Excessive Sleepiness In Parkinson’s Disease

Sleep And Parkinsons Disease

There are many sleep disorders that are associated with PD and that can be problematic throughout the disease course. These include:

• Rapid eye movement behavior sleep disorder a sleep disorder in which the affected person is not paralyzed during dreaming and can therefore act out his/her dreams
• Insomnia an inability to fall asleep at the beginning of the night or in the middle of the night upon awakening
• Restless leg syndrome uncomfortable sensations, usually in the legs, which are temporarily relieved by movement of the legs
• Sleep apnea a disorder in which breathing stops and starts through the night, leading to periods of low oxygenation in the blood and frequent awakenings
• Sleep fragmentation brief arousals during sleep cause sleep to be less restful

PD medications can interfere with sleep by causing:

• Nightmares and vivid dreams

Finally, there are motor and non-motor symptoms of PD that interfere with sleep. These include:

In addition to all the sleep issues listed above, people with PD often have fatigue, a complicated non-motor symptom of PD, characterized by a general lack of energy, which is sometimes present even in the face of what seems like intact and restful sleep. This can be due to many causes including PD medications, but can also be independent of medication use.

What Types Of Sleep Problems Do People With Parkinsons Disease Have

Parkinsons disease affects every person differently. It also impacts sleep in different ways. People with Parkinsons may have:

• Insomnia, finding it hard to fall asleep.
• Fragmented sleep, waking up many times over the night.
• Excessive daytime sleepiness, finding it hard to stay awake during the day.
• Very vivid dreams, which may cause hallucinations or confusion after waking up.
• Emotional dreams or nightmares, which may make you feel emotionally drained after waking up.

The Critical Difference Between Sleepiness And Fatigue

Fatigue is a physical or psychological feeling where people feel weary and exhausted and lacking energy. EDS is about needing and having the urge to sleep.

Fatigue is something that people can experience along with EDS however, people who experience fatigue on its ownthe feeling of being tired and out of energy do not also necessarily fall asleep when sedentary, as people who experience EDS often do.

It is estimated that EDS affects up to 50% to 75% of people living with Parkinsons and fatigue is estimated to affect 40% to 60%. Fatigue, however, is more likely to go undiagnosed.

Because the terms fatigue and sleepiness are so heavily linked, and sometimes used interchangeably, research has concluded that fatigue and EDS should be assessed separately in people with Parkinsons so that we can improve our understanding of their overlapping physiology.

With that knowledge, researchers from the University Hospital of Zurich, Switzerland designed a study to determine the overlap between fatigue and EDS and then associate them with other motor and non-motor symptoms as well as dopaminergic medication.

In their study of 88 outpatients, the researchers found that 72% experienced fatigue or EDS and just under half experienced both. Some of the key findings of the study include:

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Assessment Of Impact Of Nocturnal Symptoms On Excessive Daytime Sleepiness

To investigate the impact of nocturnal disabilities on excessive daytime sleepiness, the ESS was administered to the Parkinsons disease group, and 103 patients completed the scale satisfactorily during the same visit as the PDSS , 37 women mean age 66.9 years mean duration of disease 5.6 years mean Hoehn and Yahr score 2.7 ).

Treatment For Rem Sleep Disorder

Consider making environmental adjustments to protect the person with RBD and bed partner from injury. This may include padding the floor, creating a barrier between bed partners, or sleeping in separate beds or rooms.

Talk to your doctor about the over-the-counter sleep aid melatonin. Doses up to 12 mg one hour before bedtime can improve RBD symptoms.

Clonazepam has been shown in large case series to improve RBD in 80 to 90% of cases. It is often used when melatonin is not effective. The dose of clonazepam required is low, usually from 0.5 mg to 1.0 mg. The adverse effects of clonazepam include nocturnal confusion, daytime sedation and exacerbation of obstructive sleep apnea, if present.

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How Can Excessive Daytime Sleepiness Be Managed

If you experience daytime sleepiness, its important to speak to your specialist or Parkinsons nurse.

One way of managing it is to reduce the amount of medication you are taking that may be causing the symptom. But that may mean your Parkinsons symptoms arent as well controlled.

For mild to moderate excessive daytime sleepiness, things that can help include:

• regular, daily physical activity, such as walking
• taking a short daytime nap
• playing board games or electronic games when you begin to feel tired
• eating healthy food and avoiding alcohol

At night, good sleep hygiene can be helpful having a good nights sleep can help reduce feeling tired during the day. Sleep hygiene rules include keeping to a regular routine and reducing noise and light in your bedroom.

How Is Sleep Apnea Treated

A continuous positive airway pressure machine, a machine that blows air into your airway at a pressure that is sufficient to keep the airway open during sleep, is the most consistently effective treatment for obstructive sleep apnea. The CPAP machine is connected by a tube to a face mask worn when sleeping through the night. It controls pressure in ones throat to prevent the walls of the throat from collapsing, creating better sleep quality. CPAP should be worn for the entire night and for naps.

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Risk Factors Of Eds In Pd

To date, longitudinal studies on PD have identified several risk factors of EDS, including age, gender, disease duration and severity, some nonmotor and motor symptoms, antiparkinsonian medications and nighttime sleep problems.51,52

Gender and Age

In PD patients, men appeared to experience more and severer EDS than women, and the proportion of men with EDS was significantly higher than that of men without EDS, pointing to the gender male as a risk factor for EDS in PD.53,54 In addition, extensive research revealed that patients with EDS were older than those without EDS, suggesting that aging might play another important role in the EDS development.53,55

However, it remains unclear whether obstructive sleep apnea plays a role in the relationship of higher risk of EDS with male sex and older age in PD. As reported, OSA was common in PD patients with a prevalence of 28% and elderly men had the greater likelihood of suffering from OSA.56 Besides, OSA has been associated with severe EDS in PD patients. Similarly, another study found that PD patients with high risk of OSA had significantly higher ESS scores, compared to those with low risk of OSA.57 Therefore, the independent association of higher risk of EDS with male sex and older age in PD needs to be further clarified considering the confounding effect of OSA.

Disease Severity

Disease Duration

Solutions For Daytime Sleepiness

The Michael J. Fox foundation offers some simple solutions in sleep hygiene that may help improve nighttime sleep, which by default can help prevent daytime sleepiness:4

• Plan your daytime naps, and limit them to less than 30 minutes. Longer and later naps disrupt circadian rhythms and make it harder to fall asleep at night.
• Stick to a bedtime routine that includes sleep-friendly activities that help you relax, and maintain a consistent bedtime and wake time, even on the weekends.
• Avoid blue spectrum light exposure at night by turning off computers and handheld electronic devices an hour before bedtime. The light emitted from these screens suppresses the melatonin production in the brain which is necessary to help the brain and body transition to sleep.
• Try not to drink too much fluid before bedtime to prevent the need for nighttime trips to the bathroom.
• Avoid caffeine after lunch and alcohol at bedtime. Both will disrupt your ability to fall asleep and stay asleep.
• Daytime exercise can help the circadian system stay on track and usually leads to better sleep at night.

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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 .

Comparison Of Eds In Pd Population And Other Populations

EDS not only occurs in PD patients, but also in patients with other neurological disorders, as well as the general population. A follow-up study showed that in PD, Alzheimers disease and age-matched controls, the prevalence of subjective EDS at baseline were 41%, 18% and 10%, respectively.37 Several controlled studies found that 33.544% of PD patients suffered from subjective sleepiness compared to 16% of general population .17,47 In addition, higher mean ESS scores were reported in PD patients compared to healthy controls and AD patients.37,46 Similarly, a meta-analysis revealed that the prevalence and mean ESS scores of patients with essential tremor were significantly lower than those of PD patients, highlighting daytime sleepiness in PD subjects.48

There are comparisons on the presence of EDS in PD and other -synucleinopathies including multiple system atrophy and dementia with Lewy Bodies . A study revealed that subjective EDS was in 29% of PD patients and 28% of MSA patients compared to 2% of controls. Likewise, mean ESS scores in PD and multiple system atrophy were equally higher than those in controls.49 Another comparative study showed that 43.8% of PD patients and 61.5% of MSA patients had subjective EDS.50 Boddy et al found that subjective daytime sleepiness was also prevalent in DLB patients and PD patients with dementia with the prevalence rate of 50% and 57%, respectively, which was higher than that of PD patients without dementia.37

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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.

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.

Dont:

• 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.

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Nonpharmacologic Therapies For Excessive Daytime Sleepiness

Because drug therapies have the potential for adverse side effects, nonpharmacologic treatment approaches offer a promising alternative for preventing and managing EDS in PD.

Cognitive behavioral therapy

Cognitive behavioral therapy for insomnia is extensively used to treat insomnia in non-PD populations. It consists of behavioral and psychological approaches to teaching patients how to change their dysfunctional behaviors and thinking patterns. One small study found that the Insomnia Severity Index, PD Sleep Scale, and examiner-reported clinical global impression improved in PD patients who received CBT-I combined with light therapy. Therefore, in accordance with CBT-I, clinicians could recommend that patients strictly follow sleep hygiene rules such as having regular nap times and daytime physical activity and avoiding vigorous physical activity 34 h before sleeping. Efficacy conclusion for CBT is under investigation. CBT-I is simple to administer, but there remains insufficient evidence for its effective management of EDS in PD patients.

Light therapy

Repetitive transcranial magnetic stimulation

Long Naps And Parkinson’s Risk Factor

Research published in Innovation in Aging in 2017 looked at unplanned naps among people aged 65 or older and found that almost 60 percent of those surveyed took unplanned naps. Almost 20 percent of the same baseline population took long naps of more than 1 hour. Both groups napping behaviors were associated with poorer self-reported health and a higher number of chronic conditions.2

Some research also points to naps as being associated with a higher risk for developing PD among older men.3 The International Journal of Epidemiology published a study that found that men who napped at least an hour every day were more likely to develop PD. Fortunately, it appears that napping for 30 minutes or less did not result in the same risk factors for PD.

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Can Medication Treat Excessive Daytime Sleepiness

In some people, drug treatments may be an option. The drug Modafinil is used to treat daytime sleepiness, but it remains controversial. There is little evidence that it works for the symptom and the medication does have significant side effects. More research is needed and other drugs are also being considered.

Drinking tea and coffee, which contain caffeine, during the day is often recommended, but again, there is little evidence that it works.

Andrew was diagnosed with Parkinsons in October 2019. He began experiencing excessive daytime sleepiness after he was prescribed ropinirole, a dopamine agonist.

I had been taking levodopa 3 times a day since I was diagnosed without too many side effects. After 6 months, my Parkinsons nurse prescribed ropinirole that I took in addition to my levodopa.

My goodness the side effects hit me hard. Within 30 minutes of taking the drug, I began to feel nauseous, then had an overwhelming desire to yawn and needed to sleep. If I didnt eat something before taking my medication, I would spiral into drowsiness and experience a tightening of my chest.

I spoke to my Parkinsons nurse about these side effects and she instead gave me Repinex XL, a slow release dopamine agonist. My reactions to this medication were different, however I still had issues with fatigue. During a follow-up appointment, I was advised to take both doses before I went to bed, rather than 1 in the morning and 1 in the evening.

Talk To Your Doctor About Sleep

Here are some questions to ask yourself:

Are short, planned daytime naps useless against your EDS?

Do you take short naps that last longer than you intended?

Do you practice good sleep hygiene and still struggle with nighttime sleep problems and EDS?

If so, this might be a good time to approach a neurologist with your concerns. You might have a medication side effect to address, a hidden sleep disorder, or other health condition that needs treatment.

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How Are Sleep Problems Diagnosed In People With Parkinsons Disease

If youre having problems sleeping, sit down with your healthcare provider to discuss the issue in detail. Your provider will ask you questions to better understand your symptoms.

Be prepared to explain when sleep disruptions happen and how they affect your life. Keeping a sleep journal for a few weeks can help you remember the details.

If your provider suspects you may have a sleep disorder, they may recommend you have a sleep study. This overnight test uses electrodes attached to your skin to track how your body functions when youre sleeping.

The Relationship Between Parkinsons Disease And Sleep

Its unclear whether poor sleep causes parkinsonian symptoms to worsen or whether worsening parkinsonian symptoms cause poor sleep. In many cases its likely a case of bidirectionality, with each one exacerbating the other.

Fragmented sleep and sleep deprivation appear to leave the brain more vulnerable to oxidative stress, which has been tied to the development of Parkinsons disease. Parkinsons disease is not usually diagnosed until individuals have developed sufficient motor symptoms, by which time a significant portion of brain cells have already been damaged. If poor sleep quality or having sleep disorders foreshadows the development of parkinsonian symptoms, these could be useful in early diagnosis of the disease.

More research is needed to clarify the multifaceted relationship between Parkinsons disease and sleep. A better understanding of this connection may offer medical experts the unique opportunity to screen at-risk individuals and perhaps delay the onset of the disease.

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