Effect of successful epilepsy surgery on subjective and objective sleep parameters – a prospective study

ObjectiveTo evaluate the effect of surgery on subjective and objective measures of sleep quality among patients with medically refractory focal epilepsy.MethodsIn a prospective cohort study, patients with medically refractory epilepsy undergoing epilepsy surgery were recruited. All patients were assessed seven days pre- and three months post-surgery in terms of history pertaining to epilepsy and sleep, Epworth sleepiness score (ESS), one week sleep log and over night polysomnography (PSG).ResultsAmong 17 patients (mean age 18, 11 males), seizure frequency had reduced (p = 0.04) and self reported sleep parameters had significantly improved (reduced total duration of night time sleep, regularity on one week sleep log and ESS (p < 0.05)) three months following epilepsy surgery. Patients with good surgical outcome (n = 12) showed reduced seizure frequency (p = 0.01) and reduced ESS with corresponding reduction in arousal index (AI) (p = 0.02) and increase in total sleep time (p = 0.03), postoperatively. Three patients in the good surgical outcome group showed reduction in apnea–hypopnea index (AHI) from more than five to less than five. There was no significant change either in seizure frequency, self reported clinical parameters or PSG parameters among patients with poor surgical outcome.ConclusionEpilepsy surgery improves subjective sleep parameters in patients with medically refractory epilepsy during the early post operative period. Successful epilepsy surgery may improve objective (PSG documented) sleep quality, sleep architecture and obstructive sleep apnea with resultant reduction in excessive daytime sleepiness.     

Rapid eye movement sleep disturbance in patients with refractory epilepsy: A polysomnographic study

Objective/BackgroundPatients with epilepsy have disrupted sleep architecture and a higher prevalence of sleep disturbance. Moreover, obstructive sleep apnea (OSA) is more common among patients with refractory epilepsy. Few studies have compared subjective sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and those with medically controlled epilepsy. Therefore, this study aimed to evaluate the differences in sleep quality, sleep architecture, and prevalence of OSA between patients with refractory epilepsy and patients with medically controlled epilepsy.PatientsThis retrospective case–control study included 38 patients with refractory epilepsy and 96 patients with medically controlled epilepsy. Sleep parameters and indices of sleep-related breathing disorders were recorded by standard in-laboratory polysomnography. The scores from sleep questionnaires on sleep quality and daytime sleepiness were compared between the two groups.ResultsPatients with refractory epilepsy versus medically controlled epilepsy had statistically significantly decreased rapid eye movement (REM) sleep (13.5 ± 6.1% vs. 16.2 ± 6.1%) and longer REM latency (152.2 ± 84.1 min vs. 117.2 ± 61.9 min). Further, no differences were found in the prevalence of sleep-related breathing disorders, subjective sleep quality, prevalence of daytime sleepiness, and quality of life. Although not statistically significant, patients with refractory epilepsy have a lower rate of OSA compared with those with medically controlled epilepsy (21.1% vs. 30.2%).ConclusionsPatients with refractory epilepsy had more disrupted REM sleep regulation than those with medically controlled epilepsy. Although patients with epilepsy have a higher risk of OSA, in this study patients with refractory epilepsy were not susceptible to OSA.     

Characteristics of refractory vs. medically controlled epilepsy patients with obstructive sleep apnea and their response to CPAP treatment

Obstructive sleep apnea (OSA) commonly coexists with epilepsy, and treatment of OSA may decrease seizure frequency. However, it is unclear whether patients with medically refractory epilepsy have a higher incidence of OSA compared with well-controlled epilepsy patients and whether the two groups carry different risk factors.PurposeThis study aimed to investigate the presence of OSA in patients with refractory vs. well-controlled epilepsy and their associated risk factors. We also assessed the benefits of treatment of OSA with continuous positive airway pressure (CPAP) in refractory epilepsy patients.MethodsWe retrospectively reviewed data from patients who presented to the Jacobs Neurological Institute Comprehensive Epilepsy Center of University at Buffalo from 2007 to 2010.ResultsThere is a tendency for much higher incidence of OSA in our epilepsy population compared with the general population (15.2% vs. 4.41%). For patients with well-controlled epilepsy, older age, male gender, and higher seizure frequency were predictors of a diagnosis of OSA. However, in medically refractory epilepsy patients, diabetes and snoring predicted a diagnosis of OSA. Treatment of OSA with CPAP in refractory epilepsy patients improved their seizure control (p < 0.02).ConclusionThis study confirms that OSA is common in epilepsy patients and treatment of OSA can improve seizure control in medically refractory cases. Patients with refractory epilepsy who have diabetes are more likely to have OSA.     

Sleep disordered breathing in patients with primary Sjögren's syndrome: A group controlled study

ObjectivePatients with primary Sjögren’s syndrome (pSS) have higher fatigue levels and also suffer from excessive day time sleepiness. The underlying mechanisms for this are not fully understood. Knowing that these patients have higher salivary surface tension, we postulated that sleep disordered breathing (SDB) would be more common and would be a contributor to these symptoms amongst pSS patients. We investigated the prevalence of SDB in pSS patients and its relationship to their symptoms of fatigue and excessive daytime sleepiness.MethodsThis was an observational study of 28 pSS patients (mean ± SEM age, 58.7 ± 1.9) and 18 healthy subjects (mean ± SEM age, 55.8 ± 3.4) matched for age, sex, and BMI. All the participants underwent an overnight polysomnography. The two groups were compared for fatigue, sleepiness, anxiety, and depression scores, and for the frequency of obstructive apneas and hypopneas during sleep. Correlation analyses were used to explore relationships between sleep study variables and excess sleepiness and fatigue.ResultsFatigue, sleepiness, anxiety and depression symptoms, and sleep onset latency were significantly greater in pSS patients than controls. pSS patients had twice the frequency of obstructive apneas and hypopneas compared with control subjects (median[IQR],18.6/h [10.4–40.1] vs. 9.9/h [6.5–23.4]; p = 0.032) and OSA defined as an apnea–hypopnea index >15 events/h of sleep was more prevalent amongst pSS patients than controls (64% vs. 28%; p = 0.033). While no significant correlations were found between parameters of sleep disordered breathing and sleepiness scores or fatigue scores in the pSS group, CPAP treatment in a small subset of the pSS who were more severely affected by OSA suggested significant symptomatic benefit.ConclusionOSA appears to be increased in pSS and may be a useful therapeutic target to improve the quality of life of these patients.     

Residual sleep apnea on polysomnography after 3 months of CPAP therapy: Clinical implications,predictors and patterns

ObjectiveWe sought to determine the clinical implications, predictors and patterns of residual sleep apnea on continuous positive airway pressure (CPAP) treatment in patients with moderate-to-severe obstructive sleep apnea (OSA).MethodsWe performed a post hoc secondary analysis of data from a previously reported randomized trial. Sleepy patients with a high risk of moderate-to-severe OSA identified by a diagnostic algorithm were randomly assigned to standard CPAP titration during polysomnography (PSG) or ambulatory titration using auto-CPAP and home sleep testing. We observed them for 3 months and measured apnea–hypopnea index (AHI) on CPAP, Epworth sleepiness scale (ESS), sleep apnea quality of life index (SAQLI), CPAP pressure and objective CPAP compliance.ResultsSixty-one patients were randomized, 30 to the PSG group and 31 to the ambulatory group. Fifteen patients (25%) had residual sleep apnea (AHI >10/h on CPAP) with similar proportions in the PSG (7/30) and ambulatory (8/31) groups. Baseline variables including age, body mass index (BMI), ESS, SAQLI, respiratory disturbance index (RDI) and CPAP pressure did not differ between the groups. Outcomes including compliance were worse in patients with residual sleep apnea. Periodic breathing was prevalent among patients with residual sleep apnea.ConclusionsResidual sleep apnea is common in patients with moderate-to-severe OSA, despite careful CPAP titration, and is associated with worse outcomes.     

Snoring men with daytime sleepiness drive more than others: A population-based study

ObjectiveTo investigate whether subjects with daytime sleepiness who snore or report witnessed sleep apneas drive more than others.MethodsQuestions on snoring, witnessed sleep apnea, excessive daytime sleepiness and driving distance per year were included in the Northern Sweden component of the WHO, MONICA study. Invited were 10756 subjects aged 25–79 years, randomly selected from the population register.ResultsThere were 7905 (73%) subjects, 3858 men and 4047 women who responded to the questionnaire and attended a visit for a physical examination. Habitually snoring men with daytime sleepiness drove a mean of 22566 (95% CI 18550–26582) km a year, which was significantly more than non-snoring men without excessive daytime sleepiness who drove 17751 (95% CI 17076–18427) km a year, p = 0.02, after adjustments for age, body mass index, smoking and physical activity. Men reporting witnessed sleep apnea and excessive daytime sleepiness also drove more than their counterparts in adjusted analysis, p = 0.01. Women reporting daytime sleepiness and witnessed apnea tended to drive more, while snoring women with daytime sleepiness did not.ConclusionsMen suffering from excessive daytime sleepiness who snore habitually or report witnessed sleep apneas drive significantly more than others.     

Sleep disturbances and risk of frailty and mortality in older men

ObjectiveTo test the hypothesis that non-frail older men with poorer sleep at baseline are at increased risk of frailty and death at follow-up.MethodsIn this prospective cohort study, subjective (questionnaires) and objective sleep parameters (actigraphy, in-home overnight polysomnography) were measured at baseline in 2505 non-frail men aged ?67 years. Repeat frailty status assessment performed an average of 3.4 years later; vital status assessed every four months. Sleep parameters expressed as dichotomized predictors using clinical cut-points. Status at follow-up exam classified as robust, intermediate (pre-frail) stage, frail, or died in interim.ResultsNone of the sleep disturbances were associated with the odds of being intermediate/frail/dead (vs. robust) at follow-up. Poor subjective sleep quality (multivariable odds ratio [MOR] 1.26, 95% CI 1.01–1.58), greater nighttime wakefulness (MOR 1.31, 95% CI 1.04–1.66), and greater nocturnal hypoxemia (MOR 1.47, 95% CI 1.02–2.10) were associated with a higher odds of frailty/death at follow-up (vs. robust/intermediate). Excessive daytime sleepiness (MOR 1.60, 95% CI 1.03–2.47), greater nighttime wakefulness (MOR 1.57, 95% CI 1.12–2.20), severe sleep apnea (MOR 1.74, 95% CI 1.04–2.89), and nocturnal hypoxemia (MOR 2.28, 95% CI 1.45–3.58) were associated with higher odds of death (vs. robust/intermediate/frail at follow-up). The association between poor sleep efficiency and mortality nearly reached significance (MOR 1.48, 95% CI 0.99–2.22). Short sleep duration and prolonged sleep latency were not associated with frailty/death or death at follow-up.ConclusionsAmong non-frail older men, poor subjective sleep quality, greater nighttime wakefulness, and greater nocturnal hypoxemia were independently associated with higher odds of frailty or death at follow-up, while excessive daytime sleepiness, greater nighttime wakefulness, severe sleep apnea and greater nocturnal hypoxemia were independently associated with an increased risk of mortality.     

CPAP with algorithm-based versus titrated pressure: A randomized study

BackgroundOur goal was to evaluate whether an algorithm-prescribed pressure is effective in sleep apnea–hypopnea syndrome (SAHS) patients requiring continuous positive airway pressure (CPAP).MethodsSAHS patients with an apnea–hypopnea index (AHI) >20/h were selected for a parallel group randomized study including an in-sleep laboratory acute phase and a domiciliary chronic phase. After baseline polysomnography, patients had a second night polysomnography either with CPAP at the algorithm-calculated pressure, followed by home treatment at this pressure without any correction or adjustment (calculation group), or with auto-CPAP titration, followed by home treatment at the pressure judged to be optimal from the auto-titration (titration group). The primary outcome was the change in Epworth sleepiness scale (ESS) at 6 months.ResultsThe calculated pressure (mean (SD)) was 7.0 (1.4) in the calculation group (n = 33), while the optimal pressure was 7.0 (2.2) cmH₂O in the titration group (n = 36). During the 6-month treatment at home, the ESS decreased from 8.3 (4.9) to 5.4 (4.0) in the calculation group (n = 20) and from 8.7 (5.4) to 6.4 (5.4) in the titration group (n = 20) (between-group difference not significant).ConclusionIn these SAHS patients with moderate sleepiness treated with CPAP, we found no difference in effectiveness between an algorithm-based pressure and an auto-titrated pressure.     

Sleep misperception in persons with epilepsy

Being able to confidently ascertain the amount of sleep is critical to the clinical management of epilepsy. Sleep misperception is the phenomenon in which an individual underestimates the amount of time spent asleep. Little is known about sleep misperception in patients with epilepsy.We conducted retrospective chart reviews on individuals who self-identified as having epilepsy in a questionnaire database of patients undergoing polysomnography (PSG) at the Massachusetts General Hospital Sleep Laboratory. Our metric for sleep misperception was the difference between subjective and objective sleep latency (S–O SL) and subjective and objective total sleep time (S–O TST) with subjective values based on questionnaire and objective values based on PSG.We confirmed 64 patients with epilepsy. We then selected age- and sex-matched diagnostic PSG data for comparison from 50 patients with insomnia symptoms but no obstructive sleep apnea (OSA) and another 50 patients with OSA but no insomnia symptoms. In our cohort with epilepsy, the median SL overestimation was 20 min (p < 0.05), and the median TST underestimation was 45 min (p < 0.05). Sleep misperception was similar regardless of potential confounding factors such as categorical epilepsy refractoriness, cognitive impairment, or psychiatric comorbidity.Our findings suggest that sleep misperception occurs similarly in patients with epilepsy as in patients without epilepsy with insomnia. Our findings further support the potential clinical utility of objective PSG testing in patients with epilepsy, as this may not only identify occult OSA but also disclose sleep misperception.     

Beneficial effect of donepezil on obstructive sleep apnea: a double-blind, placebo-controlled clinical trial

Introduction/objectivesPrevious publications have shown beneficial effects of cholinergic medication on obstructive sleep apnea (OSA) in Alzheimer’s disease (AD) patients. We hypothesized that cholinergic medication could also improve OSA in non-AD patients. The present study evaluated the effects of donepezil on OSA in non-AD patients.MethodsA randomized, double-blind, placebo-controlled study was conducted. The final sample consisted of 21 male patients with mild to severe OSA and AHI >10 divided into two groups, a donepezil-treated group (n = 11) and a placebo-treated group (n = 10). The dosage was one tablet/day (5 mg) for the first two weeks and two tablets/day (10 mg) for the last two weeks. Polysomnography and sleepiness evaluations were performed at baseline and after one month of treatment. Groups were compared using two-way ANOVA for repeated measures with treatment–group and treatment–time as the main factors and time–treatment as an interaction effect.ResultsConsidering the effect of the interaction with time–treatment, there was a significant improvement in the obstructive apnea/hypopnea index, desaturation index, percentage of time with O₂ saturation ?3% lower than baseline, lowest oxygen saturation, and the Epworth Sleepiness Scale (ESS) scores with donepezil treatment (p < 0.05). Sleep efficiency significantly decreased (p < 0.01).ConclusionsDonepezil treatment improved obstructive sleep apnea index, oxygen saturation, and sleepiness in parallel with a reduction in sleep efficiency. Our findings support the concept that cholinergic transmission may influence breathing regulation in OSA patients.     

Daytime sleepiness and polysomnography in obstructive sleep apnea patients

BackgroundExcessive daytime sleepiness (EDS) is the major complaint in subjects with obstructive sleep apnea syndrome (OSAS). However, EDS is not universally present in all patients with OSAS. The mechanisms explaining why some patients with OSAS complain of EDS whereas others do not are unknown.ObjectiveTo investigate polysomnographic determinants of excessive daytime sleepiness (EDS) in a large multicenter cohort of patients with obstructive sleep apnea (OSAS).MethodsAll consecutive patients with an apnea–hypopnea index greater than 5 h⁻¹ who were evaluated between 2003 and 2005. EDS was assessed using the Epworth Sleepiness Scale (ESS), and patients were considered to have EDS if the ESS was >10.ResultsA total of 1649 patients with EDS ((mean [±SD] Epworth 15 ± 3) and 1233 without EDS (Epworth 7 ± 3) were studied. Patients with EDS were slightly younger than patients without EDS (51 ± 12 vs 54 ± 13 years, p < 0.0001), had longer total sleep time (p < 0.007), shorter sleep latency (p < 0001), greater sleep efficiency (p < 0.0001) and less NREM sleep in stages 1 and 2 (p < 0.007) than those without EDS. Furthermore, patients with EDS had slightly higher AHI (p < 0.005) and arousal index (p < 0.001) and lower nadir oxygen saturation (p < 0.01).ConclusionsPatients with OSAS and EDS are characterized by longer sleep duration and increased slow wave sleep compared to those without EDS. Although patients with EDS showed a mild worsening of respiratory disturbance and sleep fragmentation, these results suggest that sleep apnea and sleep disruption are not the primary determinants of EDS in all of these patients.     

Accuracy of portable polygraphy for the diagnosis of sleep apnea in multiple system atrophy

ObjectiveTo assess the diagnostic accuracy of portable polygraphy (PG) for the detection of sleep apnea (SA) in multiple system atrophy (MSA).MethodsThirty consecutive patients with probable MSA underwent PG (overnight recording of nasal flow, thoracic/abdominal movements and pulse oximetry), followed 4 weeks later by full polysomnography (PSG) (reference standard). The accuracy of PG was first assessed using the same threshold as for PSG (apnea–hypopnea index [AHI] ⩾ 5), then for all possible AHI thresholds using the area under the receiver operating characteristics (AUROC) curve. Inter-rater reliability of PG was assessed using the kappa coefficient.ResultsAmong 30 patients enrolled, seven were excluded for technical problems on PG or PSG and 23 were included in the main analysis. Eight out of 23 had an AHI ⩾ 5 on PSG. With the same threshold, sensitivity, specificity, positive and negative predictive values of PG for the diagnosis of SA were 87.5% (95% confidence interval: 47–99), 80% (52–96), 70% (35–93) and 92.3% (64–99), respectively. The kappa between PG raters was 0.75 (0.49–1.00) indicating good agreement. The AUROC was 0.93 (0.82–1.00). No association was found between sleep and excessive daytime sleepiness questionnaires and SA.ConclusionPortable PG seems to be valuable for ruling out SA in MSA.     

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

ObjectiveThe 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.MethodsSubjects taking ≤ 2 AEDs for ≥ 4 weeks 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 200 mg/day, and LCM 400 mg/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.ResultsFifty-two subjects (mean age: 43.5 ± 13.2 years, 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.SignificanceOur 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.     

Excessive fragmentary myoclonus in Machado–Joseph disease

ObjectiveMachado–Joseph disease (MJD) is a neurodegenerative disease which usually presents several clinical findings including cerebellar ataxia and other extracerebellar features, such as Parkinsonism, dystonia, peripheral neuropathy, and lower motor neuron disease. Some data have demonstrated a high frequency of sleep disorders in these patients, including excessive daytime sleepiness (EDS), insomnia, obstructive sleep apnea (OSA), rapid eye movement (REM) sleep behavior disorder (RBD), and restless legs syndrome (RLS). Herein, we aimed to describe the high frequency of excessive fragmentary myoclonus (EFM) in MJD.Materials and methodsWe recruited 44 patients with MJD and 44 healthy controls. All participants underwent an all-night polysomnography (PSG). EFM was evaluated and defined in accordance to the criteria of the American Academy of Sleep Medicine.ResultsHalf of the MJD patients (n = 22) had EFM diagnosed through PSG, though no healthy control participant presented this finding (P < .0001). In the MJD group, older participants and men had a higher frequency of EFM. There was no correlation between EFM and the following data: body mass index (BMI), apnea–hypopnea index (AHI), EDS, loss of atonia during REM sleep, periodic limb movements during sleep (PLMS), RLS, RBD, ataxia severity, the number of cytosine–adenine–guanine trinucleotide (CAG) repeats, disease duration, sleep efficiency, sleep fragmentation, and sleep stage percentages between patients with or without EFM.ConclusionEFM is highly prevalent in patients with MJD. Our study demonstrates that EFM must be included in the clinical spectrum of sleep disorders in MJD patients.     

Is obstructive sleep apnea a problem in Parkinson’s disease?

BackgroundParkinson’s disease (PD) is associated with sleep disorders and daytime sleepiness. Upper airway dysfunction in PD may promote obstructive sleep apnea. However, the frequency and clinical relevance of sleep-disordered breathing in PD remains unclear.MethodsSleep apnea symptoms, cardiovascular events and treatment were collected in 100 patients with PD (50 unselected, consecutive patients matched for age, sex and body mass index with 50 patients referred for sleepiness) and 50 in-hospital controls. The motor and cognitive status was evaluated in patients with PD. The 150 subjects underwent a video-polysomnography.ResultsSleep apnea (defined as an apnea–hypopnea index greater than 5) was less frequent in the PD group (27% patients, including 6% with mild, 11% with moderate and 10% with severe sleep apnea) than in the control group (40% in-hospital controls, p < 0.002). Sleep apnea was not associated with increased sleepiness, nocturia, depression, cognitive impairment and cardiovascular events in patients with PD. Sleep apnea was more frequent and severe in the most disabled patients. Patients with PD did not display sleep hypoventilation, stridor and abnormal central sleep apnea. In patients with REM sleep behavior disorders, snoring and obstructive sleep apnea occurred during REM sleep, although the chin muscle tone was maintained.ConclusionObstructive sleep apnea does not seem to be a clinically relevant issue in PD. Daytime sleepiness, nocturia and cognitive impairment are mostly caused by other, non-apneic mechanisms. The maintenance of chin muscle tone during REM sleep behavior disorder has no influence on the frequency of apneic events.     

The Children's Report of Sleep Patterns--Sleepiness Scale: a self-report measure for school-aged children

ObjectiveTo establish the psychometric properties of a self-report measure of daytime sleepiness for school-aged children.MethodsThree hundred eighty-eight children aged 8–12 years (inclusive) from paediatrician’s offices, sleep clinic/labs, children’s hospitals, schools, and the general population were recruited. A multi-method approach was used to validate the Children’s Report of Sleep Patterns – Sleepiness Scale (CRSP-S), including self-report measures (questions about typical sleep), parent-report measures (Children’s Sleep Habits Questionnaire [CSHQ], proxy version of CRSP-S, Children’s Sleep Hygiene Scale [CSHS], morningness–eveningness) and objective measures (actigraphy and polysomnography [PSG]).ResultsThe CRSP-S was shown to be internally consistent (Cronbach’s alpha = 0.77) and the scale’s unidimensionality was supported by a one-factor confirmatory factor analysis. A Rasch-Masters Partial Credit model demonstrated that items cover a broad range of sleepiness experiences with minimal redundancy, gaps in coverage, or bias against age, gender, or clinical groups. Test–retest reliability was 0.82. Construct and convergent validity were demonstrated with actigraphy, parental reports of children’s sleepiness, sleep disturbances, sleep hygiene, circadian preference, and comparison of groups of children (e.g., sleep clinic/lab vs. school children).ConclusionsThe CRSP-S is a reliable and valid self-report measure of sleepiness for school-aged children. As an adjunct to parental report measures and objective measures of sleep, the CRSP-S provides a brief and psychometrically robust measure of children’s sleepiness. Children who endorse sleepiness should have a more detailed screening for underlying sleep disruptors or causes of insufficient sleep.     

Obstructive sleep apnea is common in medically refractory epilepsy patients

BACKGROUND: Previous reports have documented the coexistence of obstructive sleep apnea (OSA) and epilepsy and the therapeutic effects of treatment on seizure frequency and daytime sleepiness. The authors' objective was to determine the prevalence of OSA and its association with survey items in a group of patients with medically refractory epilepsy undergoing polysomnography (PSG). METHODS: Thirty-nine candidates for epilepsy surgery without a history of OSA underwent PSG as part of a research protocol examining the relationship of interictal epileptiform discharges to sleep state. Subjects also completed questionnaires about their sleep, including validated measures of sleep-related breathing disorders (Sleep Apnea Scale of the Sleep Disorders Questionnaire [SA/SDQ]) and subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]). RESULTS: One-third of subjects had OSA, defined by a respiratory disturbance index (RDI) > or = 5. Five subjects (13%) had moderate to severe OSA (RDI > 20). Subjects with OSA were more likely to be older, male, have a higher SA/SDQ score, and more likely to have seizures during sleep than those without OSA (p < 0.05). Seizure frequency per month, the number or type of antiepileptic drugs (AED) prescribed, the localization of seizures (temporal versus extratemporal), and the ESS were not statistically different between the two groups. CONCLUSIONS: In our sample, previously undiagnosed obstructive sleep apnea was common, especially among men, older subjects, and those with seizures during sleep. The impact of treating OSA on seizure frequency and daytime sleepiness in medically refractory epilepsy patients warrants further controlled study.     

Quantitative evaluation of the microstructure of rapid eye movement sleep in refractory epilepsy: a preliminary study using electroencephalography and heart rate variability analysis

IntroductionPatients with epilepsy have a disturbed sleep architecture. Polysomnographic studies have shown that patients with refractory epilepsy have decreased rapid eye movement (REM) sleep and longer REM latency than those with medically controlled epilepsy. However, little is known about the differences in the REM sleep microstructure between these patient groups.MethodsWe conducted a retrospective case–control study of 20 patients with refractory epilepsy (refractory group) and 28 patients with medically controlled epilepsy (medically controlled group). All patients completed sleep questionnaires and underwent overnight in-lab polysomnography. Five-minute electroencephalogram recordings at the C3 and C4 electrodes from each REM sleep were selected for spectral analysis, and 5-min electrocardiogram segments recorded during REM sleep were used for heart rate variability analysis. The groups’ scores on the sleep questionnaires, polysomnographic sleep parameters, indices of sleep-related breathing disorders, and REM sleep electroencephalogram spectra were compared.ResultsThe refractory group had decreased REM sleep (p < 0.001) and longer REM latency (p = 0.0357) than those of the medically controlled group. Moreover, electroencephalogram spectral analysis revealed that the refractory group had decreased absolute beta power (p = 0.0039) and relative beta power (p = 0.0035) as well as increased relative delta power (p = 0.0015) compared with the medically controlled group.ConclusionsDifferences in the polysomnographic macrostructure and REM sleep microstructure between the study groups suggest REM sleep dysregulation in patients with refractory epilepsy.     

Comparison of supine-only and REM-only obstructive sleep apnoea

ObjectivesThe effect of body position and sleep state on sleep apnoea have major clinical implications in the management of patients, yet are infrequently reported in the scientific literature. The aim of this study was to compare and contrast the prevalence and severity of supine-only and rapid eye movement (REM)-only obstructive sleep apnoea (OSA) in a population.MethodsProspective cohort analysis of the influence of supine body position and REM sleep on the severity of apnoea in 100 consecutive patients with OSA (apnoea–hypopnoea index [AHI] > 5) using attended polysomnography with continuous digital monitoring in an accredited sleep laboratory. Supine-only OSA was defined as a supine:non-supine AHI ratio of >2:1 and non-supine AHI <5 events/h. REM-only OSA was defined as an REM:non-REM ratio of >2:1 and non-REM AHI <5 events/h.ResultsSupine sleep time represented a greater proportion of total sleep time than REM sleep time (40% vs 13%). The prevalence of supine-only OSA was more than twofold greater than that of REM-only OSA (23% and 10%, respectively). The supine-only group had greater overall AHI (mean 12.6 ± 6.1 vs 7.2 ± 2.2 events/h; P < 0.01) than the REM-only group. No significant differences in gender, age, or sleepiness were found between the two groups.ConclusionsSupine-only OSA is more common and is associated with a greater AHI than REM-only OSA.     

Obstructive sleep apnea in narcolepsy

Study objectivesNarcolepsy and obstructive sleep apnea syndrome (OSAS) are two conditions associated with excessive daytime sleepiness (EDS). They may coexist in the same patient but the frequency of this association and its clinical significance is unknown. The presence of obstructive sleep apnea (OSA) in a narcoleptic patient may interfere with the diagnosis of narcolepsy. The aim of the study was to determine the prevalence of OSA in narcolepsy.Design and settingUniversity hospital sleep clinic series of narcoleptic patients diagnosed with nocturnal polysomnography and multiple sleep latency test. Patients were systematically interviewed evaluating narcoleptic and OSAS features and their response to continuous positive airway pressure (CPAP) treatment when applied.PatientsOne hundred and thirty-three patients with narcolepsy.ResultsThirty-three patients (24.8%) had an apnea–hypopnea index greater than 10 with a mean index of 28.5 ± 15.7. Ten of them were initially diagnosed only with OSAS and the diagnosis of narcolepsy was delayed 6.1 ± 7.8 years until being evaluated in our center for residual EDS after CPAP therapy. In the remaining 23 patients, narcolepsy and OSA were diagnosed simultaneously. Cataplexy occurred with similar frequency in both groups. EDS did not improve in 11 of the 14 patients who were treated with CPAP. The presence of OSA was associated with male gender, older age and higher body mass index.ConclusionsOSA occurs frequently in narcolepsy and may delay the diagnosis of narcolepsy by several years and interfere with its proper management. In patients with OSA, cataplexy should be actively looked for to exclude the presence of narcolepsy. Treatment with CPAP does not usually improve EDS in narcoleptics with OSA.