FACES 2014: The Importance of

Sleep in Epilepsy

Derek Chong, MD MScAssistant Professor of NeurologyNYU Comprehensive Epilepsy Center

Weird Sleep:Seizure relationship

Good sleep tends to be protective for seizures

But…

In some people, seizures tend to happen more frequently in sleep

Why a seizure today and not yesterday?

Risk of Seizure changes

moment to moment

What affects this balance?

In many people, that balance is affecting by sleep

if you can imagine that if your brain really wants to sleep, and you are keeping yourself up, your brain needs to:

increase excitation & decrease inhibition to stay alert

Sleep vs. other factors

The impact of each factor is different for each person

in some, lack of sleep may be a major factor

Juvenile myoclonic epilepsy

in others, hormone changes or caffeine may be most significant - every brain is different

You can improve control if you learn what provokes them & know your own limits

Probably multiple reasons - often happening at the same time

Sleep deprivation

Stress, hormones (menstrual cycles)

use of stimulants?

use of depressants? Alcohol

Changes in medication levels - missed doses, change in metabolism, drug interactions

Why Seizures Today?

Sleep deprivation

Sleep is Complicated

you can’t just add up the hours

different stages of sleep

Definition of Sleep

Stages of sleep:

Stage N1 is drowsiness

Stage N2 is a bit deeper

Slow wave (Stage N3) or deep sleep is harder to wake-up from

REM is when most of your dreaming occurs

Normal Sleep Hypnogram

More REM as sleep continues

Sleep Stages

Type of Sleep% Sleep

for Infant

% Sleep for Young Child

% Sleep for Young Adult

% Sleep for

Elderly Adult

Stage 1 <5% <5% <5% 8-15%

Stage 2 25-30% 40-45% 45-55% 70-80%

Slow Wave Sleep

20% 25-30% 13-23% 0-5%*

REM Sleep 50% 25-30% 20-25% 20%

More REM and SWS improve learning

So...

short segments of sleep added together is not the same as 7-9 hrs consolidated sleep

delaying sleep (ie staying up to 3am) can also change the sleep architecture.

these issues can alter the balance of excitation:inhibition of the brain

quantity of deeper sleep stages is important for cognition

Why We sleep

Circadian Rhythm (like internal alarm clock)

early drive for sleep around 2-4pm

evening: Melatonin secretion

Homeostatic Drive (used up like phone battery)

ATP to ADP

burn energy reserve through the day

http://jpp.krakow.pl/journal/archive/02_11/articles/02_article.html

recharge

Circadian Rhythm

Autism, developmental disorders - lack reliable secretion of melatonin

Replace Melatonin - 0.5mg, 3mg, 5mg

Melatonin has 2 potential effects:

sets circadian rhythm (0.5mg)

hypnotic effect (3mg+)

Circadian Rhythm Problems

Sleep Problems

People with and without epilepsy can have problems with sleep

Symptoms include:

Excessive daytime sleepiness

fatigue

hyperactivity and attention deficit

poorer performance: school/athletics

poorer healing (growth hormone)

General Sleep Disorders

Insomnia 10-36%

Obstructive sleep apnea 3-60%

Periodic limb movements of sleep 5-44%

Restless legs syndrome 2.5-15%

Insomnia TreatmentSelf-treatments often ineffective or cause worsening of sleep or inhibiting deeper sleep: nonprescription medication, alcohol

Behavioral changes:

reverse learned associations

relaxation techniques

Sleep hygiene

Sleep HygieneGo to sleep at the same time each night, awaken at the same time each morning. Wide fluctuations between workdays and days off can further impair your sleep.

Avoid naps. Restrict to <1 hour/day, and before 4pm.

If not sleepy, either don’t go to bed or get out of bed.

Avoid stimulating, frustrating, or anxiety provoking activities in bed/bedroom (watching TV, studying, etc).

Exercise, particularly aerobic exercise, is good for both sleep and overall health; just finish stimulating exercise 5+ hours before bedtime

More TipsBedtime ritual:

Wind down: relaxing activities within 1 hour before bedtime

Sleeping environment: comfortable as possible, paying attention to temperature (<70°), noise, and light

No heavy meals just before bedtime, although a light snack might help induce drowsiness

Paper & pen by bedside: no worrying about completing/remembering a task the next day, write it down & let it go.

During the night

Don’t stay in bed, arise from bed and do quiet, relaxing activities until you are drowsy. Then return to bed.

Place clocks so that the time is not visible from the bed.

But all my seizures happen during sleep

Stage I and II = increasing brain synchronization between and within Left and Right hemispheres

also the most likely time for nocturnal seizures to occur

**Recall: increasing synchronization increases risk of seizure

REM is most protective stage of sleep

Normal sleep architecture = more REM

Poor seizure control = poor

sleep = poor seizure control = ...

nocturnal seizures can fragment sleep

these can be generalized seizures but we frequently see partial seizures wake people from sleep when we monitor them

Seizures Worsen Sleep

Seizure Meds & Sleep

SummarySeizure: imbalance Excitation versus Inhibition of the neurons

Sleep, and specific sleep stages, influence the onset and propagation of seizures

Sleep disorders can exacerbate epilepsy

Seizures in turn disrupt sleep structure

Sleep deprivation contributes to attention & memory problems

GET YOUR SLEEP!!!