Sleep Apnea And Parkinsons Disease
- Sleep Apnea and Parkinsons Disease
Connecting the dots for folks living with sleep apnea is to understand how to live the best quality of life possible. Managing your health and avoiding co-occurring conditions, or catching health issues early may minimize damage. Today I am looking at Parkinsons disease.
Parkinsons disease is caused due to the death of dopamine secreting neurons in the brain and the exact cause of this damage is still unknown. There is not just an association between Parkinsons and sleep apnea, but also the association exists between Parkinsons and other sleep disorders. Some research has had scientists arrive at the conclusion that sleep apnea is one of the possible risk factors of Parkinsons. It is no surprise there are some commonalities such as excessive daytime sleepiness, snoring and restless leg syndrome. One of the many side effects of Parkinsons is interrupted sleep and nighttime disturbances.
People with Parkinsons average about 5 hours sleep at night due to issues like insomnia, sleep fragmentation , bathroom trips along with the other physical issues.
Signs and symptoms of Parkinsons may include:
- Tremors, trembling of hands, arms, legs, jaw, and face
- Stiffness of the arms, legs, and trunk
- Slowness of movement
Getting Your Best Sleep With Parkinsons
This 1-hour webinar includes an interview of a person with Parkinsons disease, a movement disorders specialist, and a sleep sciences specialist. They discuss sleep disorders associated with Parkinsons disease, the difference between those that are a symptom the disease or a side-effect of medication, and how to treat them and live your best life with a sleep disorder.
How Does Parkinsons Disease Cause Sleep Problems
Researchers have yet to uncover every nuance of the Parkinsons and sleep connection. So far, medical experts believe several causes may contribute:
- Chemical changes in the brain: Ongoing research shows that Parkinsons disease may disrupt sleep-wake cycles. Changes to certain brain chemicals may cause people with Parkinsons to get less sleep.
- Medication: Some drugs that treat Parkinsons disease may make it harder to fall or stay asleep. A medication may also disrupt your sleep patterns by making you drowsy during the day .
- Mental health challenges: People with Parkinsons commonly deal with mood disorders, such as anxiety or depression. Any mood disorder may keep you up at night or make you sleep less soundly.
- Parkinsons symptoms: Pain, waking up at night to pee or other Parkinsons symptoms can make restful sleep harder to come by. Sleep apnea can also disrupt sleep.
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Determinants Of Eds In Pd
Levodopa equivalent dose, sleep-disordered breathing, wearing-off phenomena and REM sleep amount during polysomnography were linked to EDS in our study .
EDS and Neurodegeneration
The neurodegenerative process itself has been implicated in the pathophysiology of EDS in PD. Longer disease duration and association with UPDRS III and the HY stage have been reported. In our series, patients with advanced/severe PD did not differ from patients with light/beginning PD . However, patients with motor fluctuations a sign of advanced PD had significantly lower mean sleep latencies on MSLT. This may be related to the involvement, usually later in the course of PD, not only of the nigrostriatal dopaminergic system but also of extrastriatal dopaminergic and non-dopaminergic neurons in the lower brainstem and midbrain involved in sleep-wake regulation .
EDS and Treatment
EDS and Polysomnographic Findings
In our series, 3 polysomnographic parameters were linked to EDS.
Sleep latencies are markers of sleep propensity. Patients with shorter sleep latency at night also had shorter MSL during the day and higher ESS scores, as partially shown by others .
EDS and CSF Hypocretin-1 Levels
CSF hypocretin-1 level was measured in 3 of our patients and was in the normal range, confirming that EDS in PD may be severe even in the absence of a detectable hypocretin deficiency .
Potential Ways To Reduce Excessive Daytime Sleepiness
- Assess the underlying cause
- Improve nocturnal sleep through medications, cognitive behavioral therapy, diet, light therapy and more
- Evaluate all medicines being takensome have hypersomnia as a side effectand adjust as needed
- If taking dopaminergic medications, consider dose adjustment
- Watch consumption of alcohol or sleep-inducing foods/ingredients
- Experiment with caffeine
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S You Can Take To Reduce Fatigue
If you are feeling fatigued and exhausted all the time, what can you do about it?
First and most importantly, speak to your healthcare provider about how much the fatigue disturbs you. Does it undermine your daily activities? Does it make it more difficult to attend clinic visits or rehabilitation appointments? Does it feed into your emotional life? Does it undermine your coping ability? Once you speak to your practitioner about your fatigue, your medical professional might also recommend the following steps:
- Engage in regular physical exercise, including the use of weights to increase muscle strength. Studies show that physical exercise combats both physical and mental fatigue.
- Consider taking anti-depressant medication. Although fatigue is not caused by depression, depression can worsen fatigue . Treating depression if it is present might allow you to overcome fatigue with exercise or some other treatment.
- Consider trying stimulants like Ritalin , normally prescribed for attention deficit-hyperactivity disorder or Provigil , prescribed for sleep apnea, as an adjunct for depression and as a palliative treatment in end of life care. Some healthcare providers have reported that these drugs may help certain Parkinson’s patients.
When Should I Call My Healthcare Provider
Reach out to your provider if trouble sleeping harms your quality of life. Always call your healthcare provider if you experience symptoms that worry you, especially if they could put you or those around you in danger.
Sometimes, a sleep disturbance could be a sign of depression related to Parkinson’s disease. If youve lost interest in activities you once loved or feel numb to whats going on in your life, reach out to a provider you trust. Some people feel better after starting a new medication or talking to someone about what theyre feeling. You dont have to feel like this.
A note from Cleveland Clinic
Researchers continue to study the sleep-Parkinsons disease relationship. Understanding more about how Parkinsons affects sleep may lead to earlier detection of Parkinsons disease and more effective treatments. Even now, you have plenty of options to treat sleep problems. Be open with your provider about any sleep issues youre having. Together, you can find a plan that improves your sleep as well as any other challenges Parkinsons disease may create in your life.
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What Else Can I Do To Sleep Better With Parkinsons Disease
Practicing healthy sleep hygiene habits may also promote more restful sleep.
- Get outside during the day. Bright light tells your body its time to be awake.
- Keep your body moving during the day. Even if all you feel up to is a short walk or two, all physical activity offers benefits.
- Try at-home remedies, such as massage or a warm bath. Relaxing your mind may help your body fall asleep.
- Take long naps during the day.
- Use stimulants, such as caffeine, within six hours of bedtime.
- Use your bedroom for activities other than sleeping. Go to another room to read, watch TV or work.
Changes In Sleep With Aging
As people age, they experience a number of changes in their circadian rhythms, and among the most noticeable are the changes in the sleep-wake cycle. Older people tend to wake up earlier and go to bed earlier than they did when they were younger. They wake up more often during the night and have more difficulty going back to sleep than younger people. They also tend to sleep more during the daytime hours. Therefore, if one looks at total sleep time over the 24-hour day, the total time spent sleeping changes very little but the distribution of sleep may be quite different. Younger people experience a consolidated nighttime episode with little or no daytime sleep, whereas older individuals experience sleep episodes throughout the 24-hour day. Daytime sleepiness is affected by two major factors: the amount and quality of nighttime sleep, and the strength of the circadian rhythm. In addition, older people tend to have a reduced amount of N3 or deep slow wave sleep.
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On The Horizon: Drug Therapies For Treating Osa In Pd
Another option gaining favor is the use of sustained-release levodopa/carbidopa in people who have both PD and OSA.
This pharmacological approach uses this drug combination to improve the rigidity of the tissues of the upper airway, preventing their collapse while also improving their coordination with the muscles in the upper airways.
The recent FDA approval of the oral inhalation medication Inbrija, prescribed to treat OFF episodes in people with PD using a levodopa/carbidopa regimen, makes potential pharmaceutical relief an attractive option for those with both PD and OSA who dont respond well to or tolerate PAP therapy.
New Side Effect For Parkinson’s Drugs
The study appears in the August issue of the Archives of Neurology. Researchers interviewed 929 people with Parkinson’s disease and their doctors about their treatment and symptoms.
The results showed that more than one in five people with Parkinson’s disease reported at least one sleep attack in the last six months.
After taking account of factors such as age, sex, and duration of the disease, researchers found people treated with dopamine agonists were nearly three times as likely to report uncontrollable sleepiness as those taking other types of Parkinson’s disease drugs.
In addition, those taking one of the three dopamine agonists studied were twice as likely to experience sleep attacks as people taking levodopa alone.
No increased risk of uncontrollable sleepiness was found in association with any other drug used to treat Parkinson’s disease in this group.
Researchers say the results suggest that greater attention should be paid to the potentially dangerous side effect of this class of Parkinson’s disease drugs.
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Dreams And Parkinsons Disease
Nine in 10 people living with Parkinsons disease experience sleep disturbances, ranging from vivid dreams and nightmares to insomnia and daytime napping. Some of these problems can be alleviated through good sleep hygiene procedures, such as improving sleeping environment, maintaining a healthy diet and keeping a routine. Make sure to discuss these symptoms with a healthcare professional.
Visit the EPDAs Sleep Well campaign to find out more about sleep disturbance and Parkinsons disease.
A Phase Ii Crossover Study
To investigate this treatment further, Christian Baumann, MD, Senior Physician at University Hospital Zürich, and colleagues enrolled 18 patients into a double-blind, placebo-controlled, crossover phase IIa study. Eligible participants had Parkinsons disease and regularly took dopaminergic medication. People with sleep apnea, cognitive problems, or depression, and those who took hypnotics, were excluded from the study.
Christian Baumann, MD
The researchers randomized participants in equal groups to sodium oxybate or placebo. Study medications were taken daily at bedtime and 2.5 to four hours later for six weeks. Doses were titrated between 3 g/night and 9 g/night according to efficacy and tolerability. After a two- to four-week washout period, participants crossed over to the opposite treatment arm for six weeks.
The trials primary efficacy end point was treatment effect on mean sleep latency , as measured by the Multiple Sleep Latency Test . Secondary end points included change in subjective excessive daytime sleepiness , sleep quality, and objective sleep parameters. The investigators measured outcomes in the sleep laboratory at baseline and after six weeks of therapy.
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How Is Daytime Sleepiness Treated
Consider making certain lifestyle modifications, such as:
- Establish good sleep hygiene, including a set bedtime and wake-up time.
- Get exposure to adequate light during the day and darkness at night.
- Remember indoor lighting may not be sufficient to promote a normal circadian rhythm.
- Avoid sedentary activities during the day.
- Participate in activities outside the home. They may help provide stimulation to prevent daytime dozing.
- Get physical exercise appropriate to your level of functioning, which may also promote daytime wakefulness. Strenuous exercise, however, should be avoided six hours before sleep.
- Do NOT drive while sleepy if you experience excessive daytime sleepiness. Motor vehicle accidents increase during periods of drowsiness and may be associated with sudden onset of sleep .
- Talk to your doctor about possibly decreasing the dosage of dopamine agonists if you experience daytime sleepiness or sleep attacks.
- Talk to your doctor about decreasing stimulants like caffeine, modafinil and methylphenidate .
Trouble Staying Asleep Or Getting Restful Sleep
Some conditions, including Parkinsons disease, can interrupt sleep or make it less restful. Sleep fragmentation or interrupted sleep is one of the most common sleep complaints in Parkinsons patients. Poor sleep can lead to problems with attention and thinking, among other issues.
Several factors can lead to sleep interruptions in Parkinsons disease. These include the symptoms of the disease returning when medications wear off , frequent nighttime urination , hallucinations or altered dreams, and sleep apnea.
A large study of almost 3,200 patients found that sleep apnea was more common in people with Parkinsons than others.
Another study showed that women with sleep apnea may be at higher risk of getting Parkinsons disease.
Motor dysfunction of the laryngopharynx, the area where air and food pass through the throat, could also be involved in sleep apnea in Parkinsons disease patients, according to another study.
Sleep apnea can be treated with oral appliances or airway pressure devices such as a CPAP to keep the airways open. If these are unsuccessful, surgery might be an option.
REM sleep behavioral disorder, restless legs syndrome, and periodic limb movements in sleep are other issues that can lead to less restful or interrupted sleep. These disorders, which involve unwanted movements of the body, have a higher prevalence in Parkinsons patients and may have similar underlying causes.
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Parkinsons Sleep Problems: Diagnosis And Treatment
Parkinsons disease is chronic and progressive, meaning it tends to get worse over time. However, there are treatment options that can help manage symptoms and allow patients to get more restful sleep.
The simplest way to start sleeping better with Parkinsons disease is by adopting healthy sleep habits. Sleep hygiene tips for Parkinsons disease sufferers include:
- Sticking to regular bedtimes
- Following a consistent bedtime routine with soothing activities such as listening to music or reading a calming book
- Getting regular exercise, preferably early in the day
- Getting adequate exposure to light, whether outdoors or through light therapy
- Avoiding long naps and naps late in the day
- Creating a cool, dark, and comfortable sleeping environment
- Restricting bedtime activities to sex and sleep only
- Turning off screens an hour before bedtime
- Reducing liquid intake before bedtime
- Avoiding caffeine, alcohol, and tobacco
- Eating a healthy diet and avoiding large meals at night
Light therapy, exercise, and deep brain stimulation have been successfully used to improve overall sleep quality and to treat specific conditions, such as REM sleep behavior disorder, in patients with Parkinsons disease. Cognitive behavioral therapy for insomnia has proven effective at reducing insomnia in healthy adults, although further research is needed on the effects of CBT in patients with Parkinsons disease.
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What Treatment Options Exist For Those Experiencing Sleep Disturbance And Bad Dreams
Bad dreams are a perfectly normal occurrence and can be triggered by many factors, including stress, anxiety, sleep deprivation and medication. However, when bad and vivid dreams are accompanied by dream-enacting behaviour, people with Parkinsons can take some simple steps to minimise injury.
A safe sleeping environment is essential, so modifying sleeping arrangements should be the first step to treat REM behaviour disorders. Placing a mattress on the floor, padding corners of furniture, protecting windows and removing potentially dangerous objects from the bedroom are all simple and practical steps. Its also best to avoid alcohol intake, as this can trigger or aggravate RBD.
Two medications commonly prescribed to treat RBD are clonazepam and melatonin. Clonazepam should be used with caution in patients with dementia and gait disorders. Melatonin may have the advantage of fewer side effects and a longer-acting version, but in certain cases, only higher doses of melatonin will work.
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Sudden Onset Of Sleep And Eds
Sudden onset of sleep may warrant other measures, and those with high sleepiness scores should be advised to drive cautiously and not to drive alone or for long distances . Dopamine agonists when started should be titrated up slowly especially in older patients, and patients with excessive day-time sleepiness may respond to an alternative agonist. In patients with severe EDS, concurrent medications that may be sedating should be eliminated or reduced. Formal sleep studies may be required in some patients, and in those with a narcolepsy-like phenotype, modafinil may be useful. Modafinil, a sleepwake cycle activator, is non-stimulating and is the only drug which has shown efficacy in improving EDS without detrimental effect on PD when examined in double-blind placebo-controlled trials . A 7-week double-blind placebo crossover study of 200 mg modafinil followed by a 4-week open-label extension study by Adler et al. showed significant improvement in ESS with modafinil and improvement in clinical global impression scores for wakefulness in the open-label arm. Where EDS is thought to be secondary to the use of dopamine agonists, modafinil may allow the continuation of dopamine agonist therapy.
Figuring Out Causes Of Fatigue
The first step in easing the fatigue associated with Parkinsons disease is to rule out other causes of tiredness, says Liana Rosenthal, M.D., assistant professor of neurology at the Johns Hopkins University School of Medicine and director of clinical core at the Morris K. Udall Center Parkinsons Disease Research Center of Excellence. We evaluate patients to see if there are other things contributing to the fatigue besides their disease, she says.
Sometimes patients may be referred to a sleep specialist for an evaluation. That can help identify causes of tiredness, like sleep apnea. Rosenthal says: Our aim is to first treat any sleep issues, like insomnia, sleep apnea or other causes of poor sleep. Once we treat and address those issues, we can see if fatigue still persists.
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