showed no detrimental effects on nocturnal sleep and daytime somnolence in patients with focal epilepsy using ZNS. Since some AEDs induce sleep impairment, which is known to trigger EEG abnormalities and seizures and to worsen quality of life, our findings suggest a positive profile of ZNS.

Impact of pediatric epilepsy on sleep patterns and behaviors in children and parents

PURPOSE

Disrupted sleep patterns in children with epilepsy and their parents are commonly described clinically. A number of studies have shown increased frequency of sleep disorders among pediatric epilepsy patients; however, few have characterized the association between epilepsy and parental sleep quality and household sleeping arrangements. The purpose of this study was to explore the effect of pediatric epilepsy on child sleep, parental sleep and fatigue, and parent-child sleeping arrangements, including room sharing and cosleeping.

METHODS

Parents of children 2 to 10 years of age with and without epilepsy completed written questionnaires assessing seizure history, child and parent sleep, and household sleeping arrangements. Children's Sleep Habits Questionnaire (CSHQ) scores were used to evaluate sleep disturbances for the child. The Pittsburgh Sleep Quality Index (PSQI) and the Iowa Fatigue Scale (IFS) were used to evaluate parental sleep and fatigue, respectively. The Early Childhood Epilepsy Severity Scale (E-Chess) was used to assess epilepsy severity.

KEY FINDINGS

One hundred five households with a child with epilepsy and 79 controls participated in this study. Households with a child with epilepsy reported increased rates of both parent-child room sharing (p < 0.001) and cosleeping (p = 0.005) compared to controls. Children with epilepsy were found to have greater sleep disturbance by total CSHQ score (p < 0.001) and the following subscores: parasomnias (p < 0.001), night wakings (p < 0.001), sleep duration (p < 0.001), daytime sleepiness (<0.001), sleep onset delay (p = 0.009), and bedtime resistance (p = 0.023). Parents of children with epilepsy had increased sleep dysfunction (p = 0.005) and were more fatigued (p < 0.001). Severity of epilepsy correlated positively with degree of child sleep dysfunction (0.192, p = 0.049), parental sleep dysfunction (0.273, p = 0.005), and parental fatigue (0.324, p = 0.001). Antiepileptic drug polytherapy was predictive of greater childhood sleep disturbances. Nocturnal seizures were associated with parental sleep problems, whereas room sharing and cosleeping behavior were associated with child sleep problems. Within the epilepsy cohort, 69% of parents felt concerned about night seizures and 44% reported feeling rested rarely or never. Finally, 62% of parents described decreased sleep quality and/or quantity with cosleeping.

SIGNIFICANCE

Pediatric epilepsy can significantly affect sleep patterns for both the affected child and his or her parents. Parents frequently room share or cosleep with their child, adaptations which may have detrimental effects for many households. Clinicians must not only be attentive to the sleep issues occurring in pediatric patients with epilepsy, but also for the household as a whole. These data provide evidence of a profound clinical need for improved epilepsy therapeutics and the development of nocturnal seizure monitoring technologies.

Sleep characteristics of patients with epilepsy with pure sleep-related seizures

OBJECTIVE

Our aim was to investigate the clinical features and sleep characteristics of patients with pure sleep-related seizures.

METHODS

Patients with pure sleep epilepsy were prospectively enrolled and their clinical, EEG, and MRI findings investigated. The Medical Outcomes Study Sleep Scale (MOS-SS) was administered after receiving consent.

RESULTS

Thirty-nine of 1401 consecutive patients (2.7%) with pure sleep-related seizures were included. Of these, 30 (76.9%) had epilepsy of unknown cause and 7 had epilepsy with known structural etiologies. Twenty-seven patients reported less than one seizure per month and 19 had been seizure free for at least 1 year. Thirty-four patients participated in our MOS-SS study. Comparison of sleep problems between those with epilepsy and healthy controls and between the subgroups with frequent and rare seizures did not reveal significant differences.

CONCLUSION

Patients with pure sleep seizures had mostly undetermined etiology usually with a good prognosis, and this rare condition did not seem to affect their sleep quality.

Nonepileptic paroxysmal events in a pediatric population

Nonepileptic paroxysmal events in children are common, and may be more diverse in etiology than those seen in adults. We determined the types of nonepileptic events that are most prominent in the pediatric population, and stratified those events by age group. Ninety-four of 416 pediatric patients monitored during a 3-year period (23%) were found to have had nonepileptic events. Thirty-eight percent of these children were diagnosed with psychogenic nonepileptic seizures, and 72% of those were adolescents. In children younger than 5 years of age, behavioral events and parasomnias were the most common mimickers of epilepsy. Other events, including stereotyped movements and myoclonus, were also diagnosed. We suggest that children with refractory paroxysmal events should be considered for early inpatient monitoring.

Sleepiness, on-task behavior and attention in children with epilepsy who visited a school for special education: a comparative study

Children with epilepsy are at risk for problems in daytime functioning. We assessed daytime sleepiness, on-task behavior and attention in 17 children (aged between 7 and 11 years) with epilepsy who visited a school for special education and compared these to 17 children from a control group who visited a regular school. Within the group of children with epilepsy, we explored whether behavioral and cognitive functioning varied across days of the week and times of the day. Data were collected during four consecutive school days. Children with epilepsy had more daytime sleepiness, less on-task behavior and less attention than controls. Furthermore, sleepiness and on-task behavior varied cross days of the week and times of the day, an effect that was not found in controls. Implications for educational practice are discussed.

A single generalized seizure alters the amplitude, but not phase, of the circadian activity rhythm of the hamster

People with epilepsy exhibit high rates of sleep disturbances. In many cases, these sleep disruptions appear to be related to the occurrence of the seizures themselves. Changes in sleep structure may reflect underlying changes in the circadian clock, as circadian rhythms of locomotor activity, body temperature, and hormone release are disrupted following a seizure. The present study was designed to determine if a single generalized seizure could alter the phase and waveform of the circadian rhythm of wheel-running behavior in the Syrian hamster. Animals were housed in constant darkness, and were administered either a sham treatment or a maximal electroconvulsive shock at one of three time-points: 6 h before activity onset, 1 h after activity onset, or 6 h after activity onset. Seizures at all of these phases did not significantly affect the phase of the circadian activity rhythm. The circadian locomotor activity levels were significantly attenuated following seizures at all three phases. This attenuation was prominent over the 24 h following the seizure, and was also evident over the three post-seizure days. These data suggest that while seizures do not affect phase, they may alter the amplitude of the circadian clock. Because the amplitude of the circadian clock affects sleep quality, these findings suggest one mechanism by which persistent seizures may decrease the quality of sleep in patients with epilepsy.

Spectrum of polysomnographic abnormalities in children with epilepsy

This study sought to evaluate polysomnographic abnormalities in a cohort of 40 children with epilepsy who underwent a sleep study because of various sleep complaints. Retrospective analyses included polysomnographic variables, antiepileptic drugs, type of epilepsy, and seizure control. The subgroup with epilepsy and obstructive sleep apnea syndrome was compared with 11 children who manifested uncomplicated obstructive sleep apnea syndrome. Thirty-three patients (83%) exhibited snoring (42.5%), sleep-disordered breathing (obstructive hypoventilation, 12.5%; obstructive sleep apnea, 20%; and upper-airway resistance syndrome, 7.5%), or periodic limb movements of sleep (10%). Children with poor seizure control demonstrated significantly lower sleep efficiency, a higher arousal index, and a higher percentage of rapid-eye-movement sleep compared with children who were seizure-free or exhibited good seizure control. Patients with epilepsy and obstructive sleep apnea had significantly a higher body mass index, longer sleep latency, a higher arousal index, and a lower apnea-hypopnea index, but significantly more severe desaturation compared with patients with uncomplicated obstructive sleep apnea. A significant proportion of children with epilepsy referred for polysomnography with diverse sleep problems manifest sleep-disordered breathing, including obstructive sleep apnea syndrome.

The relationship between sleep and epilepsy

The occurrence of seizures in the sleep state is observed in nearly one third of patients. This is caused by an intimate relationship between the physiological state of sleep and the pathological process underlying epileptic seizures. Both sleep and sleep deprivation influence the frequency of epileptiform discharges on electroencephalograms as well as the occurrence of clinical seizures, typically during nonrapid eye movement sleep. The relationship of epileptiform activity to nonrapid eye movement sleep is vividly shown in the syndrome of continuous spikes in slow-wave sleep and the Landau-Kleffner syndrome. Seizure semiology can also be influenced by sleep and sleep deprivation. Sleep disorders may influence seizure control, and effective treatment of sleep disorders can improve seizure control. Seizures, antiepileptic drugs, ketogenic diet, and vagus nerve stimulation all influence sleep quality, daytime alertness, and neurocognitive function.

Anticonvulsant effect of Annona diversifolia Saff. and palmitone on penicillin-induced convulsive activity. A behavioral and EEG study in rats

PURPOSE

To evaluate hypnotic and anticonvulsant activities of Annona diversifolia Saff. and palmitone by using behavior and electroencephalographic (EEG) analysis in an experimental model of focal seizures in rats.

METHODS

For hypnotic assessment, EEG analysis of polysomnographic slow-wave sleep (SWS) and rapid eye movement (REM) sleep for a 1 h period were performed after vehicle, A. diversifolia extract or palmitone, administration. For anticonvulsant effect, 60 minutes after treatments, EEG and behavior were analyzed during penicillin-induced seizures. Latency to the onset of the first paroxystic spike, first seizure and frequency, as well as seizure severity using Racine's scale, were determined.

RESULTS

Palmitone, but not A. diversifolia extract, produced a delay in the latency to the SWS phase. In addition, both palmitone and extract decreased SWS duration and accumulated REM sleep phase. With regard to the seizures, both the extract and palmitone increased the latency to the onset of spikes and seizures, but also decreased the duration of penicillin-induced seizures. This reduction in the EEG recordings was associated with an attenuation in the severity of behavioral seizures.

CONCLUSIONS

A. diversifolia and palmitone did not produce a sedative-hypnotic effect although both of them were effective in reducing the severity of behavioral and EEG seizures induced by penicillin in rats, suggesting that the diminution in the paroxystic activity by A. diversifolia is likely produced by palmitone through GABAergic neurotransmission. This study justifies and reinforces the traditional use of this plant in epilepsy.

Effects of levetiracetam on nocturnal sleep and daytime vigilance in healthy volunteers

PURPOSE

Individuals with epilepsy commonly report daytime sleepiness, attributed to sleep disruption (frequent arousals, awakenings, and stage shifts) induced by ictal and interictal activity or antiepileptic drugs (AEDs) or both. To study the effect of levetiracetam (LEV) on sleep, at full doses but without the interference of epilepsy, we investigated the sleep architecture and daytime vigilance in healthy adults after 3 weeks of treatment.

METHODS

The study was of a double-blind crossover design with random allocation of multiple doses of two different treatments (randomly first LEV <or=2,000 mg/day or placebo for 3 weeks, washout for 4 weeks, and then the alternative treatment for another 3 weeks). Fourteen healthy volunteers were studied with polysomnography (PSG) and the Multiple Sleep Latency Test (MSLT). Epworth Sleepiness Scale (ESS) and sleep log also were evaluated.

RESULTS

After treatment with LEV, statistically significant increases were observed in total sleep time, sleep efficiency, and time spent in non-rapid eye movement (NREM) sleep stages 2 and 4. Stage shifts and wake after sleep onset were significantly decreased. Sleep latency was normal at PSG and MSLT in all subjects and did not statistically differ between placebo and LEV. No changes were found in the ESS.

CONCLUSIONS

Our findings show that in healthy volunteers, LEV consolidates sleep and does not modify vigilance, two appreciated qualities in epilepsy patients with sleep disturbance and daytime sleepiness.

Sleep and epilepsy

This article examines the relationship between sleep and epilepsy, an association that has been recognized since antiquity. The mechanisms whereby sleep facilitates seizures are under investigation, although the synchronizing role of thalamocortic networks seems contributory. Recognition of the variety of generalized and partial epileptic syndromes associated with sleep, familiarity with the differential diagnosis of nocturnal spells, and awareness of the role that antiepileptic drugs and sleep disorders may play in epilepsy are helpful in evaluating patients presenting with behavioral and motor disturbances of sleep.

Excessive daytime sleepiness and sleep complaints among children with epilepsy

OBJECTIVE

Excessive daytime sleepiness (EDS) and sleep complaints are common among adults with epilepsy. We hypothesized that children with epilepsy have worse daytime sleepiness compared with controls.

METHODS

Children with and without epilepsy between ages 8 and 18 were recruited for the study. Parents and children were asked to fill out the Pediatric Sleep Questionnaire (PSQ) and Pediatric Daytime Sleepiness Scale (PDSS), respectively. The Mann-Whitney U test was used for group comparisons, with the Fischer exact or chi2 test for categorical variables. Regression analysis was used to identify predictors of EDS.

RESULTS

Twenty-six patients and matched controls were recruited for the study. Parents of children with epilepsy more often reported EDS (P < 0.001), symptoms of sleep-disordered breathing (P < 0.001), and parasomnias (P < 0.001) compared with controls. On the PDSS, children with epilepsy reported worse daytime sleepiness scores compared with controls (15.48 +/- 6.4 vs 11.88 +/- 5.25, P = 0.037). Based on conditional logistic regression modeling, symptoms of excessive daytime sleepiness [corrected] (OR = 15.3, 95% CI = 1.4-166.6) and parasomnias (OR = 12.4, 95% CI = 1.01-151.6) were significantly associated with having epilepsy when adjusted for duration of nightime sleep. Further, 10 children (38.5%) with epilepsy reported positive sleep-disordered breathing, whereas no one in the control group reported SDB (P < 0.001) [corrected] Epilepsy syndrome, anticonvulsants used, and presence or absence of seizure freedom, however, were not significant predictors of EDS among patients.

CONCLUSIONS

Daytime sleepiness appears to be common in children with epilepsy, and may be due to underlying sleep disorders. Further confirmatory studies are needed using screening questionnaires and formal sleep studies to systematically study the prevalence of sleep complaints and role of sleep disorders in these patients.