Neuropsychiatric Symptoms of Epilepsy

8 Epilepsy and Sleep: Close Connections and Reciprocal Influences
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Evaluation and Treatment of Patients with Epilepsy and Sleep
Disorder
The proper identification and treatment of common sleep disorders is an essential
part of the overall evaluation and management of patients with epilepsy. A sleep
history is the essential tool to evaluate sleep problems and involves a thorough
review of the patients’ 24-h routine, focusing on bedtime habits, nighttime behavior,
nap and daytime behavior. Nighttime behavior after sleep onset such as parasomnias
and symptoms of OSA (snoring, gasping, breathing pauses, and restless sleep)
should also be assessed. A sleep diary can be helpful in delineating the exact sleep
pattern.
Insufficient sleep syndrome remains a major problem for adolescents. Adolescents
have some degree of delayed sleep phase syndrome, which leads to early morning
sleepiness and insufficient sleep. School start times, extracurricular activities, and
peer pressure contribute to a chronic state of sleep deprivation, placing most adolescent
patients at risk for activation of their seizure disorder. Regular sleep habits
must be recommended by physicians and enforced by parents.
Patients with epilepsy frequently complain of daytime sleepiness, usually
considered an unavoidable adverse effect of antiepileptic therapy. Nevertheless,
in patients with persistent hypersomnia, particularly if on AED monotherapy or
with low serum drug concentrations and well-controlled seizures, primary sleep
disorders should be suspected [ 82 ]. Study of these patients by video-EEG polysomnography
or home video may be indicated [ 83 ]. Evaluation of sleep with
polysomnography should be performed with extended EEG montages in patients
with epilepsy to correlate arousal with seizures and inter-ictal activity.
Monitoring for sleep-related breathing disorders, restless legs syndrome, or
parasomnias should also be performed. Therapy should be directed at resolving
any sleep disorder observed, as improved seizure control might result.
Anticonvulsant monotherapy should be attempted whenever possible to minimize
the side effects of sedation. Less sedating anticonvulsants should be used
as primary anticonvulsant therapy avoiding barbiturates, benzodiazepines, and
topiramate.
How Treatment of Sleep Disorders Affects Seizures
The treatment of an underlying sleep disorder and improvement of sleep hygiene
benefits not only daytime sleepiness but also seizure control. An example is the
beneficial effect on seizure frequency of C-PAP treatment in patients with OSA [ 84 ,
85 ], without changes in the drug regimen. Resolution of chronic sleep deprivation,
improvement in cerebral hypoxemia, and reduction in arousals from sleep have