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.
Multiple Sleep Latency Test
Each subject underwent four or five 20-minute opportunities to sleep at 2 hour intervals. For each nap, the subject was allowed 20 minutes to fall asleep. The time taken to fall asleep was measured, and the average of all naps taken to obtain the mean sleep latency. After falling asleep, the subject would be awoken after 15 minutes.
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.
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When Should I Call My Healthcare Provider
Reach out to your provider if trouble sleeping harms your quality of life. Always call your healthcare provider if you experience symptoms that worry you, especially if they could put you or those around you in danger.
Sometimes, a sleep disturbance could be a sign of depression related to Parkinson’s disease. If youve lost interest in activities you once loved or feel numb to whats going on in your life, reach out to a provider you trust. Some people feel better after starting a new medication or talking to someone about what theyre feeling. You dont have to feel like this.
A note from Cleveland Clinic
Researchers continue to study the sleep-Parkinsons disease relationship. Understanding more about how Parkinsons affects sleep may lead to earlier detection of Parkinsons disease and more effective treatments. Even now, you have plenty of options to treat sleep problems. Be open with your provider about any sleep issues youre having. Together, you can find a plan that improves your sleep as well as any other challenges Parkinsons disease may create in your life.
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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Sleep Disturbances In Parkinson’s Disease
In general, research seems to indicate that people with Parkinson’s disease have more sleep disruptions than similarly aged people without the disease. The most commonly reported sleep-related problems are the inability to sleep through the night and difficulty returning to sleep after awakening, generally referred to as maintenance insomnia. Unlike many older adults, patients with Parkinsons disease often find that they have no trouble initiating sleep, but often wake up within a few hours and find sleeping through the rest of the night to be difficult. People with Parkinson’s disease also report daytime sleepiness, nightmares, vivid dreams, nighttime vocalizations, leg movements/jerking while asleep, restless legs syndrome, inability to or difficulty turning over in bed, and awakenings to go to the bathroom.
Although all the reasons for these sleep changes are unknown, potential explanations include reactions to/side effects of medications and awakening due to symptoms such as pain, stiffness, urinary frequency, tremor, dyskinesia, depression and/or disease effects on the internal clock.
Diagnosis Of Rbd In Pd
The diagnosis of RBD can be based on a questionnaire or clinical manifestations without confirmation by polysomnography .Therefore, a detailed history of complex motor behaviors and vocalizations during REM sleep is very important for a clinical diagnosis of RBD. However, for the objective diagnosis of RBD, complex motor behaviors during REM sleep and the presence of REM sleep without atonia should be confirmed by PSG . Additionally, this sleep disturbance should not be better explained by another disorder . PSG can detect increased chin muscle tone by the submental EMG or increased phasic muscle activity by the limb EMG during REM sleep . Thus, PSG is not required for the clinical diagnosis of RBD . It has been reported that a total score of 6 or higher obtained from the RBD screening questionnaire used for the clinical diagnosis of RBD may strongly support the diagnosis .
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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.
Sleep Problems In Parkinsons Disease
Koichi Hirata
1Department of Neurology, Dokkyo Medical University, Tochigi 321-0293, Japan
2Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
3Department of Neurology, Singapore General Hospital, Singapore
4Department of Neurology, Massachusetts General Hospital, Division of Sleep Medicine, Harvard Medical School, Boston, MA, USA
In his famous monograph An Essay in Shaking Palsy, James Parkinson provided astute descriptions of impaired sleep in his case series of patients with Parkinsons disease two centuries ago. It is only three decades ago that sleep dysfunction started to attract attention of medical and scientific communities involved in the clinical care and research of PD. Tremendous advancements in our understanding of impaired sleep and alertness associated with PD have developed since then.
M. Kaminska et al. performed a review on the relationship between OSA and PD. Although the clinical significance of OSA in PD has been controversial , the authors suggest the possibility that treatment of OSA could delay cognitive decline or motor dysfunction in patients with PD. This area of research is of high significance as it is important to assess the prevalence of OSA and the impact of its treatment in the PD population.
Finally, the complex and still only partially understood interaction of impulse control disorders in PD and sleep is discussed in a review from the clinic of one of the guest editors.
Koichi Hirata
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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.
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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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 .
Characterization Of Sleep Disturbances
Mean PDSS-2 total score was 15 . One hundred and fifty-four patients scored PDSS-2< 18 and 75 patients scored 18. Table 1 shows the demographic and clinical features of these patients. Patients with sleep disturbances had more severe motor symptoms , more motor fluctuations, lower functional independence , and were taking higher doses of antiparkinsonian medication . Patients with PDSS-218 reported more frequent pain and greater pain intensity were more anxious and depressed , and had poorer quality of life than patients with PDSS-2< 18. These two groups did not differ regarding sex, age, age at disease onset, disease duration, and use of dopamine agonists and hypnotic medication.
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Table 1 Demographic, clinical, and therapeutic characteristics of PD patients according to PDSS-2 total score |
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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.
Data Collection And Assessment
All subjects provided demographic data and completed a questionnaire screening for symptoms of sleep disorders . Height, weight and neck circumference were measured, and the body mass index calculated for each subject. PD patients provided information on their disease duration and use of dopaminergic medications, and underwent further clinical assessment using Part III of the Unified Parkinson’s Disease Rating Scale and modified Hoehn and Yahr staging. The levodopa equivalent daily dose was calculated according to the standardized formulae as: LEDD = + + + + + .
The subjects were also assessed with clinical scales to evaluate subjective sleep disturbance: Insomnia was evaluated using the Insomnia Severity Index : A higher ISI score reflects higher probability of insomnia, with scores of 15 and above indicative of clinical insomnia . Excessive daytime sleepiness was assessed using the Epworth Sleepiness Scale , with a score of 10 indicating abnormal daytime sleepiness. Subjects also completed the Beck Depression Inventory : A higher score reflects a greater degree of depressive symptoms.
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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.
Parkinsons Disease And Sleep: Common Symptoms
Sleep problems can occur at any stage of Parkinsons disease. Some of the most common sleep problems for PD patients include:
- Insomnia: Difficulty falling or staying asleep
- Excessive daytime sleepiness: Feeling drowsy or fatigued during the day. In Parkinsons, sleeping all day is also common
- Nightmares or night terrors: Bad dreams that seem unusual for you
- Sleep attacks: Sudden, involuntary episodes of sleep, also known as narcolepsy
- Periodic leg movement disorder
- Restless leg syndrome
- REM sleep behavior disorder: Acting out dreams while asleep
- Sleep apnea: When breathing becomes obstructed during sleep
- Nocturia: Frequent night-time urination
When prescribing one of the drugs I take, my doctor warned me of a common side effect: exaggerated, intensely vivid dreams. To be honest, I’ve never really noticed the difference. I’ve always dreamt big. Michael J. Fox
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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.
Clinical Variables Of Participants
We recruited 70 drug-naïve patients with PD , and 30 HC . As shown in , the two groups were consistent in age, gender, percentage of living alone, educational level, and BMI. Compared with the HC group, the PD group had higher HAMA, HAMD, RBDSQ, and PSQI scores and MH prevalence . However, no significant difference was observed in the MoCA scores of the groups the mean MoCA scores of the PD and HC groups were 24.71 ± 4.16 and 24.83 ± 3.02, respectively.
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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 .