Medicina Clínica Práctica 4 (2021) 100214

www.elsevier.es/medicinaclinicapractica

Original article

Differences in the quality of life of epileptic patients with and without

sleep disturbance夽
Audry Devisanty Wuysang ∗ , Oktaviana Niken Prawitasari, Jumraini Tammasse, Susi Aulina,
Ashari Bahar
Department of Neurology, Medical Faculty, Hasanuddin University, Makassar, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Objective: To compare differences in quality of life in epilepsy patients with and without sleep disorders.
Received 24 September 2020 Methods: An analytic comparative observational method with a cross-sectional study was conducted to
Accepted 15 October 2020 patients that have been diagnosed with epilepsy for at least one year. The sample was derived using a
consecutive sampling method with inclusion criteria at the RSUP Dr. Wahidin Sudiohusodo, collaborative
Keywords: hospital, and private practice in April–May 2019. Independent variable: quality of sleep assessed by the
Epilepsy Pittsburgh Sleep Quality Index (PSQI) questionnaire. Dependent variable: insomnia assessed by Insomnia
Sleep disturbance
Severity Index (ISI) and quality of life assessed by Quality of Life in Epilepsy-31 (QOLIE-31). Statistical
ISI
PSQI
analysis was conducted using the unpaired t-test, Mann–Whitney test, and Chi-square test.
QOLIE-31 Results: Sixty-eight subjects met the inclusion criteria; 35 subjects with good sleep quality and 33 sub-
jects with poor sleep quality, consist of 5 subjects with no clinically significant insomnia, 16 subthreshold
insomnia, nine moderate insomnia, and three severe insomnia. The results showed a significant differ-
ence between 2 groups (p = 0.018). A significant difference (p = < 0.01) can be seen in the component of
overall quality of life, emotional well-being, energy/fatigue, and social function. While in seizure worry
(p = 0.256), cognitive (p = 0.261) and medication effects (p = 0.897) the differences were not statistically
significant.
Conclusion: There are differences in the quality of life of epileptic patients with and without sleep dis-
turbance. Epileptic patients with sleep disturbance have a poorer quality of life compared to epileptic
patients without sleep disturbance.
© 2021 The Authors. Published by Elsevier España, S.L.U. This is an open access article under the CC
BY license (http://creativecommons.org/licenses/by/4.0/).

Introduction Neurologist Specialist Association in several hospitals in 5 major

islands in Indonesia (2013) found 2288 people with epilepsy with
Epilepsy is a brain disorder characterized by a tendency to cause 21.3% new patients.3
epileptic seizures that are continuous, with neurobiological, cogni- The most common age is the productive age, with the most
tive, and social consequences. In contrast, epileptic seizures occur common etiology of epilepsy is a head injury, central nervous sys-
for a momentary sign and symptom due to abnormal and excessive tem infections, strokes, and brain tumors. Poor sleep can induced
neuronal activity in the brain.1,2 Epilepsy is a chronic disease that is seizures. Sleep is a physiological and recurring form of reversal of
found in 0.5–1% of the total population. According to WHO, an esti- consciousness that reverses a decline in cognitive function globally
mated 50 million people worldwide have epilepsy. The prevalence so that the brain does not respond adequately to the surround-
and incidence of epilepsy in Indonesia are not known with cer- ing stimulus. The average sleep cycle starts from phase 1 NREM
tainty. The results of the Epilepsy Study Group of the Indonesian followed by phase 2, then SWS after that returns to phase 2 and
continues with the REM cycle. In healthy adults, this cycle can occur
5–7× each sleep period. The cycle time is around 90 min, and in gen-
eral, the first cycle occurs the shortest compared to other cycles. In
夽 Peer-review under responsibility of the scientific committee of the Technology 1/3 of the sleep period, the SWS predominates, whereas the first
Enhanced Medical Education International Conference (THEME 2019). Full-text and REM usually occurs 70–90 min after sleep begins. In adults expe-
the content of it is under responsibility of authors of the article.
∗ Corresponding author.
riencing 2–5% of the sleep period is in phase 1 NREM, 45–55% in
E-mail addresses: [email protected], [email protected]
phase 2, 13–23% in the SWS phase, and 20–25% in the REM phase.4,5
(A.D. Wuysang). The duration and distribution of the sleep phases vary at each age

https://doi.org/10.1016/j.mcpsp.2021.100214
2603-9249/© 2021 The Authors. Published by Elsevier España, S.L.U. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
A.D. Wuysang, O.N. Prawitasari, J. Tammasse et al. Medicina Clínica Práctica 4 (2021) 100214

of human life. In stone born babies, the duration of each cycle Result
lasts for approximately 60 min, whereas in young adults, approx-
imately 90 min. Sleep duration decreases according to a person’s The total research subjects who met the inclusion criteria were
age (Table 1). 68 people, from a minimum sample of 24 subjects from each group.
In adults, the duration of sleep lasts between 7.5 and 8 h each Baseline data from the study subjects showed that the male and
day. Recent research shows that the global effects of epilepsy are female gender composition in this study was almost balanced, with
quite high. Surveys show that patients with epilepsy have the 35 men (51.5%) and 33 women (48.5%), with the highest age distri-
opportunity to have a lower quality of life than the general popu- bution at ages 26–35 in 27 subjects (39.7%), then 18–25 years were
lation. Sleep disorders in people with epilepsy are 2–3 times more 18 subjects (26.5%), and in the age group, 46–50 subjects were four
frequent than in the general population.3 Sleep disorders are gen- people (5.9%).
erally not too problematic for healthy people, but a considerable The highest level of education is senior high school, which is 29
influence on patients with chronic diseases, especially in patients subjects (42.6%), where most of the research subjects are private or
with epilepsy, the consequences are more severe, sleep deprivation independent workers. A total of 40 study subjects (58.8%) under-
can cause memory dysfunction, severe drowsiness during the day, went epilepsy treatment under ten years. The number of seizures
and directly can contribute to the emergence of seizures. The causes in the last one month was grouped into three groups, namely <1×
of sleep disorders in epilepsy patients are similar to the average monthly generation, 1–5× monthly and >5× monthly, and the high-
population in general, such as lack of sleep, sleep-hygiene.4 During est number of subjects in the study with 1–5× monthly frequency
epilepsy seizures, abnormal electrical discharges occur that syn- was 34 subjects (50%).
chronize in the local area or throughout the brain. The observation Most of our research subjects had a normal BMI of 48 subjects
supports the effect of sleep on epilepsy that in specific epilepsy (70.6%). Of 68 research subjects, 35 people (51.5%) had good sleep
syndromes, seizures occur in the NREM phase, and in all epilepsy quality, while as many as 33 people (48.5%) research subjects had
syndromes, the interictal epileptic discharge is more common in poor quality. From 33 people with poor sleep quality, five people did
the NREM phase than in the REM phase.6 not have insomnia (15.2%), 16 people with mild insomnia (48.5%)
Neuronal synchronization in the thalamocortical pathway dur- had mild insomnia, nine people had moderate insomnia (27.3%),
ing the NREM phase causes more even neuronal excitability, and and 3 had severe insomnia (4.4%). Overall, there were 55 subjects
this can facilitate seizures in most partial epilepsy. Neuronal syn- with good quality of life and (80.9%) and 13 people had poor quality
chronization stops when waking up or transitioning to REM. Sleep of life (19.1%), all of whom were insomnia patients, 5 of whom were
disturbance in epilepsy patients can directly or indirectly affect mild insomnia (38.5%), five moderate insomnia (38.5%) and three
the quality of life of patients, which can be measured by one mea- severe insomnia (23.1%)
suring instrument in the form of a questionnaire called QOLIE-31.
QOLIE-31 is a questionnaire that has been studied and proven Characteristics of samples
useful in determining the quality of life of epilepsy patients.
Therefore, researchers want to compare the quality of life of Table 2 shows a group of study subjects with good sleep quality
epilepsy patients who have sleep disorders compared with epilepsy (PSQI < 5) and research subjects with poor sleep quality (PSQI > 5).
patients without sleep disorders using the QOLIE-31 question- PSQI has seven components, namely subjective sleep quality, sleep
naire. Based on the description above, the researcher wants to latency, sleep duration, sleep efficiency, sleep disturbance, use of
conduct a study that examines the comparison of the quality of sleeping pills, and activity dysfunction. The table below illustrates
life of epilepsy patients with sleep disorders and without sleep the differences in each component in PSQI in research subjects with
disorders.3,4,6,7 good sleep quality and poor sleep quality.

Relationship of PSQI, insomnia, and quality of life of epilepsy

Method patients

Research design Table 3 shows the relationship between research subjects with
PSQI both and Uruk with the degree of insomnia and quality of life.
This research is a type of observational comparative analytic In QOLIE-31, the quality of life of epilepsy patients is assessed in
study using cross-sectional studies. The affordable population is general, then broken down into seven components, namely anx-
all patients with epilepsy who seek treatment at the Nerve Poly iety generation, quality of life, emotional disturbances, energy or
Wahidin Sudirohusodo Education Hospital and Network Hospital, fatigue, cognition, treatment effects, and social functions.
as well as private practices in April–May2019.
Samples were taken from the study population based on the Discussion
order of admission to the hospital (consecutive sampling). The sam-
ple size required for two-sided testing is obtained by the formula Sleep disorders are generally not too problematic for healthy
(Lemeshow, 1997) with a minimum sample of 24 people per group. people, but considerable influence on patients with chronic dis-
eases, especially in patients with epilepsy, the consequences can be
more severe, lack of sleep can cause memory dysfunction, severe
Research samples and sampling techniques drowsiness during the day and directly can contribute to the emer-
gence of seizures. The causes of sleep disorders in epilepsy patients
The study was conducted at the Neurology Polyclinic at Wahidin are similar to the average population in general, such as lack of
Sudirohusodo General Hospital, Network Hospital, and private sleep, sleep-hygiene, circadian rhythm disorders (Table 4).
practice in April–May 2019. The sample of this study was epilepsy In our results the distribution of male and female research sub-
sufferers, who met the inclusion criteria. The sample is obtained jects, most were unmarried, and most age distributions were below
by consecutive sampling method, which is taking a sample that 35 years, we did not include research subjects with age above 50
is in accordance with the conditions or requirements of the sam- years because the sleep quality of elderly patients tended to be
ple from a particular population that is most easily reached or worse, according to Sang-Ahm Lee’s research, 2015. Most of the
obtained.3 educational levels of research subjects were high school, while we

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A.D. Wuysang, O.N. Prawitasari, J. Tammasse et al. Medicina Clínica Práctica 4 (2021) 100214

Table 1
The characteristics of the research subjects are related to PSQ.

Characteristics PSQI Total p-Value

Good Poor

Gender
Man
n 14 21 35 0.088
% 40.0 60.0 100.0

Women
n 21 12 33
% 63.6 36.4 100.0

Age
18–25 yo
n 12 6 18 0.386
% 66.7 33.3 100.0

26–35 yo
n 13 14 27
% 48.1 51.9 100.0

36–45 yo
n 9 10 19
% 47.4 52.6 100.0

46–65 yo
n 1 3 4
% 25.0 75.0 100.0

Education
Junior High School
n 6 6 12 0.555
% 50.0 50.0 100.0

Senior High School

n 13 16 29
% 44.8 55.2 100.0

College
n 16 11 27
% 59.3 40.7 100.0

Work
Unemployment
n 11 6 17 0.495
% 64.7 35.3 100.0

Pharmacist
n 1 0 1
% 100.0 0.0 100.0

Laborers
n 0 1 1
% 0.0 100.0 100.0

Student
n 5 5 10
% 50.0 50.0 100.0

Farmer
n 0 1 1
% 0.0 100.0 100.0

Civil
n 6 4 10
% 60.0 40.0 100.0

Self-employed
n 12 16 28
% 42.9 57.1 100.0

BMI
Underweight
n 5 1 6 0.147
% 83.3 16.7 100.0

Normal

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A.D. Wuysang, O.N. Prawitasari, J. Tammasse et al. Medicina Clínica Práctica 4 (2021) 100214

Table 1 (Continued)

Characteristics PSQI Total p-Value

Good Poor

n 25 23 48
% 52.1 47.9 100.0

Overweight
n 5 9 14
% 35.7 64.3 100.0

Total
n 35 33 68
% 51.5 48.5 100.0

Table 2
Characteristic PSQI components.

PSQI Overall sleep quality Latency sleep Sleep duration Sleep efficiency Sleep disturbance Sleep medication use Daytime disfunction

Good
Mean 0.17 1.09 0.74 0.14 0.83 0.17 0.71
SD 0.38 0.89 0.85 0.36 0.38 0.45 0.86

Poor
Mean 1.00 3.30 1.76 1.18 1.24 0.82 2.42
SD 0.75 1.42 0.79 0.95 0.44 0.88 1.28

p-Value <0.001* <0.001* <0.001* <0.001* <0.001* <0.001* <0.001*

*
Mann–Whitney test.

Table 3
Relationship of PSQI and ISI.

PSQI Insomnia Total p-Value

No insomnia Mild insomnia Moderate insomnia Severe insomnia

Baik <0.001
n 35 0 0 0 35
% 87.5 0.0 0.0 0.0 51.5

Buruk
n 5 16 9 3 33
% 12.5 100.0 100.0 100.0 48.5

Jumlah
n 40 16 9 3 68
% 100.0 100.0 100.0 100.0 100.0

* Chi-Square test.

Table 4
Relationship of the degree of insomnia with QOLIE-31.

Insomnia QOLIE 31 Total p-Value

Good quality of life Poor quality of life

No insomnia <0.001
n 40 0 40
% 72.7 0.0 58.8

Mild insomnia
n 11 5 16
% 20.0 38.5 23.5

Moderate insomnia
n 4 5 9
% 7.3 38.5 13.2

Severe insomnia
n 0 3 3
% 0.0 23.1 4.4

Total
n 55 13 68
% 100.0 100.0 100.0

* Chi-Square test.

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A.D. Wuysang, O.N. Prawitasari, J. Tammasse et al. Medicina Clínica Práctica 4 (2021) 100214

Table 5
Relationship of PSQI and QOLIE-31.

PSQI QOLIE-31 Total p-Value

Good quality of life Poor quality of life

Good <0.001
n 35 0 35
% 63.6 0.0 51.5

Poor
n 20 13 33
% 36.4 100.0 48.5

Total
n 55 13 68
% 100.0 100.0 100.0

* Chi-Square test.

Table 6
Relationship of PSQI and QOLIE-31 components.

PSQI QOLIE31 Seizure worries Quality of life Emotional well-being Energy/Fatigue Cognitive Medications effect Social function

Good
Mean 69.45 13.92 11.00 10.77 8.14 34.16 4.35 16.23
SD 10.41 6.56 1.68 2.01 1.51 12.51 2.02 3.46

Poor
Mean 40.89 12.70 9.80 8.04 5.76 30.57 4.87 12.30
SD 6.18 6.57 6.34 2.31 1.78 14.60 2.27 3.71

p-Value 0.018** 0.256** <0.001** <0.001* <0.001* 0.261** 0.897** <0.001*

*
T independent test.
**
Mann–Whitney test.

did not include subjects with mental retardation. The most exten- Conclusion
sive distribution of treatment duration is less than ten years, with
most types of seizures frequent. The weight of our study subjects There is a difference in the overall quality of life of epilepsy
was mostly healthy. We did not include research subjects with patients with sleep disorders and without sleep disorders, where
BMI > 30 to avoid bias because obese patients often experience OSA the quality of life of epilepsy patients with sleep disorders is
(Table 5). worst. Besides, there are differences in emotions, fatigue, and social
Sleep quality of the subjects on PSQI has a relatively low cut-off function in epilepsy patients with sleep disorders and epilepsy
value, where subjects with a questionnaire value >5 out of a total patients without statistically significant sleep disorders. There are
score of 21 are said to have poor sleep quality. There is no further differences in seizure anxiety, cognition, and treatment effects in
explanation regarding the reduced level of sleep quality difference epilepsy patients with sleep disorders and epilepsy patients with-
between patients with PSQI > 5. There were no statistically signif- out sleep disorders, but not statistically significant.
icant differences in the characteristics of the study subjects such
as gender, age, level of education, occupation, and length of educa- Conflict of interest
tion, all of which gave a value of p > 0.05. Of all these characteristics,
only the sex showed the most difference, where sleep quality in The authors declare no conflict of interest.
male subjects was worse than in women, but it was not statisti- References
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