FACES 2014: The Importance of Sleep in Epilepsy

1. FACES 2014: The Importance of Sleep in Epilepsy • Derek Chong, MD MSc • Assistant Professor of Neurology • NYU Comprehensive Epilepsy Center

2. Weird Sleep:Seizure relationship • Good sleep tends to be protective for seizures • But… • In some people, seizures tend to happen more frequently in sleep

3. Why a seizure today and not yesterday?

4. Risk of Seizure changesmoment to moment

5. 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

6. 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

7. Why Seizures Today? • 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 • Sleep deprivation

8. Sleep is Complicated • you can’t just add up the hours • different stages of sleep

9. 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

10. Normal Sleep Hypnogram • More REM as sleep continues

12. Sleep Stages

13. More REM and SWS improve learning

14. 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

15. 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

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18. 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+)

20. Circadian Rhythm Problems

21. 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)

22. General Sleep Disorders • Insomnia 10-36% • Obstructive sleep apnea 3-60% • Periodic limb movements of sleep 5-44% • Restless legs syndrome 2.5-15%

23. Insomnia Treatment • Self-treatments often ineffective or cause worsening of sleep or inhibiting deeper sleep: nonprescription medication, alcohol • Behavioral changes: • reverse learned associations • relaxation techniques • Sleep hygiene

24. Sleep Hygiene • Go 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

25. More Tips • Bedtime 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.

26. 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

27. Normal sleep architecture = more REM

28. 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

29. Seizures Worsen Sleep

30. Seizure Meds & Sleep

31. Summary • Seizure: 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

32. GET YOUR SLEEP!!!