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.
Rbd And Other Parasomnias
In patients with PD, beyond the well-known and peculiar occurrence of REM sleep behavior disorder , non-REM-sleep parasomnias and parasomnia overlap disorder have also been described.
Bassetti and co-workers systematically investigated the presence of sleepwalking in 165 consecutive PD patients. 3.6% reported adult-onset sleepwalking. In 4 out of 6 patients, RBD was detected on video-polysomnography . In another study, video-polysomnography was used to assess 30 patients with PD . Again, 8 out of 10 patients with a history of sleepwalking presented RBD on vPSG. Sleepwalking in this cohort was associated with depression, higher disease severity, and functional disability. Due to the frequent occurrence of overlap parasomnia, the authors suggested that a common underlying disturbance of motor control during sleep exists in PD .
The diagnostic criteria for RBD comprise repeated episodes of sleep-related vocalization and/or complex motor behaviors, and these behaviors need to be documented by PSG as occurring during REM sleep, or, based on a clinical history of dreaming, are presumed to occur during REM sleep. In addition, it is obligatory that polysomnographic recording demonstrates REM sleep without atonia . Other sleep-related movement disorders that are frequent in PD might produce similar symptoms mimicking RBD by history and need to be excluded.
How Are Sleep Problems Treated In People With Parkinsons Disease
Your provider will recommend treatments that address whats causing your sleeping challenges. Your provider may:
- Change your medication: If a medication could be causing your sleep issues, your provider may decide to adjust your treatment plan. Reducing the dose or switching medicines may solve the problem.
- Prescribe a new medication or therapy: If you have a sleep disorder, your provider will discuss your options. In some cases, your provider may recommend a new medication. If you have sleep apnea, wearing a special oral appliance can help. The device enables you to get a steady flow of oxygen, so your body doesnt gasp for air.
- Suggest lifestyle changes: Your daily habits and sleeping environment can help or hurt your sleep efforts. Setting regular sleep and wake times, keeping the room dark and avoiding electronic screens at bedtime may improve how well you sleep. If you have REM sleep disorder, your provider will discuss options for how best to protect you while you sleep.
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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.
Highlights From The Episode
In case you missed it, the August broadcast of Dr. Gilbert Hosts was a very informative conversation, and we encourage you to watch the full episode. For your convenience, weve listed the topics and questions from the episode below with timestamps, so you can skip to what may interest you most:
00:48 Introduction of Dr. Ospina
01:27 Dr. Ospinas presentation about sleep issues
23:37 My husband sleeps fairly well at night but sleeps a lot during the day. How do we get him to not sleep so much during the day?
25:19 My father has had much improvement in his sleep by taking CBD. What is your opinion on this?
27:20 Discussion of OFF time
31:23 Will Prozac affect my sleep? Is it better to take it in the morning or at lunch rather than at night?
32:48 Does deep brain stimulation help insomnia and sleep issues?
35:13 I wake up frequently with leg and foot cramps/dystonia. How should I treat this?
36:51 Is it OK to take Nyquil for insomnia? Melatonin? If so, how much melatonin should I take?
38:05 Could numbness in the feet be associated with restless leg syndrome?
39:36 Can you get accustomed to sleep medications whereby the medication is no longer effective?
40:40 What should I do if Im wide awake in the middle of the night? Should I try to be active and get something done, or should I try to stay in bed?
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Treatment Of Excessive Daytime Sleepiness In Pd
The first step in the treatment of EDS should be the correction of underlying conditions . For example, it may be useful to treat the conditions that disturb sleep quality at night or to arrange medications that cause daytime sleep episodes. After that, pharmacological treatment options for EDS should be considered. Nonpharmacological treatment approaches can be performed in the treatment of mild to moderate EDS cases . Modafinil is widely used for the symptomatic treatment of EDS, which appears to stimulate catecholamine production . Common side effects of modafinil are insomnia, headache, dry mouth, dizziness, nausea, nervousness, and depression . A review has reported that sodium oxybate and methylphenidate have inadequate evidence that they are effective in the treatment of EDS in PD . Amantadine and selegiline are reported to have an alerting effect . Thus, amantadine and selegiline may be preferentially used in PD patients with EDS.
The Need For An Instrument Such As The Pdss
Work from our own group and others indicates that the aetiology of nocturnal disabilities in Parkinsons disease is multifactorial and that nocturnal motor symptoms are of importance. Traditionally, sleep assessments in Parkinsons disease have taken the form of pure subjective questioning or, in some cases, measurement of sleep architecture. These techniques, however, do not provide a holistic assessment of the night time problems of sufferers from Parkinsons disease. It can be arguedgiven the importance of sleep function in this diseasethat assessment of night time problems requires a specific instrument similar to the UPDRS. The PDSS aims to provide this. Some currently available tools, including the ESS, only address single items such as excessive daytime sleepiness and are thus not comprehensive. In a study of excessive daytime sleepiness and its potential relation to sudden onset sleep in 638 patients with Parkinsons disease, Lang et al recently concluded that the ESS has poor sensitivity for predicting falling asleep while driving, and may not be appropriate for assessing susceptibility to unintended sleep episodes. Other studies have indicated that ESS scores do not correlate significantly with multiple sleep latency test scores, thought to be the gold standard for measuring sleep, and especially REM sleep latency during the daytime. Thus we feel the PDSS may offer a more practical and relevant way of assessing sleep disruption in Parkinsons disease.
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Why Do Parkinsons Patients Have Trouble Sleeping
Despite having daytime tremors, Parkinsons patients do not shake in their sleep. However, both Parkinsons disease itself and the medications used to treat it can give rise to a number of sleep problems that lead to insomnia and excessive daytime sleepiness.
Patients with motor symptoms may have trouble adjusting sleeping positions to get comfortable. Others may experience distressing nocturnal hallucinations when trying to fall asleep. These may be a result of medications or cognitive impairment.
In turn, excessive daytime sleepiness may occur as a consequence of sleeping poorly at night. It may also be triggered by medications. Parkinsons patients who suffer from EDS may be at a higher risk of accidents and unable to safely carry out activities such as operating a motor vehicle.
Since insomnia frequently goes hand-in-hand with anxiety and depression, it may be a contributing factor to sleep problems in people with Parkinsons disease. For that reason, doctors often look for mental health disorders in people with Parkinsons disease who have sleep problems.
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 .
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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 .
Spend Time Outside During The Day
Take advantage of the sunlight when its out in the daytime. Consider spending time outdoors for exercise. Simple walking or running can contribute to your daily exercise quota, but avoid heavy exercises and activities after 8:00 PM.
Your goal for spending time outdoors is to get enough light. You could invest in a light therapy box for artificial light if you have trouble going outdoors. Such tools are available at drug stores.
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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.
Neuropathology Of Rbd In Pd
There are a number of proposed explanations put forth by researchers to try and explain the cognitively impaired phenotype of PD that is linked to RBD. The first is that RBD affects sleep quality/content, which in turn could lead to cognitive dysfunction through various neuronal mechanisms. However, there is not much research support for this idea and there is a lack of association between different sleep disorders, such as insomnia, and cognitive decline in PD.
A reduction in grey matter volume and cortical thinning, especially in the frontal cortex and inferior parietal lobe of the brain, have also been proposed as the potential cause of PDRBD. Due to the link of cortical and subcortical brain regions in these areas with cognition and REM sleep. The left insular cortex in particular has shown much greater levels of cortical thinning in PDRBD compared to PD without RBD. An area of the brain considered an integrating hub of higher-level cognitive processes with social-emotional and sensorimotor functioning. However, there are a lot of inconsistent results within the literature surrounding differences in grey matter volume, and so alterations in brain matter volume are seen as a less reliable neurological marker.
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Diagnosis Of Insomnia In Pd
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 .
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Tips To Help You Sleep Better
As you work with your doctor to pinpoint and treat the cause of your sleep problem, practising good sleep hygiene may help you get a better nights sleep.
Keep a sleep diary or use technology to track your sleep. Important notes to record include the time you go to bed and get up, how many times you awaken during the night and why, and how many hours you sleep. Keep track of the caffeinated beverages you drink , if you nap and your exercise routine. These notes will help you to have a productive conversation with your doctor about your sleep.
Limit daytime naps. Sleeping too much during the day, especially late in the day will likely prevent you from sleeping well at night.
Avoid caffeine, alcohol and exercise later in the day. Caffeine consumed in the afternoon can keep you awake at night. Although alcohol may seem to help you fall asleep more easily, it may interrupt your sleep later in the night. Working out regularly earlier in the day can improve sleep overall but exercising too close to bedtime might make it harder to fall asleep.
Dont drink too much fluid before bed. This is especially important if you experience frequent nighttime urination.
Use the bedroom only for sleep and intimacy. Dont watch television, read, use your telephone or do anything other than sleep in bed. When you use your bed only for sleep, your body and mind will automatically know whats supposed to happen when you get into bed.
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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.
Sleep Disorders In Parkinson’s Disease
Issue title: Mental Dysfunction in Parkinson’s Disease
Article type: Review Article
Authors: Schrempf, Wiebke | Brandt, Moritz D. | Storch, Alexander | Reichmann, Heinz
Affiliations: Division of Neurodegenerative Diseases, Department of Neurology, Dresden University of Technology, Dresden, Germany | Department of Neurology, Dresden University of Technology, Dresden, Germany | German Center for Neurodegenerative Diseases , Research Site Dresden, Dresden, Germany
Note: Correspondence to: Wiebke Schrempf, MD, Division of Neurodegenerative Diseases, Department of Neurology, Dresden University of Technology, 01307 Dresden, Germany. Tel.: +49 351 458 3876 Fax: +49 351 458 5802 E-mail:
Keywords: Parkinson’s disease, non-motor symptoms, sleep, REM sleep behaviour disorder , restless legs syndrome , insomnia
DOI: 10.3233/JPD-130301
Journal: Journal of Parkinson’s Disease, vol. 4, no. 2, pp. 211-221, 2014
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Administration And Repeatability Of The Pdss
We found the scale easy to administer and to comprehend. It can be completed by patient or caregiver with occasional proxy, as is commonplace with most scales employed in chronic neurodegenerative disorders. There was high intrapatient and interpatient reliability. The time interval between the two administrations was relatively short to try to ensure stable conditions however, we do not feel that bias caused by remembering previous scores was likely to have been introduced. The visual analogue system is advantageous in this respect.
Rem Sleep Behavior Disorder With Parkinsons Disease Can Be A Nightmare
Acting out dreams could indicate REM sleep behavior disorder. What you should know about the symptoms, diagnosis and treatment.
Certain sleep disorders are common in people with Parkinsons disease.
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One of them REM sleep behavior disorder is a condition characterized by the acting out of dreams that are vivid, intense and violent. People have been known to yell or talk while asleep, carry on conversations or hit themselves or their bed partner. Even if physical damage does not occur, the condition can be frightening for the bed partner to witness.
REM behavior disorder does not necessarily disrupt the quality or quantity of sleep itself. But it is potentially harmful because of the physical movements involved.
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