faces 2014: the importance of sleep in epilepsy
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FACES 2014: The Importance of Sleep in Epilepsy. Derek Chong, MD MSc Assistant Professor of Neurology NYU 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. - PowerPoint PPT PresentationTRANSCRIPT
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FACES 2014: The Importance of
Sleep in Epilepsy
Derek Chong, MD MScAssistant Professor of NeurologyNYU Comprehensive Epilepsy Center
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Weird Sleep:Seizure relationship
Good sleep tends to be protective for seizures
But…
In some people, seizures tend to happen more frequently in sleep
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Why a seizure today and not yesterday?
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Risk of Seizure changes
moment to moment
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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
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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
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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
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Sleep is Complicated
you can’t just add up the hours
different stages of sleep
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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
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Normal Sleep Hypnogram
More REM as sleep continues
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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%
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More REM and SWS improve learning
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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
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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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http://jpp.krakow.pl/journal/archive/02_11/articles/02_article.html
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recharge
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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+)
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Circadian Rhythm Problems
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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)
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General Sleep Disorders
Insomnia 10-36%
Obstructive sleep apnea 3-60%
Periodic limb movements of sleep 5-44%
Restless legs syndrome 2.5-15%
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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
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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
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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.
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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
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Normal sleep architecture = more REM
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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
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Seizures Worsen Sleep
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Seizure Meds & Sleep
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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
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GET YOUR SLEEP!!!