Parkinson’s And Sleep Patterns

Why Sleep Disorders May Precede Parkinson’s And Alzheimer’s

When the bodys biological clock goes awry, insomnia and related disruptions may be an early sign of pending cognitive decline

Some people literally act out their dreams. Their bodies fail to undergo the normal paralysis that accompanies REM sleep, the stage most associated with dreaming. Their bodies may quake violently, pantomiming the scenes unfolding in their heads. This dream state often is a sign of larger health problems to come.

More than 80 percent of people with rapid eye movement sleep behavior disorder , as the condition is known, go on to develop certain neurodegenerative maladies such as Parkinsons disease, multiple system atrophy or dementia with Lewy bodies, studies have found. Autopsies of RBD patients have revealed that clumps of proteins deep in the brain, known asalpha-synuclein aggregates, congregate in the regions that regulate rapid eye movement sleep.

In a review published in Science last month, Erik Musiek and David Holtzman of Washington University School of Medicine in Saint Louis, discussed the evidence for a link between sleep and neurodegeneration and the mechanisms by which disruption of the bodily clocks may influence diseases of later life.

How To Take Action And Improve Your Sleep

Protect your bedroom. Avoid blue light , preserve your circadian rhythm and dont interfere with natural melatonin production. If you get anxious about not being able to sleep and you find yourself watching the clock, remove any visible clockfaces from view in the bedroom.

Prepare your sleeping area. Reduce light and noise, cool the temperature of your room and consider using a white noise machine or app to lull you to sleep.

Set a sleep schedule and develop a routine based on whats optimal for you. Make sure to follow a regular bedtime and wake-up time, even on the weekends, because consistent sleep patterns will help you in the long run.

Limit your daytime naps. If you do find yourself needing to nap, try to schedule it for 7-9 hours after youve woken up in the morning and limit it to 20-30 minutes so that you dont impede your sleep the next night.

Watch when and what you eat. Many people with Parkinsons have constipation and/or acid reflux , so tailoring your diet to avoid exacerbating those problems can also help you sleep. Avoid spicy or acidic foods, avoid too much protein and avoid sugary snacks or caffeine .

Limit your liquids. Be extra careful about consuming caffeine and alcohol, especially close to your bedtime. Caffeine competes with adenosine and therefore keeps you awake rather than letting you fall asleep. Alcohol, though it may put you to bed faster initially, actually ends up causing lower sleep quality and can make you wake up more often.

Develop A Bedtime Routine

Your bedtime routine should help you prepare for bed. So be sure to follow it every evening. Essential tasks that every bedtime routine must have include:

• Having a Light Snack: Eat only light snacks if you get hungry before bed. Heavy meals before going to bed are unhealthy and can result in weight gain. Also, avoid snacks that might contain stimulant ingredients like alcohol and caffeine.
• Taking a Warm Bath: Bathing in warm water before bed may improve sleep quality. However, be sure not to spend too much time in the bath as it may wake up your body.
• Go to the Toilet: Be sure to finish your business in the bathroom before bed. Minimize your liquid intake at least three hours before bedtime to help avoid nocturia.
• Brush Your Teeth: Brushing your teeth right before bed helps prevent dental problems, including cavities and decay. Although it is indirectly related to better sleep, having this step in a bedtime routine is helpful.

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Diagnosis And Treatment Of Parkinsons Sleep Problems

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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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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Sleep And Depression In Parkinson’s Disease

Depression is seen in approximately 40% of PD patients in the course of their disease. Most persons with depression, including PD patients, also will experience problems with sleep. In depression, sleep does not refresh you like it used to, or you wake up too early in the morning. Dreams for depressed people are different, too–they are rare and often depict a single image.

Nighttime Hallucinations Psychosis & Confusion

Nighttime hallucinations and confusion may result from any combination of cognitive impairment, dopaminergic medications, age and PD-related vision changes and lack of sleep. Psychosis may first appear after infection, trauma, surgery or prolonged hospitalization. Symptoms may range from a sensation that someone or something is standing at the side of or behind the person, to very detailed and often frightening visions. Delusions may occur as well.

Treating Parkinsons Psychosis

The first-line approach to treatment of PD psychosis involves simplification of the anti-PD medication regimen and adjusting dose timing , treating other sleep disturbances, providing a consistent and familiar sleep environment , and in more severe cases, the use of atypical antipsychotic drugs.

Most of the available anti-psychotics are always avoided in PD psychosis because they block dopamine receptors and can cause significant problems with movement. However, two anti-psychotic medications, quetiapine and clozapine, are sometimes used as they have less of an ability to worsen motor symptoms. However, data for the use of quetiapine is limited and clozapine requires the patient to undergo frequent blood draws to monitor blood counts. A newer medication pimavanserin, was approved by the FDA to treat PD psychosis. It has a different mechanism of action, and does not block the dopamine system, but rather the serotonin system, and therefore does not increase motor symptoms.

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Parkinson’s And Sleeping A Lot

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How Can I Reduce Time In Bed Awake

Reducing the amount of time you spend in bed awake can help strengthen or re-establish the triggers for sleepiness.

If you are not sleeping, it may be tempting to stay in bed until you fall asleep. And it may help in the short term, but its not effective in the long run.

As you spend longer in bed, sleep becomes more broken and restless, and the insomnia symptoms carry on.

Even if you dont think youre spending too much time in bed, there is no reason to stay in bed if youre not asleep.

Find out more about insomnia and other sleep issues you may experience.

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Sleep Disorder And Parkinson’s

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Rem Sleep Behavior Disorder And Parkinson’s

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Sleep: A Mind Guide To Parkinsons Disease

This 36-page booklet explains normal sleep patterns, the body clock, how much sleep we should get, challenges to sleeping well, tips for good sleep hygiene, and sleep in normal aging before discussing symptoms, diagnosis and treatment of sleep disorders, including insomnia, REM sleep behavior disorder, sleep apnea, restless leg syndrome, and daytime sleepiness.

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Circadian Rhythms And Sleep

The 24-hour day/night cycle is a rhythmic environmental time cue that affects almost all forms of life, most of which have an internal timekeeping mechanism to anticipate and adapt to geophysical time a so-called circadian clock. Androsthenes, an admiral who served under Alexander the Great, provided the earliest account of the circadian process, when he described diurnal leaf movements of the tamarind tree in the 4th century BC . However, rigorous scientific evidence for internal circadian clocks only began to emerge in the latter half of the 20th century.

While the circadian clock is strongly associated with the sleep-wake cycle, it has been increasingly implicated in a stunning array of other cellular, physiological and behavioral processes, ranging from hormone secretion and metabolism , to cardiovascular health , cancer susceptibility , and neurodegenerative disorders . The latter of these has attracted particular attention, and since the turn of the century researchers have increasingly elucidated undeniable ties between sleep, circadian rhythms and neuropathology.

Fig. 2

Whats The Relationship Between Parkinsons And Sleep

Parkinsons disease and sleep are connected in complex ways that not even scientists completely understand quite yet.

Sometimes, Parkinsons disease directly causes sleep problems. According to one study, sleep-related symptoms may be one of the earliest signs of Parkinsons disease. These signs may include things like thrashing while youre asleep.

Other factors can also play a role. One thing is clear: For many people with Parkinsons disease, a restful nights sleep can be hard to find.

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Circadian Rhythm Sleep Disorders

Circadian rhythm sleep disorders potentially influence daytime and nocturnal dysfunctions. It is common to find that PD patients go to bed and wake up very early therefore, a phase advance may occur . Advanced sleep phase is usually associated with older age and characterized by involuntary sleep and waking times that are generally more than 3 h earlier than usual sleep times. For patients with PD, both age-related changes and brain damage can provoke circadian rhythm sleep abnormalities. This relationship deserves more careful clarification, although it is complex. For instance, a slower absorption rate of levodopa during nighttime, possibly related to delayed gastric emptying, has been reported in PD patients . In agreement with this example, it has been documented that phase advance in PD is possibly influenced not only by age but also by dopaminergic therapy and disease severity . Given the complexity of this issue, an abnormal pattern of daily activities and associated comorbidities, such as depressive symptoms and daytime sleepiness, could also influence circadian rhythms . Thus, the analysis of this complex issue must take all of these variables into careful consideration.

Sleep Architecture In Healthy Adults

Sleep is divided into non-rapid eye movement sleep , and rapid eye movement sleep which alternate intermittently throughout the night . NREMS is further divided into 4 stages , where stages 3 and 4 are collectively known as Slow Wave Sleep .

A healthy adult falls asleep within 10 min and undergo a cyclic sequence of the five sleep stages, beginning with NREMS stage 1 advancing onto stage 2, followed by SWS and finally REMS. The individual then resumes back to NREMS , and the cycle recommences.

REMS and NREMS substitute throughout the night in an ultradian pattern every 85â100 min consisting of 3â5 cycles each night , where NREMS dictates the first half of the night mostly with SWS, whereas REMS and stage 2 NREMS abound in the latter half of the night .

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Hallucinations And Rem Sleep Disorders In Parkinson’s Disease

At timestamp 1:58 in this recording of Thrive: HAPS 2020 Caregiver Conference, you will find a one hour talk by neurologist Joohi Jimenez-Shahed, MD. In it she delves into what REM sleep behavior disorder is and is not, and the distinctions between hallucinations, delusions, and delirium. Managment options for RBD and hallucinations are included.

Somnolence And Excessive Daytime Sleepiness

Somnolence and EDS occur commonly in PD. Etiologies of somnolence in PD include reversal of the sleepwake cycle, the disease process itself, disrupted sleep due to a variety of motor and nonmotor causes, and the use of dopamine agonists and other antiparkinsonian medications. Several studies have found that dopamine agonists are more likely to cause somnolence than levodopa. The soporific effects of the commonly used dopamine agonists appear to be similar as assessed by Epworth Sleepiness Scale scores.36

EDS occurs in PD patients, and is usually associated with dopamine agonist use. EDS may occur with use of other PD medications, including levodopa/carbidopa. However, EDS as measured by the ESS does not always correspond to shortened sleep latency as quantified by the Multiple Sleep Latency Test .10 In addition, nocturnal sleep disturbance as measured by polysomnogram may not account for the severity of daytime sleepiness in PD patients with EDS.10

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Limit Lights In Your Room

Minimize your exposure to artificial lights when preparing for bed. Sleep in a cool, dark place. Avoid bright lights when sleeping. You could keep dim night lights if sleeping in complete darkness is uncomfortable.

Avoid watching television and using mobile devices before bed or lying in bed. These devices emit blue lights that could affect your sleeping habits.

Diagnosing And Treating Rbd

If you suspect that you or a loved one might have RBD, a movement disorder neurologist or a sleep physician should conduct an evaluation. The specialist might order a sleep study that would spot abnormal muscle movements during REM sleep. Hallucinations or waking up during a certain stage of sleep is different from REM sleep behavior disorder and might indicate a different condition.

If a diagnosis is confirmed, we recommend the following safety precautions:

• Lower the bed if possible to prevent falls.

• Pad the side rails if youre sleeping in a hospital bed.

• Pad the floor around the bed.

• Move nightstands away from the bed.

• Move the bed away from walls or windows.

• Sleep in separate beds or rooms if necessary .

• Use a sleeping bag with a zipper to restrict arm and leg movements.

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