Daytime sleepiness in epilepsy patients: evaluation by means of the Epworth sleepiness scale

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Sleep and Epilepsy

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

Louis EK, Reichard RR, Edwards WD, Ackerman MJ, Somers VK. Confirmation of Cause of Death Via Comprehensive Autopsy and Whole Exome Molecular Sequencing in People With Epilepsy and Sudden Unexpected Death

Background

Sudden cardiac arrest is the leading mode of death in the United States. Epilepsy affects 1% of Americans; yet epidemiological data show a prevalence of 4% in cases of sudden cardiac arrest. Sudden unexpected death in epilepsy (SUDEP) may share features with sudden cardiac arrest. The objective of this study was to report autopsy and genomic findings in a large cohort of SUDEP cases.

Methods and Results

Mayo Clinic Sudden Death Registry containing cases (ages 0–90 years) of sudden unexpected and unexplained deaths 1960 to present was queried. Exome sequencing performed on decedent cases. From 13 687 cases of sudden death, 656 (4.8%) had a history of seizures, including 368 confirmed by electroencephalography, 96 classified as SUDEP, 58 as non‐SUDEP, and 214 as unknown (insufficient records). Mean age of death in SUDEP was 37 (±19.7) years; 56 (58.3%) were male; 65% of deaths occurred at night; 54% were found in bed; and 80.6% were prone. Autopsies were obtained in 83 cases; bystander coronary artery disease was frequently reported as cause of death; nonspecific fibrosis was seen in 32.6% of cases, in structurally normal hearts. There were 4 cases of Dravet syndrome with pathogenic variants in SCN1A gene. Using whole exome sequencing in 11 cases, 18 ultrarare nonsynonymous variants were identified in 6 cases including CACNB2, RYR2, CLNB, CACNA1H, and CLCN2.

Conclusions

This study examined one of the largest single‐center US series of SUDEP cases. Several cases were reclassified as SUDEP, 15% had an ECG when alive, and 11 (11.4%) had blood for whole exome sequencing analysis. The most frequent antemortem genetic finding was pathogenic variants in SCN1A; postmortem whole exome sequencing identified 18 ultrarare variants.

Sleep Disruption Worsens Seizures: Neuroinflammation as a Potential Mechanistic Link

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

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

BACKGROUND

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Subjective and objective hypersomnia highly prevalent in adults with epilepsy

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Evaluation of sleep quality in spouses of people with epilepsy

OBJECTIVE

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

METHODS AND MATERIALS

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

RESULTS

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

CONCLUSION

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

Sleep and circadian defects in a Drosophila model of mitochondrial encephalomyopathy

Mitochondrial encephalomyopathies (ME) are complex, incurable diseases characterized by severe bioenergetic distress that can affect the function of all major organ systems but is especially taxing to neuromuscular tissues. Animal models of MEs are rare, but the Drosophila ATP6¹ mutant is a stable, well-characterized genetic line that accurately models progressive human mitochondrial diseases such as Maternally-Inherited Leigh Syndrome (MILS), Neuropathy, Ataxia, and Retinitis Pigmentosa (NARP), and Familial Bilateral Striatal Necrosis (FBSN). While it is established that this model exhibits important hallmarks of ME, including excess cellular and mitochondrial reactive oxygen species, shortened lifespan, muscle degeneration, and stress-induced seizures, it is unknown whether it exhibits defects in sleep or circadian function. This is a clinically relevant question, as many neurological and neurodegenerative diseases are characterized by such disturbances, which can exacerbate other symptoms and worsen quality of life. Since Drosophila is highly amenable to sleep and circadian studies, we asked whether we could detect disease phenotypes in the circadian behaviors of ATP6¹. Indeed, we found that day-time and night-time activity and sleep are altered through disease progression, and that circadian patterns are disrupted at both the behavioral and neuronal levels. These results establish ATP6¹ as an important model of sleep and circadian disruption in ME that can be studied mechanistically at the molecular, cellular, and behavioral level to uncover underlying pathophysiology and test novel therapies.

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A Drosophila model of mitochondrial disease (ATP6¹) displays altered sleep patterns.

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ATP6¹ sleep quantity and consolidation are reduced in advanced disease.

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ATP6¹ is behaviorally arrhythmic under conditions of constant darkness.

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Selected neurons of the circadian circuit display altered daily firing rates in ATP6¹.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep-disordered breathing among patients admitted for inpatient video-EEG monitoring

Objective

To examine the prevalence and risk factors of sleep-disordered breathing (SDB) in individuals with epilepsy and psychogenic nonepileptic seizures (PNES).

Methods

We conducted a cross-sectional study of consecutive patients admitted for inpatient video-EEG monitoring at The Royal Melbourne Hospital, Australia, between December 1, 2011, and July 31, 2017. Participants underwent routine clinical investigations during their monitoring period including polysomnography, neurocognitive testing, and screening instruments of daytime somnolence, sleep quality, and quality of life.

Results

Our study population consisted of 370 participants who received a diagnosis of epilepsy (n = 255), PNES (n = 93), or both disorders (n = 22). Moderate to severe SDB (defined by an apnea-hypopnea index ≥15) was observed in 26.5% (98/370) of individuals, and did not differ across subgroups: epilepsy 26.3% (67/255), PNES 29.0% (27/93), or both disorders 18.2% (4/22; p = 0.610). Following adjustment for confounders, pathologic daytime sleepiness predicted moderate to severe SDB in epilepsy (odds ratio [OR] 10.35, 95% confidence interval [CI] 2.09–51.39; p = 0.004). In multivariable analysis, independent predictors for moderate to severe SDB in epilepsy were older age (OR 1.07, 95% CI 1.04–1.10; p < 0.001) and higher body mass index (OR 1.06, 95% CI 1.01–1.11; p = 0.029), and in PNES older age (OR 1.10, 95% CI 1.03–1.16; p = 0.002).

Conclusion

Polysomnography during inpatient video-EEG monitoring identified a substantial number of patients with undiagnosed SDB. This was remarkable in the subgroup with PNES, who were often female and obese. Identification of risk factors may improve management of SDB in these populations. The association with pathologic daytime sleepiness suggests that SDB may be an important contributor to these common and disabling symptoms in patients with epilepsy.

[An effect of epilepsy on sleep structure]

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

SIGNIFICANCE

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

Subjective sleep disturbance in Chinese adults with epilepsy: Associations with affective symptoms

BACKGROUND

As well as being a very common neurological disease worldwide, epilepsy significantly impairs patients' emotional, behavioral, and cognitive functioning. Sleep disturbances are the most frequent complaint in patients with epilepsy. The present study assesses the impact of a range of affective symptoms on subjective sleep quality and sleep disturbances in Chinese adults with epilepsy.

METHODS

Adults with epilepsy who visited our epilepsy clinic from July 2015 to March 2016 were enrolled in our study. Both patients and healthy controls completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Beck Depression Inventory-II (BDI-II), Beck Anxiety Inventory (BAI), and Mini-mental State Examination (MMSE). Subjective sleep quality and sleep disturbances were examined with regard to self-reported symptoms of depression and anxiety, seizure-related factors, and demographic factors.

RESULTS

The PSQI scores and ISI scores of patients were significantly higher (indicating lower quality sleep and more serious insomnia) than those of the control group. Symptoms associated with depression and anxiety were independently related to impaired subjective sleep quality and insomnia. Affective symptoms explained more of the variance in PSQI scores and ISI scores than did seizure-related or demographic variables. In addition, these variables also seemed to be less powerful contributing factors to subjective sleep quality and insomnia than affective symptoms, several seizure-related factors, such as seizure control, partial seizures and duration of epilepsy, which are also significantly associated with subjective sleep quality and insomnia. In addition, use of lamotrigine (LTG) was also associated with insomnia and use of clonazepam (CZP) and phenobarbital (PB) with daytime sleepiness in patients with epilepsy.

CONCLUSION

Chinese adults with epilepsy have poorer self-reported subjective sleep quality and a higher prevalence of insomnia than the control group. Depressive- and anxiety-related symptoms independently exert an adverse effect on the subjective sleep quality and insomnia of patients. In addition, seizure control, partial seizures, and the duration of epilepsy affect the quality of sleep and insomnia in patients, but seem less powerful predictors of sleep quality and insomnia than affective symptoms. Early identification and treatment of affective symptoms is of great importance in improving the sleep quality and insomnia of patients with epilepsy.

How do people with drug-resistant mesial temporal lobe epilepsy sleep? A clinical and video-EEG with EOG and submental EMG for sleep staging study

This study aimed to assess subjective and objective sleep parameters in a homogeneous group of drug-resistant mesial temporal lobe epilepsy (MTLE) patients through internationally validated clinical questionnaires, video-electroencephalographic (VEEG) and polysomnographic (PSG) studies. Fifty-six patients with definite diagnosis of MTLE who were candidates for epilepsy surgery underwent a detailed clinical history, the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Stanford Sleepiness Scale (SSS), neurological examination, 1.5 T brain magnetic resonance imaging, VEEG and PSG. Sixteen percent of patients reported significant daytime sleepiness as measured by ESS and 27% reported low levels of sleep quality as measured by PSQI. Patients with medically resistant epilepsy by MTLE showed increased wakefulness after sleep onset (WASO) with mean ± standard deviation of 17.4 ± 15.6, longer non-rapid eye movement (NREM) 1 (7.5 ± 4.6%) and NREM3 sleep (26.6 ± 11.8%), abnormal rapid eye movement (REM) latency in 30/56 patients, shorter REM sleep (16.7 ± 6.6%), and abnormal alpha delta patterns were observed in 41/56 patients. The analysis of interictal epileptic discharges (IEDs) evidenced highest spiking rate during NREM3 sleep and higher concordance with imaging data when IEDs were recorded in sleep, mainly during REM sleep. We concluded that patients with MTLE showed disrupted sleep architecture that may result in daytime dysfunction and sleep complaints. Furthermore, NREM sleep activated focal IEDs and them - when recorded during sleep - had higher localizing value.

Severity of self-reported insomnia in adults with epilepsy is related to comorbid medical disorders and depressive symptoms

BACKGROUND

Few studies have systematically investigated insomnia in adults with epilepsy.

METHODS

We performed a prospective cross-sectional investigation of the prevalence, severity, and comorbidities of insomnia in 90 adults with epilepsy using a battery of self-reported instruments and polysomnography. We quantified insomnia severity using the Insomnia Severity Index (ISI).

RESULTS

Fifty-nine of 90 (65.5%) adults with epilepsy reported insomnia (ISI≥8), moderate or severe (ISI≥15) in 28.9%. Good agreement between standard clinical diagnostic criteria and ISI was found for patients with ISI scores <8 and ≥15. Scores on the modified Beck Depression Inventory (mBDI) (r=0.25, p=0.021), the original BDI (r=0.32, p=0.002), and self-reported total sleep duration (TSD) (r=-0.3, p=0.006) were significantly related to ISI score. A multiple regression model found that decreased TSD (ß=-0.93, p=0.007), head trauma (ß=4.37, p=0.003), sedative-hypnotic use (ß=4.86, p=0.002), AED polytherapy (ß=3.52, p=0.005), and asthma/COPD (ß=3.75, p=0.014) were predictors of a higher ISI score. For 63 patients with focal epilepsy, an increased mBDI (ß=0.24, p=0.015), decreased TSD (ß=-1.11, p=0.008), asthma/COPD (ß=4.19, p=0.02), and epilepsy surgery (ß=5.33, p=0.006) were significant predictors of an increased ISI score. Patients with temporal lobe epilepsy (TLE) showed a trend for greater severity compared with those with extra-TLE (ß=-2.92, p=0.054).

CONCLUSIONS

Our findings indicate that severity of insomnia in adults with epilepsy is more likely to be associated with comorbid medical and depressive symptoms and less likely to be directly related to epilepsy. Good agreement between standard clinical diagnostic criteria for insomnia and the ISI for subjects without insomnia symptoms and for those with moderate-to-severe symptoms supports the use of this instrument in epilepsy research.

Associations of impaired sleep quality, insomnia, and sleepiness with epilepsy: A questionnaire-based case-control study

PURPOSE

The purpose of this study was to document the frequency of sleep problems including poor sleep quality, excessive daytime sleepiness, and insomnia in subjects with epilepsy compared with healthy controls and to determine the factors associated with these sleep disturbances.

METHODS

We recruited 180 patients with epilepsy (age: 43.2 ± 15.6 years, men: 50.0%) and 2836 healthy subjects (age: 44.5 ± 15.0 years, men: 49.8%). Sleep and the anxiety/mood profiles were measured using the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Insomnia Severity Index, Goldberg Anxiety Scale, and Patient Health Questionnaire-9 depression scale. Associations of sleep problems with epilepsy and other factors were tested by multiple logistic regression analysis, adjusted for age, gender, body mass index, alcohol intake, smoking, perceived sleep insufficiency, and habitual snoring.

RESULTS

Sleep disturbances were more common in the group with epilepsy than in the controls (53.3% vs. 25.5%; p<0.001). Poor sleep quality, excessive daytime sleepiness, and insomnia were significantly associated with epilepsy (odds ratio [95% confidence interval]: 3.52 [2.45-5.05], 2.10 [1.41-3.12], 5.91 [3.43-10.16], respectively). Depressive mood, anxiety, and perceived sleep insufficiency contributed to the presence of sleep disturbances. In the group with epilepsy, seizure remission for the past year related to a lower frequency of insomnia, whereas age, sex, type of epilepsy, and number of antiepileptic drugs were not correlated with sleep problems.

CONCLUSION

Epilepsy was significantly associated with the higher frequency of sleep disturbances, which supports the importance of screening sleep problems in patients with epilepsy and providing available intervention.

Depressive symptoms predict the quality of sleep in patients with partial epilepsy--A combined retrospective and prospective study

INTRODUCTION

Epilepsy is one of the most common neurological diseases and has many detrimental effects on the patients' well-being as well as sleep quality. The aim of this study was to assess the subjective quality of sleep and influencing factors on subjective sleep quality in patients with partial epilepsy using a combined retrospective and prospective study design.

METHODS

We conducted a combined retrospective and prospective study in patients with partial epilepsy and analyzed subjective ratings of sleep quality in 32 patients (17 female, 15 male; mean age: 40.41 ± 12.67 years, range: 20-64) with partial epilepsy (mean duration of epilepsy diagnosis: 18.31 ± 13.26 years) and 32 healthy gender-matched and age-matched controls. All patients filled out a seizure diary for 90 days, which included the number, duration, and type (partial vs. secondary generalized) of epileptic seizures and intake of antiepileptic and sleep medications. At baseline, all participants completed the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Beck's Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Poor sleepers were defined by a PSQI score of ≥ 5.

RESULTS

Twenty-three patients (72%) reported 15.17 ± 25.54 seizures in the previous three months, and nine (28%) patients reported being seizure-free. During the 90-day diary period, twenty-two patients (69%) documented a total of 319 epileptic seizures, while ten patients (31%) reported that they were seizure-free. The mean PSQI score of all patients was 4.88 ± 2.92 (range: 1-14) and the mean ESS score was 5.25 ± 2.98 (range: 0-10). The mean PSQI score of the control group was 3.25 ± 1.57 (range: 1-6), and their mean ESS score was 6.72 ± 3.48 (range: 0-14). The comparison of the two groups showed a significantly higher PSQI score in the patient group (t = 2.778, p = 0.008), but no statistically significant difference regarding their ESS score (t = -1.811, p = 0.075). Sixteen (50%) patients were poor sleepers. Good sleepers showed a significantly lower PSQI (2.69 ± 1.08 vs. 7.06 ± 2.49; p < 0.001) and BDI scores (2.38 ± 2.50 vs. 9.63 ± 7.63; p < 0.002) than poor sleepers. Linear regression analysis showed that the BDI score was the significant predictor for the PSQI score (estimate: 0.2019; p = 0.00819) and for the ESS score (estimate: 0.2251; p = 0.0321).

CONCLUSION

In patients with partial epilepsy, a higher depression score was the best predictor for a poor subjective sleep quality and increased daytime sleepiness.

Sleep and Epilepsy

Sleep and epilepsy are common bedfellows. Sleep can affect frequency and occurrence of interictal spikes and occurrence, timing, and threshold of seizure. Epilepsy can worsen sleep architecture and severity of sleep disorders. Thus, a vicious cycle is set. Certain epilepsy syndromes are so intertwined with sleep that they are considered sleep-related epilepsies. Poor sleep in epilepsy is multifactorial and is worsened by poorly controlled seizures. On the contrary, poor sleep is associated with worsened quality of life, psychological function, and memory. Improving sleep has been noted to improve seizure frequency and an overall well-being in patients with epilepsy. Hence, an emphasis should be given to address sleep in patients with epilepsy. These interactions are discussed in detail in this review.

A new model to study sleep deprivation-induced seizure

BACKGROUND AND STUDY OBJECTIVES

A relationship between sleep and seizures is well-described in both humans and rodent animal models; however, the mechanism underlying this relationship is unknown. Using Drosophila melanogaster mutants with seizure phenotypes, we demonstrate that seizure activity can be modified by sleep deprivation.

DESIGN

Seizure activity was evaluated in an adult bang-sensitive seizure mutant, stress sensitive B (sesB(9ed4)), and in an adult temperature sensitive seizure mutant seizure (sei(ts1)) under baseline and following 12 h of sleep deprivation. The long-term effect of sleep deprivation on young, immature sesB(9ed4) flies was also assessed.

SETTING

Laboratory.

PARTICIPANTS

Drosophila melanogaster.

INTERVENTIONS

Sleep deprivation.

MEASUREMENTS AND RESULTS

Sleep deprivation increased seizure susceptibility in adult sesB(9ed4)/+ and sei(ts1) mutant flies. Sleep deprivation also increased seizure susceptibility when sesB was disrupted using RNAi. The effect of sleep deprivation on seizure activity was reduced when sesB(9ed4)/+ flies were given the anti-seizure drug, valproic acid. In contrast to adult flies, sleep deprivation during early fly development resulted in chronic seizure susceptibility when sesB(9ed4)/+ became adults.

CONCLUSIONS

These findings show that Drosophila is a model organism for investigating the relationship between sleep and seizure activity.

Daytime sleepiness in de novo untreated patients with epilepsy

The aims of our study were to evaluate excessive daytime sleepiness in a group of de novo untreated people with epilepsy using a comprehensive and standardized approach, including subjective evaluation and neurophysiological and performance tests, and to compare these results with those obtained in a control group. Forty-seven patients with epilepsy (17 affected by primary generalized epilepsy and 30 by partial epilepsy), with a new epilepsy diagnosis and never treated, and 44 controls underwent Multiple Sleep Latency Test (preceded by nocturnal polysomnography), simple/complex visual reaction times, and Epworth Sleepiness Scale evaluation. Newly diagnosed and drug-free patients with epilepsy did not differ from controls in any of the tests performed to evaluate daytime sleepiness. In clinical practice, daytime sleepiness is a well-known and frequent complaint of patients with epilepsy, but different mechanisms and causes, such as associated psychiatric or sleep disorders, nocturnal seizures, sleep fragmentation, and antiepileptic drugs, must be taken into account. Excessive daytime sleepiness should not be considered an unavoidable consequence of epilepsy. Thus, a complete diagnostic work-up in patients with epilepsy and sleepiness should be undertaken whenever possible.

Excessive daytime sleepiness and epilepsy: a systematic review

Background. Sleep complaints are common in patients with epilepsy (PWE). Excessive daytime sleepiness (EDS) is one of the most reported complaints and its impact is still a matter of debate. Objective. Evaluate the relationship between EDS and epilepsy, with emphasis on prevalence, assessment, and causes. Methods. A systematic review on PubMed database in the last 10 years (2002 to 2012). The search returned 53 articles and 34 were considered relevant. After citation analysis, 3 more articles were included. Results. Most studies were cross-sectional and questionnaire based. 14 papers addressed EDS as the primary endpoint. 14 adult and 3 children studies used subjective and objective analysis as methodology. The number of studies increased throughout the decade, with 21 in the last 5 years. Adult studies represent almost three times the number of children studies. EDS prevalence in PWE varies from 10 to 47.5%. Prevalence was higher in developing countries. Conclusion. EDS seems to be related more frequently to undiagnosed sleep disorders than to epilepsy-related factors, and although it affects the quality of life of PWE, it can be improved by treating comorbid primary sleep disorders.

Provider practices impact adequate diagnosis of sleep disorders in children with epilepsy

Sleep disorders significantly affect the lives of children with epilepsy. Limited data exist about provider practices concerning detection and correct diagnosis of sleep problems in epilepsy. The authors conducted this study to identify and correlate sleep screening methods, referral practices, referral reasons and final sleep diagnoses. They identified that 94% of the providers who had referred patients to the sleep center of a major children's hospital used routine screening and 70% of them used 2 to 3 screening questions. This method, however, underidentified the patients at risk for sleep disorders. Moreover, in 40% of the children, sleep disorder was incorrectly anticipated, based on the initial symptoms. Of these children, 10% had no sleep disorder and 30% had unexpected sleep disorder. The authors conclude that better screening methods should be used for sleep disorders. Once identified, these patients should have formal sleep evaluation and management. Further studies are needed to develop screening questionnaires.

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.

Sleep apnea and epilepsy: who's at risk?

Obstructive sleep apnea (OSA) is highly prevalent, affecting 25% of men and 10% of women. Treatment reduces seizures in some patients. Awareness of the comorbidity of sleep disturbances in epilepsy has been increasing. No study has explored OSA predictors in patients unselected for epilepsy severity and sleep disorder symptoms. We assessed cross-sectional OSA prevalence and predictors (apnea-hypopnea index [AHI] ≥10) in 130 consecutive adults using structured interview, subjective assessments, and polysomnography. Obstructive sleep apnea prevalence was 30%, 16% having moderate-severe disease, rates that markedly exceed general population estimates. Obstructive sleep apnea predictors in multivariate modeling included age, dental problems, and standardized AED dose. Male gender, older age, higher BMI, hypertension, and dental problems were associated with higher AHI. Adults with epilepsy appear at increased risk for OSA, increasing with age and AED load, regardless of gender, BMI, and seizure frequency. These findings support the implementation of routine OSA screening in adult epilepsy clinics.

Excessive daytime sleepiness in patients with epilepsy: a subjective evaluation

OBJECTIVE

The main objective of the study was to evaluate excessive daytime sleepiness (EDS) in patients with epilepsy from a tertiary outpatient clinic in Rio de Janeiro, Brazil.

METHODS

Ninety-nine unselected patients from the epilepsy outpatient clinic were invited and their sleep-wake habits were assessed by means of a clinical interview and four validated instruments: Epworth Sleepiness Scale, Beck Depression Inventory, Beck Anxiety Inventory, and the Basic Nordic Sleep Questionnaire. Sociodemographic information and characteristics of the epilepsy syndrome were collected.

RESULTS

Complaints about EDS (Epworth Sleepiness Scale score >10) were reported by 47.5% (95% CI: 37.3-57.7) of the patients. In the sample, 52.6% (95% CI: 0.41-0.60) were overweight or obese, and 53.1% (95% CI: 0.43-0.62) had less than 8 years of formal education. Mainly anxiety, but also neck circumference, was correlated with EDS. Our patients did not exhibit quantitative sleep deprivation. No other epilepsy-related variable showed relationship with EDS. The prevalence of EDS in our population was higher than in similar studies performed in other countries. This finding does not seem to be related to epilepsy itself, but rather to other clinical factors, such as neck circumference, and mainly psychiatric factors, such as anxiety.

CONCLUSIONS

Psychiatric comorbidities such as anxiety are linked to EDS and should be recognized and treated. More studies based on objective sleep quality analysis are needed to help elucidate these relationships in the Brazilian population.

Comparative levels of excessive daytime sleepiness in common medical disorders

INTRODUCTION

Sleep restriction and sleep disorders are common causes of excessive daytime sleepiness (EDS). Medical disorders (MD) can also cause EDS, but previous studies have used non-standardized measures, selected samples, or have examined EDS in singular disorders. This study describes the relative degree of EDS associated with medical disorders to provide comparative data across a range of common medical conditions in a large unselected community-based sample.

METHODS

Responses of 2612 individuals (aged 18-65) were assessed after excluding those with suspected sleep disordered breathing, narcolepsy, and shift workers. Participants across a range of medical disorders were evaluated using the Epworth Sleepiness Scale (ESS) and patient reports of nocturnal sleep.

RESULTS

Sixty-seven percent of the sample reported a MD. The prevalence of EDS (ESS>or=10) was 31.4% in individuals with MD and increased as a function of a number of MD (0 MD=29.4%, 1 MD=28.4%, 2 MD=31.0%, 3 MD=35.3%, 4 MD=38.4%). Disorders which were independent predictors of EDS were ulcers OR=2.21 (95% CI=1.35-3.61), migraines OR=1.36 (95% CI=1.08-1.72), and depression OR=1.46 (95% CI=1.16-1.83) after controlling for other conditions, age, gender, time in bed, caffeine, smoking and alcohol use. Participants with ulcers had the highest prevalence of sleepiness, 50.0%, as well as the highest level of problems falling asleep (40.8%) and awakenings during the night (62.5%).

CONCLUSIONS

Individuals with ulcers, migraines, and depression have independent and clinically significant levels of EDS relative to other common MD.

Epilepsy and sleep

A sleep history should be taken routinely in patients with epilepsy. Treatment of sleep disorders and improvement in sleep hygiene may improve seizure control, daytime cognitive functioning, and quality of life. Patients with recurrent sleepiness interfering with daily activities or an Epworth Sleepiness Scale score more than 10 should be considered for additional evaluation by a sleep specialist. Treatment options for insomnia include improvements in sleep hygiene, cognitive behavior therapies, and sedative or hypnotic drugs. Alterations in the timing or type of antiepileptic drugs (AEDs) may be helpful (for example, using sedating medications before bedtime and avoiding evening use of drugs that may exacerbate insomnia ). Improvements in sleep hygiene alone are less effective than cognitive behavioral therapy or pharmacologic therapy. Cognitive behavioral therapy is more efficacious and its effects longer lasting than pharmacologic treatments. Sedative and hypnotic drugs may exacerbate AED cognitive adverse effects during the day and should be used only after other therapies have failed. Excessive daytime sleepiness (EDS) in patients with epilepsy may be secondary to AEDs, nocturnal seizures, or a concomitant sleep disorder such as sleep apnea or restless leg syndrome. Sedating AEDs should be minimized during the day, and activating AEDs should be used as appropriate. Video electroencephalogram polysomnography should be performed when EDS interferes with daily activities and the etiology of sleepiness is unclear. AEDs that are associated with weight gain should be avoided in patients with sleep apnea. AEDs that may promote weight loss should be considered for obese patients with sleep apnea. Continuous positive airway pressure is the treatment of choice for sleep apnea.

Clinical utility of the Chinese version of the Pediatric Daytime Sleepiness Scale in children with obstructive sleep apnea syndrome and narcolepsy

AIM

The present study examined the psychometric properties of the Chinese version of the Pediatric Daytime Sleepiness Scale (PDSS) and the utility of the PDSS as a screening tool for pathological daytime sleepiness in teenagers with obstructive sleep apnea (OSA) and narcolepsy.

METHODS

The PDSS was first administered to 238 middle and high school students to assess the reliability of the scale, and then administered to 28 teenagers with OSA, 31 teenagers with narcolepsy, and 34 normal controls to evaluate its clinical utility.

RESULTS

Test-retest reliability and internal consistency were acceptable. The PDSS scores were significantly higher in narcoleptic subjects than in subjects with OSA, and higher in OSA syndrome (OSAS) subjects than normal controls. Furthermore, the scores decreased in narcoleptic subjects after medical treatment. Both reliability and validity were proven to be good. As a screening tool for narcolepsy, receiver operator characteristic (ROC) curve analysis showed that the PDSS, with a cut-off score of 16/17, had good sensitivity (87.1%) and fair specificity (74.3%) for identifying individuals with narcolepsy. When used for screening OSA, however, the differentiating power was not as good.

CONCLUSION

The PDSS is a reliable and valid tool for the measurement of sleepiness in clinical youth populations. When used as a screening tool, it is useful for sleep disorders involving more severe pathological sleepiness, as in narcolepsy.

Influence of sleep disturbance on quality of life of patients with epilepsy

The frequency of sleep disturbances in patients with epilepsy and their impact on quality of life (QoL) have been documented in a few reports, and the results are conflicting. We identified 124 consecutive epilepsy out-patients who visited the epilepsy out-patient clinics at the University Hospital of Alexandroupolis, the AHEPA Hospital in Thessaloniki and the Aeginitio Hospital in Athens. We measured excessive daytime sleepiness (EDS) with the Epworth Sleepiness Scale (ESS), obstructive sleep apnea (OSA) with the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ), and insomnia with the Athens Insomnia Scale (AIS). We evaluated quality of life by the Quality of Life in Epilepsy Inventory (QOLIE-31). EDS was found in 16.9% (21/124) of epileptic patients, OSA in 28.2% (35/124), and insomnia in 24.6% (30/122). In multivariate analysis, we found that insomnia was an independent negative factor for Total score (p<0.001), Overall QoL (p=0.002), Emotional well-being (p<0.001), Energy/fatigue (p<0.001), Cognitive functioning (p=0.04) and Social functioning (p=0.03), and OSA only for Cognitive functioning (p=0.01). According to our findings, EDS, OSA, and insomnia are frequent in epileptic patients. Epileptic patients with sleep disturbance, mainly insomnia, have significant QoL impairment.

Subjective somnolence relates mainly to depression among patients in a tertiary care epilepsy center

Many patients with epilepsy complain of decreased energy and somnolence. There is increased awareness that comorbidity, especially depression, plays an important role in determining the quality of life for patients with epilepsy. We set out to determine how subjective somnolence is affected by depression, age, hours of sleep, sleep apnea, seizure frequency, and numbers of antiepileptic drugs and central nervous system drugs. A questionnaire and chart review were used to investigate patients in a tertiary referral center. We found that subjective somnolence was prominent and that it relates mainly to depression, less to obstructive sleep apnea, and not to the other variables. Further investigation is needed into the relationship between depression and subjective somnolence in 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.

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

The aim of the study was to assess sleep-wake habits and disorders and excessive daytime sleepiness (EDS) in an unselected outpatient epilepsy population. Sleep-wake habits and presence of sleep disorders were assessed by means of a clinical interview and a standard questionnaire in 100 consecutive patients with epilepsy and 90 controls. The questionnaire includes three validated instruments: the Epworth Sleepiness Scale (ESS) for EDS, SA-SDQ for sleep apnea (SA), and the Ullanlinna Narcolepsy Scale (UNS) for narcolepsy. Sleep complaints were reported by 30% of epilepsy patients compared to 10% of controls (p=0.001). The average total sleep time was similar in both groups. Insufficient sleep times were suspected in 24% of patients and 33% of controls. Sleep maintenance insomnia was more frequent in epilepsy patients (52% vs. 38%, p=0.06), whereas nightmares (6% vs. 16%, p=0.04) and bruxism (10% vs. 19%, p=0.07) were more frequent in controls. Sleep onset insomnia (34% vs. 28%), EDS (ESS >or=10, 19% vs. 14%), SA (9% vs. 3%), restless legs symptoms (RL-symptoms, 18% vs. 12%) and most parasomnias were similarly frequent in both groups. In a stepwise logistic regression model loud snoring and RL-symptoms were found to be the only independent predictors of EDS in epilepsy patients. In conclusion, sleep-wake habits and the frequency of most sleep disorders are similar in non-selected epilepsy patients as compared to controls. In epilepsy patients, EDS was predicted by a history of loud snoring and RL-symptoms but not by SA or epilepsy-related variables (including type of epilepsy, frequency of seizures, and number of antiepileptic drugs).

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.

Subjective sleep disturbance in patients with partial epilepsy: a questionnaire-based study on prevalence and impact on quality of life

PURPOSE

This study was designed to assess whether sleep disturbance is more frequent among patients with partial seizures and what impact on quality of life (QoL) sleep disturbance may have on patients with partial seizures.

METHODS

Questionnaire booklets were mailed to 1,183 patients from four Dutch clinics. Each patient was asked to find two age- and gender-matched controls to complete the same set of questionnaires [Sleep Diagnosis List (SDL), Medical Outcomes Study (MOS)-Sleep Scale, Groningen Sleep Questionnaire, Epworth Sleepiness Scale, and the SF-36 Health Survey]. The prevalence of sleep disturbance, based on the SDL, was compared between those with partial epilepsy and controls. Mean scores on sleep and the SF-36 Physical (PCS) and Mental (MCS) Component Summary scales were compared.

RESULTS

Responses from 486 patients and 492 controls were analyzed. Respondents with partial epilepsy had a highly significant, twofold higher prevalence of sleep disturbance compared with controls (38.6 vs. 18.0%; p < 0.0001). Most sleep-disorder subscales showed significant abnormalities in respondents with epilepsy, compared with controls. Mean SF-36 MCS and PCS scores were significantly lower in respondents with epilepsy compared with controls in both the strata with sleep disturbance and without (all p values <0.05). The presence of a sleep disturbance in respondents with epilepsy was associated with the greatest impairment in QoL.

CONCLUSIONS

Sleep disturbance is more than twice as prevalent in persons with partial epilepsy compared with controls, and most domains of sleep are significantly disturbed. Persons with partial epilepsy have significant QoL impairment, and sleep disturbance further compounds this.

Excessive daytime sleepiness and sleep disturbances in patients with neurological diseases: epidemiology and management

Up to 12% of the general population experience excessive daytime sleepiness (EDS), with increasing prevalence in the elderly. EDS may lead to cognitive impairment, resulting in inattentiveness, poor memory, mood disorders and an increased risk of accidents. As a result, quality of life is reduced in most patients with EDS as well as in their caregiving spouses. There are a variety of causes leading to EDS, including CNS pathology, neurological dysfunction, associated sleep disorders with insufficient or fragmented sleep, and drug therapy. Since EDS accompanies many neurological disorders, such as neurodegenerative and neuromuscular diseases, neurologists should be familiar with the diagnosis, its major causes and with treatment options. The main focus of this article is on movement disorders, neuromuscular diseases, multiple sclerosis, dementia, cerebrovascular diseases, head and brain trauma, pain and epilepsy. General management strategies for EDS in all these neurological diseases include sleep hygiene aspects such as extensions of noctural time in bed and frequent naps during the day. Pharmacological treatment is generally achieved with stimulants such as amphetamine, methylphenidate and pemoline, or newer compounds such as modafinil.