Tuesday, November 22, 2022

Parkinson’s Disease Sleeping All The Time

Long Naps And Parkinsons Risk Factor

Ask the Parkinson’s Expert: How Sleep Changes over Time with Davis Phinney

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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Increased Feelings Of Anxiety Or Depression

Anxiety and depression have been linked to Parkinsons. In addition to movement problems, the disease can also have an impact on your mental health. Its possible that changes in your emotional well-being can be a sign of changing physical health as well.

If you are more anxious than usual, have lost interest in things, or feel a sense of hopelessness, talk to your doctor.

Benefits Of Napping For Parkinson’s

Excessive daytime sleepiness , defined by the Davis Phinney Foundation for Parkinsons, is an inability to maintain wakefulness and alertness during the major waking episodes of the day that results in periods of irrepressible need for sleep or unintended lapses into drowsiness or sleep.1 In other words, EDS can be life-altering and disabling for people with PD.

Daytime napping, when planned and kept to a short period can be restorative for sleepy folks living with PD. It can also be helpful to take these naps before 3 pm, as they can provide an energizing second wind later in the day.

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Sleep Attacks And Medication Side Effects

In the last 10 years, the phenomena of sleep attacks in PD, defined as an event of falling asleep suddenly, unexpectedly and irresistibly while engaged in some activity have received a great deal of attention.

Compared to levodopa, the ergot agonists and non-ergot D2-D3 dopamine agonists show an increased risk of daytime sleepiness and episodes of unintended sleep . With the exception of a dose-related effect, levodopa is generally not sedating in PD or DLB . In a sample of 6,620 PD respondents to a questionnaire, 42.9% reported the sudden onset of sleep that was predicted by exposure to a non-ergot dopamine agonist . Factors contributing to sleepiness with dopamine agonists include older age, male gender, history of sleep problems, cognitive impairment, dysautonomia and an overall higher dopaminergic load . Unlike levodopa, the ergot and non-ergot dopamine agonists are more likely to aggravate cognitive impairment and may elicit or intensify hallucinations .

Polysomnography data reveal that sleep attacks are objectively characterized as intrusions of non-REM stage 1 and 2 sleep, and a subset are represented by microsleep episodes, which last 15-120 s . Whether sleep attacks are truly abrupt and occur in the absence of a history of sleep disturbance is a point of contention, particularly since patients often have reduced awareness of daytime sleepiness and microsleep episodes are often not perceived by patients .

Diagnosis Of Insomnia In Pd

Parkinsons Disease and Sleep Problems: Symptoms ...

In the diagnosis of insomnia in PD, the clinical history including the stages of insomnia and its associated factors are essential. For example, the factors associated with initial insomnia should be learned from the clinical history because the identification of factors associated with insomnia is necessary for the treatment plan. Table 2 shows the factors associated with insomnia . For example, for the diagnosis of RLS, as a reason for the difficulty of falling into sleep, clinical assessment is sufficient. Thus, patients should be asked for the features in the definition mentioned below for the diagnosis of RLS . In contrast to idiopathic RLS, family history of RLS is less frequent in PD . Polysomnography and actigraphy can be used to detect the objective findings of the insomnia . It has been reported that insomnias PSG findings may be an increase in the number of brief EEG arousalsor arousal index, number of stage shifts to stage 1 or wake, wake time after sleep onset , and percentage of stage 1 sleep . The actigraphic findings of insomnia include the presence of irregularity in sleep onset and increased number of awakening times during the night . One review has been reported that studies comparing PSG to actigraphy in insomnia show that PSG and actigraphy have no significant difference in showing the measurements of WASO, total sleep time , and sleep efficacy .

Factors

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Clinical Features Of Eds

Excessive daytime sleepiness is a chronic or episodic sleepiness seen throughout the day in PD patients . Anxiety and depression, cognitive dysfunction, changes in sleeping habits, changes in circadian rhythm, the side effects of medications that can produce sleep attacks such as dopamine agonists, and concomitant systemic diseases can cause sleepiness . Also these factors can cause fatigue . Studies have reported that EDS is very common in PD. Verbaan et al. found that compared to controls , 43% of PD patients had EDS. One study found that EDS was related to age and male gender . Also, other sleep disorders such as PLMS, and sleep fragmentation which cause the deterioration of night sleep quality may be the other causes of EDS .

Daytime Tips For Better Sleep

  • Wake up at the same time every day, using an alarm if you have to.
  • Get out of bed right after you wake up. Too much time spent in bed can lead to more waking at night.
  • Eat regular, healthy meals, and eat at the same time every day. Three to four small meals are better than 1-2 large meals.
  • Limit daytime napping to a 40-minute NASA nap . Too many or too-long naps can make sleep at night more difficult.
  • Do not drink coffee, tea, sodas, or cocoa after noon. They contain caffeine and can interfere with normal sleep.
  • Do not drink alcohol after dinner. It may help you fall asleep faster, but makes sleep shallower later in the night. Alcohol can also make snoring and sleep apnea worse.
  • Use caution when taking headache and cold medicines. Some contain stimulants that can affect sleep.
  • Stop smoking. Cigarette smoking stimulates the body and makes sleep difficult.
  • Increase or start doing daily exercise. Regular exercise helps to deepen sleep. Avoid heavy exercise 2 hours before bedtime.

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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.

What Types Of Sleep Problems Do People With Parkinsons Disease Have

Sleep Problems and Parkinson’s Disease

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.

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Diagnostic Assessment Of Sleep Disorders In Pd

The history taken from the patient and its neighbors is very important in assessing sleep disorders in PD. The type of sleep disorder should be identified in the history, and information about possible related factors should be obtained from the history. In PD, general and specific scales can be used to investigate the subtype of sleep disorder and to determine its severity. Objective methods can be used to further investigate the diagnosis of these disorders. Further investigative techniques include sleep recording methods such as actigraphy or PSG. Polysomnographic findings of each sleep disorder have been explained in the relevant section. In addition, information about screening scales used in each sleep disorder has been described in the relevant section.

Actigraphy is an electrophysiological device that measures the movements of the patient during sleep by recording from wrist or ankle for many days. Actigraphy evaluates indirectly the circadian sleepwake patterns . It is especially used in circadian rhythm disorders or insomnia and prolonged daytime sleepiness .

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 .

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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

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Memory Or Thinking Problems

How To Sleep Better With Parkinson

Having issues with thinking and processing things could mean your disease is progressing. Parkinsons is more than a movement disorder. The disease has a cognitive part as well, which means it can cause changes in the way your brain works.

During the final stage of the disease, some people may develop dementia or have hallucinations. However, hallucinations can also be a side effect of certain medications.

If you or your loved ones notice that youre getting unusually forgetful or easily confused, it might be a sign of advanced-stage Parkinsons.

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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.

Insomnia And Motor Symptoms Of Pd

Nocturnal motor symptoms of PD frequently contribute to insomnia and can occur in over 60% of patients . This includes symptoms of tremor, dystonia, akinesia, and restlessness. One study evaluated a cohort of 412 patients with PD, 209 of whom had trouble with initiation of sleep or fragmentation during the 5-year study . Motor fluctuations of tremor and rigidity were significantly associated with difficulty falling asleep, obtaining too little sleep and awakening too early in this study. Immobility in bed due to hypokinesia from PD has also been associated with an increased wake after sleep onset . One study evaluated nocturnal mobility in patients with PD by using an accelerometer and number of turnover movements in bed . Turnover movements were negatively correlated with increasing disease duration, levodopa equivalent daily dose, modified Hoehn and Yahr ratings, and UPDRS III scores . This would suggest that sleep dysfunction due to motor symptoms is not as prominent early in or with a less severe disease state.

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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:

How Does Parkinsons Disease Cause Sleep Problems

Sleep and Parkinson’s Disease

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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Sleep Problems At Later Stages Of Pd

In addition to the conditions already mentioned, during the later stages of PD, you also may experience sleep problems related to higher doses of medications, such as hallucinations.

As many as 33% of Parkinson’s patients during mid and later stages of the disorder experience hallucinations, related to medication side effects. Hallucinations tend to occur visually rather than hearing them . They are frequently associated with vivid dreams.

  • Cartwright, R. . Dreaming as a mood regulation system. In: Principles and Practice of Sleep medicine. 4th edition, pps 565-572.
  • Kumar, S., Bhatia, M., & Behari, M. . Sleep disorders in Parkinson’s disease. Mov Disord, 17, 775-781.
  • Larsen, J. P., & Tandberg, E. . Sleep disorders in patients with Parkinson’s disease: epidemiology and management. CNS Drugs, 15, 267-275.
  • Olson, E. J., Boeve, B. F., & Silber, M. H. . Rapid eye movement sleep behaviour disorder: demographic, clinical and laboratory findings in 93 cases. Brain, 123 , 331-339.
  • Pappert, E. J., Goetz, C. G., Niederman, F. G., Raman, R., & Leurgans, S. . Hallucinations, sleep fragmentation, and altered dream phenomena in Parkinson’s disease. Mov Disord, 14, 117-121.
  • Stacy, M. . Sleep disorders in Parkinson’s disease: epidemiology and management. Drugs Aging, 19, 733-739.

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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