Insomnia symptoms in South Florida military veterans with epilepsy

Insomnia in neurological disorders: Prevalence, mechanisms, impact and treatment approaches

Insomnia is more prevalent in neurological disorders compared to the general population, with rates ranging from 11 to 74.2% in neurodegenerative disorders, 20 to 37% in vascular diseases, 13.3 to 50% in inflammatory diseases, 28.9 to 74.4% in epilepsy, and nearly 70% in migraines. Insomnia in neurological disorders stems from a variety of factors, encompassing physical and neuropsychiatric factors, behavioral patterns, and disruptions in the biological clock and circadian rhythm. There are bidirectional connections between neurological disorders and insomnia. Insomnia in neurological disorders worsens symptoms, resulting in heightened depressive symptoms, elevated mortality rates, reduced quality of life, and intensified acute symptoms. Managing comorbid sleep disorders, especially in the presence of psychiatric comorbidities, is crucial. Cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommendation for insomnia management in neurological disorders. Other treatments are second-line strategies. Melatonin may demonstrate effectiveness in addressing insomnia, with soporific and chronobiotic effects. Furthermore, it has the potential to alleviate "sundowning" and behavioral disturbances, while generally being well-tolerated. Other treatment options that may be of interest include morning bright light therapy, sedative antidepressants, new orexin dual antagonists and levodopa specifically indicated for Parkinson's disease. Benzodiazepines and z-drugs can be used primarily during acute phases to prevent pharmacotolerance and minimize side effects. However, they should be avoided in patients with neurological disorders and not used in patients over 75 years old due to the risk of falls and confusion. In neurological disorders, insomnia has a profound impact on daytime functioning, making its management crucial. Effective treatment can result in improved outcomes, and additional research is necessary to investigate alternative therapeutic options and enhance patient care.

Effects of insomnia and levels of depression and anxiety symptoms on quality of life in people with epilepsy

OBJECTIVES

The association between insomnia and quality of life (QOL) in epilepsy is poorly understood and may involve interactive variables. We aimed to investigate whether and how insomnia, levels of depression and anxiety symptoms interact to influence QOL in people with epilepsy (PWE).

METHODS

A consecutive cohort of 179 PWE was enrolled. We collected data on insomnia, levels of depression and anxiety symptoms, and QOL. The Insomnia Severity Index (ISI), Depression Inventory for Epilepsy (NDDI-E), Generalized Anxiety Disorder-7 (GAD-7), and QOL in Epilepsy Inventory (QOLIE-31) were used. The direct, indirect, and total effects of insomnia on QOL were estimated based on a moderated mediation model.

RESULTS

Depression symptom levels mediated the association between insomnia and QOL (B = 0.09 SE = 0.03, p = 0.01). Depression symptom levels accounted for 34.7% of the total effect of insomnia on QOL. The mediating effect of depression symptom levels was positively moderated by anxiety symptom levels (B = 0.09, SE = 0.03, p = 0.01).

CONCLUSION

The effect of insomnia on QOL can be partially explained by the mediation of depression symptom levels. Additionally, improving anxiety symptoms may attenuate the indirect effect of insomnia on QOL through depression symptom levels.

Drugs for patients with epilepsy and excessive daytime sleepiness

Excessive daytime sleepiness (EDS) and attentional deficits are often observed in people with epilepsy. They may be the consequence of seizures and subclinical discharges as well as of comorbid conditions as obstructive sleep apnea/hypopnea syndrome (OSAS), attention deficit hyperactivity disorder (ADHD), or other less frequent disorders. Excessive daytime sleepiness may also be caused or worsened by antiseizure medications (ASMs). Several meta-analyses suggested that lamotrigine, lacosamide, and perhaps eslicarbazepine are less sedative than other traditional and new ASMs and, in patients prone to somnolence, might be preferred over ASMs with more sedative properties. In patients with severe EDS and/or ADHD, advantages and risks of a treatment with a psychostimulant need to be considered. Methylphenidate, modafinil, armodafinil, pitolisant, and solriamfetol are authorized for use in ADHD and EDS in patients with narcolepsy and some of them also in OSAS. These agents are off-label for the treatment of EDS associated with epilepsy. They do not have proconvulsant effects, although there are several possible risks for patients with epilepsy. The risks of cardiovascular events and psychiatric symptoms should be carefully evaluated as such disorders can coexist with epilepsy and be triggered by these agents. Finally, combination of psychostimulants with ASMs may be associated with several pharmacokinetic drug-drug interactions.

The risk factors for insomnia and sleep-disordered breathing in military communities: A meta-analysis

BACKGROUND

Many reviews and meta-analyses had been conducted to investigate risk factors for sleep disorders in the general population. However, no similar research has been performed in the military population though insomnia and sleep-disordered breathing are quite prevalent in that population.

OBJECTIVES

To investigate risk factors for insomnia and sleep-disordered breathing in military personnel.

METHODS

A systematic literature search was performed from inception to March 2021 and 6496 records were produced. Two authors independently screened records for eligibility. Results were presented as odds ratios, and a random-effect model was used to pool results. Data analysis was performed respectively according to military personnel type (i.e., veteran, active-duty personnel). Risk factors were sorted into three categories: sociodemographic, army-specific, and comorbidity. This meta-analysis was registered in PROSPERO before data analysis (registration No: CRD42020221696).

RESULTS

Twenty-seven articles were finally included in the quantitative analysis. For sleep-disordered breathing in active-duty personnel, four sociodemographic (i.e., overweight/obesity, higher body mass index, male gender, >35 years old) and one comorbidity (i.e., depression) risk factors were identified. For insomnia in active-duty personnel, four sociodemographic (i.e., aging, alcohol dependence, white race, and female gender), two army-specific (i.e., deployment experience, combat experience), and four comorbidity (i.e., depression, post-traumatic stress disorder, traumatic brain injury, and anxiety) risk factors were identified. For insomnia in veterans, one army-specific (i.e., combat experience) and one comorbidity (i.e., post-traumatic stress disorder) risk factor was identified.

CONCLUSIONS

Several risk factors were identified for insomnia and sleep-disordered breathing in the current meta-analysis. Risk factors for veterans and active-duty personnel were partially different. Research on sleep breathing disorders remains limited, and more convincing evidence would be obtained with more relevant studies in the future.

Insomnia in neurological diseases

Insomnia is defined as difficulties of initiating and maintaining sleep, early awakening and poor subjective sleep quality despite adequate opportunity and circumstances for sleep with impairment of daytime performance. These components of insomnia - namely persistent sleep difficulties despite of adequate sleep opportunity resulting in daytime dysfunction - appear secondary or co-morbid to neurological diseases. Comorbid insomnia originates from neurodegenerative, inflammatory, traumatic or ischemic changes in sleep regulating brainstem and hypothalamic nuclei with consecutive changes of neurotransmitters. Symptoms of neurological disorders (i.e motor deficits), co-morbidities (i.e. pain, depression, anxiety) and some disease-specific pharmaceuticals may cause insomnia and/or other sleep problems.This guideline focuses on insomnias in headaches, neurodegenerative movement disorders, multiple sclerosis, traumatic brain injury, epilepsies, stroke, neuromuscular disease and dementia.The most important new recommendations are: Cognitive behavioral therapy (CBTi) is recommended to treat acute and chronic insomnia in headache patients. Insomnia is one of the most frequent sleep complaints in neurodegenerative movement disorders. Patients may benefit from CBTi, antidepressants (trazodone, doxepin), melatonin and gaba-agonists. Insomnia is a frequent precursor of MS symptoms by up to 10 years. CBTi is recommended in patients with MS, traumatic brain injury and. Melatonin may improve insomnia symptoms in children with epilepsies. Patients with insomnia after stroke can be treated with benzodiazepine receptor agonists and sedating antidepressants. For patients with dementia suffering from insomnia trazodone, light therapy and physical exercise are recommended.

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

RATIONALE

Patients with epilepsy experience frequent episodes of fragmented sleep which may contribute to chronic sleep loss. Enhancing sleep patterns might lead to improved quality of life in these patients. Currently, unlike some other antiepileptic drugs (AEDs), there are no data on the effects of clobazam, a novel AED on sleep. Therefore, we tested the hypothesis that patients with epilepsy will have longer, more consolidated sleep after treatment with clobazam.

METHODS

In this prospective study, we included adults with drug-resistant epilepsy who were being considered for treatment with clobazam. Patients with known untreated moderate/severe sleep apnea or with major circadian rhythm disorders were excluded. We tested a set of the following subjective sleep measures: Pittsburgh Sleep Quality Inventory (PSQI), Epworth Sleepiness Scale (ESS), Karolinska Sleepiness Scale (KSS), Insomnia Severity Index (ISI), and Quality of Life in Epilepsy (QOLIE) prior to starting the treatment, as well as after achieving a stable clobazam dose. We also measured sleep pattern using wrist actigraphy - before starting therapy and after achieving stable dose.

RESULTS

A total of 12 participants completed all parts of the study. After treatment, a lower number of awakenings and less wake after sleep onset (WASO) were seen, as well as a lower number of seizures. Average pretreatment bedtime was 23:45, and average wake time was 8:24. A higher seizure frequency significantly correlated with all subjective sleep measures, as well as with a higher amount actigraphy measured WASO and less total sleep time (TST) measured both by sleep log and by actigraphy. Those with higher baseline WASO by actigraphy also had more depressive symptoms, worse quality of life, longer duration of epilepsy, and a higher seizure frequency.

CONCLUSION

Both objective and subjective sleep metrics correlate with depressive symptoms and quality of life. After treatment, there were fewer awakenings as well as fewer seizures.

Analysis of the evidence of related factors, associated conditions and at-risk populations of the NANDA-I nursing diagnosis insomnia

Objectives

To summarize evidence in the literature on the predictors of insomnia in adults and to determine correspondences with diagnostic indicators of the NANDA-I diagnosis Insomnia.

Methods

An integrative review performed in Pubmed, Virtual Health Library and CINAHL. Forty-eight articles published in Portuguese, English or Spanish from 2011 to 2018 were included. An analysis of correspondence between the predictors and the NANDA-I related factors and associated conditions for Insomnia was performed.

Results

There was a correspondence of the predictors found in this review with NANDA-I related factors and associated conditions, except for grieving and frequent naps during the day. Smoking, caffeine intake, dysfunctional sleep beliefs, obesity and caregiver role strain are possible new related factors; chronic illness is a possible new associated condition and individuals going through changes in marital status, economically disadvantaged, female gender, increasing age and night shift worker are possible new at-risk populations.

Conclusion

The predictors of insomnia that had a correspondence with the NANDA-I elements can support the evidence base of the nursing diagnosis. The predictors found without a correspondence with the diagnosis can be considered for inclusion in the NANDA-I classification, thereby supporting the clinical reasoning of nurses and students.

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.

Group-based cognitive behavioral therapy program for improving poor sleep quality and quality of life in people with epilepsy: A pilot study

Sleep difficulties are commonly reported by patients with epilepsy and can have a detrimental impact on overall quality of life. The purpose of this pilot study was to assess the efficacy of a psychotherapeutic approach, namely Cognitive Behavioral Therapy for Insomnia (CBT-I), in improving sleep quality in patients with epilepsy. Twenty outpatients with epilepsy who reported poor sleep quality were randomized to either a control or CBT-I treatment group, which involved four group-based CBT-I sessions, delivered on a weekly basis. In addition to completing a range of standardized measures related to sleep quality and quality of life, participants also monitored their sleep with a self-completed sleep diary over a two-week period, on two separate occasions. Following CBT-I treatment, no between-group difference was found on any sleep or quality of life measure. However, both the treatment and control groups improved on measures of sleep quality, quality of life, sleep hygiene behaviors, and dysfunctional beliefs about sleep. These findings suggest that sleep monitoring alone may have the potential for prompting healthy behavior change in this clinical population.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An Evidence Map of the Women Veterans' Health Research Literature (2008-2015)

BACKGROUND

Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning.

METHODS

The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps.

RESULTS

We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials.

CONCLUSIONS

Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.

Effect of lamotrigine, levetiracetam & topiramate on neurobehavioural parameters & oxidative stress in comparison with valproate in rats

Background & objectives:

Though newer antiepileptic drugs are considered safer than conventional antiepileptics, the effects of lamotrigine, levetiracetam and topiramate on neurobehavioural functions are yet to be established. This study evaluated neurobehavioural parameters and oxidative stress markers in brain tissue of rats treated with lamotrigine, levetiracetam and topiramate compared to sodium valproate.

Methods:

Five groups of male Wistar rats were treated respectively with normal saline (control), sodium valproate (370 mg/kg), lamotrigine (50 mg/kg), levetiracetam (310 mg/kg) and topiramate (100 mg/kg) for 45 days. Neurobehavioural parameters were assessed using elevated plus maze (EPM), actophotometer, rotarod, passive avoidance and Morris water maze (MWM) at baseline and at the end of treatment. Oxidative stress parameters [malondialdehyde (MDA), reduced glutathione (GSH) and superoxide dismutase (SOD)] were estimated in rat brain at the end of treatment.

Results:

Valproate and lamotrigine showed no significant effect on learning and memory in passive avoidance and MWM tests. However, levetiracetam and topiramate reduced retention memory significantly as compared to control (P<0.01) and lamotrigine (P<0.05) groups. Performances on EPM, rotarod and actophotometer were not significantly different between the groups. In comparison to control group, MDA was higher in the levetiracetam and topiramate (360.9 and 345.9 nmol/g of homogenized brain tissue, respectively) groups. GSH and SOD activity were significantly reduced by valproate and levetiracetam treatment. Lamotrigine did not induce significant oxidative stress.

Interpretation & conclusions:

Long-term and therapeutic dose treatment with levetiracetam and topiramate significantly impaired learning and memory, which was not seen with valproate and lamotrigine in rats. Levetiracetam, topiramate and valproate augmented oxidative stress, whereas lamotrigine has little effect on it. These antiepileptic drugs are used in clinical practice, hence pharmacovigilance studies are required to evaluate their safety profile.

The relationship between mood disorder and insomnia depends on race in US veterans with epilepsy

PURPOSE

Few data exist on race, medical/psychiatric comorbidities, and insomnia symptoms in US veterans with epilepsy. Our aims were to examine 1) whether insomnia symptom prevalence was different between Black and White veterans and 2) whether predictors of insomnia symptoms varied by race.

METHODS

This retrospective, cross-sectional study included veterans evaluated in an epilepsy clinic over the course of 1.5years. Individuals completed standardized assessments for epilepsy and sleep complaints. Insomnia criteria were met by 1) report of difficulty with sleep initiation, maintenance, or premature awakenings accompanied by daytime impairment or 2) sedative-hypnotic use on most days of the month. Demographics, medical/psychiatric comorbidities, and medications were determined per electronic medical record review. Hierarchical multivariable logistic regression analyses were performed to determine if race, medical/mental health comorbidities, and the potential interaction of race with each comorbid condition were associated with insomnia.

RESULTS

Our sample consisted of 165 veterans (32% Black). The unadjusted prevalence of insomnia was not different between Black and White veterans (42% vs 39%, p=0.68). In adjusted analyses, the association between mood disorder and insomnia varied by race. Depressed White veterans had over 11-times higher predicted odds of insomnia (OR 11.4, p<0.001) than non-depressed White veterans, while depressed Black veterans had 4-times higher predicted odds of insomnia (OR 4.1, p=0.06) than non-depressed Black veterans. Although mood disorder diagnosis was associated with insomnia for both racial groups, White veterans had a stronger association between mood disorder diagnosis and insomnia than Black veterans.

CONCLUSIONS

The relationship between mood disorder diagnosis and insomnia was stronger for White than Black veterans with epilepsy. Future studies are needed to explore mental health symptoms and psychosocial determinants of insomnia with larger samples of minority individuals with epilepsy.

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.

Traumatic brain injury and epilepsy: Underlying mechanisms leading to seizure

Post-traumatic epilepsy continues to be a major concern for those experiencing traumatic brain injury. Post-traumatic epilepsy accounts for 10-20% of epilepsy cases in the general population. While seizure prophylaxis can prevent early onset seizures, no available treatments effectively prevent late-onset seizure. Little is known about the progression of neural injury over time and how this injury progression contributes to late onset seizure development. In this comprehensive review, we discuss the epidemiology and risk factors for post-traumatic epilepsy and the current pharmacologic agents used for treatment. We highlight limitations with the current approach and offer suggestions for remedying the knowledge gap. Critical to this pursuit is the design of pre-clinical models to investigate important mechanistic factors responsible for post-traumatic epilepsy development. We discuss what the current models have provided in terms of understanding acute injury and what is needed to advance understanding regarding late onset seizure. New model designs will be used to investigate novel pathways linking acute injury to chronic changes within the brain. Important components of this transition are likely mediated by toll-like receptors, neuroinflammation, and tauopathy. In the final section, we highlight current experimental therapies that may prove promising in preventing and treating post-traumatic epilepsy. By increasing understanding about post-traumatic epilepsy and injury expansion over time, it will be possible to design better treatments with specific molecular targets to prevent late-onset seizure occurrence following traumatic brain injury.

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.