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 changes moment 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. 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

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 Type of Sleep % Sleep for Infant % Sleep for Young Child % Sleep for Young Adult % Sleep for Elderly Adult Stage 1<5% 8-15% Stage 225-30%40-45%45-55%70-80% Slow Wave Sleep20%25-30%13-23%0-5%* REM Sleep50%25-30%20-25%20%

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

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

17. recharge

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!!!