Sleep and Epilepsy Nancy Foldvary-Schaefer, DO, MS
Burden of epilepsy Affects over 50 million people worldwide; 2 million new cases/yr Estimated 30-40% continue to have seizures despite anti-seizure medications Substantial risk including accidents, injuries, poor performance at school and work, sudden unexplained death Management strategies beyond traditional medical and surgical therapies are needed Mohanraj R and Brodie MJ 2006; Tomson T 2008.
Relationships between sleep and epilepsy have been recognized for centuries Sleep wake cycle influences expression of seizures and epileptic discharges on EEG Sleep deprivation increases risk of seizures and epileptic discharges on EEG Conditions that lead to sleep fragmentation including sleep disorders increases seizures Sleep fragmentation and sleep disorders cause daytime sleepiness - the most common complaint of people with epilepsy that impairs quality of life
What is sleep? A naturally recurring state characterized by reduced consciousness, relatively suspended sensory and nonmotor activity, inactivity of nearly all voluntary muscles Distinguished from quiet wakefulness by decreased ability to react to stimuli, but it is more easily reversible than coma Active state of growth and rejuvenation of immune, nervous, skeletal and muscular systems
How much sleep is enough? Age Recommended Sleep per 24 Hr 0-12 mo 12-18 hr, multiple naps 1-3 yr 12-14 hr, one 1-2 hr nap 3-5 yr 11-13 hr, reduced napping 5-12 yr 10-11 hr Teens Adults 8.5-9.5 hr 7.5-8.5 hr The need for sleep is genetically determined and cannot be modified
Sleep deprivation is an epidemic! Adults sleep 6.7 hr on weekdays, 7.1 hr on weekends. National Sleep Foundation 2009 Sleep In America Poll.
Sleep deprivation not just for adults anymore 20% of teens get 9 hr of sleep on weekdays; 45% get less than 8 hr Inadequate sleep nights increase with the number of bedroom electronics More than 50% of teens report daytime sleepiness 90% of parents believe their teen is getting enough sleep Teens who feel unhappy/tense and drink >2 caffeinated beverages/day are more likely to sleep less/feel sleepy Teens who get optimal sleep get better grades National Sleep Foundation 2006 Sleep In America Poll.
Consequences of sleep deprivation Mood Cognitive Tasks Motor Tasks
You might as well be drunk! Sleep loss impairs physical, cognitive and emotional functioning 21 hrs of wakefulness is comparable to being legally intoxicated Dawson D and Reid K 1997.
Motor Vehicle Accidents Daylight saving time & traffic accidents: Modest sleep loss can have major consequences 2850 SPRING SHIFT 4300 FALL SHIFT 2800 2750 2700 2650 2600 2550 2500 2450 4200 4100 4000 3900 3800 3700 Before Post 1 day Post 1 week Before Post 1 day Post 1 week Coren S 1996.
Some sleep facts Nearly 75% of adult Americans experiences sleep disorder symptoms at least a few nights per week Sleep loss impacts on all facets of life Untreated apnea doubles the risk of heart arrhythmias Sleep disorders cause school and behavior problems in children Sleep loss increases the risk of obesity and diabetes Drowsy driving is responsible for $12 billion in reduced productivity and property loss/yr
Sleep disorder symptoms on the rise 2004 2005 2006 2007 2008 Adults with sleep disorder symptoms at least 3 nights per week National Sleep Foundation 2008 Sleep In America Poll.
Short sleep is associated with a variety of adverse consequences Elevated blood sugar and type II diabetes mellitus Obesity High blood pressure Cardiovascular events Mortality Depression and substance abuse Increased doctor visits and hospital admissions On-the-job injuries and motor vehicle accidents Banks S; Dinges DF. J Clin Sleep Med 2007;3:519-528.
Sleep activates seizures and epileptic discharges Non REM sleep stages and the transition from wake to sleep and sleep to wake are prime times for seizures Some people have seizures only during sleep or when feeling drowsy Convulsive seizures occur more often from sleep than wake In most types of epilepsy, epileptic discharges on EEG are much more frequent in sleep than wake Herman S 2001; Gibbs and Gibbs 1947.
Sleep deprivation is a common seizure trigger Extreme sleep deprivation can cause seizures Minor amounts of sleep loss can provoke seizures in some people with epilepsy Sleep deprivation before an EEG increases the likelihood of recording abnormalities People with seizures who sleep 6 hrs or less have more frequent seizures than those who sleep longer Rowan AJ 1982; Rajna P 1993; Rodriguez CL 2006.
Treatments Sleep Disorders Epilepsy Seizures Sleep Instability Sleep-Wake Complaints Unstable sleep leads to seizures and daytime sleepiness
Sleep apnea what everyone should know Affects 24% of men and 9% of women Over 80% of affected people are NOT diagnosed Sleep study (polysomnogram) shows repeated episodes of breathing cessation in sleep accompanied by at least one of the following: Daytime sleepiness, sleep attacks, unrefreshing sleep, fatigue, insomnia Waking with breath holding, gasping, choking Observer reports loud snoring, breathing interruptions International Classification of Sleep Disorders, 2nd ed. American Academy of Sleep Medicine. 2005.
A narrow and floppy airway provides the basis for sleep apnea No problems when awake (muscle tone increases) Narrower when asleep (muscle tone decreases) Essential collapse during REM (no muscle tone)
Risk factors for sleep apnea Men, older age, obesity, increasing neck size, snoring and apnea reported by observers predict moderate to severe sleep apnea Risk in women increases increasing weight and postmenopausal status Positive family history Alcohol and sedative hypnotic medications Allergies Smoking
Consequences of sleep apnea Hypertension Coronary artery disease Congestive heart failure Atrial fibrillation Stroke Hyperlipidemia Diabetes mellitus type II Obesity Cognitive impairment Daytime sleepiness
Treatments for sleep apnea Conservative measures Sleeping off the back Weight reduction Avoid sleep deprivation, sedative medications, alcohol Treat nose blockages (nasal sprays, Breathe-Rites) Treat underactive thyroid Positive airway pressure (PAP) Surgery of nose or throat Oral appliances/mouth guards Bariatric surgery Didgeridoo
Positive airway pressure is the most effective treatment for significant sleep apnea Reduces blood pressure Reduces cholesterol Normalizes blood sugar Normalizes metabolism by suppressing hunger Reduces risk of heart attack, stroke, cardiac rhythm disturbances and sudden death Girardin JL 2008.
Sleep apnea is exceptionally common in people with seizures not controlled with medications Epilepsy 1 No Epilepsy Men 59% 24% Women 19% 9% People with sleep apnea were more likely to be older, male, obese, snorers and have seizures in sleep 1 Malow BA 2000; 2 Young T 1993. Dr. Modic presentation - sleep
Why are people with epilepsy at risk? Effects of medications and vagus nerve stimulation Increased weight due to lack of physical activity and medications Increased risk for medical disorders related to sleep apnea, including polycystic ovarian syndrome and hypothyroidism Neurologic disorders associated with epilepsy AND sleep apnea, such as stroke and brain tumors
Treatment of sleep apnea reduces seizures and epileptic discharges on EEG Up to 30% of people with epilepsy become seizure free after treatment of sleep apnea with PAP therapy or surgery Children and adults seem to benefit from treatment of sleep apnea Treatment with PAP therapy reduces epileptic discharges on EEG Devinsky O 1994; Malow BA 1997; Vaughn BV 1996; Höllinger P 2006. Dr. Modic presentation - sleep
Managing sleep problems in people with epilepsy Epilepsy providers should be aware of the interactions between sleep and epilepsy and ask about sleep problems When sleep disorders are suspected, sleep testing should be considered Tell your doctor about daytime sleepiness, snoring and other sleep complaints Ask your doctor if anti-seizure medications are affecting your ability to sleep/stay awake Avoid situations and factors that cause sleep deprivation
Practice good sleep hygiene Establish fixed bed and wake times Relax before going to bed Maintain a comfortable sleeping environment Avoid clock watching Follow a 20 min Toss and Turn rule Use the bedroom for sleep only Avoid daytime naps Avoid caffeine, alcohol, nicotine within 6 hr of sleep Avoid strenuous activities within 3 hr of sleep
Keep a seizure and sleep diary
Sleep disorder resources National Sleep Foundation www.sleepfoundation.org American Insomnia Association www.americaninsomniaassociation.org American Sleep Apnea Association www.sleepapnea.org Narcolepsy Network www.narcolepsynetwork.org Restless Legs Syndrome Foundation www.rls.org Dr. Modic presentation - sleep