Primary Sleep Disorders and Paroxysmal Nocturnal Nonepileptic Events in Adults With Epilepsy From the Perspective of Sleep Specialists

Nonrapid Eye Movement Parasomnias

SUMMARY

Non-REM parasomnias are often observed during childhood and adolescence, by which time they typically remit. For a small percentage, these nocturnal behaviors can persist into adulthood, or in some cases, present as a new onset in adults. Non-REM parasomnias (also known as disorders of arousal) can offer a diagnostic challenge in patients who have an atypical presentation where REM sleep parasomnias, nocturnal frontal lobe epilepsy, and overlap parasomnia should be considered as part of the differential. The purpose of this review is to discuss the clinical presentation, evaluation, and management of non-REM parasomnias. The neurophysiology behind non-REM parasomnias is considered, and this gives insights into their cause and the potential for treatment.

Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders among the general population, and they may often coexist in patients with sleep-disordered breathing (SDB). The higher prevalence of insomnia symptoms in patients with OSA (40–60%) compared to that observed in the general population has thus led researchers to identify a new disorder named comorbid insomnia and OSA (COMISA), whose true burden has been so far largely underestimated. The combined treatment of COMISA patients with positive-airway pressure ventilation (PAP) with cognitive behavioral therapy for insomnia (CBTi) has shown a better patient outcome compared to that obtained with a single treatment. Furthermore, recent evidence has shown that an innovative patient-centered approach taking into consideration patient characteristics, treatment preferences and accessibility to treatment is recommended to optimize clinical management of COMISA patients. However, in this complex mosaic, many other sleep disorders may overlap with COMISA, so there is an urgent need for further research to fully understand the impact of these therapies on outcomes for OSA patients with comorbidity. In light of this need, this review focuses on the major sleep disorders comorbid with OSA and the recent advances in the management of these insomniac patients.

The parasomnias: mechanisms and treatment

Although parasomnias should be considered benign conditions without a deleterious impact on sleep quality and quantity, especially in children, it is important to recognize and properly diagnose these phenomena. Moreover, parasomnias may be misdiagnosed as epileptic seizures, in particular seizures with a predominant complex motor behavior as seizures occurring in nocturnal frontal lobe epilepsy (NFLE), leading to unnecessary and expensive investigations and prolonged and unsuccessful treatment. In this article we describe the clinical and neurophysiologic features of the most common parasomnias, giving the most reliable elements of differential diagnosis between parasomnias and epileptic nocturnal seizures, namely the typical seizures occurring in NFLE. The diagnostic value of history-taking, video-polysomnography, home video recording, and diagnostic scales is discussed. Next we describe the intriguing aspect of the frequent coexistence, in the same family and even in the same patients, of epileptic and parasomniac attacks, giving a common neurophysiologic interpretation. Finally some brief indications to the treatment of parasomnias are suggested.