Biomedical Research

Abstract

Sleep disordered breathing is a condition when upper airway has been obstructed and sleep pattern is not in normal cycles. It comprises of snoring, upper airway resistance syndrome, central sleep apnea and obstructive sleep apnea (OSA). The most commonly used treatment for OSA is Continuous Positive Airway Pressure (CPAP) [1]. Epilepsy like any other chronic disease has significant impact on the quality of life. Seizure frequency will influence quality of life in epilepsy patients and it can be influenced by disordered sleep[2]. This is a crosssectional study done to measure quality of life for epileptic patients with obstructive sleep apnea and outcome of treatment of OSA. This study enrolled 180 epileptic patients who were seen in Neurology Clinic of the Hospital Universiti Sains Malaysia. Each patient was administered two set of questionnaires; Epworth Sleepiness Scales (ESS) and Quality of Life in Epilepsy patients (QOLIE-31). Quality of life in epilepsy patients was assessed using Malay version of QOLIE-31 [3]Patients with score of ESS more than 10 went for overnight Polysomnography test. Patients who were positive for OSA by overnight Polysomnography were treated with CPAP. After that patients were assessed again with QOLIE-31 questionnaires. In our study, the frequency of OSA was positively associated with age. Seizure worry was significantly more in epilepsy patients with OSA compared to those without OSA.( p value < 0.005) and quality of life scores were lower in this group with high sezure worry. There were significant differences (, p value < 0.005) in medication effects, cognitive functioning, overall quality of life and seizure worry. We conclude that patients with epilepsy and OSA may have frequently seizure attack or severe seizure which influences their QoL and this situation improved with treatment of OSA using CPAP

Keywords

Sleep disorder, snoring, obstructive sleep apnea, continuous positive airway pressure

Introduction

Apnea is defined as the absent of air flow for a minimum 10 sec. Apnea usually associated with drop of oxygen saturation in the haemoglobin, followed by brief microarousal which result the sleep fragmentation and decreased amount of slow wave and REM sleep [4].

Obstructive sleep apnea (OSA) is common major seen in adult men with 24% where as 9% adult women and 2% in children [5-7]. The best estimates of OSAS based on several studies suggest prevalence in middle age men is 2- 4 % and 1-2% of women [8].

The most available and usually treatment for OSA is Continuous Positive Airway Pressure (CPAP). The CPAP will prevent air way collapse during respiration at sleep [1]. In early recognition of OSA the only effective treatment available is tracheostomy. This treatment will create a surgical airway which helps patients to breath during sleep [8].

The principle of CPAP is by applied a positive pressure via nose or mouth depend their types. The airway wall is strengthened and snoring is suppressed. The minimum period required to reduce symptoms is not know and probably varies in a complex way between each individuals [8].

Factors that influenced quality of life in epilepsy patients in [9] study were mood disorder and seizure frequency. In study conducted by [10] found that factors that significantly affected overall quality of life were female gender, high seizure frequency, using of more than one antiepileptic drugs, high anxiety and depressive symptom.

Epilepsy patients with sleep disturbance specifically insomnia have impairment in their quality of life. In cross sectional study by [11] they found that sleep disturbances the most strong predictor had influence on QOLIE- 31.Besides sleep disturbances socioeconomic status, female gender and high frequency also predicted to lower quality of life in epilepsy patients. According to [12] they revealed sleep disturbances associated with the greatest impairment in partial epilepsy patients.

In Polysomnography study by [13] they found that obstructive sleep apnea influence quality of life in patients and bed partners. To improve their quality of life patients and bed partners were given CPAP treatment.

Excessive sleepiness and lack of physical activity affected the quality of life in obstructive sleep apnea patients [14]. To improve quality of life in patients they should do physical activity and have healthy active life style.

In our study we investigate quality of life of epilepsy patients between patients with OSA and Non OSA by using Malay version QOLIE-31 [3]. Besides that we investigate quality of life of epilepsy patients before and after treatment with Continuous positive airway pressure (CPAP).

Methods

This is a cross-sectional study done to measure quality of life for epileptic patients with obstructive sleep apnea (OSA) and outcome of treatment of OSA. This study enrolled 180 epileptic patients from 200 epileptic who were seen in Neurology Clinic of the Hospital Universiti Sains Malaysia with principal diagnosis of epilepsy. The population was epilepsy patients who attended neuroclinic HUSM, Kubang Kerian, Kelantan between 2008 and April 2010.Each patient who attended in the clinic would be given two set of questionnaires; Epworth Sleepiness Scales (ESS) and Quality of Life in Epilepsy patients (QOLIE-31). Patients with score of ESS more than 10 went for overnight Polysomnography test. Patients who were had a positive for OSA by overnight Polysomnogra phy were given treatment. After that patients will assess again with QOLIE-31 questionnaires.

Each variable from the patients of score ESS more than 10 and less than 10 was tested for the normality of the distribution. Differences between both groups were tested by using independent T-test. The data for the epileptic’s patients with OSA and Non OSA did not present normal distribution and were analyzed by non-parametric tests. Quality of life was compared to another by using Mann Whitney test. To analyze quality of life in five epileptic’s patients with OSA before and after treatment we used Wilcoxon. The Statistical package for Social Sciences (SPSS for Windows) was used for all statistical analyses. Values of p< 0.05 were considered statistically significant.

Results

There was significant association between the age of patients with OSA in our study. There were no significant associations between AED usage, gender and seizure type.

There is significant different in Seizure worry between group of OSA and non OSA patients. It showed quality of life in Seizure worry was lower in OSA compare to Non OSA. There were no significant different in others subscales, Social functioning, Medication effects, Cognitive functioning, Energy/Fatigue, Emotional and Overall Quality of Life Table 3 shows the quality of life in epilepsy patient with OSA before and after giving treatment with CPAP. There were significant different in Medication effects, Cognitive functioning, Overall quality of life and Seizure worry. It showed that quality of life in five subscales was increased after using CPAP. The other subscales in QOLIE-31 have no significant different with p value more than 0.05.

Table 1: Demographic and clinical variables with OSA

Table 2: Quality of life in epilepsy patients undergo Polysomnography test

Table 3: Quality of life in epilepsy patients with OSA before and after treatment with CPAP

Discussion

Quality of life in epilepsy patients with OSA and Non OSA.

Obstructive sleep apnea most common cause to excessive sleepiness among patients influenced to quality of life. In our study using QOLIE-31 to access quality of life it showed significant different between OSA and Non OSA in only Seizure worry subscale.

Seizure worry subscale consist of such items as worry about future seizures, apprehension over future injury resulting from seizures, trepidation over adverse side effects of medication regimens and social embarrassment over having seizure. We suggest that patients with epilepsy and OSA may have frequently seizure attack or severe seizure which influences their quality of life. Patients with epilepsy alone already have lower quality of life so when they have another symptom of OSA their quality of life will be worst. According to (15) their research across sixth epilepsy patients with OSA found that OSA would precipitate seizure among the patients. They found that OSA interrupted the architecture of sleep pattern then would cause seizures. Patients with sleep apnea syndrome typically reach only the light stages of sleep and may have frequent short arousals.

It is postulated that about one- third or more of patients with epilepsy would suffered from OSA and usually occur in medically unmanageable seizure patients. There was an evidence for the worsening of seizures in older adults who are diagnosed with OSA. It is also found that OSA was associated with increasing age, male gender and seizure during sleep [16].

A research by [17] show that coexistence of OSA in epilepsy patients unselected for sleep disorder is common. There is increase rate of OSA in a larger epilepsy patient’s series that involved epilepsy with different epilepsy syndromes and various degrees of disease severity. Factors which associate between epilepsy and OSA are not fully understood. However it could derive from the fact of both disorders, when present in a single subject, interact with each other, facilitating reciprocal manifestations and emphasizing the comorbidity.

According to [18], it was observed that the co-occurrence of OSA and epilepsy was 5%. The high frequency of OSA among epilepsy patients suggests a link between both diseases. There is a possible temporal relationship between onset of OSA symptoms and change in seizure control in about two thirds of patients.

According to [19] OSA could contribute to a new seizure appearance in epilepsy older patients but they still did not get clear answer. Older patients are most at risk for seizure and for OSA. They confirmed older epilepsy patients would have high prevalence of OSA. In our subjects, the frequency of OSA was positively correlated with age. Our data not comparable with this study. Most of our OSA patients age from 30-72 years old, only one of the patients age around 70 years.

Quality of life in epilepsy patients with OSA before and after treatment with CPAP.

In our study there were significant different in Medication effects, Cognitive functioning, Overall quality of life and Seizure worry. It showed that quality of life in five subscales was increased after using CPAP.

Medication effects measure task such as effects of medication to their physical, effects of medication to their mental and their worry taking medications will be bad if taken for a long time. Cognitive functioning measure task such as concerning memory, concentration, and reasoning. In this study we suggest that when a patient is well treated they will increase in their cognitive functioning because they will less worry about their seizure and effect of medication.

In our study after using CPAP as treatment for OSA in epilepsy patients showed increase of quality in Medication effects, Cognitive functioning, Overall quality of life and Seizure worry. As we know sleep disruption will triggered seizure attack [4]. We suggest when OSA symptoms is well treated by using CPAP patients will have a good quality sleeps as well as improving their quality of life.

The CPAP will prevent air way collapse during respiration at sleep [1]. In early recognition of OSA the only effective treatment available is tracheostomy. This treatment will create a surgical airway which helps patients to breath during sleep[8].In case report by [20] it showed dramatically improved in seizure control. When patients have less seizure attack they will definitely will less worry of their seizure and the effect of medication towards them.

Conclusion

In our study using QOLIE-31 to access quality of life it showed significant different between OSA and Non OSA in only Seizure worry subscale. We suggest that patients with epilepsy and OSA may have frequently seizure attack or severe seizure which influences their quality of life. In our study, the frequency of OSA was positively correlated with age. In our study there were significant different in Medication effects, Cognitive functioning, Overall quality of life and Seizure worry. It showed that quality of life in five subscales was increased after using CPAP. We suggest when OSA symptoms is well treated by using CPAP patients will have a good quality sleeps as well as improving their quality of life.

Acknowledgements

I wish to thank Universiti Sains Malaysia for the scholarship awarded to me for twenty four months of study and also for the grant that supporting my research for three years. This study was supported fully from the RU grant USM No. PPSKBP/1002/8120193.

References

1. Casale M, Pappacena M, Bressi F, Rinaldi V, Baptista P, Salvinelli F. Obstructive Sleep Apnea Syndrome: From Phenotype to Genetic Basis. Current Genomics 2009; 10: 119-126.
2. Berto P. Quality of life in patients with epilepsy and impact of treatments. Pharmacoeconomic 2002; 15: 1039-1059.
3. Hashim SN, Abdullah B, Tharakan JKJ, Yaakob NA. The Malay Version of the Quality-of-Life in Epilepsy Inventory (QOLIE-31 Version): Translation, Validity and Reliability. International Medical Journal 2011; 3(18): 199 -201.
4. Mcnicholas WT. Diagnosis of obstructive sleep apnea in adults.Proc Am Thorac Soc 2008;5: 154-160.
5. Collop NA and Cassell DK. Snoring and sleep disordered breathing', in Teofilo L Lee Chiong, Michael J Sateia, and Mary A Carskadon (eds.), Sleep Medicine Philadelphia: HANLEY & BEFUS, INC 2002.
6. Hoffstein V. 'Snoring', in Meir H. Kryger, Thomas Roth, and William C. Dement (eds.), Principles and practice of Sleep Medicine. third edition; Philadelphia: W.B. SAUNDERS COMPANY 2002.
7. Sanders M. H. 'Sleep Breathing Disorders', Principles and practice of Sleep Medicine. Medications, sleep and breathing; Philadelphia: W.B. Saunders Company 2002.
8. Gibson GJ. Obstructive sleep apnoea syndrome: underestimated and undertreated. British Medical Bulletin 2005; 72: 49-64.
9. Phabphal K, Geater A, Limapichart K, Satirapunya P, and Setthawatcharawanich S. Quality of life in epileptic patients in southern Thailand. J. Med. Assoc. Thai 2009; 92(6) : 762-768.
10. Mosaku KS, Fatoye FO, Komolafe M, Lawal M, Ola BA. Quality of life and associated factors among adults with epilepsy in Nigeria. Int. J.Psychiatry Med 2006; 36(4): 469-81.
11. Guevara A, Pena E, Corona T, Ayala L.T, Meza L.E and Gomez, M. Sleep disturbances, socioeconomic status, and seizure control as main predictors of quality in epilepsy. Epilepsy & Behaviour 2005; 7: 481-485.
12. Weerd AD, Haas SD, Otte A, Erp GV, Cohen A, Kam MD, Gerven JV. Subjective sleep disturbance in patients with partial epilepsy: A questionnaire based study on prevalence and impact on quality of life. Epilepsia 2004; 45 (1): 1397- 1404.
13. Parish JM, Lyung PJ. Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuos positive airway pressure. Chest 2008; 124: 942-947.
14. Lopes C, Esteves AM, Bittencourt LRA, Tufik S, Mello MT. Relationship between the quality of life and the severity of obstructive sleep apnea syndrome. Brazilian Journal of Medical and Biological Research 2008; 41: 909-913.
15. Devinsky O, Ehrenberg B, Barthlen GM, Abramson H. S, Luciano D. Epilepsy and sleep apnea syndrome. Neurology Asia 1994; 44: 2060-2064.
16. Malow BA, Levy K, Maturen K, Bowes R. Obstructive sleep apnea is common in medically refractory epilepsy patients. Neurology 2000; 55: 1002-1007.
17. Manni R, Michele T, Carla A, Ivana S, Carlo Andrea G, Amelia T. Obstructive sleep apnea in a clinical series of adult epilepsy patients: frequency and features of the comorbidity. Epilepsia 2003; 44 (6): 836-840.
18. Hollinger P, Khatami R, Gugger M, Hess CW, Bassetti CL. Epilepsy and obstructive sleep apnea. European Neurology 2006; 55: 74-79.
19. Chihorek AM, Abou-Khalil B, Malow BA. Obstructive sleep apnea is associated with seizure occurrence in older adults with epilepsy. Neurology 2007; 69: 1823-1827.
20. Beran R.G, Holland G.J, and Yan K.Y. The use of CPAP in patients with refractory epilepsy. Seizure 1997; 6: 323-325.