Basic and Clinical

February 2013, Volume 4, Number 1

Prevalence of Sleep Disorders and their Effects on Sleep

Quality in Epileptic Patients
Zohreh Yazdi1, Khosro Sadeghniiat-Haghighi2, Shoaib Naimian3, Mohammad Ali Zohal1, Mostafa Ghaniri4

1. Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
2. Department of Occupational Medicine, Tehran University of Medical Sciences, Tehran, Iran
3. Qazvin University of Medical Sciences, Qazvin, Iran
4. General physician

Article info: A B S T RAC T

Received: 7 March 2012
First Revision: 4 May 2012 Introduction: Epilepsy is a complex pervasive neurobehavioral and social condition
Accepted: 6 September 2012 accompanied by a wide range of comorbid conditions that can adversely affect the quality of
life of patients. Sleep complaints are common among patients with epilepsy. The aim of this
study was to assess the prevalence of subjective sleep disturbances and its effects on sleep
quality in epileptic patients.
Methods: In this cross-sectional study, 152 consecutive epileptic patients and 152 controls
were interviewed. We used Epworth Sleepiness Scale, Insomnia Severity Index, Berlin
Questionnaire and Pittsburg Sleep Quality Index to measure excessive daytime sleepiness,
insomnia, obstructive sleep apnea and sleep quality. R estless leg syndrome was diagnosed
using three questions.
Results: The age, gender and average total sleep time was similar in patients and control group.
The frequency of excessive sleepiness scale and subjective complaint of sleep maintenance
Key Words: was higher in epileptic patients than control group (P<0.05). The symptoms of restless leg
Epilepsy, syndrome were reported by 32.3% of patients and 11.8% of controls (P<0.05).
Seizure, Discussion: Daytime sleepiness, difficulty in sleep maintenance, poor sleep quality and RLS
Sleep Disorders, appear to be common in patients with epilepsy. Further confirmatory studies are needed using
Excessive Daytime Sleepiness. objective sleep studies to detect underlying mechanisms of sleep disorders in these patients.

1. Introduction had significantly more impairment of quality of life

E
compared to people without sleep problems (Piperi-
pilepsy is a chronic disease that affects dou et al., 2008; Senol et al., 2007). Both nocturnal and
0.5 to 1% of the population (Weerd et al., daytime seizures appear to affect sleep architecture and
2004). The recent study reported that the sleep quality (Kotagal et al., 2008).
global adverse effects of epilepsy are high
and includesg 0.5% of the whole burden The interrelationship between sleep disorders and epi-
of diseases of the entire world (Leonardi et al., 2002). lepsy has been described. Type of seizures, time of sei-
zures and antiepileptic drugs may change sleep pattern
A survey conducted on epileptic patients confirmed and decrease sleep quality. In turn, epileptic patients
that people with epilepsy tend to have lower quality that suffer from sleep disorders may have more difficul-
of life compared with general population. In addition, ties in seizures control (Bazil et al., 2003; Szaflarski et
people with epilepsy who reported sleep disturbances al., 2004; Placidi et al., 2000).

* Corresponding Author:
Zohreh yazdi, PhD
Assistant Professor, Qazvin University of Medical Sciences, Qazvin, Iran.
Tel 0098 281 3336002 / Fax: 0098 281 3359503
E-mail: [email protected]

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February 2013, Volume 4, Number 1

In addition, some sleep disorders including periodic The ethical committee of Qazvin University of Medi-
leg movement disorder, restless leg syndrome and other cal Sciences approved this case-control study, and
parasomnia may mimic epileptic seizures (Malow and signed informed consent forms were obtained from all
Vaughn, 2002). Undiagnosed sleep disturbances can of participants.
result in daytime drowsiness, worsening memory, and
deteriorating seizure control. All of the data were collected by questionnaires ad-
ministered by one interviewer for both of patients and
Early diagnosis and treatment of coexisting sleep the control group. Demographic data and information
disorders may help to improve patient's condition and about age at onset, type of seizures, seizure frequency,
control of seizures. Therefore, understanding the preva- seizure time and duration of illness, were collected for
lence of sleep disorders and its effects on sleep quality patients group. We collected information about partici-
is critical for clinicians in optimizing management of pants' sleep habits: when he goes to bed, for how many
the seizures (Babu et al., 2009; Foldvary-Scaefer 2002; hours he sleeps, and when he usually wakes up.
Rocamora et al., 2008).
The validated Persian version of sleep questionnaires
The results from studies on prevalence of sleep dis- were used for information collection. The Persian ver-
orders in epileptic patients are contradictory. The ex- sionss of these questionnaires have been used in previ-
cessive daytime sleepiness is commonly reported in ous studies.
patients with epilepsy (Bazil et al., 2002). The daytime
sleepiness measured by Epworth Sleepiness Scale was The Epworth Sleepiness Scale consists of eight ques-
found in 11 to 28% of patients. The cause of EDS in tions that subjectively evaluate urge of patients to sleep
these patients may be due to side effects of antiepileptic in different life situations . ESS was designed based on
drugs or to other sleep disorders, poor control of seizures Likert scale rating from 0 to 3. Scores 10 are con-
and inadequate sleep (Crespel et al., 2000; Khatami et sidered excessive daytime sleepiness (Halvani et al.,
al., 2006; Vignatelli et al,. 2006). There are a few data 2009).
about prevalence of insomnia, obstructive sleep apnea
and parasomnias in epileptic patients but the frequency The Insomnia Severity Index is composed of seven
of them was reported between 10-65% in OSA, and 10- items assessing recent problems with sleep onset, sleep
33% in parasomnias (Vaughn and D'Cruz 2003; Dyken maintenance, early morning awakening, and satisfac-
et al., 2001). tion with sleep patterns. In addition, the ISI estimates
perceived impairment due to insomnia by subjects. Pa-
In this cross-sectional study, we assessed the preva- tients rate each item on a 0-4 scale and a total score
lence of subjective sleep disturbances and its effects on 8 is considered as insomnia (sadeghniiat et al., 2008).
sleep quality in epileptic patients. We used Berlin questionnaire to screen sleep breathing
disorder. The BQ includes eight items about snoring,
2. Methods daytime somnolence and history of hypertension. The
patients were categorized as being at low risk or high
Adults 18 years or older and with a known diagnosis risk of having sleep apnea (Amra et al., 2011).
of epilepsy who attended our neurology clinic between
September 2010 and February 2011 were approached The PSQI is an instrument used to measure the quality
for subjective sleep disorders. Adult family members in and patterns of sleep in the adults. It differentiates poor
the same age range without a history of epilepsy who sleep from good sleep by measuring seven items: sub-
accompanied the epileptic patients were assessed in jective sleep quality, sleep latency, sleep duration, ha-
our study for subjective sleep disorders as thea control bitual sleep efficiency, sleep disturbances, use of sleep-
group. Subjects in control were comparable with pa- ing medication, and daytime dysfunction during the last
tients in respect to age and sex. A total of 152 epileptic month. Scoring of answers is based on a likert scale 0 to
patients and 152 age and gender matched controls were 3, whereby 3 reflects the negative extreme on the scale.
included in this study. A global score of "5" or greater indicates a poor sleep
(Farrahi et al., 2012).
Patients who had chronic respiratory disease or pro-
gressive neurological disorder and any patient or control We diagnosed restless leg syndrome using three ques-
subject with a history of shift work, were excluded from tions. : a) Do you have the tendency to move your legs
the study. when lying down or sitting? b) Do you feel partial relief

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 February 2013, Volume 4, Number 1

with leg movement? c) Is your complaint about the feel- The mean age of patients was 31.0614.7 years and 85
ings worse at night? People who responded yes to all of them (56%) were male. The mean body mass index
three questions were considered as people who suffer was 24.34.6. The mean years of suffering from sei-
from RLS (Sharifian et al., 2009). zure were 5.35.7, and the average age at diagnosis was
22.69.4. Patients with less than one seizure per month
The internal consistency of these questionnaires in our constituted 143 (94%), and patients with more than one
study was high with a cronbachs alpha of 0.75, 0.71, seizure during month comprised 8 (6%) of the patients.
0.82, 0.79 and 0.85, respectively. Only in 27 (17.7%) of patients seizures predominantly
occurred during sleep.
SPSS for windows, Version 13.0 was used for data
analysis. The differences in proportions between the Table 1 shows descriptive statistics off the main demo-
groups were compared using Fisher's exact test and graphic features in epileptic patients and control group.
independent t test or Mann-Whitney U test. The data As the table shows, there is no difference between pa-
had non normal distribution. We used Pearson correla- tients and control groups in age (31.06 years vs. 28.9
tion coefficient to assess correlation between variables. years), gender, and BMI.
Values were considered statistically significant at P-
value<0.05. Of 152 epileptic patients, 98 (64.5%) had generalized
epilepsy and 54 (35.5%) had focal epilepsy (34 patients
3. Results with temporal lobe epilepsy and 20 patients with frontal
lobe epilepsy). Prevalence of sleep disturbances were
During the study period 152 epileptic patients were not different between patients in terms of locality in epi-
eligible for participation in our study. Control partici- leptogenic foci (P>0.05). Majority of epileptic patients
pants were recruited through people without any history (86.8%) were on polytherapy and. remaining (13.1%)
of seizure, who could be age- and gender matched with on monotherapy. Furthermore, there was no differences
epileptic patients. between the prevalence of sleep disturbances in patients
with different types of treatment regimen (P>0.05).

Table 1. Demographic features of patients and control

Epileptic Patients Control P-value

Age 31.0614.7 28.910.5 0.08

Male/female 85/67 94/58 0.22

Family status

Single 59 (38.8%) 45 (29.6%) 0.09

Married 88 (57.9%) 100 (65.8%)
Divorced 5 (3.3%) 7 (4.6%)

Education 6.93.1 8.92.7 0.06

0.1
BMI 24.34.6 22.95.9
Occupation

Employed 105 (69.1%) 131 (86.2%) 0.09

Unemployed 47 (30.9%) 21 (13.8%)

The average total sleep time in epileptic and control vs. n= 4 who asleep less than 5 and n= 19 vs. n= 6 who
group was similar, as well as duration taken to fall asleep more than 7 hours respectively).
asleep each night. After we categorized total hours of
sleep during the night, number of patients with total Table 2 and 3 show and compare sleep habits and sleep
sleep time less than 5 or more than 7 was higher sta- disturbance for each group. As the tables show, subjec-
tistically in epileptic patients than control group (n= 9 tive complaint of sleep maintenance (P<0.05) and, EDS

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Basic and Clinical
February 2013, Volume 4, Number 1

(both of ESS 10 and ESS14) was more common in The result of PSQI showed that poor sleep quality was
patients compared with the control group. There is no higher in epileptic patients than control group (total
difference between number of patients and controls how score 6.2 vs. 4.3 respectively, P<0.05). Table 4 shows
had low, moderate and high risk of OSA (P>0.05). The and compares different distinct subscales of PSQI for
frequency of restless leg syndrome, as assessed with each group. Epileptic patients had significantly poor
three questions, was higher in epileptic patients (32.3% subjective sleep quality, longer sleep duration and more
vs. 12%, P<0.05). sleep disturbances during the night. Also, prevalence
of daytime dysfunction was more prevalent in patients
than in the control group.

Table 2. Prevalence of insomnia and excessive daytime sleepiness

Epileptic Patients Control P-value

Sleep Onset Insomnia 38.1%(58) 40.1%(61) 0.081

Sleep Maintenance Insomnia 58.6%(89) 33.5%(51) 0.01

Early Morning Awakening 28.3%(43) 24.3%(37) 0.12

Isi Score 8 17.7%(27) 14.5%(22) 0.086

Epworth Sleepiness Score (10) 23% (35) 10.5%(16) 0.001

Epworth Sleepiness Score (14) 10.5%(11) 33.3%(5) 0.004

Ess Mean (range) 6.2 (4-21) 2.9 (0-9) 0.009

Table 3. Prevalence of obstructive sleep apnea and restless leg syndrome

Epileptic Patients Controls P-value

Obstructive Sleep Apnea

Low risk 121(79.6%) 118 (77.6%) 0.29

Moderate risk 24 (15.8%) 29 (19%)
High risk 7 (4.6%) 5 (3.3%)

Restless Leg Syndrome %32.3(49) 11.8%(18) 0.005

Table 4. Results from different distinct subscales of PSQI in epileptic patients and control group

Components of PSQI Epileptic Patients Controls P-value

Subjective Sleep Quality 2.10.9 1.40.5 0.03

Sleep Latency 1.10.5 0.90.4 0.62

Sleep Duration 1.80.7 1.40.3 0.021

Habitual Sleep Efficiency 1.10.9 0.90.4 0.36

Sleep Disturbances 2.31.2 1.10.5 0.004

Use of Sleep Medication 2.41.1 0.80.3 0

Daytime Dysfunction 1.80.8 0.70.4 0.038

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 February 2013, Volume 4, Number 1

4. Discussion In a recent study, no difference was detected between

epileptic patients and control group in terms of preva-
As we saw in the results, excessive daytime sleepiness lence of OSA (Khatami et al., 2006 and Malow et al.,
and difficulty in sleep maintenance is seen to be more 1997). In another study, 615 patients with OSA were in-
prevalent in epileptic patients than the control group. vestigated and, it became clear that the prevalence of epi-
However, there was no difference in terms of obstruc- lepsy in these patients was 3.4% which was higher than
tive sleep apnea. Also, it was showed that sleep quality epilepsy in normal population (Haellinger et al., 2000).
in epileptic patients was worse than the control group.
Several mechanisms have been mentioned as the causes
Most studies run on this issue indicate that prevalence of the increase in OSA prevalence in epilepsy. One of
of sleepiness in epileptic patients has been higher com- them is weight gain following treatment with anti epilep-
pared to the normal population. Of course, the studies tic drugs (Manni et al., 2003 and Tattara et al., 2000). The
show some slight differences in prevalence of EDS. reason for lack of difference on OSA between patients
These differences could be attributed to different groups and control group in our study could be attributed to
of patients being studied. In some studies, a correlation sameness of body mass index in both groups.
has been observed between the type of medication and
seizure time with sleepiness. But some other studies In our study, patients with epilepsy had worse sleep
have showed that excessive daytime sleepiness in epi- quality likely due to the fragmentation of sleep. Results
leptic patients had commenced even before starting the obtained from ISI questionnaire (higher prevalence of
medication (Piperidou et al., 2008; Placidi et al., 2000; sleep maintenance insomnia in epileptic patients) and
Manni and Tattara 2000). PSQI questionnaire confirmed this issue. The scores
from subjective sleep quality and sleep disruption were
In our study there was no association between type significantly raised in epileptic patients. Our findings
of medication and EDS. In a study conducted on 622 supported by other studies (Khatami et al. 2006, Krish-
epileptic patients it was demonstrated that experience nan et al. 2012)
of sleepiness was higher at the beginning of medication
just to be followed by a reduction of that, 3 month after Also due to the results of our study, the prevalence of
medication (Mattson 1989). Some studies demonstrated RLS in epileptic patients was higher than the control
that EDS is higher in patients with polytherapy com- group. There are case reports that have reported RLS in
pared to patients with monotherapy (Manni and Tattara epileptic patients during taking some AEDs medication
2000). We did not come across any evidence of this (Arico et al., 2011; Radtke 2001). However, in our study
claim which might be related to the fact that most of our no association was found between different medication
patients were on polytherapy treatment. regimes and RLS syndrome, likely to be caused by lack
of any considerable difference among patients regimes
Moreover, some studies have showed that patients of AEDs.
with concurrent existence of other types of sleep disor-
ders such as restless leg syndrome and obstructive sleep This study has a few limitations that need to be consid-
apnea suffer from more severe excessive daytime sleep- ered. One limitation of our study relates to the absence
iness (Malow et al., 1997). The findings indicate that of objective sleep tests (polysomnography, MSLT, and
there are complex phenomena in pathogenesis of EDS, MWT) to confirm suspected sleep disorders and the
which needs a more investigation. In our study, the presence of EDS. Another limitation of our study is its
prevalence of high risk patients for OSA was almost the retrospective design and the small sample size. Further
same as the control group. Results obtained from other longitudinal studies and objective sleep tests are needed
studies have been controversial. The instrument applied to establish our findings. Also, we suggest that taking
for diagnosis of OSA has been different in these stud- history from sleep disturbances is important in patients
ies, which might be an explanation for the difference in with epilepsy.
results. In a study that sleep apnea was diagnosed with
polysomnography, it has been revealed that 10.8% of In sum, results from our study demonstrated the high
patients were suffering from sleep apnea that is similar prevalence of excessive daytime sleepiness, restless leg
to the results obtained from our research (Manni et al., syndrome and poor sleep quality in patients with epilepsy.
2003). Results from other studies that survey prevalence Our findings support undertaking objective sleep tests
of OSA in epileptic patients have been different. for early diagnosis of sleep disturbances in these patients.
We believe that our findings have implications for both

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Basic and Clinical
February 2013, Volume 4, Number 1

clinical and research purposes. Moreover, it seems neces- Manni, R., Tattara, A. (2000) Evaluation of sleepiness in epi-
sary to pay more attention to diagnosis and treatment of lepsy. Clinical Neurophy, 111, S111-S114.

sleep disorders in epileptic patients by physicians. Mattson, R.H. (1989) Selection of antiepileptic drug therapy. In:
Levy R, -Mattson RH, Meldrum B, Penry JK, editors. Anti-
ceptic drugs, 3rd ed. pp. 103-105.

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