|Year : 2015 | Volume
| Issue : 2 | Page : 103-108
Sleep disturbances among patients with epilepsy in Nigeria
Morenikeji A Komolafe1, Taofiki Ajao Sunmonu2, Olubunmi A Ogunrin3, Jimoh O Disu2, Birinus A Ezeala4, Sani A Abubakar5, Emmanuel Iwuoso5
1 Department of Medicine, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun, Nigeria
2 Department of Medicine, Federal Medical Centre, Owo, Ondo, Nigeria
3 Department of Medicine, University of Nigeria Teaching Hospital, Benin, Edo, Nigeria
4 Department of Medicine, University of Nigeria Teaching Hospital, Enugu, Nigeria
5 Department of Medicine, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna, Nigeria
|Date of Web Publication||19-Feb-2015|
Taofiki Ajao Sunmonu
Department of Medicine, Federal Medical Centre Owo, Ondo
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: There is a complex inter-relationship between sleep disorders and epilepsy, and there are few studies in Nigeria on sleep disorders in epilepsy. This study was carried out to determine the prevalence, pattern and predictors of sleep disturbances among persons with epilepsy (PWE).
Materials and Methods: This was a multi-center, cross-sectional study of 124 PWE in Nigeria. A questionnaire was used to collect data on social and demographic variables, epilepsy- related variables and sleep disturbances in PWE. Exclusion criteria were mental retardation, and use of sedative drugs. The data was analyzed using Statistical Package for Social Sciences version 11.0 and P < 0.05 was considered as significant.
Results: There were 77 males and 47 females with a mean age of 33.4 ± 13.1 years. The mean age of seizure onset was 23.7 ± 14.6 years, while the mean duration of epilepsy was 9.5 ± 9.4 years. The commonest type of epilepsy was secondarily generalized tonic-clonic seizures (62%). The prevalence of sleep disorders in PWE was 82%. Parasomnias occurred in 46%, followed by obstructive sleep apnea in 23%, insomnia (19%) excessive daytime sleepiness (EDS) (17%), and restless leg syndrome (11%). None of the socio-demographic or epilepsy- related variables was predictive of EDS or parasomnias in PWE (P > 0.05).
Conclusion: There is a high frequency of sleep disorders among PWE. Clinicians should screen PWE for sleep disturbances.
| Abstract in French|| |
Contexte: Il ya une inter-relation complexe entre les troubles du sommeil et de l'ιpilepsie, et il ya peu d'ιtudes au Nigeria sur les troubles du sommeil chez l'ιpilepsie. Cette ιtude a ιtι effectuιe afin de dιterminer la prιvalence, les motifs et facteurs prιdictifs de troubles du sommeil chez les personnes atteintes d'ιpilepsie (PWE).
Matιriel et Mιthodes: Il s'agissait d'une ιtude multicentrique, en coupe transversale de 124 PWE au Nigeria. Un questionnaire a ιtι utilisι pour recueillir des donnιes sur les variables sociales et dιmographiques, les variables liιs ΰ l'ιpilepsie et des troubles du sommeil ΰ PWEU. Les critθres d'exclusion ιtaient un retard mental, et l'utilisation de sιdatifs. Les donnιes ont ιtι analysιes ΰ l'aide du logiciel statistique pour les sciences sociales et la version 11.0 P < 0,05 a ιtι considιrιe comme significative.
Rιsultats: Il y avait 77 hommes et 47 femmes avec un βge moyen de 33,4 13,1 annιes. L'βge moyen de dιbut des crises ιtait de 23,7 14,6 annιes, alors que la durιe moyenne de l'ιpilepsie ιtait de 9,5 9,4 ans. Le type le plus courant de l'ιpilepsie a ιtι secondairement gιnιralisιe tonico-cloniques (62%). La prιvalence des troubles du sommeil ΰ PWEU a ιtι de 82%. Les parasomnies sont survenus dans 46%, suivie d'une apnιe obstructive du sommeil dans 23%, l'insomnie (19%) la somnolence diurne excessive (SDE) (17%), et le syndrome des jambes sans repos (11%). Aucune des variables socio-dιmographiques ou liιs ΰ l'ιpilepsie ιtait prιdictive d'EDS ou parasomnies dans PWE (P > 0,05).
Conclusion: Il ya une frιquence ιlevιe des troubles du sommeil chez les PWEU. Les cliniciens devraient ιcran PWEU pour les troubles du sommeil.
Mots clιs: ιpilepsie, somnolence excessive le jour, le Nigeria, l'apnιe obstructive du sommeil, des troubles du sommeil
Keywords: Epilepsy, excessive daytime sleepiness, Nigeria, obstructive sleep apnoea, sleep disturbances
|How to cite this article:|
Komolafe MA, Sunmonu TA, Ogunrin OA, Disu JO, Ezeala BA, Abubakar SA, Iwuoso E. Sleep disturbances among patients with epilepsy in Nigeria. Ann Afr Med 2015;14:103-8
|How to cite this URL:|
Komolafe MA, Sunmonu TA, Ogunrin OA, Disu JO, Ezeala BA, Abubakar SA, Iwuoso E. Sleep disturbances among patients with epilepsy in Nigeria. Ann Afr Med [serial online] 2015 [cited 2021 Apr 18];14:103-8. Available from: https://www.annalsafrmed.org/text.asp?2015/14/2/103/149880
| Introduction|| |
Epilepsy is the most common noninfections neurological disease in developing countries. , Sleep disorders are common; snoring has been reported in a third of the general population, while parasomnias occur in a quarter to two-thirds of Nigeria adult population. ,, The frequency of sleep disorders has been observed to be higher in persons with epilepsy (PWE). In particular, excessive daytime sleepiness (EDS), insomnias and parasomnias, ,, were observed to be common and could result in cognitive impairment and poorly controlled seizures.
In sub-Saharan Africa, myths, misconceptions are common in epilepsy and contribute to late presentation for orthodox medical care. Similar misconceptions have been observed in sleep disorders. For instance, any unusual occurrence during sleep is usually attributed to the nocturnal warfare caused by spiritual enemies, and this is described as "Ogun Oru."  There has been no previous work on the occurrence of sleep disorders among PWE in Nigeria and hence we carried out this cross-sectional study to determine the prevalence, pattern and predictors of sleep disturbances among PWE.
| Materials and Methods|| |
This was a cross-sectional, multi-center study carried out among PWE from five tertiary health care centers in Nigeria. The study sites were the neurology clinics of Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife, and the Federal Medical Centre, Owo located in South-West Nigeria, the University of Benin Teaching Hospital, Benin in the South-South, University of Nigeria Teaching Hospital, Enugu in the South-East and Ahmadu Bello University Teaching Hospital, Zaria in the North-Central zone. A questionnaire was used to collect information on demographic variables, epilepsy related variables and sleep disturbances among the study participants; the questionnaire had been validated in a previous study.  Information on epilepsy related variables was also documented. Patients with cognitive defects, patients with known psychiatric co-morbidity and use of hypnotic drugs were excluded from the study. Informed consent was obtained from the patients and approval obtained from the Research Ethics Committee of the participating centers. Verbal consent was also obtained prior to administering the questionnaire.
Epilepsy was diagnosed and classified according to International League Against Epilepsy criteria.  Patients with EDS had an Epworth sleepiness score of ≥10. Clinically suspected obstructive sleep apnea (CSOSA) was defined in accordance with the 2001 International Classification of Sleep Disorder, Revised (ICSD-R): Habitual and loud snoring, witnessed apneas and EDS. 
Parasomnia was defined according to ICSD-R as undesirable physical events, experiences that occur during entry into sleep, within sleep or during arousal from sleep.  Disorders of rapid eye movement (REM) sleep include nightmares, isolated sleep paralysis and REM sleep behavior disorder. Disorders of non-REM (NREM) sleep includes sleepwalking, sleep terrors and confusional arousal, while disorder of sleep-wake transition include sleep talking and sleep starts. Other parasomnias include enuresis, sleep-related dissociative disorder, sleep-related groaning, sleep-related hallucinations etc. 
Restless leg syndrome (RLS) was defined according to ICSD-R as an irresistible urge to move the legs usually accompanied or caused by unpleasant sensation in the legs and this worsens during the period of lying down or sitting. The unpleasant sensation is relieved by movement of the legs. This condition is not better explained by another sleep disorder, medical or neurological disorders, mental disorder, medication use or substance abuse disorder. 
The data were analyzed using Statistical Package for Social Sciences (SPSS) version 15.0 (SPSS Inc. Chicago IL) Bivariate analysis was performed using Pearson's Chi-square test for categorical variables, and Student's t-test was used to compare the means of continuous variables. Logistic regression analyses were done to determine the predictive factors for the occurrence of EDS and parasomnias in the PWE. The level of significance was 0.05.
| Results|| |
There were 124 subjects comprising 77 males and 47 females PWE. The mean age in years was 33.4 ± 13.1 with a range of 18-70 years. Among the study population, majority were Yorubas (52%), while the other ethnic groups were Hausa's (17%), Ibo's (18%), while other minority groups were (13%). [Table 1] shows the background social and demographic profile of the study participants.
Epilepsy related variables
The mean age of seizure onset was 23.7 ± 14.6 years. The mean duration of epilepsy in years was 9.5 ± 9.4. Majority of PWE's had secondarily generalized tonic-clonic seizures (62%) followed by complex partial seizures (34%). One hundred and thirteen patients (91%) were on anti-epileptic drugs (AEDs) and the range of drug dosages were as follows; carbamazepine, 100-1800 mg/day, phenytoin, 100-300 mg/day and phenobarbitone, 30-60 mg/day. [Table 2] shows other epilepsy-related variables.
Prevalence of sleep disorders in persons with epilepsy
One hundred and two (82%) PWE comprising 63 males (62%) and 39 females (38%) had one or more sleep disorders. The average total sleep time was 7.8 h/day. Twenty-nine PWE reported a sleep time of below 6 h/day, while a total sleep time of >10 h/day was reported by nine PWE. The prevalence of various sleep disorders in the study participants is shown in [Table 3]. The commonest sleep disorders was parasomnias (46%), followed by OSA (23%), insomnia (19%), EDS (17%) and RLS (9%).
There was no relationship between the sociodemographic or epilepsy-related variables and the presence of EDS or parasomnias. [Table 4] highlights the logistic regression analysis result of the relationship between these variables and presence of EDS.
| Discussion|| |
Patients with epilepsy are at a higher risk for sleep disorders, due to nocturnal seizures altering sleep organization and architecture. Some types of seizures are facilitated by specific sleep stages. In general, seizures are likely to occur during NREM sleep. ,, The effect of sleep on the occurrence of epilepsy was described earlier by some workers. , The sleep disorders identified were CSOSA, RLS, parasomnias, EDS and insomnia.
Touchon et al. showed that insomnia is very common in PWE. In a prospective study of 100 PWE  sleep maintenance insomnia was reported in 52% while 34% had sleep onset insomnia. This figure was higher than the 13% and 7% observed in PWE in this study. A Greek study  showed a prevalence of 24% for insomnia in PWE which was also higher than what was observed in this study. The reason for a lower figure in this study might be due to the small sample size of the study.
The incidence of OSA in general population is 4-7%,  while the incidence of OSA in patients with refractory epilepsy may be as high as 33%.  In highly selected PWE that were referred for polysomnography (PSG), 77% were shown to have OSA in a study.  The prevalence of CSOSA in this study was 23% which is similar to that of 15% observed in an Italian study which utilized a structured apnea questionnaire to evaluate PWE. We had no facility for PSG. Patients with co-morbid epilepsy and OSA in previous studies were more likely to be men, overweight and have their first seizures later in life. 
Periodic limb movement disorder is characterized by periodic episodes of repetitive and highly stereotyped limb movements during sleep.  In study by Malow et al. 35% of PWE  had features of RLS using PSG. In the study by Khatami et al. symptoms of RLS were present in 18% of PWE. In this study the prevalence of RLS in PWE was 9%, a lower prevalence rate, probably because PSG, which is more sensitive for detection of RLS, was not done due to nonavailability of this facility at the time of study.
Excessive daytime sleepiness is also common among PWE and may be a direct result of the disease. The prevalence of EDS ranged from 18% to 50% in adult PWE in previous studies. ,,, In our study, we observed a frequency of 17% for EDS, which is similar to the findings from these earlier studies. EDS could be due to insufficient sleep at night following obstructive apnea, ,,,,,,,, presence of other co-morbid sleep disorders such as narcolepsy and periodic limb movement syndrome, or side effect of AEDs.  In this study, gender, age, type and number of AEDs were not associated with presence of EDS, which is similar to the findings in other previous studies. ,,,,, In this study, the neck circumference was not associated with EDS, which is different from what was observed in a previous study  and the reason for this discrepancy is not clear at the moment and need to be explored in a large scale polysomnographic study in the future.
Parasomnias typically occur in association with deeper NREM sleep stages usually in the first one-third of the night. ,, The second type of parasonmias occur in REM sleep and includes nightmares, sleep paralysis and REM sleep behavior disorders, which are observed during the final one-third of the night. , Previous studies carried out by Oluwole,  and Ohaeri et al.,  demonstrated that parasomnias particularly nightmares were common among the general population in Nigeria. Multiracial studies in USA also observed that parasomnias are more common among African-Americans compared to Caucasians and that traumatic events were associated with an increased frequency of parasomnias in the population , In this study, the prevalence of parasomnias in PWE was 46% which was consistent with the findings from the previous studies. , The prevalence of parasomnias in this study is higher than that reported by Busulli et al.,  who observed that 34% of patients with nocturnal frontal lobe epilepsy had NREM parasomnias and that of Manni et al.,  with a prevalence of 10% for REM sleep behavior disorder in elderly subjects with epilepsy. In the previous study carried out by Oluwole  among medical student's, increased duration of sleep and alcohol intake were associated with parasomnias, while smoking, intake of caffeinated drink and male gender were not associated with parasomnias. Though there is a paucity of literature on the risk factors that were predictive of the presence of parasomnias in PWE however in this study, none of the sociodemographic or epilepsy-related variables predicted the occurrence of parasomnias in the PWE, the reasons for this finding are unclear but might probably be due to possibility of differences in risk factors that could predispose the general population and PWE to development of parasomnias.
| Conclusion|| |
Sleep disorders are common among PWE in Nigeria. Further studies are needed to determine the effect of sleep disturbances on quality of life of PWE. Neurologists and general medical practitioners should always inquire about the presence of sleep disturbances in PWE.
In this study, PSG could not be done in any of the study centers because of nonavailability of a sleep laboratory. A follow-up study would be done in the near future with the availability of PSG facilities in these patients.
| Acknowledgments|| |
The authors wish to thank Dr. Adewole O. O. (Department of Medicine, Obafemi Awolowo University Ile-Ife, Osun, Nigeria) for supplying the sleep questionnaire that was used for this study and Dr. Akin Omisore of Department of Community Health, Osun State University, Osogbo, Nigeria for assisting with the statistical analysis.
| References|| |
Osuntokun BO. Epilepsy in Africa. Epidemiology of epilepsy in developing countries in Africa. Trop Geogr Med 1978;30:23-32.
Ogunniyi A, Oluwole OS, Osuntokun BO. Two-year remission in Nigerian epileptics. East Afr Med J 1998;75:392-5.
Adewole OO, Adeyemo H, Ayeni F, Anteyi EA, Ajuwon ZO, Erhabor GE, et al.
Prevalence and correlates of snoring among adults in Nigeria. Afr Health Sci 2008;8:108-13.
Oluwole OS. Lifetime prevalence and incidence of parasomnias in a population of young adult Nigerians. J Neurol 2010;257:1141-7.
Ohaeri JU, Odejide AO, Ikuesan BA, Adeyemi JJ. Features of isolated sleep paralysis among Nigerians. Natl Med Assoc1989;81:805-8.
Derry CP, Duncan S. Sleep and epilepsy. Epilepsy Behav 2013;26:394-404.
Khatami R, Zutter D, Siegel A, Mathis J, Donati F, Bassetti CL. Sleep-wake habits and disorders in a series of 100 adult epilepsy patients - a prospective study. Seizure 2006;15:299-306.
Manni R, Terzaghi M. Comorbidity between epilepsy and sleep disorders. Epilepsy Res 2010;90:171-7.
Aina OF, Famuyiwa OO. Ogun Oru: a traditional explanation for nocturnal neuropsychiatric disturbances among the Yoruba of Southwest Nigeria. Transcult Psychiatry 2007;44:44-54.
Fisher RS, Acevedo C, Arzimanoglou A, Bogacz A, Cross JH, Elger CE, et al.
ILAE official report: a practical clinical definition of epilepsy. Epilepsia 2014;55:475-82.
Obstructive sleep apnea syndrome. In: American Sleep Disorder Association, editors. The International Classification of Sleep Disorders, Revised: Diagnostics and Coding Manual. Rochester, MN, American Sleep Disorder Association; 2001.
Ryvlin P, Minotti L, Demarquay G, Hirsch E, Arzimanoglou A, Hoffman D, et al.
Nocturnal hypermotor seizures, suggesting frontal lobe epilepsy, can originate in the insula. Epilepsia 2006;47:755-65.
Minecan D, Natarajan A, Marzec M, Malow B. Relationship of epileptic seizures to sleep stage and sleep depth. Sleep 2002;25:899-904.
Steriade M, McCormick DA, Sejnowski TJ. Thalamocortical oscillations in the sleeping and aroused brain. Science 1993;262:679-85.
Gowers W. Epilepsy and Other Chronic Comvulsive Diseases. London: Williams Wood; 1885.
Janz D. The grand mal epilepsies and the sleeping-waking cycle. Epilepsia 1962;3:69-109.
Touchon J, Baldy-Moulinier M, Bilhard M, Besset A, Cadilhac J. Sleep organization and epilepsy
. In: R Degan, Rodin E, editors. Epilepsy, Sleep and Sleep Deprivation. 2 nd
ed. New York: Elsevier; 1991. p. 73-81.
Piperidou C, Karlovasitou A, Triantafyllou N, Terzoudi A, Constantinidis T, Vadikolias K, et al.
Influence of sleep disturbance on quality of life of patients with epilepsy. Seizure 2008;17:588-94.
Park JG, Ramar K, Olson EJ. Updates on definition, consequences, and management of obstructive sleep apnea. Mayo Clin Proc 2011;86:549-54.
Malow BA, Levy K, Maturen K, Bowes R. Obstructive sleep apnea is common in medically refractory epilepsy patients. Neurology 2000;55:1002-7.
Malow BA, Fromes GA, Aldrich MS. Usefulness of polysomnography in epilepsy patients. Neurology 1997;48:1389-94.
Manni R, Terzaghi M, Arbasino C, Sartori I, Galimberti CA, Tartara A. Obstructive sleep apnea in a clinical series of adult epilepsy patients: frequency and features of the comorbidity. Epilepsia 2003;44:836-40.
Malow BA, Bowes RJ, Lin X. Predictors of sleepiness in epilepsy patients. Sleep 1997;20:1105-10.
Manni R, Politine L, Ratti MT, Sartori I, Galiberti CA. Sleep hygiene in epilepsy patients: A questionnaire based survey in 270 epileptic patients of adult age. Sleep 1998;21;175.
Adverse reactions to antiepileptic drugs: a multicenter survey of clinical practice. Collaborative Group for Epidemiology of Epilepsy. Epilepsia 1986;27:323-30.
Malow BA, Bowes RJ, Lin X. Predictors of sleepiness in epilepsy patients. Sleep 1997;20:1105-10.
Weintranb D, Resor S, Brazil C, Hirsch L, Head to head comparison of the sedating effect of anti-epileptic drugs in adult with epilepsy. Neurology 2005;64;A22-3.
Manni R, Politini L, Sartori I, Ratti MT, Galimberti CA, Tartara A. Daytime sleepiness in epilepsy patients: evaluation by means of the Epworth sleepiness scale. J Neurol 2000;247:716-7.
Xu X, Brandenburg NA, McDermott AM, Bazil CW. Sleep disturbances reported by refractory partial-onset epilepsy patients receiving polytherapy. Epilepsia 2006;47:1176-83.
Carrion MJ, Nunes ML, Martinez JV, Portuguez MW, da Costa JC. Evaluation of sleep quality in patients with refractory seizures who undergo epilepsy surgery. Epilepsy Behav 2010;17:120-3.
Gastant H, Broughton RJ. A clinical and polygraphic study of episodic phenomena during sleep. Bull Psychiatry 1965;7:197.
Keefauver SP, Guldieminant PC. Sleep terrors and sleep walking. In: Kryger M, Rothdement WC, editors. Principles and Practice of Sleep Medicine. 2 nd
ed. Philadelphia: WB Saunders; 1994. p. 567.
Fisher C, Byrne J, Edwards A, Kahn E. A psychophysiological study of nightmares. J Am Psychoanal Assoc 1970;18:747-82.
Schenck CH, Bundlie SR, Ettinger MG, Mahowald MW. Chronic behavioral disorders of human REM sleep: a new category of parasomnia. Sleep 1986;9:293-308.
Paradis CM, Friedman S. Sleep paralysis in African Americans with panic disorder. Transcult Psychiatry 2005;42:123-34.
Neilsen T. Nightmare frequency as a function of age, gender and September 11 2001: Findings from an internet questionnaire. Dreaming 2006;16:145-8.
Busulli F, Naldi I, Vetrigno R, et al
. Paroxysmal motor disturbances during sleep, study of the frequency of parasomnias in patients with nocturnal frontal lobe epilepsy and their relatives. Epilepsia 2005;46:284.
Manni R, Terzaghi M, Zambrelli E. REM sleep behaviour disorder in elderly subjects with epilepsy: frequency and clinical aspects of the comorbidity. Epilepsy Res 2007;77:128-33.
[Table 1], [Table 2], [Table 3], [Table 4]