The effects of levetiracetam on objective and subjective sleep parameters in healthy volunteers and patients with partial epilepsy

The prevalence and predictors of poor sleep quality and excessive daytime sleepiness in epilepsy: A single tertiary centre experience in Malaysia

BACKGROUND AND OBJECTIVE

People with epilepsy frequently encounter sleep disruptions that can stem from a variety of complex factors. Epilepsy-related sleep disturbance can lead to reduced quality of life and excessive daytime hypersomnolence. Identification of sleep disturbances may help in the overall management of epilepsy patients. This study was conducted to determine the prevalence and predictors of poor sleep quality and daytime sleepiness in epilepsy.

METHODS

A cross-sectional study on 284 epilepsy patients was performed in a local tertiary centre. The demographic and clinical epilepsy data were collected. The Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS) questionnaires were utilised to determine the quality of life and daytime hypersomnolence of epilepsy patients, respectively.

RESULTS

Poor sleep quality was reported in 78 (27.5%) patients while daytime hypersomnolence was present in 17 (6%) patients. The predictors of poor sleep quality include structural causes (OR = 2.749; 95% CI: 1.436, 5.264, p = 0.002), generalised seizures (OR = 1.959, 95% CI: 1.04, 3.689, p = 0.037), and antiseizure medications such as Carbamazepine (OR = 2.34; 95% CI: 1.095, 5.001, p = 0.028) and Topiramate (OR 2.487; 95% CI: 1.028, 6.014, p = 0.043). Females are 3.797 times more likely score higher in ESS assessment (OR 3.797; 95% CI: 1.064, 13.555 p = 0.04).

DISCUSSION

Sleep disturbances frequently coexist with epilepsy. Patients should be actively evaluated using the PSQI and ESS questionnaires. It is imperative to identify the key factors that lead to reduced sleep quality and heightened daytime sleepiness in patients with epilepsy, as this is essential to properly manage their condition.

Disturbed laterality of non-rapid eye movement sleep oscillations in post-stroke human sleep: a pilot study

Sleep is known to promote recovery post-stroke. However, there is a paucity of data profiling sleep oscillations in the post-stroke human brain. Recent rodent work showed that resurgence of physiologic spindles coupled to sleep slow oscillations (SOs) and concomitant decrease in pathological delta (δ) waves is associated with sustained motor performance gains during stroke recovery. The goal of this study was to evaluate bilaterality of non-rapid eye movement (NREM) sleep-oscillations (namely SOs, δ-waves, spindles, and their nesting) in post-stroke patients vs. healthy control subjects. We analyzed NREM-marked electroencephalography (EEG) data in hospitalized stroke-patients (n = 5) and healthy subjects (n = 3). We used a laterality index to evaluate symmetry of NREM oscillations across hemispheres. We found that stroke subjects had pronounced asymmetry in the oscillations, with a predominance of SOs, δ-waves, spindles, and nested spindles in affected hemisphere, when compared to the healthy subjects. Recent preclinical work classified SO-nested spindles as restorative post-stroke and δ-wave-nested spindles as pathological. We found that the ratio of SO-nested spindles laterality index to δ-wave-nested spindles laterality index was lower in stroke subjects. Using linear mixed models (which included random effects of concurrent pharmacologic drugs), we found large and medium effect size for δ-wave nested spindle and SO-nested spindle, respectively. Our results in this pilot study indicate that considering laterality index of NREM oscillations might be a useful metric for assessing recovery post-stroke and that factoring in pharmacologic drugs may be important when targeting sleep modulation for neurorehabilitation post-stroke.

Disturbed laterality of non-rapid eye movement sleep oscillations in post-stroke human sleep: a pilot study

Sleep is known to promote recovery post-stroke. However, there is a paucity of data profiling sleep oscillations post-stroke in the human brain. Recent rodent work showed that resurgence of physiologic spindles coupled to sleep slow oscillations(SOs) and concomitant decrease in pathological delta(δ) waves is associated with sustained motor performance gains during stroke recovery. The goal of this study was to evaluate bilaterality of non-rapid eye movement (NREM) sleep-oscillations (namely SOs, δ-waves, spindles and their nesting) in post-stroke patients versus healthy control subjects. We analyzed NREM-marked electroencephalography (EEG) data in hospitalized stroke-patients (n=5) and healthy subjects (n=3) from an open-sourced dataset. We used a laterality index to evaluate symmetry of NREM oscillations across hemispheres. We found that stroke subjects had pronounced asymmetry in the oscillations, with a predominance of SOs, δ-waves, spindles and nested spindles in one hemisphere, when compared to the healthy subjects. Recent preclinical work classified SO-nested spindles as restorative post-stroke and δ-wave-nested spindles as pathological. We found that the ratio of SO-nested spindles laterality index to δ-wave-nested spindles laterality index was lower in stroke subjects. Using linear mixed models (which included random effects of concurrent pharmacologic drugs), we found large and medium effect size for δ-wave nested spindle and SO-nested spindle, respectively. Our results indicate considering laterality index of NREM oscillations might be a useful metric for assessing recovery post-stroke and that factoring in pharmacologic drugs may be important when targeting sleep modulation for neurorehabilitation post-stroke.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep, neuronal hyperexcitability, inflammation and neurodegeneration: Does early chronic short sleep trigger and is it the key to overcoming Alzheimer's disease?

Evidence links neuroinflammation to Alzheimer's disease (AD); however, its exact contribution to the onset and progression of the disease is poorly understood. Symptoms of AD can be seen as the tip of an iceberg, consisting of a neuropathological build-up in the brain of extracellular amyloid-β (Aβ) plaques and intraneuronal hyperphosphorylated aggregates of Tau (pTau), which are thought to stem from an imbalance between its production and clearance resulting in loss of synaptic health and dysfunctional cortical connectivity. The glymphatic drainage system, which is particularly active during sleep, plays a key role in the clearance of proteinopathies. Poor sleep can cause hyperexcitability and promote Aβ and tau pathology leading to systemic inflammation. The early neuronal hyperexcitability of γ-aminobutyric acid (GABA)-ergic inhibitory interneurons and impaired inhibitory control of cortical pyramidal neurons lie at the crossroads of excitatory/inhibitory imbalance and inflammation. We outline, with a prospective framework, a possible vicious spiral linking early chronic short sleep, neuronal hyperexcitability, inflammation and neurodegeneration. Understanding the early predictors of AD, through an integrative approach, may hold promise for reducing attrition in the late stages of neuroprotective drug development.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Assessment of psychiatric and behavioral adverse effects of antiepileptic drugs monotherapy: Could they have a neuroendocrine correlation in persons with epilepsy?

OBJECTIVE

The study investigated overall adverse event (AE) burden and specifically psychiatric and behavioral side effects (PBAEs) in persons with epilepsy (PWE) on antiepileptic drugs (AEDs) monotherapy. It also assessed their correlation with neuroendocrine and oxidative stress biomarkers.

METHODS

This cross-sectional observational study was conducted at a tertiary care hospital between 2016 and 2018. Persons with epilepsy above 18 years on monotherapy of levetiracetam (LEV) and conventional AEDs {carbamazepine (CBZ), phenytoin (PHT), or valproate (VPA)} for at least 6 months were enrolled. Validated questionnaires, 'Mini-International Neuropsychiatric Interview (MINI 7.02)', 'Depression, Anxiety, and Stress Scale 21 (DASS-21)', 'Buss-Perry Aggression Questionnaire (BPAQ)', 'patient-weighted Quality of life Index in Epilepsy (QOLIE-10)', 'Pittsburgh Sleep Quality Index (PSQI)', and 'Liverpool Adverse Events Profile (LAEP)' were used to assess the PBAEs, quality of life, sleep quality, and AE profile. A subgroup of PWE recruited consecutively were considered for estimation of the following neuroendocrine biomarker levels: brain-derived neurotrophic factor (BDNF), homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA), and total antioxidant capacity (TAC) which were then correlated with scores of above questionnaires.

RESULTS

After screening 220 PWE, 163 PWE (58 on LEV and 105 on conventional AEDs) with a mean age of 29 ± 10 years were enrolled. Mini-International Neuropsychiatric Interview revealed that LEV group had higher association with PBAEs and lower quality of sleep compared to conventional AEDs (p = 0.032 and 0.046, respectively). Other scales did not show significant difference between LEV and conventional AEDs. In the subset of PWE (n = 74, 36 on LEV and 38 on conventional AEDs), LEV group had more association with the PBAEs (p = 0.010), higher physical aggression and anger components of BPAQ (p = 0.03 and 0.02, respectively), and more AE (p = 0.049) than conventional AED group. However, there was no significant difference in neuroendocrine biomarker levels.

CONCLUSION

Levetiracetam had a higher association with PBAEs and more AE when compared to conventional AEDs. There was no differential correlation of AEDs with the following neuroendocrine markers: BDNF, HVA, 5-HIAA, and TAC. These facts necessitate exploration of other mechanisms for LEV-induced PBAEs.

The Mutual Interaction Between Sleep and Epilepsy on the Neurobiological Basis and Therapy

BACKGROUND

Sleep and epilepsy are mutually related in a complex, bidirectional manner. However, our understanding of this relationship remains unclear.

RESULTS

The literatures of the neurobiological basis of the interactions between sleep and epilepsy indicate that non rapid eye movement sleep and idiopathic generalized epilepsy share the same thalamocortical networks. Most of neurotransmitters and neuromodulators such as adenosine, melatonin, prostaglandin D2, serotonin, and histamine are found to regulate the sleep-wake behavior and also considered to have antiepilepsy effects; antiepileptic drugs, in turn, also have effects on sleep. Furthermore, many drugs that regulate the sleep-wake cycle can also serve as potential antiseizure agents. The nonpharmacological management of epilepsy including ketogenic diet, epilepsy surgery, neurostimulation can also influence sleep.

CONCLUSION

In this paper, we address the issues involved in these phenomena and also discuss the various therapies used to modify them.

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).

Sleep Disorders in Neurologic Practice: A Case-based Approach

Sleep disorders are common in neurology practice, but are often undiagnosed and untreated. Specific patient cohorts, such as older adults, patients residing in nursing homes, and patients with underlying chronic neurologic and psychiatric disorders, are at particular risk. If these sleep problems are not properly evaluated and managed the patient may experience exacerbation of the underlying neurologic disorder. This article highlights some of the key sleep disorders relevant to practicing neurologists, emphasizing hypersomnolence, insomnia, and sleep-related movement disorders in the setting of neurologic disorders to enhance the tools available for evaluation, and discusses management strategies.

Circadian rhythm and profile in patients with juvenile myoclonic epilepsy and temporal lobe epilepsy

ObjectiveThis study intended to compare the circadian rhythm and circadian profile between patients with juvenile myoclonic epilepsy (JME) and patients with temporal lobe epilepsy (TLE).MethodWe enrolled 16 patients with JME and 37 patients with TLE from the Outpatient Clinic of UNICAMP. We applied a questionnaire about sleep-wake cycle and circadian profile.ResultsFourteen (87%) out of 16 patients with JME, and 22 out of 37 (59%) patients with TLE reported that they would sleep after seizure (p < 0.05). Three (19%) patients with JME, and 17 (46%) reported to be in better state before 10:00 AM (p < 0.05).ConclusionThere is no clear distinct profile and circadian pattern in patients with JME in comparison to TLE patients. However, our data suggest that most JME patients do not feel in better shape early in the day.

Childhood epilepsy and sleep

Sleep and epilepsy are two well recognized conditions that interact with each other in a complex bi-directional way. Some types of epilepsies have increased activity during sleep disturbing it; while sleep deprivation aggravates epilepsy due to decreased seizure threshold. Epilepsy can deteriorate the sleep-related disorders and at the same time; the parasomnias can worsen the epilepsy. The secretion of sleep-related hormones can also be affected by the occurrence of seizures and supplementation of epileptic patients with some of these sleep-related hormones may have a beneficial role in controlling epilepsy.

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.

Insomnia symptoms in South Florida military veterans with epilepsy

BACKGROUND

Despite the high prevalence of insomnia in veterans with epilepsy, it remains understudied. Our aim was to identify the associations of insomnia with epilepsy, comorbidities, and treatment-related variables in South Florida veterans.

METHODS

We performed a cross-sectional analysis of veterans attending an epilepsy clinic over 18 months. Participants completed standardized assessments of seizure and sleep. Insomnia was defined as 1) difficulty with sleep onset, maintenance, or premature awakenings with daytime consequences or 2) sedative-hypnotic use on most nights of the previous month.

RESULTS

One hundred sixty-five veterans (87% male, age 56 ± 15 years) were included: 66 reporting insomnia (40%). In logistic regression analysis, insomnia was significantly associated with post-traumatic seizure etiology, lamotrigine prescription, and mood and psychotic disorders. Female gender and levetiracetam treatment were associated with lower odds for insomnia.

CONCLUSION

Insomnia was associated with post-traumatic epilepsy, mood/psychotic comorbidities, and antiepileptic regimen. Insomnia represents an under-recognized opportunity to improve comprehensive epilepsy care.

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.

Pregabalin increases slow-wave sleep and may improve attention in patients with partial epilepsy and insomnia

Insomnia is a common phenomenon particularly in patients with epilepsy. This study was performed to look at the effects of pregabalin, an anticonvulsant known to increase sleep depth and decrease arousals, in patients with insomnia and well-controlled epilepsy.

METHODS

This was a double-blind, placebo-controlled, crossover study of subjects with insomnia and epilepsy. Each subject was treated with pregabalin 150 mg BID or placebo for two weeks, followed by a two-week washout period, then the other treatment for two weeks. Polysomnography and neuropsychological testing were performed at baseline and at the end of each treatment arm.

RESULTS

There was a significant increase in percentage of slow-wave sleep and a decrease in stage 1 sleep when subjects were taking pregabalin. Sleep efficiency increased during pregabalin treatment, although this was not statistically significant (84.5+/-4.6% for placebo versus 90.4+/-2.6% for pregabalin). There were a significant improvement in attention in the pregabalin group based on trial one of the Rey-Auditory Verbal Learning Test and a trend toward improvement in the psychomotor vigilance task; other neuropsychological measures were not significantly changed.

CONCLUSION

Concurrent treatment with pregabalin improves sleep depth in patients with insomnia and epilepsy and improves daytime attention.

Restless Leg Syndrome in ADHD children: levetiracetam as a reasonable therapeutic option

The comorbidity of Attention Deficit Hyperactivity Disorder (ADHD) with sleep disorders has been extensively studied. In particular, Restless Legs Syndrome (RLS) appears to be consistently more frequent in children with ADHD. Several papers also draw attention to the frequent occurrence of epileptic seizures and EEG abnormalities in ADHD children. We performed a preliminary open label study to evaluate the efficacy of Levetiracetam (LEV) to ameliorate the sleep pattern and reduce RLS symptoms in children with a complex comorbidity between Attention Deficit Hyperactivity Disorder (ADHD), RLS and focal interictal epileptic discharges (IEDs) on EEG. We recruited seven children (all males, aged between 5 and 12years) who fulfilled the following criteria: ADHD diagnosis combined subtype; presence of idiopathic RLS; and presence of focal IEDs on EEG. All children were given LEV at a starting dose of approximately 10-20mg/kg/day followed by 10mg/kg/day incrementing at 1-week intervals up to 50-60mg/kg/day given in two separate doses. At a 3 and 6month follow-up, all children showed significant improvement (p<0.05) in global International RLS Rating Scale (IRLS-RS). Parents' reports revealed improved sleep quality with fewer awakenings and restorative sleep in their children. LEV was well tolerated and no major side effects were reported. With an accessory report we observed the reduction of epileptiform EEG activity during sleep. In most patients (6 on 7) the discharges completely disappeared; in the last patient epileptiform EEG activity was significantly reduced. These children may represent a subgroup of ADHD patients in which the hyperactivity and attention difficulties might be aggravated by sleep disturbances and by IEDs. LEV could represent a therapeutic option for these comorbid conditions.

The relationship between sleep and epilepsy: the effect on cognitive functioning in children

AIM

The purpose of this review was to examine the possible pathophysiological links between epilepsy, cognition, sleep macro- and microstructure, and sleep disorders to highlight the contributions and interactions of sleep and epilepsy on cognitive functioning in children with epilepsy.

METHOD

PubMed was used as the medical database source. No language restriction was placed on the literature searches, and citations of relevant studies in the paediatric age range (0-18 y) were checked. Studies including a mixed population but with a high percentage of children were also considered.

RESULTS

The searches identified 223 studies. One reviewer scanned these to eliminate obviously irrelevant studies. Three reviewers scanned the remaining 128 studies and their relevant citations. The review showed that several factors could account for the learning impairment in children with epilepsy: aetiology, electroencephalographic (EEG) discharges, and persistence and circadian distribution of seizures, etc. EEG discharges may affect cognition and sleep, even in the absence of clinical or subclinical seizures. The sleep deprivation and/or sleep disruption affect the neurophysiological and neurochemical mechanisms important for the memory-learning process, but also influence the expression of EEG discharges and seizures. Learning and memory consolidation can take place over extended periods, and sleep has been demonstrated to play a fundamental role in these processes through neuroplastic remodelling of neural networks. Epilepsy and EEG paroxysms may affect sleep structure, interfering with these physiological functions.

INTERPRETATION

Improvement in the long-term cognitive-behavioural prognosis of children with epilepsy requires both good sleep quality and good seizure control. The antiepileptic drug of choice should be the one that interferes least with sleep structure and has the best effect on sleep architecture--thus normalizing sleep instability, especially during non-rapid eye movement sleep.

Nocturnal seizures and the effects of anticonvulsants on sleep

Epilepsy is a common condition that affects up to 1% of the population. Patients with epilepsy are particularly sensitive to the adverse effects of sleep disruption. Failure to recognize and treat sleep disturbances can lead to worsening of attention, cognitive functioning, and quality of life, and can increase seizures. Anticonvulsant agents have the potential to either improve or worsen sleep and sleep disorders in patients with epilepsy. Therefore, awareness of the implications of sleep disorders and anticonvulsants is critical for the optimal care of patients with epilepsy.

Sleep and epilepsy: what we know, don't know, and need to know

Long-term video-EEG and, more recently, video-polysomnography, have provided the means to confirm and expand on the interconnections between sleep and epilepsy. Some of these relationships have become firmly established. When one of the authors (N.F.S.) presented part of this paper at a symposium on the Future of Sleep in Neurology at an American Clinical Neurophysiology Society annual meeting in 2004, the purpose was to summarize what we know, don't know, and need to know about the effects of sleep on epilepsy and epilepsy on sleep. Here we seek to summarize some of the more firmly established relationships between sleep and epilepsy and identify intriguing associations that require further elucidation.

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.

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.

Sleep and childhood epilepsy

The inter-relationship between sleep and epilepsy is well recognized. Sleep is known to activate inter-ictal epileptiform discharges. A special timing of seizure in relation to sleep wake cycle is certainly a childhood epileptic syndrome. Children with epilepsy commonly have sleep problems which may be due to seizures or due to anxiety. Somnolence and diurnal sedation are frequent side effects of anti-epileptic drugs. Thus epilepsy and its treatment can affect sleep leading to adverse effect on behavior, cognition and seizure control. Lack of sleep is an important trigger for epileptic seizures, therefore regular sleep must be a part of management strategy in children with epilepsy.

Hypersomnia in an Epilepsy Patient Treated with Levetiracetam

We report a patient with focal epilepsy in whom increased sleep needs (hypersomnia) developed in the absence of subjective excessive daytime sleepiness (EDS) during an add-on treatment with levetiracetam (LEV).

Comprehensive Care of the Epilepsy Patient-Control, Comorbidity, and Cost

Traditionally, control of seizures in patients with epilepsy is viewed as the most important clinical outcome. Yet, current antiepileptic drugs (AEDs) do not always achieve this. Around 30-40% of patients remain uncontrolled despite pharmacological intervention. Poor tolerability of AEDs is a large part of the problem and contributes as much to the overall effectiveness of therapy as efficacy. Comorbid conditions are present in many patients, and appropriate management of these can further improve seizure control and quality of life. Patients with epilepsy often experience--among other disorders--neuropsychological effects, migraines, and psychological problems (especially anxiety and depression). Sleep disturbances are also common and have been shown to contribute to the intractability of seizures in some patients. Many anticonvulsant treatments have the potential to improve--or in some cases worsen--these concurrent conditions, and these properties should therefore be considered in the total care of the patient. Finally, the costs of uncontrolled epilepsy are measured not only in terms of direct healthcare-related costs, but also in terms of lost productivity and opportunity. The indirect costs of epilepsy are substantial and account for 70-85% of total disease-related costs. Patients with uncontrolled seizures contribute disproportionately to healthcare costs, reinforcing the need for the development of newer AEDs with improved profiles of efficacy and tolerability, but with minimal adverse effects on behavior, cognition, and sleep.

Sleep, Sleep Apnea, and Epilepsy

Sleep disorders occur commonly in patients with epilepsy, and can be responsible for symptoms of daytime somnolence and also can contribute to the intractability of epilepsy. The most important aspect of treating sleep disorders, especially sleep apnea, is the recognition of the problem. In a busy clinical practice, symptoms of sleep disorders are frequently overlooked or mistaken. Whenever sleep disruption or excessive daytime somnolence is potentially problematic, the patient should be referred to a sleep specialist and, if indicated, diagnostic testing performed (usually polysomnography with or without multiple sleep latency tests). The author also recommends that all patients receive basic counseling about sleep hygiene, because its principles are often helpful to patients in general. Even in the absence of a sleep disorder, the choice of an anticonvulsant can be partly tailored to the sleep needs of the patient, with alerting drugs (lamotrigine and felbamate) dosed early in the day and relatively sedating agents (phenobarbital and phenytoin) dosed later or at bedtime.

Effects of antiepileptic drugs on sleep structure : are all drugs equal?

Good-quality sleep is an important and frequently overlooked component of general health, but it is particularly essential to patients with epilepsy. Their sleep can be affected by seizures, concurrent sleep disorders and seizure treatment. Worsening sleep can result not only in poor daytime functioning but also potentially in worsening epilepsy. The effects of antiepileptic drugs (AEDs) on sleep are of particular concern. Some agents have detrimental effects on sleep, particularly benzodiazepines and barbiturates but also phenytoin and, possibly, carbamazepine. Others, especially gabapentin, seem to actually improve sleep quality. Much research in this area is confounded by the effects of seizures and concurrent conditions on sleep, making it difficult to isolate the direct effects of AEDs on sleep. But because AEDs have independent effects on sleep quality, the choice of an appropriate agent not only determines whether seizures are completely controlled but also whether the patient performs optimally on a daily basis.

Aggressive behavior of epilepsy patients in the course of levetiracetam add-on therapy: report of 33 mild to severe cases

Levetiracetam (LEV) was shown to be very efficacious and well tolerated as add-on therapy for refractory epilepsy. Here we report 33 patients with longstanding histories of epilepsy who experienced aggressive episodes during LEV therapy. This corresponds to 3.5% of LEV-treated patients as compared with less than 1% of patients not on LEV. Among these cases, 24 showed only moderate, partly transient irritability, with 10 patients requiring reduction or discontinuation of LEV. More strikingly, 9 patients displayed severe symptoms of aggression with physical violence and, in 2 cases, the need for psychiatric emergency treatment. One patient developed additional psychotic symptoms. We suggest that, specifically in patients with a previous history of aggression, behavioral tolerability of LEV should be carefully monitored.