Parkinson’s And Sleep Problems

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.

Pathophysiology Of Excessive Daytime Sleepiness In Pd

It has been reported that there are three main causes of sleepiness in PD deterioration of night sleep quality, neurodegeneration of sleepwake-related brain regions, as a result of disease pathology, and the side effects of antiparkinsonian medications . However, many of the abovementioned causes may be related to EDS. For this reason, it is necessary to consider these causes in the diagnosis and treatment of EDS.

Tips For Better Sleep

• Keep a regular sleep schedule go to bed at the same time and get up at the same time.
• Choose your bedtime based on when you want to get up. Plan to spend seven to eight hours a night in bed.
• Make a bedtime routine for example, snack, bath, tooth-brushing, toileting and follow it every evening.
• Spend time outdoors and exercise every day, in the morning if possible. Avoid exercise after 8:00 p.m.
• If you cant get outdoors, consider light therapy sitting or working near a light therapy box, available at drug stores and department stores.
• If you nap, try to do so at the same time every day, for no more than an hour, and not after 3:00 p.m.
• Sleep in a cool dark place and use the bed only for sleeping and sexual activity.
• Do not read or watch television in bed.
• Use satin sheets and pajamas to make moving in bed easier.
• Minimize drinking liquids for three hours before bedtime to avoid frequent nighttime urination.
• Go to the bathroom immediately before retiring.
• Place a commode next to the bed, to minimize the effort, and light to get up during the night.
• Avoid:
• Alcohol, caffeine and other stimulants such as nicotine
• Heavy late-night meals
• Heavy exercise within six hours of bedtime
• Thoughts or discussions before bedtime about topics that cause anxiety, anger or frustration
• Clock watching
• Screen time television, phones, tablets one or two hours before bed.

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Parkinsons Disease And Sleep

Reviewed by David Rye, MD, and Mark Mahowald, MD. Published by the National Sleep Foundation

This web article offers a detailed description of Parkinsons disease and the challenges it presents to restorative rest and recuperation. Some suggestions are included for improving sleep and the environment around sleeping.

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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Conflict Of Interest Statement

GL received honoraria for participation in clinical trial as sub-investigator from UCB Pharma PC received honoraria for speaking engagements or consulting activities from Allergan Italia, Lundbeck Italy, UCB Pharma S.p.A, Chiesi Farmaceutici, AbbVie srl, Eli Lilly and Company, Zambon FP received honoraria for speaking engagements or consulting activities from Sanofi and Bial. The other authors declare no conflict of interest.

Evaluation Of Sleep Hygiene Program: Sleep Diary

Monitoring the effectiveness of behavior changes is best done by keeping a diary. The table below depicts a sample diary that could be kept by the bedside and filled out upon arising by the patient or caregiver. If daytime sleepiness and napping are problems, items can be added to record the number, time, and duration of napping episode. The diary can be carried with the patient.

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Insomnia And Daytime Sleepiness In Patients With Parkinsons Disease

As outlined above, patients with PD frequently experience insomnia, most often as a disorder of sleep maintenance, but also as a disorder of sleep onset or early morning awakening. The diagnosis of insomnia is always based on subjective symptoms. Patients report difficulties falling asleep or maintaining sleep, early awakening or non-restorative sleep, associated with subjective concern or daytime impairment . Notably, there is sometimes a discrepancy between subjective complaints of insomnia and only subtle disturbances of sleep structure in otherwise healthy people, whereas in patients with PD, in addition to the subjective complaints of insomnia, there is often a significant manifest disruption of the integrity of sleep macro and microstructure.

Joy and co-workers evaluated newly diagnosed levodopa-naïve patients with PD and reported frequent and variable alteration of sleep macro-architecture in these patients . However, Ferreira and co-workers reported poor sleep quality and sleep architecture changes in PD patients, which improved with levodopa following improvement of motor symptoms , but dopamine did not reverse sleep architecture changes .

Strategies That Improve Wakefulness During The Day

Non-pharmacologic interventions for EDS

• Encourage daily exercise and activities a person without an activity planned is much more likely to doze than one who is engaged in an activity. Be realistic about scheduling a person with advanced PD, but aim for at least one scheduled activity a day
• Light therapy Light therapy, in which a person is exposed to bright light via a light box, is used as a treatment modality for sleep disorders and psychiatric disorders not associated with PD. A small clinical trial testing its efficacy in PD was conducted and demonstrated an improvement in sleep and in excessive daytime sleepiness.

Pharmacologic interventions for EDS

There are no FDA approved medications for EDS in the context of PD. However, clinicians sometimes prescribe medication off-label for EDS. These include modafinil, methylphenidate, and caffeine. Istradefylline is a medication approved to treat motor symptoms of PD. A small trial demonstrated its potential improvement of EDS as well. Talk with your physician about the possibility of using a medication to maintain wakefulness during the day.

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Causes Not Related To Parkinsons

There are a number of other causes of sleep problems that are not related to Parkinsons, such as pain not connected to Parkinsons or sleep apnea. People with sleep apnea experience frequent interruptions in their breathing as they sleep, which can further fragment sleep and cause low levels of oxygen in the blood.

Finally, simply failing to prepare the bedroom for rest by minimizing outside light and activities as well as reducing noise can have a major impact on sleep quality. Exercising too late in the afternoon or evening can sometimes make it difficult to fall asleep. Similarly, drinking too many liquids, especially alcohol or caffeine, can interfere with sleep at night.

Good Night: Sleep And Parkinsons Disease

Lack of good sleep can worsen Parkinsons symptoms. In this 45-minute lecture, Dr. Rafael Zuzuárregui addresses causes of sleep loss and the latest treatments for: insomnia, restless leg syndrome, REM sleep behavior disorder, nocturnal urination, hallucinations, wearing off of medication, dystonia and sleep apnea.

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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.

Sleep Disorders In Parkinson’s Disease By Amer G Aboukasm

Although the daytime clinical manifestation of Parkinson’s disease have been well recognized for almost two centuries, the nocturnal symptoms, which occur in as many as 75% of patients and the associated sleep disorders were not studied until the 1960s. A variety of psychological and physiological processes can lead to disruption of the normal rhythm of the sleep-wake cycle in patients with Parkinsonism. First, the degenerative process in Parkinson’s disease affects the neurophysiological and neurochemical systems responsible for sleep organization, thus results in disruption of sleep. Second, the motor, respiratory and behavioral phenomena accompanying the disease may produce nocturnal symptoms. Third, the medication used in its treatment may induce new symptoms, such as nightmares or nocturnal movements. All these effects on sleep have implications for treatment planning.

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Sleep Tips From Survey Respondents

• Exercise helps me go to sleep, say more than an hour of brisk walking or an hour at the gym.
• Bedtime routine I find a bedtime routine helps most with getting to sleep. I dont go to bed too early, and must read for a while before trying to settle down.
• Specialised beds and bedding I have a silky sheet underneath me which helps me to turn over. I also have some bars which stop me falling out of bed.

You might be interested in reading more information and advice on sleep and early morning off on the following page of the Parkinsons UK website parkinsons.org.uk/information-and-support/sleep-and-parkinsons

Beating The Lockdown Blues

Did you knowBodily functions are heavily influenced by biological clocks which are distributed throughout your body . Your clocks primary role is timing and orchestrating your bodys everyday vital functions and aligning these to geophysical and social schedules. Disruptions to your daily routine derail your clock which reflects negatively on your mood, energy, sleep, digestion, heart and immune system, just to name a few!

With COVID-19-related lockdowns causing unanticipated disruptions to our routine, Researchers at the University of Queensland have developed some guidelines to stay on a schedule to improve sleep and support your health and wellbeing.

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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.

The Different Stages Of Sleep

• Rapid eye movement sleep
• Non-rapid eye movement sleep

The lightest stage of sleep is NREM, after which comes deeper sleep states. As people move back through to the lighter stages, they enter the REM state. If awoken during REM sleep, the sleeper will often report a dream.

• Requip

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United Towards Better Treatments

Researchers from a biotech company, Clexio, are dedicated to developing new drugs and novel treatments for neurological conditions. They are in the process of developing a potential new treatment that aims to help with sleep problems and early morning off in Parkinsons. They wanted to understand more about these issues from the perspective of people with Parkinsons to ensure their research is aligned with the needs of the Parkinsons community.

With the help of our involvement team at Parkinsons UK, the researchers put together a survey to help capture peoples experiences. The survey was reviewed by two groups of dedicated Parkinsons UK volunteers before being shared with people with Parkinsons.

Dr. Elijahu Berkovich, Head of Emerging Science and Innovation at Clexio, shares what they wanted to achieve through the survey –

We really wanted to understand from the perspective of people living with Parkinsons how sleep problems impact their daily lives and what the unmet needs are in terms of treatment options.

Alongside this we want to use the insights from the survey to help people affected by Parkinsons and healthcare professionals to understand the importance of treating these symptoms.

Working with Parkinsons UK has enabled us to get an insight into what people with Parkinsons want and need from future treatments.

Sleep Problems In Pd Patients

The overall mean total PDSS score was 102.8 , and 17% of the patients had a total PDSS score under 82. A more detailed examination of the PDSS sub-scales and proportion of patients scoring below 5 are shown in Table ). In total, 70% had a total score under 5 on one or more items of the PDSS. There were no significant differences in Hoehn and Yahr stage 12 vs 34 for any of the PDSS items.

Table 1 Sleep problems, by PDSS items, for 176 patients with Parkinsons disease

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Clinical Features Of Insomnia

Insomnia is defined as difficulties initiating sleep , sleep maintenance problem or early awakening . In studies, it has been reported that the frequency of insomnia in patients with PD varies from 27 to 80% . It has been reported that the most common types of insomnia in PD patients are sleep fragmentation , and early awakenings . It has been reported that insomnia may occur alone or accompany comorbid mental or systemic illnesses, and it is associated with disease duration and female gender . Sleep fragmentation is defined as a deterioration of sleep integrity , and it leads to a lighter sleep or wakefulness . In studies, it has been reported that sleep fragmentation is the most common sleep disorder in patients with PD .

Sleep Benefit And Positive Effect Of Sleep Deprivation In Patients With Pd

The complex interaction of sleep and motor function is reflected in two interesting phenomena: sleep benefit, i.e. the experience of an improvement of motor function upon awakening , and a positive effect of sleep deprivation on motor function .

Sleep benefit was first described based on patients reports, and systematically evaluated in large cohorts of patients with PD with contrasting results. Some groups reported this phenomenon to be common in a subgroup of PD patients with specific clinical characteristics, e.g. with longer disease duration and younger age at onset of disease . This phenomenon has been reported to be so relevant to allow PD patients with sleep benefit to skip or delay medication . A study systematic evaluating motor state a night before sleep and in the morning upon awakening reported a slight motor improvement in the morning in patients with sleep benefit, without polysomnographic differences between the two groups . Another study using PSG reported shorter total sleep times and longer sleep latencies in PD patients reporting sleep benefit .

However, other groups found no actual improvement in motor functioning in PD patients reporting sleep benefit , or only in a small percentage of them , or reported in those patients with PD experiencing sleep benefit no association with the previously reported clinical variables , maybe because of methodological issues.

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Possible Causes Of Excessive Daytime Sleepiness:

• Poor nighttime sleep all the sleep disorders and PD symptoms that interfere with sleep that were mentioned above can lead to non-restorative sleep at night. This can in turn lead to an overwhelming urge to sleep during the day
• Medication side effect
• Neurodegeneration in the areas of the brainstem that are responsible for maintaining wakefulness
• Neurodegeneration may also occur in the area of the brain that controls circadian rhythms a system of regulation of the sleep-wake cycle and any other process, including hormonal release and body temperature fluctuations, that varies according to the 24-hour clock. If the circadian rhythm mechanism is impaired, the sleep-wake cycle may be interrupted. In its most extreme form, people with advanced PD may have a complete reversal of their day and night.

Treatment for EDS: a two-pronged approach:

• Improving nighttime sleep as much as possible
• Trying strategies that improve wakefulness during the day

Assessment Of Sleep Disturbances In Patients With Pd

In general, a comprehensive sleep history is often a very useful first step to narrow down the type of sleep disorders in patients with PD. It should start with the time when the patient goes to bed and gets up and also include planned daytime naps. It should involve the perceived sleep latency, perceived awakenings . The Epworth sleepiness scale or other scales can be used .

Specifically, the evaluation of insomnia should rule out sleep hygiene or circadian disorders. Patients should be questioned specifically about the presence of impulse control disorders and nighttime activities, particularly in case of suspected circadian rhythm disturbances. If a circadian disorder, such as delayed or advanced sleep phase syndrome or non-24-h sleepwake disorder is suspected, assessments with actigraphy or dim light melatonin onset may prove useful .

For patients with prominent daytime sleepiness, polysomnography should be used in every case , but a multiple sleep latency test is also warranted .

Respiration questioning should at least include snoring and witness apneas, positional dependence, breathing pauses, intensity of snoring, nocturnal hypertranspiration or nocturia. In specific cases stridor should also be assessed. If underlying sleep disordered breathing is suspected, cardiorespiratory polygraphy or polysomnography should be performed .

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