- I WOULD LIKE TO WELCOME YOU ALL TO THE PATIENT CAREGIVER CALL TITLED "EPILEPSY AND SLEEP." MY NAME IS SEAN GAMBLE, AND I'M WITH THE EMPLOYEE EDUCATION SERVICES IN ST. LOUIS, AND I AM A PROJECT MANAGER FOR THIS CALL. EVERYBODY'S LINES ARE MUTED AND WILL BE OPENED UP AT THE END OF THE PRESENTATION WHEN WE ARE READY FOR QUESTIONS. PLEASE LIMIT YOUR QUESTIONS TO ONE OR TWO PER PERSON TO ENSURE EVERYONE HAS A CHANCE TO ASK ANY THAT THEY MAY HAVE. TO COMPLETE THE EVALUATION FOR THIS PROGRAM, PLEASE FOLLOW THE LINK FOUND IN THE BROCHURE, OR IF YOU DO NOT HAVE ACCESS TO THE VA WEBSITE, YOU CAN CONTACT ME AT SEAN.GAMBLE@VA.GOV. NOW LET ME WELCOME OUR SPEAKER FOR TODAY. DR. BOUDREAU, IT'S ALL YOURS. - THANK YOU, SEAN. I APPRECIATE EVERYBODY TAKING THEIR TIME OUT TODAY OUT OF THEIR BUSY SCHEDULE TO TALK ABOUT THIS REALLY IMPORTANT TOPIC. OVER THE NEXT 45 MINUTES, I PLAN ON COVERING SOME BASICS ABOUT SLEEP, SUCH AS HOW MUCH SLEEP WE ACTUALLY NEED, TALKING ABOUT SOME BASIC COMPONENTS OF SLEEP, COMMON SLEEP PROBLEMS AND THEIR POTENTIAL IMPACT ON EPILEPSY, AND THEN I'D LIKE TO END WITH SOME BEST PRACTICES AND SOME SUGGESTIONS FOR HOW EVERYBODY, INCLUDING PEOPLE WITH EPILEPSY, AS WELL AS CAREGIVERS, CAN GET A RESTFUL NIGHT OF SLEEP, WHICH I THINK IS EVERYBODY'S GOAL. I'D ACTUALLY LIKE TO START OUT WITH THINKING ABOUT HOW MUCH SLEEP WE ACTUALLY GET IN OUR SOCIETY. SO EVEN THOUGH WE DON'T KNOW EXACTLY WHY WE SLEEP, WE KNOW THAT IT'S A KEY PHYSIOLOGIC PROCESS AND THAT CHRONICALLY GETTING INSUFFICIENT SLEEP IS DETRIMENTAL, AND IT'S EVEN MORE DETRIMENTAL TO INDIVIDUALS WHO HAVE CHRONIC ILLNESSES, SUCH AS EPILEPSY. THERE WAS AN INTERESTING SURVEY DONE IN 2006 BY THE CENTERS FOR DISEASE CONTROL AND PREVENTION, AND IT WAS A TELEPHONE SURVEY WHERE THEY CALLED PEOPLE AND ASKED THEM ABOUT HOW MUCH SLEEP THEY THOUGHT THEY HAD GOTTEN OVER THE PAST MONTH. AND IT WAS REALLY DESIGNED TO GET AT HOW MUCH PEOPLE TYPICALLY FELT THAT THEY WERE SLEEPING, AND WHAT IT SHOWED WAS THAT ONLY 30% OF INDIVIDUALS REPORTED THAT THEY FELT THEY HAD GOTTEN ADEQUATE SLEEP EVERY DAY IN THE PREVIOUS MONTH, AND 10% OF INDIVIDUALS REPORTED THAT THEY NEVER--NOT ONE SINGLE NIGHT--DID THEY FEEL THAT THEY ACTUALLY GOT ADEQUATE REST. AND WE BELIEVE THAT THIS PROBLEM IS CONTINUING AND IN FACT THAT IT'S REALLY WORSENING, AND IT REALLY AFFECTS PEOPLE OF ALL AGES, FROM SMALL CHILDREN, WHO WE THINK ARE CHRONICALLY SLEEP-DEPRIVED, TO THE ELDERLY, SO IT'S SOMETHING THAT REALLY IMPACTS EVERYBODY. AND I THINK PART OF THIS IS THAT OUR SOCIETY HAS BECOME SO ACCUSTOMED TO OPERATING 24 HOURS A DAY, 7 DAYS A WEEK THAT WE MAY HAVE MISTAKENLY GIVEN OURSELVES THE IMPRESSION THAT ADEQUATE SLEEP IS SOMETHING OPTIONAL, THAT HAVING TO SLEEP REGULARLY EVERY NIGHT IS INCONVENIENT, AND WE'RE REALLY LEARNING THAT NOTHING COULD BE FURTHER FROM THE TRUTH, THAT SLEEP IS ABSOLUTELY CRITICAL AND IMPORTANT TO US AND THAT WE NEED TO PROTECT OUR SLEEP TIME, AND IF YOU TAKE ONE THING AWAY FROM MY TALK TODAY, I HOPE IT'S THAT WE REALLY NEED TO TAKE OUR SLEEP SERIOUSLY AND THAT WE NEED TO SCHEDULE OUR DAYS, KEEPING IN MIND THAT SLEEP IS JUST AS IMPORTANT AS EATING OR EXERCISING AND THAT WE JUST REALLY NEED TO GIVE OURSELVES PERMISSION TO NOT OVERSCHEDULE OURSELVES AND TO REALLY TELL PEOPLE, "LOOK, PLEASE DON'T CALL ME BETWEEN THESE HOURS" OR DON'T SCHEDULE ACTIVITIES, FROM WORK TO SOCIAL ACTIVITIES, DURING TIMES WHEN WE REALLY NEED TO BE GEARING DOWN AND GETTING READY TO SLEEP. SO NOW THAT I'VE HOPEFULLY ESTABLISHED FOR YOU THAT IN GENERAL WE REALLY DON'T GET THE SLEEP THAT WE NEED, I WANT TO TAKE A LOOK AT HOW MUCH SLEEP WE THINK WE ACTUALLY GET. SO THE AVERAGE ADULT, WE THINK, NEEDS AT LEAST 7 1/2 OR 8 HOURS. THERE'S SOME INDIVIDUAL VARIABILITY. SOME PEOPLE JUST NATURALLY REALLY NEED 9 OR 10 HOURS, AND THERE'S A SMALL SEGMENT, VERY SMALL SEGMENT OF THE POPULATION THAT SEEMS TO DO FINE WITH LESS. BUT IN GENERAL, PEOPLE REALLY NEED TO BE SHOOTING FOR ABOUT 8 HOURS OF SLEEP A NIGHT. WE ALSO KNOW THAT IF YOU SLEEP A LOT LONGER, LIKE 10 OR 11 HOURS, OR A LOT LESS--LESS THAN 4 OR 5 HOURS--THAT PEOPLE SEEM TO HAVE A HIGHER CHANCE OF DEATH DUE TO CORONARY ARTERY DISEASE, STROKE, AND CANCER. AND IT SEEMS MORE INTUITIVE THAT THE SHORTER YOU SLEEP THAT THAT MIGHT INTERFERE WITH OPTIMAL PHYSIOLOGIC FUNCTIONING. WE'RE NOT REALLY CLEAR WHY PEOPLE WHO SLEEP A LOT LONGER ALSO HAVE THE SAME PROBLEMS, BUT THAT'S JUST BEEN AN OBSERVATION FROM EPIDEMIOLOGIC STUDIES. I ALSO THINK IT'S INTERESTING TO NOTE THAT IN THE PRE-LIGHT-BULB VICTORIAN ERA, WHEN PEOPLE WERE VERY MUCH TIED TO LIGHT/DARK CYCLES AND DIDN'T HAVE A LOT OF EXTERNAL LIGHT COMING FROM OTHER SOURCES, MAN-MADE SOURCES, THAT PEOPLE ON AVERAGE SLEPT CLOSER TO 10 HOURS PER DAY. SO IT'S VERY CLEAR THAT ALL THESE MAN-MADE CONVENIENCES WE HAVE HAVE HAD THE IMPACT OF GRADUALLY ERODING THE TIME THAT WE HAVE FOR SLEEP. SO THOSE ARE ALL THINGS WE NEED TO TAKE INTO CONSIDERATION. AND IF WE LOOK AT TYPICAL SLEEP NEEDS OVER THE LIFETIME, WE KNOW THAT NEWBORNS REALLY NEED UP TO 18 HOURS OF SLEEP, AND ANYBODY WHO'S EVER CARED FOR A NEWBORN KNOWS THAT. INFANTS FROM 3 MONTHS TO 11 MONTHS NEED LESS SLEEP--UP TO 12 HOURS, PLUS THEY OFTEN TAKE 2 OR 3 30-MINUTE NAPS. TODDLERS GRADUALLY DECREASE THEIR SLEEP NEEDS, ALTHOUGH THEY REALLY STILL NEED ABOUT 12 TO 14 HOURS; PRESCHOOLERS, 11 TO 13 HOURS; AND SCHOOL-AGE KIDS FROM 5 TO 12 STILL NEED 10 TO 11 HOURS. AND WHAT WE KNOW IS THAT IN GENERAL OUR ELEMENTARY SCHOOL KIDS ARE NOT GETTING SUFFICIENT SLEEP, AND THINGS LIKE TELEVISION AND BEING ON THE COMPUTER AND COMPUTER-SCREEN GAMES ACTUALLY ERODE THEIR SLEEP TIME. AND WE KNOW THAT THE MORE TELEVISION AND COMPUTER TIME KIDS HAVE, THE LESS THEY ACTUALLY SLEEP. SO IT'S SOMETHING IMPORTANT TO KEEP IN MIND. TEENS STILL NEED 8 1/2 TO JUST OVER 9 HOURS OF SLEEP, AND ADULTS, AS I MENTIONED, NEED SOMEWHERE BETWEEN 7 1/2, 8 HOURS OF SLEEP WITH A SOMEWHAT VARIABLE RANGE. CONTRARY TO WHAT PEOPLE THINK-- PEOPLE SOMETIMES THINK AS THEY GET OLDER, THEY DON'T NEED AS MUCH SLEEP. IN FACT, OLDER ADULTS STILL REALLY NEED THAT MEDIAN TIME OF 8 HOURS OF SLEEP A NIGHT. SO THOSE ARE THE KINDS OF TARGETS WE SHOULD BE SHOOTING FOR WHEN WE PLAN THE SLEEP NEEDS FOR OURSELVES AND FOR OUR FAMILY MEMBERS. I'D LIKE TO SHIFT GEARS NOW AND JUST GIVE YOU SOME BASICS ABOUT SLEEP AND SOME SLEEP PHYSIOLOGY. SO WE GENERALLY THINK OF TWO COMPLEMENTARY PROCESSES GOVERNING HOW WE SLEEP, AND THE FIRST IS WHAT'S CALLED THE CIRCADIAN SYSTEM. YOU MAY HAVE HEARD OF IT. WE ALSO OFTEN TALK ABOUT IT BEING SORT OF AN INTERNAL BODY CLOCK, AND THIS INTERNAL BODY CLOCK IS STRONGLY TIED TO THE LIGHT/DARK CYCLE, MEANING WE HAVE A STRONG BIOLOGICAL DRIVE TO BE ASLEEP WHEN IT'S DARK AND TO BE AWAKE AND MORE ALERT WHEN THERE'S LIGHT OUTSIDE. AND THERE'S A SECOND SYSTEM THAT WE CONCEPTUALLY THINK OF. IT SORT OF KEEPS TRACK OF HOW LONG WE'VE BEEN AWAKE. SO IN A PERFECT WORLD, IF YOU WAKE UP IN THE MORNING AT ABOUT 7:00 OR 8:00, OPTIMALLY RESTED, YOUR BODY SORT OF STARTS A COUNTER, AND IT KEEPS TRACK OF HOW LONG YOU'VE BEEN AWAKE. AND FOR MOST PEOPLE, AFTER THEY'VE BEEN AWAKE ABOUT 16 HOURS, THEY REALLY HAVE THIS STRONG DRIVE THAT THEY NEED SLEEP, AND IN A PERFECT WORLD, THAT DRIVE TO GO TO SLEEP AFTER YOU'VE BEEN AWAKE FOR 16 HOURS COINCIDES WITH WHAT'S GOING ON WITH THE CIRCADIAN SYSTEM AND THAT AS IT GETS DARK AT NIGHT, YOU'VE BEEN UP 16 HOURS, AND BOTH SYSTEMS SORT OF WORK TOGETHER TO MAKE YOU WANT TO GO TO BED AND SLEEP. ONE THING I LIKE TO BRING UP TO PEOPLE THAT I TALK TO SLEEP ABOUT IS THAT I THINK THE CIRCADIAN SYSTEM HAS SOME MINOR UPS AND DOWNS THROUGHOUT THE DAY. MOST PEOPLE FEEL PRETTY GOOD WHEN THEY GET UP IN THE MORNING AND GET GOING IF THEY'VE HAD ADEQUATE REST. AND EVEN IF YOU'RE WELL-RESTED, MOST PEOPLE SLOW DOWN A BIT IN THE AFTERNOON, AND IF THEY'RE DOING VERY QUIET ACTIVITIES--READING A BOOK, SITTING, OR MAYBE WORKING ON THE COMPUTER--THERE'S A TENDENCY TO FEEL A LITTLE TIRED OR DROWSY. THAT'S ACTUALLY NORMAL. THERE'S A LITTLE LULL IN YOUR CIRCADIAN SYSTEM IN SORT OF MID-AFTERNOON, AND THEN AS THE AFTERNOON WEARS ON, AND EARLY EVENING, MOST PEOPLE GET A LITTLE BIT MORE ENERGY AND GET GOING, AND THEN THEY GET TIRED AGAIN LATER IN THE EVENING. THERE'S A LOT OF THINGS, THOUGH, THAT CAN WORK TO DISRUPT THAT DELICATE BALANCE BETWEEN THE SYSTEMS, SO ONE, FOR INSTANCE, IS SHIFT WORK. SO YOUR CIRCADIAN SYSTEM IS STILL WORKING TO TRY TO KEEP YOU AWAKE WHEN IT'S LIGHT OUT AND ASLEEP WHEN IT'S DARK, BUT IF YOU HAVE TO BE UP ALL NIGHT, EVEN IF YOU'RE TRYING TO GET SLEEP DURING THE DAY, IT CAN BE CHALLENGING TO GET ADEQUATE SLEEP DURING THE DAY BECAUSE THAT CIRCADIAN SYSTEM IS STILL TELLING YOU, "GOSH, IT'S LIGHT OUT. YOU'RE REALLY SUPPOSED TO BE OUT THERE MOVING ABOUT." SO THAT'S ONE THING THAT CAN BE CHALLENGING. CAREGIVER ACTIVITIES, WHETHER IT'S FOR THE YOUNG OR IF YOU'RE TAKING CARE OF OLDER FAMILY MEMBERS, CAN ALSO BE REALLY CHALLENGING. AS WE KNOW, SMALL CHILDREN ARE SOMETIMES UP AT NIGHT, PARTICULARLY INFANTS, AND MANY OLDER INDIVIDUALS, PARTICULARLY IF THEY'VE GOT SOME ADVANCED DISEASES SUCH AS DEMENTIA, REALLY CAN STRUGGLE WITH KEEPING THAT BALANCE OF BEING AWAKE DURING THE DAY AND ASLEEP AT NIGHT, AND OFTEN CAREGIVERS HAVE TO BE UP, AND THIS CAN BE REALLY EXHAUSTING AND MAKE IT VERY CHALLENGING FOR PEOPLE TO STICK ON THEIR REGULAR SCHEDULES. AND THEN THERE ARE THINGS THAT WE SORT OF DO OURSELVES. WE OFTEN HAVE VERY BUSY DAYS, AND SOMETIMES THE ONLY TIME THAT PEOPLE HAVE TO RELAX IS LATE AT NIGHT AFTER THEY'VE PUT OTHER FAMILY MEMBERS TO SLEEP, MAYBE GOTTEN THEIR NIGHTTIME CHORES DONE, AND PEOPLE WILL STAY UP LATE WATCHING TELEVISION. THIS DOES TWO THINGS. FIRST, IT KEEPS US UP LATER THAN WE MIGHT NORMALLY BE UP, AND THE LIGHT FROM THE TELEVISION OR LIGHT FROM THE COMPUTER SCREEN CAN REALLY CONFUSE OUR INTERNAL CIRCADIAN CLOCK. SO IT'S BEST TO DEVELOP SOME KIND OF NIGHT RITUAL WHERE YOU'RE GRADUALLY HAVING THINGS SLOW DOWN FOR YOU, WHERE YOU'RE MINIMIZING THE AMOUNT OF LIGHT FROM TELEVISION AND FROM THE COMPUTER. REALLY GET INTO THE HABIT OF HAVING THAT NIGHTTIME RITUAL, REDUCING LIGHT FROM THOSE SOURCES AND GETTING TO SLEEP TO REALLY HELP US GET THE ADEQUATE SLEEP WE NEED AND PREVENT OUR INTERNAL BODY CLOCK AND OUR CIRCADIAN SYSTEM FROM GETTING CONFUSED. AND I'LL TOUCH MORE ON THESE A LITTLE BIT LATER WHEN I TALK ABOUT GETTING AN OPTIMAL NIGHT OF SLEEP. SO THE OTHER THING I WANTED TO DISCUSS IS THAT WE TYPICALLY HAVE SOME NIGHTTIME SLEEP CYCLES, SO A LOT OF PEOPLE HAVE HEARD THAT THERE ARE VARIOUS STAGES OF SLEEP. THERE'S LIGHTER STAGES OF SLEEP, AND THEN THERE'S WHAT WE CALL SLOW-WAVE SLEEP, WHICH TENDS TO BE DEEPER. IT CAN BE VERY, VERY DEEP IN YOUNGER INDIVIDUALS, IN KIDS. ANYBODY WHO'S EVER TRIED TO AWAKEN AN ELEMENTARY-SCHOOL CHILD FROM A VERY, VERY DEEP SLEEP KNOWS THAT IT CAN BE VERY CHALLENGING, AND THAT'S WHAT WE CALL SLOW-WAVE SLEEP. AND THEN THERE'S THE RAPID- EYE-MOVEMENT SLEEP THAT OCCURS OFTEN. THIS IS WHEN WE HAVE DREAMING. AND THE BODY TYPICALLY GOES THROUGH THE CYCLES OF LIGHT SLEEP, SLOW-WAVE SLEEP, AND REM SLEEP 4 TO 6 TIMES PER NIGHT, WITH EACH SLEEP CYCLE LASTING APPROXIMATELY 90 MINUTES. BUT NOT ALL THE SLEEP CYCLES ARE EQUAL. THE FIRST THIRD OF THE NIGHT, WE TEND TO HAVE MAINLY THE LIGHT SLEEP AND THE SLOW-WAVE SLEEP WITH JUST VERY BRIEF PERIODS OF RAPID-EYE-MOVEMENT SLEEP, AND AS THE NIGHT GOES ON, WE TEND TO HAVE MUCH LESS SLOW-WAVE SLEEP, AND THE LAST THIRD OF THE NIGHT IS REALLY DOMINATED BY THE RAPID-EYE- MOVEMENT SLEEP, WHICH IS OFTEN WHY PEOPLE REPORT, IF THEY WAKE UP, THAT'S WHEN THEY'RE DREAMING, IS IN THAT LAST THIRD OF THE NIGHT. AND IT'S IMPORTANT TO KEEP THAT IN MIND BECAUSE THE PROPENSITY, FOR INSTANCE, TO HAVE SEIZURES FROM SLEEP IS NOT EQUAL IN ALL SLEEP STAGES, AND VARIOUS MEDICATIONS, INCLUDING ANTI- EPILEPTIC DRUGS, IMPACT THE DIFFERENT SLEEP STAGES DIFFERENTLY. SO LET'S TURN NOW TO LOOK AT WHAT WE KNOW ABOUT SLEEP AND EPILEPSY. SO WE KNOW THAT SEIZURES AT NIGHT CAN BE COMMON WITH SOME TYPES OF EPILEPSY, AND WHILE THE EXACT INFLUENCE OF SLEEP ON SEIZURES ISN'T KNOWN, THERE ARE SOME KEY OBSERVATIONS THAT PEOPLE HAVE MADE. FIRST OF ALL, NOT SURPRISINGLY, SEIZURES AT NIGHT FROM SLEEP CAN ACTUALLY DISRUPT THOSE NORMAL SLEEP CYCLES THAT I JUST SPOKE ABOUT, AND FOR MANY INDIVIDUALS, BEING SLEEP- DEPRIVED, EITHER ACUTELY OR CHRONICALLY, CAN INCREASE SEIZURE FREQUENCY. AND THE LAST THING I WANT TO MAKE A POINT ON IS THAT DEPRESSION AND ANXIETY CAN BE MORE COMMON IN INDIVIDUALS WITH EPILEPSY, SO WE KNOW THAT BOTH OF THOSE THINGS CAN LEAD TO A LOT OF SLEEP DISRUPTION. SO IT'S ALMOST LIKE A DOUBLE HIT, BUT IF YOU'RE DEALING AND STRUGGLING WITH EPILEPSY, THAT IF YOU'RE ALSO HAVING ISSUES WITH DEPRESSION AND ANXIETY, THAT THOSE PROCESSES ADDITIONALLY CAN DISRUPT YOUR SLEEP. SO THOSE ARE ALL THINGS THAT WE NEED TO KEEP IN MIND. IN GENERAL, THE SEIZURES ARE MORE LIKELY TO OCCUR FROM WHAT WE CALL STAGE-TWO--WHAT USED TO BE CALLED STAGE-TWO OR N2 SLEEP--SORT OF THE LIGHTER SLEEP--BUT THEY CAN OCCUR IN ANY SLEEP CYCLE. WE ALSO KNOW THAT DIFFERENT-- SOME NEW DATA INDICATES THAT DIFFERENT TYPES OF EPILEPSY MIGHT BE IMPACTED DIFFERENTLY BY DIFFERENT SLEEP STAGES, BUT THAT'S SOMETHING THAT'S A RELATIVELY NEW IDEA AND IS STILL BEING WORKED OUT. BUT WE DEFINITELY KNOW THAT AND THERE ARE SOME PEOPLE WHO TEND TO HAVE SEIZURES JUST FROM SLEEP AND MAY BE AWOKEN AS THE PROCESS OF THEIR SEIZURE GOES ON, AND THEN SOME PEOPLE MAY HAVE THEM FROM SLEEP AND NOT EVEN REALIZE IT UNLESS THAT PARTNER OR FAMILY MEMBER TELLS THEM THEY'VE HAD IT. THERE ARE ALSO CERTAIN TYPES OF EPILEPSY WHERE PEOPLE MAY HAVE EARLY MORNING SEIZURES AS PART OF THEIR EPILEPSY SYNDROME. SO WE KNOW THAT THERE'S THIS CYCLE WHERE SLEEP AND SLEEP STAGES IMPACT YOUR PROPENSITY FOR HAVING SEIZURES, BUT THIS IS SOMETHING THAT PEOPLE HAVE BEEN WORKING ON A LONG TIME, AND WE STILL HAVEN'T COMPLETELY UNRAVELED IT, BUT WE'RE LEARNING MORE ABOUT IT. SO GIVEN THAT, I'D NOW LIKE TO DISCUSS JUST SOME COMMON SLEEP PROBLEMS IN THE GENERAL POPULATION AND GO OVER THEM AND THEN SPECIFICALLY LOOK AT HOW THEY IMPACT EPILEPSY AND HOW EPILEPSY CAN IMPACT THE PRESENTATION OF THESE COMMON DISORDERS. SO THE 3 THAT I'M GOING TO TALK ABOUT ARE SLEEP-DISORDERED BREATHING, OR SLEEP APNEA, WHICH PEOPLE ARE HEARING A LOT MORE IN THE POPULAR MEDIA ABOUT; INSOMNIA-- JUST DIFFICULTY GETTING TO SLEEP AND STAYING ASLEEP, WHICH MANY PEOPLE ARE ALSO FAMILIAR WITH; AND ALSO SOMETHING CALLED RESTLESS-LEG SYNDROME, WHICH HAS ALSO BEEN PROMINENT IN THE MEDIA IN THE LAST FEW YEARS. SO I'M GOING TO START WITH SLEEP APNEA. THIS IS A REALLY COMMON DISORDER IN WHICH THERE IS DIFFICULTY BREATHING FOR DISCRETE PERIODS AT NIGHT, THOUGH WE DON'T EVEN REALLY COUNT THEM UNLESS THEY LAST 10 SECONDS, AND THIS IS WHEN PEOPLE EITHER STOP BREATHING OR THEY JUST STRUGGLE TO BREATHE, AND THIS IS USUALLY DUE TO COLLAPSE OF THE UPPER AIRWAY. WHEN PEOPLE ARE LYING DOWN SUPINE, ESPECIALLY ON THEIR BACK, THERE'S A TENDENCY FOR THE AIRWAY TO BE MORE COLLAPSIBLE, OR THE THROAT TO COLLAPSE, AND FOR IT TO BE HARDER TO GET AIR OUT. SO IN THE CASE OF OBSTRUCTIVE SLEEP APNEA, WHICH IS THE MOST COMMON, PEOPLE ARE STILL TRYING TO BREATHE, BUT THEY'RE BREATHING AGAINST A CLOSED AIRWAY. AND THERE'S A NUMBER OF FACTORS THAT CAN INFLUENCE WHY PEOPLE DEVELOP SLEEP APNEA. ONE OF THE MOST COMMON IS JUST YOUR NATURAL AIRWAY STRUCTURE. SOME PEOPLE TEND TO HAVE LARGER AIRWAYS THAN OTHERS, AND SO IF YOU HAVE NATURALLY A SMALLER AIRWAY AND IT COLLAPSES, YOU'RE GOING TO BE MORE LIKELY TO DEVELOP APNEA. A BIG MODIFIABLE RISK FACTOR FOR SLEEP APNEA IS WEIGHT, AND AS THE POPULATION HAS INCREASING STRUGGLES WITH OBESITY, WE FIND THAT SLEEP APNEA IS BECOMING MORE AND MORE COMMON. HOWEVER, I DO WANT TO EMPHASIZE THAT EVEN PEOPLE WHO ARE NOT OVERWEIGHT, THEY CAN STILL HAVE SLEEP APNEA. IT'S JUST NOT AS COMMON. WE THINK THAT IN GENERAL THE NUMBERS THAT ARE USUALLY CITED ARE ABOUT 3 TO 4% OF MALES BETWEEN 18 AND 55 HAVE SLEEP APNEA, AND IT MAY BE ABOUT 2 TO 3% FOR WOMEN. BUT IN PATIENTS THAT ARE OVERWEIGHT, THAT NUMBER GOES UP CONSIDERABLY AND CAN BE AS HIGH AS 20% OR HIGHER. AND SO THAT'S SOMETHING TO KEEP IN MIND. IT CAN BE ESPECIALLY CHALLENGING IN EPILEPSY BECAUSE SOME OF THE DRUGS USED TO TREAT EPILEPSY CAN CAUSE PEOPLE TO GAIN WEIGHT, AND SO THIS CAN COME ON AS A RESULT OF SOME OF THE MEDICATIONS WE USE, TOO, BECAUSE OF THE WEIGHT ISSUE. ONE OF THE REASONS WE THINK THAT SLEEP APNEA CAN BE DETRIMENTAL IS THAT IT'S ALSO ASSOCIATED WITH A BRIEF, TEMPORARY DROP IN OXYGEN LEVEL AND THAT THIS MAY PUT EXTRA STRESS ON THE BRAIN. IT ALSO PUTS EXTRA STRESS ON THE HEART, AND WHEN PEOPLE STOP BREATHING OR HAVE DIFFICULTY BREATHING FOR 10 SECONDS OR LONGER, YOUR NERVOUS SYSTEM TENDS TO KICK INTO OVERDRIVE. YOU GET THAT FIGHT-OR-FLIGHT SENSE THAT, GOSH, YOUR BODY NEEDS TO GET AIR, AND IT OFTEN CAUSES A BRIEF AROUSAL, SO IT CAN BE VERY DISRUPTIVE TO REGULAR SLEEP, AS WELL AS CAUSING SOME EXTRA STRESS AND STRAIN ON YOUR HEART AND CARDIOVASCULAR SYSTEM. SO THERE'S A NUMBER OF THINGS THAT SLEEP APNEA CAN CAUSE, AND IF IT HAPPENS NIGHT AFTER NIGHT, YEAR AFTER YEAR, IT CAN BE ASSOCIATED WITH SOME CHRONIC HEALTH CONDITIONS. THE STRONGEST LINKS WE HAVE ARE BETWEEN SLEEP APNEA AND HIGH BLOOD PRESSURE. WE REALLY THINK IT'S AN INDEPENDENT RISK FACTOR FOR HIGH BLOOD PRESSURE, AND ALSO WE'RE NOW FINDING ASSOCIATIONS BETWEEN SLEEP APNEA AND DIABETES, HEART DISEASE, AND SO WE REALLY THINK THAT IT'S SOMETHING THAT WE NEED TO PAY A LOT OF ATTENTION TO AND TRY TO TREAT AGGRESSIVELY IN INDIVIDUALS. SO WHEN WE LOOK AT--IT'S NATURAL FOR PEOPLE TO HAVE SOME PAUSES IN BREATHING AT NIGHT. FOR ADULTS, LESS THAN 5 EVENTS PER HOUR IS CONSIDERED NORMAL. BUT AS WE START GETTING ABOVE THAT NUMBER, PARTICULARLY WHEN WE REACH 15 OR MORE EVENTS PER HOUR, THAT'S WHERE WE THINK WE START SEEING SOME LONG-TERM HEALTH CONSEQUENCES. AND IN ADDITION TO THOSE LONG- TERM HEALTH CONSEQUENCES, WE KNOW THAT WITH SLEEP APNEA, PEOPLE CAN ALSO BE REALLY TIRED DURING THE DAY. THEY CAN WAKE UP IN THE MORNING WITH HEADACHES, WHICH ARE DUE TO RETAINING CO2. NORMALLY WHEN YOU'RE UP AND WALKING AROUND AND AWAKE, YOU'RE BREATHING IN OXYGEN AND THEN YOU'RE BREATHING OUT CO2, OR CARBON DIOXIDE. AT NIGHT WITH SLEEP APNEA, PEOPLE TEND TO RETAIN THE CARBON DIOXIDE, AND THAT CAN GIVE THEM A HEADACHE IN THE MORNING. PEOPLE CAN ALSO FEEL EXHAUSTED OR MAYBE NOT PERFORM AS WELL DURING THE DAY. SO THERE ARE REALLY TWO REASONS WE LIKE TO EVALUATE SLEEP APNEA MORE THOROUGHLY. ONE IS THAT IN GENERAL, PEOPLE FEEL BETTER WHEN WE'RE ABLE TO TREAT THEM, AND TWO, WE REALLY WANT TO PREVENT THE LONG-TERM COMPLICATIONS OF SLEEP APNEA, SUCH AS HIGH BLOOD PRESSURE, CARDIOVASCULAR DISEASE, AND EVEN STROKE. SO THOSE ARE KEY THINGS THAT WE THINK ABOUT. MORE RECENTLY WE HAVE ACTUALLY LEARNED THAT IT APPEARS THAT HAVING SEIZURES MAY ALSO INCREASE YOUR RISK OF HAVING SLEEP APNEA, AND AS MANY AS UP TO 30% OF PATIENTS WITH SEIZURES MAY ALSO HAVE SLEEP APNEA. SO WE'RE INCREASINGLY REALIZING THAT WE NEED TO BE VIGILANT AND MAKE SURE THAT WE ASK OUR PATIENTS WITH EPILEPSY ABOUT SIGNS AND SYMPTOMS OF SLEEP-DISORDERED BREATHING. AND AS I MENTIONED, SOME OF THE RISK FACTORS INCLUDE BEING OVERWEIGHT. PEOPLE WHO HAVE A LARGER NECK CIRCUMFERENCE TEND TO BE AT INCREASED RISK. WE THINK MALES ARE AT HIGHER RISK THAN FEMALES, BUT POST-MENOPAUSALLY, WOMEN TEND TO GET MORE SLEEP APNEA, AND THEIR RISK OF SLEEP APNEA POST-MENOPAUSALLY APPROACHES THAT OF MEN. AND EVERYTHING ELSE BEING EQUAL, WE ALSO KNOW, AS PEOPLE GET OLDER, THEIR AIRWAY JUST BECOMES MORE COLLAPSIBLE. SO THOSE ARE ALL THINGS THAT INCREASE PEOPLE'S RISK OF GETTING APNEA AND THAT WE LOOK AT WHEN WE'RE EVALUATING PEOPLE THAT WE THINK MIGHT HAVE IT. SO THERE ARE SOME COMMON SIGNS AND SYMPTOMS. SNORING IS ONE OF THEM. MANY PEOPLE SNORE WHO DON'T HAVE SLEEP APNEA, BUT IN GENERAL, MOST PEOPLE WHO HAVE APNEA DO SNORE. OFTEN BED PARTNERS WILL REPORT SEEING PAUSES IN BREATHING AND EVEN SOMETIMES HAVING TO SHAKE A LOVED ONE TO SORT OF GET THEM BREATHING AGAIN. OTHER SIGNS, AS I MENTIONED, ARE MORNING HEADACHES. THOSE ARE GENERALLY MILD AND THEY GO AWAY IN ABOUT 30 TO 60 MINUTES. IN MEN, DRY MOUTH OR FREQUENT URINATION AT NIGHT CAN ALL BE SIGNS THAT YOU'VE GOT SLEEP-DISORDERED BREATHING. TYPICALLY WE NEED TO BRING SOMEONE INTO THE SLEEP LABORATORY TO DIAGNOSE IT. PARTICULARLY IF YOU HAVE EPILEPSY, WE LIKE TO DO IN-LABORATORY STUDIES. THESE INVOLVE COMING IN. WE PUT IN EEG ELECTRODES SUCH AS YOU MAY HAVE HAD FOR A ROUTINE EEG IN THE NEUROPHYSIOLOGY LAB. WE DON'T GENERALLY STICK ON AS MANY ELECTRODES AS WE WOULD IF WE WERE DOING AN EEG, BUT THERE ARE A NUMBER OF ELECTRODES THAT WE STICK ON PEOPLE'S HEAD, AND THAT HELPS US DETERMINE WHAT SLEEP STAGE THEY'RE IN THROUGHOUT THE NIGHT, AND IT ALSO ALLOWS US, FOR PEOPLE WITH EPILEPSY, TO MONITOR IF THEY'RE HAVING SEIZURES AT NIGHT, TOO. WE ALSO ADD SENSORS AROUND THE MOUTH AND NOSE TO DETERMINE WHEN PEOPLE ARE HAVING DIFFICULTY WITH BREATHING. THAT'S HOW WE SCORE THE NUMBER OF EPISODES OF BREATHING PROBLEMS THEY HAVE PER NIGHT. AND THEN THERE'S ALSO GENERALLY A BELT AROUND THE CHEST AND ABDOMEN TO MEASURE YOUR CHEST MOVEMENTS AND YOUR ABDOMINAL MOVEMENTS WITH BREATHING. AND ALSO WE STICK A LEAD ON THE LEG TO MEASURE LEG MOVEMENTS, AND ALSO A PAIR OF EKG LEADS, JUST TO MONITOR HEART RATE. SO THOSE ARE ALL INVOLVED IN THE TYPICAL IN-LABORATORY SLEEP STUDY. OFTEN THE FIRST HALF OF THE NIGHT, THEY'LL JUST DO WHAT'S CALLED A DIAGNOSTIC STUDY, AND IF A LOT OF PAUSES IN BREATHING ARE SEEN, THEN THE TECHNICIAN WILL OFTEN COME IN AND PUT A MASK ON THE PERSON FOR THE SECOND NIGHT AND ACTUALLY TRY TO USE POSITIVE AIRWAY PRESSURE TO STOP THOSE PERIODS OF PAUSES IN BREATHING. THAT TREATMENT IS GENERALLY CALLED CPAP THERAPY, OR THERE'S ANOTHER FORM, SLIGHT MODIFICATION, CALLED BIPAP THERAPY, AND THIS ESSENTIALLY JUST GIVES YOU SOME AIR PRESSURE. IT PUSHES AIR INTO YOUR AIRWAY, AND IT SPLINTS THAT AIRWAY OPEN, SO IT KEEPS THAT AIRWAY FROM BEING AS COLLAPSIBLE, AND WHAT WE DO IS THE TECHNICIAN, OVER THE COURSE OF THE NIGHT, WILL GRADUALLY INCREASE THE PRESSURE UNTIL YOU'RE NOT HAVING ANY MORE PAUSES IN BREATHING AND UNTIL YOU'RE NOT HAVING AS MANY AROUSALS AND YOUR OXYGEN SATURATION ISN'T DROPPING. SO THAT'S REALLY THE GOAL WITH THERAPY. AND THERE'S NOW SOME EVIDENCE FROM STUDIES THAT PEOPLE WILL EVEN HAVE FEWER SEIZURES IF WE CAN GET THEIR SLEEP APNEA TREATED. SO IT BECOMES EVEN MORE IMPORTANT FOR PATIENTS WITH EPILEPSY WHO ARE EXPERIENCING PROBLEMS TO GET EVALUATED BY A SLEEP PHYSICIAN AND TO GET A SLEEP STUDY SO WE CAN SEE IF THEY HAVE SLEEP APNEA AND GET THEM TREATED. AND ONCE PEOPLE HAVE A SLEEP APNEA MACHINE, IT'S REALLY CRITICAL THAT THEY USE IT EVERY NIGHT AND IF THEY'RE NAPPING AT ALL DURING THE DAY THAT THEY USE IT WITH THEIR MOUTHS BECAUSE USING IT ON A REGULAR BASIS WILL HELP KEEP YOUR SEIZURES UNDER CONTROL AND WILL HELP PREVENT THE LONG-TERM COMPLICATIONS AS WELL AS ENSURING THAT YOU'RE FEELING VERY WELL-RESTED THE NEXT DAY. SO AS I LEAVE SLEEP-DISORDERED BREATHING, I REALLY WANT TO EMPHASIZE THAT THERE ARE TWO REASONS WE LIKE TO TREAT IT IN INDIVIDUALS AND ESPECIALLY PATIENTS WITH EPILEPSY: IN THE SHORT TERM, IN GENERAL PATIENTS FEEL BETTER. IN SOME CASES, PATIENTS EVEN WITH SEVERE SLEEP APNEA DON'T NOTICE A HUGE DIFFERENCE, BUT THAT DOESN'T MEAN THERAPY IS NOT WORKING. WE KNOW THAT EVEN IN THOSE INDIVIDUALS THAT DON'T NOTICE A HUGE DIFFERENCE IN THEIR LEVEL OF DAYTIME SLEEPINESS, AND SOME PATIENTS EVEN DON'T FIND THAT THEY'RE TIRED FROM THEIR SLEEP APNEA, THAT USING CPAP REGULARLY CAN PREVENT LONG-TERM COMPLICATIONS, AND AS I MENTIONED, WE NOW HAVE SOME EVIDENCE THAT PEOPLE WITH SEIZURES MAY HAVE FEWER SEIZURES IF WE CAN GET THEIR SLEEP APNEA UNDER CONTROL. SO IT'S REALLY, REALLY IMPORTANT THAT IF PEOPLE ARE HAVING SIGNS OR SYMPTOMS OF SLEEP APNEA THAT THEY GET EVALUATED AND TREATED AND THAT THEY USE THAT THERAPY ON A REGULAR BASIS. NOW WHAT I'D LIKE TO DO IS-- ACTUALLY, BEFORE I LEAVE SLEEP APNEA, THERE'S ONE OTHER POINT I WANT TO MAKE, IS THE STANDARD TREATMENT IS THE CPAP THERAPY. THERE IS SURGERY AVAILABLE FOR SLEEP APNEA. WE USUALLY USE THAT AS A LAST RESORT. IT'S A MORE INVOLVED SURGERY THAT INVOLVES OFTEN CUTTING PART OF THE PALATE, THE UVULA, AND WE CAN'T TELL BEFOREHAND WHO'S GOING TO RESPOND TO SURGERY AND WHO WON'T, SO IT'S VERY POSSIBLE THAT YOU COULD HAVE SURGERY AND STILL NEED CPAP THERAPY. SO WE GENERALLY RESERVE THAT FOR PEOPLE WHO ARE JUST NOT ABLE TO TOLERATE CPAP THERAPY AT ALL, BUT THAT'S REALLY A MORE MINORITY OF INDIVIDUALS, SINCE WE'RE ABLE TO WORK WITH PEOPLE AND GET THEM USED TO USING THE EQUIPMENT. THE OTHER THING THAT THERE'S INCREASING ATTENTION ON IS ORAL APPLIANCES, AND THESE ORAL APPLIANCES ARE MOUTHPIECES THAT REALLY NEED TO BE FIT BY A DENTIST WHO KNOWS HOW TO DO THIS, AND THEY SHIFT THE BOTTOM JAW FORWARD AND CAN OPEN THE AIRWAY. THESE ARE GENERALLY BEST FOR PEOPLE WHO HAVE MILD TO MODERATE SLEEP APNEA, AND IN GENERAL I DON'T RECOMMEND THEM FOR MY PATIENTS WITH EPILEPSY, AND THE REASON IS THAT THEY'RE NOT SECURED IN YOUR MOUTH. YOU POP THEM IN AND OUT, AND IF YOU WERE TO HAVE A BAD SEIZURE AT NIGHT, THE AIRWAY, THE ORAL APPLIANCE COULD BREAK OR BECOME DISLODGED AND BLOCK YOUR AIRWAY AND CREATE A PROBLEM. SO AS I SAY, I DON'T RECOMMEND THE ORAL APPLIANCES FOR MY PATIENTS WITH EPILEPSY. I REALLY FOCUS ON HAVING THEM USE THE CPAP THERAPY BECAUSE I THINK THERE ARE SOME DANGERS ASSOCIATED WITH HAVING THAT ORAL APPLIANCE THAT'S NOT SECURE IN THEIR MOUTH AND POPS IN AND OUT IN THEIR MOUTH AT NIGHT IF THEY'RE HAVING SEIZURES, SO THAT'S SOMETHING TO KEEP IN MIND. NOW WHAT I'D LIKE TO DO IS I'D LIKE TO MOVE ON TO INSOMNIA, AND THIS IS SOMETHING THAT AFFECTS A LOT OF THE POPULATION. UP TO 9% OF THE GENERAL POPULATION AT SOME POINT HAS ISSUES WITH EITHER FALLING ASLEEP OR ONCE THEY'RE ASLEEP STAY ASLEEP OR, LESS COMMONLY, WAKING UP TOO EARLY IN THE MORNING. AND THERE CAN BE A LOT OF CAUSES. DISRUPTIONS IN YOUR REGULAR SCHEDULE. MEDICATIONS CAN DISRUPT--YOU KNOW, MAKE PEOPLE HAVE DIFFICULTY GETTING TO SLEEP. TOO MUCH DAYTIME NAPPING OR A DISRUPTION IN YOUR REGULAR SLEEP SCHEDULE--SHIFT WORK CAN CAUSE PEOPLE TO THEN HAVE TROUBLE GETTING TO SLEEP AT NIGHT WHEN THEY'D LIKE TO. AND THERE ARE TWO GENERAL TREATMENT APPROACHES. ONE IS WHAT WE CALL COGNITIVE BEHAVIORAL THERAPY AND GOOD SLEEP PRACTICES OR SLEEP HYGIENE, AND THESE INVOLVE-- I'LL GO OVER SOME OF THEM TOWARD THE END OF THE TALK, BUT THEY INVOLVE KEEPING A REGULAR SLEEP SCHEDULE, AND AS I MENTIONED BEFORE, NOT GETTING A LOT OF LIGHT LATE AT NIGHT, HAVING A REGULAR BEDTIME ROUTINE, AND REALLY TRYING TO GEAR DOWN AND RELAX AT NIGHT. SO THAT CAN BE REALLY IMPORTANT. MEDICATIONS CAN BE USED, BUT IF PEOPLE HAVE THINGS IN THEIR ENVIRONMENT THAT ARE DISRUPTING THEIR SLEEP OR THEIR SLEEP HABITS AREN'T REALLY CONDUCIVE TO GETTING THEM TO SLEEP, I'VE FOUND THAT LONG-TERM MEDICATIONS WILL WORK FOR A WHILE, BUT THEN THEY TEND NOT TO WORK SO MUCH. SO IT'S REALLY IMPORTANT TO JUST PROTECT THAT SLEEP TIME AND SORT OF HAVE A REGULAR ROUTINE. YOU CAN ALSO TALK TO YOUR PHYSICIAN ABOUT BEHAVIORAL COGNITIVE THERAPY. IN SOME INSTITUTIONS--I KNOW OUR VA HAS A SLEEP-IMPROVEMENT CLASS THAT USES BEHAVIORAL COGNITIVE THERAPY, AND IT MEETS OVER A NUMBER OF SESSIONS, AND IT CAN BE VERY, VERY EFFECTIVE, JUST AS EFFECTIVE OR MORE EFFECTIVE LONG-TERM THAN MEDICATIONS. SO IF YOU ARE EXPERIENCING A LOT OF PROBLEMS WITH INSOMNIA, IT'S ACTUALLY IMPORTANT TO SPEAK WITH YOUR PHYSICIAN ABOUT THAT AND LET THEM KNOW. THEY CAN TAKE A LOOK AT YOUR MEDICATIONS AND TALK TO YOU ABOUT YOUR SCHEDULE AND SEE IF THERE ARE ANY THINGS THAT CAN BE USED TO HELP IMPROVE YOUR SLEEP. AT THIS POINT I ALSO WANT TO MENTION, BEFORE I MOVE ON TO RESTLESS LEGS, THE EFFECT OF ALCOHOL ON BOTH SLEEP AND EPILEPSY. PEOPLE OFTEN, WHEN THEY HAVE ALCOHOL AT NIGHT, FEEL THAT IT MAKES THEM DROWSY, AND SOME PEOPLE EVEN WILL USE ALCOHOL TO MAKE THEM GO TO SLEEP. THIS IS PROBLEMATIC FOR A NUMBER OF REASONS, SO WHILE ALCOHOL SHORT-TERM MAKES YOU MORE TIRED, WHAT WE KNOW IS THAT LATER ON IN THE NIGHT, AS THE ALCOHOL WEARS OFF, IT'S REALLY DISRUPTIVE TO THE LATER STAGES OF SLEEP, ESPECIALLY RAPID-EYE-MOVEMENT SLEEP, AND SO IT'S REALLY NOT GOOD TO HAVE A LOT OF ALCOHOL. PARTICULARLY BINGE DRINKING IS VERY DISRUPTIVE TO SLEEP, AND IT'S NOT UNCOMMON FOR PEOPLE WHO HAVE HAD A COUPLE OF DRINKS, FOR THEM TO WAKE UP IN THE EARLY MORNING HOURS AND HAVE DIFFICULTY GETTING BACK TO SLEEP. THAT'S ACTUALLY A LATE EFFECT OF THE ALCOHOL WEARING OFF. THE OTHER THING IS, IN ADDITION TO DISRUPTING THE SLEEP SCHEDULE, WE KNOW THAT ALCOHOL CAN INCREASE YOUR CHANCE OF A SEIZURE. YOU KNOW, HAVING A DRINK IF YOU'RE NOT PARTICULARLY SENSITIVE TO IT OR HAVEN'T HAD ALCOHOL PROBLEMS IS PROBABLY FINE, BUT WHEN YOU START GETTING INTO TWO OR 3 DRINKS AT A SITTING OR MORE, WE KNOW THAT THAT CAN BE NOT ONLY DETRIMENTAL TO YOUR SLEEP BUT CAN ACTUALLY LOWER YOUR SEIZURE THRESHOLD OR INCREASE YOUR CHANCE OF HAVING A SEIZURE. AND IT'S NOT ACTUALLY THE ALCOHOL ITSELF. IT'S AS THE ALCOHOL IS WEARING OFF, THAT'S WHEN YOU'RE MOST LIKELY TO HAVE IT CAUSE A SEIZURE. SO IT'S VERY IMPORTANT NOT TO USE ALCOHOL AS A MECHANISM FOR GETTING TO SLEEP IF YOU'RE HAVING INSOMNIA, AND IT'S IMPORTANT TO AVOID ANY KIND OF BINGE DRINKING BECAUSE IT WILL NOT ONLY DISRUPT YOUR SLEEP AND COULD CAUSE YOU TO HAVE SEIZURES AS IT WEARS OFF, BUT THE SLEEP DEPRIVATION THAT IT CAN CAUSE COULD ALSO INCREASE YOUR CHANCE OF HAVING A SEIZURE. SO IT'S VERY IMPORTANT TO BE VERY CAREFUL ABOUT ALCOHOL, ESPECIALLY WHEN WE'RE TALKING ABOUT SLEEP AND EPILEPSY. I'D NOW LIKE TO MOVE ON TO THE LAST SLEEP DISORDER I WANTED TO SPEAK ABOUT, WHICH IS RESTLESS LEG SYNDROME, AND THIS IS SOMETHING THAT THERE ARE A LOT OF COMMERCIALS FOR MEDICATIONS ON TELEVISION, AND PEOPLE HAVE TALKED A LOT MORE ABOUT, AND MAKING THIS DIAGNOSIS, YOU DON'T NEED A SLEEP STUDY FOR IT. WE MAKE IT BASED ON THE HISTORY, AND THE IMPORTANT THING ABOUT THE HISTORY IS IT'S NOT THE LEG MOVEMENTS THEMSELVES. THE CLINICAL DIAGNOSIS IS BASED ON PEOPLE HAVING AN URGE TO MOVE THEIR LEGS. SO PEOPLE WHO HAVE RESTLESS LEG SYNDROME WILL TELL YOU THAT, YOU KNOW, "IF I'M SITTING STILL OR IN THE EVENING, I FEEL LIKE I HAVE TO MOVE MY LEGS." IT'S A KEY COMPONENT. BY DEFINITION, IT BEGINS OR WORSENS WHEN PEOPLE ARE AT REST, SO EITHER SITTING QUIETLY OR LYING DOWN TO GO TO BED. IN GENERAL IT IS RELIEVED WITH MOVEMENT. EVEN IF IT'S JUST TEMPORARILY, PEOPLE WILL TELL YOU IF THEY MOVE THEIR LEGS AROUND A LITTLE OR GET UP AND WALK THAT AT LEAST BRIEFLY THEIR SYMPTOMS OF FEELING LIKE THEY HAVE TO MOVE THEIR LEGS WILL GO AWAY, AND IT'S WORSE OR ONLY OCCURS AT NIGHT. PEOPLE CAN GET SYMPTOMS DURING THE DAY, BUT IN GENERAL, THEY DEVELOP SYMPTOMS FIRST AT NIGHT, AND THEN IF IT WORSENS, THEY CAN GET THEM IN THE AFTERNOON. THEY MAY START GETTING THEM EARLIER AND EARLIER IN THE DAY OR EVEN IN THE MORNING. BUT IN GENERAL THEIR SYMPTOMS ARE BEST IN THE MORNING, IN GENERAL THEY INVOLVE SORT OF THE LEGS, AND IN SOME PEOPLE, RARELY, THEY CAN INVOLVE THE HANDS OR OTHER PARTS OF THE BODY. BUT THEY REALLY USUALLY START IN THE LEGS. SO THAT'S WHAT WE FOCUS ON WHEN WE MAKE A DIAGNOSIS. WE THINK SOMEWHERE BETWEEN 10 AND 15% OF THE GENERAL POPULATION HAS SOME SYMPTOMS OF RESTLESS LEGS. IT CAN RUN IN FAMILIES. SOME PEOPLE START OUT AS KIDS OR TEENAGERS, AND SOME START AS ADULTS. AND THE SYMPTOMS CAN RANGE FROM BEING AN ANNOYANCE A COUPLE OF TIMES A MONTH TO WHEN THEY'RE SEVERE, PEOPLE HAVE SYMPTOMS EVERY DAY THAT PREVENTS THEM FROM GETTING TO SLEEP. AS FAR AS WE KNOW, THERE'S NO INCREASED RISK OF RESTLESS LEGS IN PATIENTS WITH EPILEPSY, BUT BECAUSE IT'S SO COMMON IN THE GENERAL POPULATION, IT'S POSSIBLE THAT YOU COULD HAVE EPILEPSY AND RESTLESS LEGS AT THE SAME TIME. WE KNOW THAT IF PEOPLE ARE HAVING SYMPTOMS EVERY NIGHT THAT ARE REALLY DISRUPTIVE, THAT'S WHEN WE GET MUCH MORE AGGRESSIVE ABOUT TRYING TO TREAT IT. WE THINK THAT IT IS IN PART DUE TO DECREASED DOPAMINE IN CERTAIN PARTS OF THE BRAIN. DOPAMINE IS AN IMPORTANT NEUROTRANSMITTER OR CHEMICAL THAT'S USED TO SIGNAL BETWEEN CELLS. AND INTERESTINGLY, SOME OF THE MEDICATIONS DEVELOPED AS ANTIEPILEPTICS, SUCH AS GABAPENTIN AND CLONAZEPAM, ACTUALLY HAVE BEEN USED TO TREAT RESTLESS LEGS. IN GENERAL, THEY'RE NOT OUR FIRST-LINE AGENTS, BUT THEY MAY IN FACT--SOME OF THE ANTIEPILEPTICS MAY IN FACT ACTUALLY MAKE SYMPTOMS OF RESTLESS LEG SYNDROME GET BETTER. THERE ARE A LOT OF NON- PHARMACOLOGIC INTERVENTIONS THAT PEOPLE CAN MAKE, ESPECIALLY IF THEIR SYMPTOMS ARE INFREQUENT, SO ONE OF THE BIGGEST OFFENDERS IS CAFFEINE. SO PEOPLE TEND TO DRINK BIG MUGS OF COFFEE OR CAFFEINATED SODAS THROUGHOUT THE DAY. THAT CAN REALLY INCREASE THE SYMPTOMS FOR PEOPLE, AND IT REALLY DOESN'T SEEM TO MATTER WHAT TIME OF DAY PEOPLE HAVE CAFFEINE. I'VE HAD PATIENTS TELL ME THAT THEIR MORNING--IF THEY HAVE MORE COFFEE IN THE MORNING, THAT NIGHT THAT THEY'LL HAVE PROBLEMS WITH THEIR RESTLESS LEGS. SO IF YOU'RE HAVING A LOT OF CAFFEINE THROUGHOUT THE DAY, ONE THING YOU CAN DO IS START TO CUT BACK ON THAT, AND SOME COMMON STRATEGIES CAN BE, IF YOU'RE MAKING COFFEE AT HOME, YOU CAN TRY MIXING DECAF AND REGULAR COFFEE WHEN YOU MAKE IT, AND THAT WAY YOU CAN GRADUALLY DECREASE YOUR RELIANCE ON CAFFEINE. AND A LOT OF CAFFEINE CAN ALSO DISRUPT YOUR NIGHTTIME SLEEP AND LEAD TO INSOMNIA, SO THAT'S SOMETHING TO KEEP IN MIND. WE REALLY TRY TO ADVISE PEOPLE TO MINIMIZE CAFFEINE. TEA ALSO HAS CAFFEINE--NOT AS MUCH AS A STANDARD CUP OF COFFEE, BUT IT DOES HAVE SOME, AND IF PEOPLE ARE, PARTICULARLY IN THE SUMMER, DRINKING A LOT OF ICED TEA, THAT CAN BE A CONSIDERABLE SOURCE OF CAFFEINE, AS WELL AS, YOU KNOW, CARBONATED BEVERAGES. ONE THAT I LIKE TO WARN PEOPLE ABOUT, BECAUSE THEY OFTEN DON'T REALIZE IT HAS CAFFEINE IS MOUNTAIN DEW. EVEN THOUGH IT'S NOT A COLA LIKE PEPSI OR COKE, WHICH MOST PEOPLE REALIZE HAS SUBSTANTIAL AMOUNTS OF CAFFEINE, IT HAS A LOT OF CAFFEINE. SO THAT'S SOMETHING TO WATCH OUT FOR, AND CERTAIN MOST OF THE ENERGY DRINKS HAVE A LOT OF CAFFEINE IN THEM, SO YOU NEED TO BE CAREFUL ABOUT THAT. OTHER THINGS THAT CAN TRIGGER SYMPTOMS OF RESTLESS LEG SYNDROME INCLUDE NICOTINE, SMOKING. ALCOHOL CAN MAKE IT WORSE. SOMETIMES PEOPLE, IF THEY MASSAGE THEIR LEGS OR THEY HAVE WARM BATHS OR A WARM SHOWER BEFORE BEDTIME, THAT CAN HELP. I DON'T RECOMMEND THAT PATIENTS WITH EPILEPSY ARE IN BATHTUBS OR HOT TUBS BY THEMSELVES BECAUSE OF THE RISK OF GETTING INTO TROUBLE IF THEY HAVE A SEIZURE IN THE TUB, BUT SOMETIMES A WARM SHOWER, PEOPLE FIND THAT THAT CAN REALLY HELP. AND THE OTHER THING THAT WE OFTEN CHECK IS THAT LOW IRON STORES SOMETIMES CAN CAUSE PEOPLE TO HAVE SYMPTOMS OF RESTLESS LEG. SO OFTEN WE'LL CHECK WHAT'S CALLED A FERRATIN LEVEL, WHICH IS A MEASURE OF HOW MUCH IRON YOU HAVE, AND WE'LL DO IRON REPLACEMENT WITH VITAMIN C. AS I SAY, THERE'S A NUMBER OF TREATMENTS FOR IT THAT RANGE FROM MODIFICATIONS IN YOUR DIET, DECREASE OF CAFFEINE, NICOTINE, AND ALCOHOL TO MEDICATIONS. IN GENERAL, MOST OF THE EPILEPSY MEDICATION, SUCH AS GABAPENTIN OR CLONAZEPAM, EVEN LAMOTRIGINE AND CARBAMAZEPINE, GENERALLY MAKE THE SYMPTOMS OF RLS BETTER. BUT IF YOU ARE EXPERIENCING THESE PROBLEMS, IT'S ACTUALLY IMPORTANT TO LET YOUR CAREGIVER KNOW SO THAT THEY CAN APPROPRIATELY SCREEN YOU AND GUIDE YOU ON WHAT THE BEST TREATMENT WOULD BE. SO I'D JUST LIKE TO SUMMARIZE WHAT WE TALKED ABOUT WITH REGARD TO SLEEP AND EPILEPSY. SO EPILEPSY AND SEIZURES CAN LEAD TO POOR SLEEP QUALITY, IN PART BECAUSE OF DISRUPTION FROM SEIZURES AND DISRUPTION OF NORMAL SLEEP ARCHITECTURE. AND WE ALSO KNOW THAT THINGS LIKE SLEEP APNEA, WHICH ARE COMMON IN THE GENERAL POPULATION, ARE PROBABLY EVEN MORE COMMON IN PATIENTS WITH EPILEPSY. THE EXACT REASON WHY ISN'T CLEAR, BUT WE KNOW THAT WE REALLY NEED TO GO AHEAD AND SCREEN PEOPLE AGGRESSIVELY AND MAKE SURE THEY GET TREATED IN PART TO PREVENT THE LONG-TERM COMPLICATIONS OF SLEEP APNEA, BUT ALSO TO ENSURE THAT THEIR SEIZURES ARE OFTEN MORE CONTROLLED. AND WE ALSO KNOW THAT SOME OF THE ANTIEPILEPTIC MEDICATIONS CAN IMPACT SLEEP ARCHITECTURE, SO WE NEED TO KEEP ALL OF THAT INTO CONSIDERATION. SO THEREFORE IF YOU FIND YOU'RE HAVING SLEEP PROBLEMS, IT'S IMPORTANT TO BRING THAT UP TO YOUR CARE PROVIDER, AND THEY CAN ASSESS WHETHER YOU NEED TO GO SEE A SLEEP SPECIALIST AND WHETHER YOU NEED FURTHER INTERVENTION. I KNOW WE'RE GETTING TO THE END OF THE TALK, BUT I'D LIKE TO JUST SPEND A MINUTE OR TWO TALKING ABOUT BEST SLEEP PRACTICES. SO AS I MENTIONED EARLIER, IT'S REALLY IMPORTANT TO PROTECT OUR SLEEP TIME. SLEEP ISN'T OPTIONAL, AND IF YOU HAVE EPILEPSY, IT'S MORE IMPORTANT THAT YOU REALLY JUST LET PEOPLE KNOW THAT THESE ARE YOUR SLEEP HOURS. YOU SHOULD, IF POSSIBLE, TURN OFF YOUR PHONE. LET PEOPLE KNOW THAT YOU REALLY ARE GOING TO PROTECT THAT TIME. THE OTHER THING IS, TRY TO SET UP YOUR BEDROOM ONLY FOR SLEEP, AND DON'T HAVE THE COMPUTER AND THE TV ON IN YOUR ROOM. TRY TO MAKE YOUR BEDROOM A QUIET PLACE THAT'S REALLY RELAXING FOR YOU AND HAVE A REGULAR SLEEP ROUTINE. IT'S VERY HARD FOR PEOPLE WHO ARE RUNNING AROUND ALL DAY TO SUDDENLY SHUT THEMSELVES OFF. IT'S IMPORTANT TO GET IN THE HABIT WITH YOUR WHOLE FAMILY, INCLUDING KIDS. YOU START SLOWING DOWN AT NIGHT. YOU MAY DO SOME READING. TURN OFF THE COMPUTER AND THE TELEVISION, OTHER STIMULATING THINGS. GET THE LIGHTS DOWN LOWER AND REALLY LET YOUR BODY FOLLOW ITS NATURAL SIGNALS AT NIGHT TO GO TO SLEEP. IF IT'S SUMMER AND THERE'S LOTS OF LIGHT OUTSIDE, CLOSE THOSE WINDOWS. TRY TO AVOID, IF YOU CAN, A LOT OF SHIFT WORK OR DISRUPTIONS IN YOUR SCHEDULE. SOMETIMES IT'S JUST NOT POSSIBLE IF YOU'RE A CAREGIVER, YOU HAVE SMALL KIDS, OR OTHER REASONS, BUT REALLY TRY TO PROTECT THAT SLEEP TIME. AVOID ALCOHOL BEFORE BEDTIME AND LIMIT YOUR CAFFEINATED BEVERAGES. AND IF YOU ARE HAVING PROBLEMS WITH SLEEP, IT'S CRITICAL TO DISCUSS THEM WITH YOUR CARE PROVIDER. AND IMPROVING SLEEP IN EPILEPSY INVOLVES JUST OPTIMIZING YOUR EPILEPSY TREATMENT WITH YOUR DOCTOR. MAKE SURE YOU'RE NOT HAVING A LOT OF NIGHTTIME SEIZURES, AND DISCUSS ANY MEDICATION SIDE EFFECTS WITH YOUR PROVIDER. PRACTICE GOOD SLEEP HYGIENE, WHICH WE JUST SPOKE ABOUT, AND IF YOU THINK THAT YOU'RE HAVING SPECIFIC SLEEP PROBLEMS SUCH AS THE ONES WE'VE SPOKEN ABOUT, IT'S IMPORTANT TO LET YOUR PRIMARY CARE PHYSICIAN AND YOUR EPILEPSY DOCTOR KNOW THAT YOU'RE HAVING THESE ISSUES AND THAT YOU'D LIKE TO GET SOME MORE EVALUATION. SO ON THAT, I'D LIKE TO END. I REALLY APPRECIATE YOUR TAKING THE TIME TO LET ME TALK TO YOU ABOUT THIS TOPIC THAT IS NEAR AND DEAR TO MY HEART, AND HOPEFULLY I'VE GIVEN YOU SOME INFORMATION TODAY THAT WILL HELP YOU HAVE A BETTER UNDERSTANDING OF HOW SLEEP IMPACTS SEIZURES AND WHAT YOU CAN DO TO GET A BETTER NIGHT'S SLEEP. WE DO HAVE A FEW MINUTES FOR QUESTIONS, AND THEY'VE TOLD ME THAT THEY'D REALLY LIKE TO TRY TO LIMIT QUESTIONS TO ONE PER PERSON. THAT WAY WE CAN MAKE SURE THAT EVERYBODY HAS AN OPPORTUNITY. AND ALSO, IT'S BEST IF I ANSWER JUST MORE GENERAL QUESTIONS ABOUT THE THINGS THAT I'VE SPOKEN ABOUT. IF YOU HAVE SPECIFIC QUESTIONS ABOUT YOUR SLEEP AND YOUR EPILEPSY, IT'S REALLY IMPORTANT THAT YOU MAKE AN APPOINTMENT TO MEET WITH YOUR DOCTOR AND DISCUSS THOSE. SO IF YOU DO HAVE THOSE SPECIFIC QUESTIONS, I REALLY STRONGLY ENCOURAGE YOU TO PICK UP THE PHONE AFTER WE GET DONE AND LET YOUR PHYSICIAN KNOW THAT YOU NEED TO COME IN AND SPEAK ABOUT THOSE PROBLEMS. SO THANK YOU VERY MUCH FOR YOUR TIME, AND I THINK, SEAN, WE'RE READY FOR QUESTIONS NOW. - ALL RIGHT. THE LINES ARE OPEN. IS THERE ANY QUESTIONS FOR THE DOCTOR? - YES. JUST-- - I HAVE A QUESTION. - EVERYBODY TRY NOT TO TALK OVER EACH OTHER. ONE AT A TIME. - OK. IS THIS DOWNLOADABLE WHERE I CAN LISTEN TO IT LATER, AS WELL? - IT WILL BE DOWNLOADABLE THROUGH THE VA WEB SITE. IF YOU HAVE ACCESS TO THE VA WEB SITE, YOU WILL BE ABLE TO DOWNLOAD THIS. - OK. WHAT IS THAT ADDRESS? - WE WILL SEND IT-- GET IN CONTACT WITH RYAN RIEGER, AND HE WILL HAVE ACCESS TO IT, AND WE'LL MAKE SURE YOU GET A HOLD OF THAT, OR YOU CAN JUST E-MAIL ME AT SEAN.GAMBLE-- S-E-A-N.GAMBLE@VA.GOV. - SEAN, CAN I SAY THE ADDRESS? - YEAH. - IT'S WWW.EPILEPSY, SPELLED E-P-I-L-E-P-S-Y, .VA.GOV, G-O-V, AND ANY COMPUTER CAN ACCESS THAT. - OK. GREAT. THANK YOU. - MY NAME IS KELLY. I'M A CAREGIVER FOR MY 8-YEAR-OLD DAUGHTER. SHE HAS EPILEPSY. SHE RECENTLY HAD... [CONTINUES INDISTINCTLY] - I'M HAVING TROUBLE HEARING YOU. YOU'RE COMING IN AND OUT. COULD YOU REPEAT THAT? - SURE. I HAVE AN 8-YEAR-OLD DAUGHTER WITH EPILEPSY. - MM-HMM. - SHE'S ON KEPPRA. SHE'S BEEN SEIZURE-FREE FOR ALMOST A YEAR NOW, BUT I FEEL LIKE SHE DOESN'T GET ENOUGH SLEEP. IN THIS SITUATION, WOULD YOU RECOMMEND THAT WE ELIMINATE SOME OF HER EXTRACURRICULAR ACTIVITIES SO SHE CAN GET MORE TIME FOR REST? - YOU KNOW, I THINK THAT'S A REALLY IMPORTANT QUESTION, AND AS A MOM MYSELF, KIDS HAVE A LOT OF COMPETING ACTIVITIES TODAY, AND ALL OF US DO. I THINK THIS WOULD BE SOMETHING TO ACTUALLY SIT DOWN AND DISCUSS WITH HER EPILEPSY PROVIDER. IT'S REALLY LOOKING AT HER SCHEDULE AND LOOKING AT HOW MUCH SLEEP OPPORTUNITIES SHE HAS. YOU KNOW, IS HOMEWORK OR OTHER ACTIVITIES INTERFERING WITH HER REGULAR TIME? SO THAT'S AN IMPORTANT THING TO SIT DOWN AND DISCUSS WITH YOUR PROVIDER AND GET THEIR OPINION ON IT. I THINK THE OTHER THING THAT I LIKE TO DO WITH MY PATIENTS IS REALLY CHAT WITH THEM, AND IF I SENSE THEY'RE FEELING STRESSED ABOUT THE ACTIVITIES AND THAT THEY DON'T HAVE ENOUGH OPPORTUNITIES FOR SLEEP, SOMETIMES WHAT MY JOB IS TO ACTUALLY GIVE THEM PERMISSION TO SAY, "YOU KNOW WHAT? IT'S OK TO PROTECT YOUR SLEEP. IT'S OK TO DIAL ACTIVITIES DOWN," BUT I THINK THAT'S AN IMPORTANT CONVERSATION YOU SHOULD HAVE WITH YOUR PHYSICIAN AND REALLY BECAUSE IT'S SO INDIVIDUAL, BUT I THINK THAT I'M GLAD YOU BROUGHT IT UP BECAUSE IT'S IMPORTANT TO LOOK AT THE IMPACT ALL THESE ACTIVITIES HAVE ON OUR SLEEP OPPORTUNITY, IS WHAT WE CALL IT, AND I THINK PEOPLE ARE BEGINNING TO REALIZE THAT--YOU KNOW WHAT?-- MAYBE WE DON'T NEED TO HAVE QUITE AS CRAZY SCHEDULES AS WE DO. PEOPLE ARE BEGINNING TO REALIZE THAT, "YOU KNOW, IF I DIAL THINGS DOWN A BIT, THINGS ARE STILL GONNA BE OK, AND LIFE WILL JUST BE CALMER," BUT I APPRECIATE YOU BRINGING THAT UP, AND I WOULD REALLY ENCOURAGE YOU TO DISCUSS IT WITH THEM, AND THEY MAY ALSO WANT TO DO SOME SCREENING TO MAKE SURE SHE DOESN'T HAVE SLEEPING DISORDERS, TOO, AND IT'S IMPORTANT TO PROTECT HER SLEEP BUT ALSO TO PROTECT YOUR SLEEP AS CAREGIVER, AND IT'S REALLY IMPORTANT. THE OTHER THING TO TRY TO DO IS GIVE CAREGIVERS PERMISSION, THAT YOUR SLEEP NEEDS TO BE A PRIORITY, THAT--YOU KNOW WHAT?-- EVERYBODY IS GONNA BE FINE IF THE HOUSE DOESN'T GET CLEANED OR SOME OTHER THING DOESN'T GET DONE, LIKE THAT, AS CAREGIVER, YOU CAN'T BE THE BEST CAREGIVER THAT YOU CAN BE AND YOU CAN'T HELP THEM MUCH UNLESS YOU REALLY PROTECT YOUR SLEEP, AND YOU NEED TO CONSIDER THAT A PRIORITY SO THAT YOU GET THE REST YOU NEED, TOO. - ALL RIGHT. THANK YOU. - I HAVE A QUESTION, AS WELL. YOU HAD INDICATED THAT ONE OF THE INDICATORS OF MAYBE SLEEP APNEA WOULD BE HEADACHES AND WAKING UP IN THE-- HEADACHES AND FREQUENTLY GOING TO THE BATHROOM. - MM-HMM. - AM I CORRECT IN THAT? - YEAH. SO, YOU KNOW, THERE'S A LOT OF THINGS THAT CAN CAUSE HEADACHES, BUT TYPICALLY, THE HEADACHE THAT'S ASSOCIATED-- SO WHEN SOMEONE COMES IN AND I SCREEN THEM FOR SLEEP APNEA, I'LL ASK THEM, "ARE YOU SNORING? HAS ANYBODY SEEN PAUSES IN BREATHING?" AND IF THEY TELL ME YES AND THEN THEY ALSO TELL ME, "GEE, WHEN I WAKE UP SOME MORNINGS, "I HAVE A DULL HEADACHE, AND IT GOES AWAY IN ABOUT 30 TO 60 MINUTES," THAT'S ANOTHER SIGN AND SYMPTOM THAT CAN GO ALONG WITH THE OTHER SYMPTOMS, AND, AS I MENTIONED, IT TYPICALLY HAS TO DO WITH IF YOU'RE HAVING THESE PAUSES IN BREATHING THROUGHOUT THE NIGHT, YOU'RE NOT BLOWING OFF CARBON DIOXIDE AS WELL AS YOU WOULD NORMALLY AND AS YOU DO DURING THE DAY. SO IN GENERAL, THESE ARE MILD. WHEN PEOPLE GET UP AND START MOVING AROUND, THEY BLOW OFF THAT CO2, AND THEN THE HEADACHE GOES AWAY. SO THE OTHER THING IS, SEE, THERE ARE LOTS OF REASONS FOR HAVING FREQUENT URINATION AT NIGHT-- ACUTE PROSTATE PROBLEMS, OTHER THINGS-- BUT IN GENERAL, THERE ARE CHANGES IN HORMONES GO ON WITH COMMON SLEEP APNEA THAT CAN MAKE YOU URINATE MORE FREQUENTLY AT NIGHT, AND SO THAT'S ANOTHER SIGN OR SYMPTOM THAT WE LOOK FOR IN CONSTELLATION WITH THE OTHER THINGS THAT I SPOKE ABOUT, AND I'M OFTEN SURPRISED. EVEN PEOPLE WITH PROSTATE PROBLEMS OR OTHER REASONS FOR FREQUENT URINATION, HOW MUCH IT IMPROVES ONCE THEY GET THEIR SLEEP APNEA TREATED. THEY REALLY AREN'T GETTING UP AS MUCH AT NIGHT, BUT THAT'S AN IMPORTANT THING IF YOUR HAVING THOSE ISSUES, TO DISCUSS THEM WITH YOUR PHYSICIAN BECAUSE THEY CAN HELP YOU SORT OUT IF THEY THINK IT'S DUE TO SLEEP ISSUES OR DUE TO SOMETHING ELSE, TOO. - OK. HAVE YOU HEARD THAT KEPPRA COULD BE A-- HEADACHES THAT COME FROM TAKING KEPPRA. HAVE YOU SEEN ANYTHING ABOUT THAT? - YOU KNOW, THERE'S A LOT OF-- A LOT OF THE ANTIEPILEPTICS CAN CAUSE, YOU KNOW, A NUMBER OF SIDE EFFECTS, AND SO I'D REALLY ENCOURAGE YOU TO DISCUSS YOUR PARTICULAR HEADACHE QUALITIES WITH YOUR PHYSICIAN. I THINK THAT IT SOUNDS LIKE IT'S REALLY AN ISSUE FOR YOU AND THAT THEY CAN REALLY GO THROUGH AND EVALUATE WHETHER THEY THINK IT'S MEDICATION SIDE EFFECT OR THERE'S SOMETHING ELSE, YOU KNOW, GOING ON. HEADACHES ARE SO COMMONLY FOUND THAT IT'S IMPORTANT TO LET YOUR DOCTOR KNOW SO THEY CAN SORT OF SORT THROUGH IS THIS SOMETHING THAT YOU'RE GETTING FROM SLEEP APNEA OR IF IT'S SOMETHING YOU'RE GETTING FROM A MEDICATION SIDE EFFECT, AND THEY CAN WORK WITH YOU TO HOPEFULLY MITIGATE THAT. - OK. THANK YOU. - IT'S AN IMPORTANT POINT, AND PLEASE DO DISCUSS THAT WITH YOUR PHYSICIAN SO YOU CAN GET SOME RELIEF FROM IT. - AND IF IT APPLY, ALSO MY DAUGHTER TAKES KEPPRA. - MM-HMM. - SHE ALSO GET HEADACHES. - OK. - MAY I ADDRESS THIS QUESTION TO-- - WAIT. UH-HUH? AND JUST BEFORE YOU DO THAT, TO THE PERSON WHO JUST MADE THE COMMENT ABOUT THE KEPPRA AND THE SLEEP APNEA HEADACHES, IF THEY'RE STILL GOING ON, IT'S ACTUALLY IMPORTANT TO LET-- I KNOW I KEEP EMPHASIZING "PLEASE TALK TO YOUR PROVIDER," BUT THESE ARE IMPORTANT POINTS THAT IN A LIMITED APPOINTMENT, WE MAY NOT GET A CHANCE TO COVER EVERYTHING. SO WRITE THIS DOWN AND MAKE AN APPOINTMENT TO GO IN AND MAKE SURE YOU DISCUSS IT WITH THEM BECAUSE YOUR PROVIDER CAN HELP YOU UNRAVEL WHAT TO DO, AND IF SHE'S GOT SLEEP APNEA AND ISN'T FULLY TREATED, SHE MAY NEED TO SEE THE SLEEP DOCTOR AGAIN, OR THEY MAY NEED TO MAKE SOME OTHER ADJUSTMENTS. SO MAKE SURE YOU BRING THAT UP TO THEM. I'M SORRY. THERE WAS ANOTHER QUESTION? - YES. THANK YOU SO MUCH. I HAVE A QUICK QUESTION. I HAVE A SON, AN 8-YEAR-OLD SON, AND WE ARE HAVING A PROBLEM IN WHAT SEEMS TO BE EITHER LIGHT OR STAGE TWO SLEEP WHERE HE WAKES UP AND HE'S VERY ITCHY. SOMETIMES HE DOES HAVE SOME INVOLUNTARY MOVEMENT OF HIM KIND OF REALLY WITH THE RESTLESS LEGS. - MM-HMM. - DOCTORS ARE SAYING THEY DON'T THINK IT'S RELATED TO THE MEDICATION, BUT IT'S HAPPENING QUITE OFTEN. HE'LL WAKE UP, AND HE'LL BE ITCHY. IT'S NOT LOCALIZED. IT'S ALL OVER HIS BODY. - YEAH. - WE CAN'T QUITE GET TO THE BOTTOM OF IT, AND IT EXHAUSTS US. - MM-HMM. YOU KNOW, THERE CAN BE A LOT OF THINGS IN KIDS THAT DISRUPT SLEEP, THAT CAN WAKE THEM UP. IT SOUNDS LIKE YOU ARE WORKING WITH HIS PHYSICIANS TO TRY TO SORT IT OUT. YOU KNOW, ANYTHING THAT CAUSES KIDS TO SHIFT OUT OF SLEEP-- PARTICULARLY, KIDS CAN GET INTO PRETTY HEAVY SLEEP-- THEY MAY BE A LITTLE BIT CONFUSED WHEN THEY WAKE UP. THEY MAY TALK IN THEIR SLEEP. THEY MAY BE WIDE-EYED BUT NOT AWAKE WHEN YOU FIRST WAKE THEM UP. SO ANYTHING THAT GONNA CAUSE THEM TO SUDDENLY SHIFT OUT OF A DEEP SLEEP OR INTO A LIGHTER STAGE OF SLEEP, IT'S GONNA CAUSE AROUSAL, BE DISRUPTIVE, AND I'M SURE YOU'VE DISCUSSED WITH YOUR PHYSICIANS, BUT ANY NUMBER OF THINGS CAN CAUSE ITCHING--FROM MEDICATIONS, TO SOAPS YOU USE, THE PERFUMES TO-- - BUT IT'S HAPPENING WHEN HE'S TRYING TO SLEEP. IT DOESN'T HAPPEN DURING THE DAY AT ALL, ONLY IN THE EARLY STAGES OF SLEEP, AND IT'S ALMOST EVERY NIGHT. - AS I SAY, NOTHING ELSE OTHER THAN THE GENERAL THINGS ARE COMING TO MIND SPECIFICALLY WITH THAT, BUT I CAN URGE YOU TO CONTINUE TO WORK WITH YOUR PHYSICIAN TO DISCUSS THAT AND JUST TRY A NUMBER OF THINGS TO SEE IF YOU CAN RELIEVE THAT BECAUSE IT DOES SOUND LIKE IT'S CAUSING BOTH HIM AND YOU A LOT OF DISTRESS. OK. GOOD LUCK WITH THAT. - THANK YOU VERY MUCH. - I HAVE A QUESTION. - MM-HMM? - CAN YOU HEAR ME? - YES. I CAN. - GOOD. THANK YOU. IS A NIGHTLY READING, A HABIT OF READING IN BED, IS THAT CONSIDERED A DISRUPTIVE BEHAVIOR? - THAT'S AN INTERESTING QUESTION. SOME PEOPLE HAVE GONE AS FAR AS TO SAY, "OH, YOU SHOULDN'T READ IN BED," BUT I REMEMBER A GREAT STORY TOLD BY AN OLDER SLEEP PHYSICIAN, AND HE HAD A PATIENT COME IN AND SAY, "I STARTED HAVING INSOMNIA," AND HE GAVE HIM THE EXACT DATE, AND HE SAID, "WHAT HAPPENED?" HE GOES, "WELL, THAT'S WHEN I READ AN ARTICLE "THAT YOU'RE NOT SUPPOSED TO READ IN BED, "AND I'VE STOPPED READING IN BED, AND I'VE HAD INSOMNIA EVER SINCE." SO I THINK YOU HAVE TO USE COMMON SENSE. I PERSONALLY FIND THAT READING A BOOK AT NIGHT MAKES ME DROWSY, AND IF IT'S NOT CAUSING DISRUPTION, I WOULDN'T WORRY ABOUT IT. I THINK WHERE IT BECOMES AN ISSUE IS IF YOU'RE HAVING A LOT OF PROBLEM. YOU'VE GOT A REALLY BRIGHT LIGHT. YOU MAY WANT TO TRY DOING SOMETHING ELSE. I KNOW I HAVE COLLEAGUES WHO WILL SUGGEST TO PEOPLE IF THEY THINK THAT THEIR NIGHTTIME READING IS DISRUPTING THEIR SLEEP WHO'LL HAVE THEM LISTEN TO BOOKS ON TAPE, OR IF THEY WAKE UP AT NIGHT, WE OFTEN HAVE PEOPLE LEAVE THE BEDROOM AND SIT QUIETLY. WE ENCOURAGE THEM NOT TO TURN ON THE TV OR SOMETHING, AND MY COLLEAGUES WILL THEN HAVE PEOPLE LISTEN TO BOOKS ON TAPE, BUT I WOULD SAY IF IT'S NOT CAUSING A PROBLEM FOR YOU, DON'T WORRY ABOUT IT. JUST FOR A LOT OF PEOPLE, IT'S A RELAXING RITUAL THAT HELPS THEM GET TO SLEEP. SO I NEVER TELL PEOPLE NOT TO DO IT UNLESS IT BECOMES A SPECIFIC PROBLEM FOR THEM, AND THEN YOU COULD TRY SHIFTING TO RELAXING MUSIC AND/OR BOOKS ON TAPE AS LONG AS THE BOOK ON TAPE OR THE BOOK YOU'RE READING ISN'T SO GRIPPING THAT IT KEEPS YOU UP. - THAT SOUNDS GREAT. THANK YOU. - I HAVE A QUESTION. - HELLO. I--SORRY. - GO AHEAD. - YOU WERE FIRST, I THINK. - YES. I CAN HEAR YOU. - I'VE HAD EPILEPSY ALL MY LIFE, AND THE LAST COUPLE YEARS AT NIGHT BEFORE I GO TO BED, I START HAVING THESE LIGHT FLASHES IN MY HEAD THAT I CAN FEEL BEHIND MY EYES, AND THEY KEEP ME AWAKE. - I'M SORRY TO HEAR THAT. IT SOUNDS REALLY DISRUPTING, AND IT SOUNDS LIKE IT WOULD BE HARD TO GET TO SLEEP WITH THAT GOING ON, AND THIS IS ONE WHERE THIS IS SUCH AN INDIVIDUAL THING, I REALLY ENCOURAGE YOU TO WRITE DOWN YOUR SYMPTOMS WHEN YOU'RE HAVING THEM SO YOU CAN HAVE A GOOD RECORD AND BRING THAT IN TO YOUR PROVIDER AND LET THEM KNOW BECAUSE THERE COULD BE ANY NUMBER OF THINGS GOING ON, AND THIS'D BE SOMETHING REALLY IMPORTANT NOT ONLY TO LET THEM KNOW THIS IS OCCURRING NIGHTLY, BUT ALSO THAT IT'S STARTED TRULY DISRUPTING YOUR SLEEP, AND THAT WILL ALLOW THEM TO FOCUS AND WORK WITH YOU ON WHAT COULD BE CONTRIBUTING TO THIS, BUT I THINK IT HIGHLIGHTS HOW DISTRESSING SOME OF THESE THINGS CAN BE AND HOW THEY REALLY DO DISRUPT YOUR SLEEP AND, AS A RESULT THEN, YOUR QUALITY OF LIFE BECAUSE YOU JUST CAN'T GET THE SLEEP YOU NEED, AND OFTEN PEOPLE, WHEN THEY GET INTO A CYCLE OF THIS HAPPENING, THEY THEY'RE ALMOST AFRAID TO GO INTO THE BEDROOM BECAUSE THEY KNOW THEY'RE GONNA HAVE THESE PROBLEMS AND IT'S JUST GONNA BE TOUGH. SO IT'S REALLY, REALLY CRITICAL THAT YOU WRITE DOWN THE SYMPTOMS, WRITE DOWN THE FREQUENCY. MUCH LIKE YOU KEEP A SEIZURE DIARY, KEEP A SLEEP DIARY AND LET PEOPLE KNOW WHAT'S GOING ON, AND WHEN YOU BRING THAT IN TO MEET WITH YOUR PHYSICIAN, THEY CAN USE THAT TO HELP TRY TO IDENTIFY WHAT MIGHT BE TRIGGERING THIS AND HELP YOU GET SOME RELIEF FROM WHAT SOUNDS LIKE SOMETHING THAT'S VERY DISTRESSING, AND I'M REALLY SORRY YOU'RE EXPERIENCING THAT. - OK. THANK YOU. - HELLO. I HAVE A QUESTION. - MM-HMM? - I HAVE A 13-YEAR-OLD DAUGHTER WHO IS AN EPILEPTIC SINCE SHE WAS A YEAR OLD, AND SHE HAS CONTROL DURING THE DAY, BUT SHE HAS SOME PRETTY GOOD SEIZURES AT NIGHT, AND EVERY EEG SHE'S EVER HAD, THEY'VE NOTED THAT SHE DOES NOT HAVE SLEEP SPINDLES, BUT EVERY NEUROLOGIST I'VE EVER ASKED DOESN'T SEEM TO KNOW WHAT [INDISTINCT] DOES AND WHETHER THAT HAS ANYTHING TO DO WITH EPILEPSY, AND I WAS WONDERING IF YOU COULD EXPLAIN SLEEP SPINDLES TO ME. - YEAH. SO SLEEP SPINDLES-- SO WE HAVE THESE FEATURES OF DIFFERENT STAGES OF SLEEP THAT WE OFTEN SEE ON AN EEG, AND SLEEP SPINDLES ARE SOMETHING THAT ARE GENERATED IN A PLACE IN THE BRAIN CALLED THE THALAMUS, WHICH IS A RELAY STATION IN THE BRAIN, AND IT'S ASSOCIATED WITH WHAT USED TO BE CALLED STAGE TWO SLEEP OR N2 SLEEP, AND IF WE SEE THEM, WE NOTE THEM DOWN. THEY'RE A COMMON THING. THEY, AS I SAY, HELP US SCORING N2, OR STAGE TWO, SLEEP. AS FAR AS IF WE DON'T SEE IT ON A ROUTINE RECORDING, THEY TELL PATIENTS NOT TO WORRY ABOUT IT. THERE ARE OTHER FEATURES THAT CAN HELP PEOPLE IDENTIFY STAGE TWO, NOT JUST SOMETHING THAT WE COMMONLY LOOK FOR, AND THERE CAN BE A NUMBER OF THINGS THAT CAN IMPACT SLEEP SPINDLES, FROM MEDICATIONS TO INDIVIDUAL VARIABILITY. SO MY SHORT ANSWER TO THAT, OR SUMMARY ANSWER, WOULD BE, JUST BECAUSE THEY DON'T SEE THEM, WE DON'T KNOW OF ANYTHING SPECIFICALLY ASSOCIATED WITH EPILEPSY THAT WOULD MAKE YOU NEED TO BE EXTRA CONCERNED THAT SHE DOESN'T HAVE THEM, AND SOMETIMES IN INDIVIDUALS, WE JUST DON'T SEE THEM DURING OUR BRIEF RECORDINGS, BUT IT DOESN'T NECESSARILY INDICATE THAT THERE'S ANYTHING THAT YOU WOULD NEED TO TAKE EXTRA ACTION ON OR THAT THEY WOULD NECESSARILY NEED TO CHANGE HER THERAPY FOR JUST BECAUSE THEY DON'T SEE THEM. THE ISSUE IS JUST MAKING SURE THAT SHE'S OPTIMALLY TREATED AND THAT THE SEIZURES THAT SHE IS HAVING AT NIGHT AREN'T SO DISRUPTIVE TO HER SLEEP THAT SHE'S NOT ABLE TO FUNCTION THE NEXT DAY. SO JUST USING CRITICAL GUIDANCE IS IMPORTANT, BUT I'M UNAWARE OF ANYTHING THAT I'VE EITHER READ OR IN THE LITERATURE THAT WOULD INDICATE THAT YOU NEED TO BE WORRIED THAT THEY HAVEN'T SEEN THE SLEEP SPINDLES. IT'S JUST A COMMON FEATURE, AND IF WE DON'T SEE IT, WE CAN LET IT GO. IT'S NOT ANYTHING THAT SHOULD CAUSE YOU ANY EXTRA ALARM. - GOOD. THANK YOU VERY MUCH. THANK YOU. - SURE. SEAN, I THINK THAT OUR TIME IS UP. I REALLY APPRECIATE EVERYBODY'S ATTENTION AND TIME AND HOPE THAT WE'VE GOTTEN SOMETHING HELPFUL OUT OF THE LAST HOUR THAT WE'VE SPENT TOGETHER AND THAT YOU CAN TAKE SOME OF THE SUGGESTIONS I'VE MADE TO HELP YOU GET A BETTER NIGHT OF SLEEP, AND IF YOU CONTINUE TO HAVE SLEEP ISSUES OR QUESTIONS, DON'T HESITATE TO BRING THESE UP TO YOUR PHYSICIAN. THERE ARE THINGS YOU CAN DO TO GET RELIEF. SO DON'T GET DISCOURAGED ABOUT IT. THERE ARE TREATMENTS AVAILABLE THAT CAN HELP YOU FEEL BETTER DURING THE DAY. THANK YOU VERY MUCH. - DR. BOUDREAU, I WANT TO THANK YOU FOR TAKING THE TIME TO TALK TO US. - THANK YOU VERY MUCH. - THANKS, EVERYBODY. GOOD LUCK. BYE-BYE.