Expert Opinion: Managing sleep disturbances in people with epilepsy

Abstract

Poor sleep and daytime sleepiness are common in people with epilepsy. Sleep disorders can disrupt seizure control and in turn sleep and vigilance problems can be exacerbated by seizures and by antiepileptic treatments. Nevertheless, these aspects are frequently overlooked in clinical practice and a clear agreement on the evidence-based guidelines for managing common sleep disorders in people with epilepsy is lacking. Recently, recommendations to standardize the diagnostic pathway for evaluating patients with sleep-related epilepsies and comorbid sleep disorders have been presented. To build on these, we adopted the Delphi method to establish a consensus within a group of experts and we provide practical recommendations for identifying and managing poor night-time sleep and daytime sleepiness in people with epilepsy. We recommend that a comprehensive clinical history of sleep habits and sleep hygiene should be always obtained from all people with epilepsy and their bed partners. A psychoeducational approach to inform patients about habits or practices that may negatively influence their sleep or their vigilance levels should be used, and strategies for avoiding these should be applied. In case of a suspected comorbid sleep disorder an appropriate diagnostic investigation should be performed. Moreover, the possible presence of sleep fragmentation induced by sleep-related seizures should be ruled out. Finally, the dose and timing of antiepileptic medications and other co-medications should be optimized to improve nocturnal sleep and avoid daytime sedation.

Sleep and epilepsy: A snapshot of knowledge and future research lines

“…Recently, a consensus review on the "Standard procedures for the diagnostic pathway of SRE and co-morbid sleep disorders" was published under the auspices of the European Academy of Neurology, the European Sleep Research Society, and the European chapter of the International League Against Epilepsy (Nobili et al, 2020(Nobili et al, , 2021. (Nobili et al, 2021).…”

On the relationships between epilepsy, sleep, and Alzheimer’s disease: A narrative review

“…Ju et al pointed out that up to 2/3 of patients with epilepsy [42] have sleep disturbances that lead to sleep fragmentation and disruption of normal sleep architecture. Additionally, antiseizure medication (ASM) can further induce changes in sleep architecture or have a soporific effect, like, for example barbiturates and phenytoin [43]. Smolensky et al further focused on circadian rhythms in epilepsy with a tendency of different epilepsy types to occur during a specific time of the day, for example temporal lobe seizures in the morning, parietal lobe seizures in the early evening, and frontal lobe seizures in the second part of the night [44].…”

“…Seizure frequency in patients with epilepsy has also been reduced [143], but not interictal epileptiform activity [144]. In addition, gabapentin often induces weight gain, which may promote or enhance obstructive [43]. Again, a careful combination ASM could be appropriate.…”

Sleep Disturbances in Neurological Disease: A Target for Intervention

“…For example, vagal nerve stimulation may affect sleep-wake parameters opposingly by stimulus intensity, with beneficial effects at lower intensities and detrimental effects at higher intensities, and may also contribute to increased OSA risk. 20 Taken together, while much work remains, epilepsy therapies should be considered in the evaluation and management of sleep disturbance in epilepsy.…”

“…Despite overall agreement that sleep disturbance and epilepsy have a reciprocal relationship, evidence-based practice guidelines for diagnosing and managing sleep problems in epilepsy are lacking. A few recent papers have begun to address this gap, synthesizing findings from the literature and expert consensus into clinical practice recommendations [18][19][20] . The most comprehensive of these to date is a 2021 expert opinion piece by Nobili et al, where the authors used the Delphi method to establish a consensus pathway to diagnose and manage sleep disturbances in epilepsy patients.…”