Sunday, August 7, 2022

Sleepiness And Parkinson’s Disease

Rbd And Other Parasomnias

Sleep Disorders in Parkinson’s Disease: Dr. Andrew Berkowski

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.

Why Do Parkinsons Patients Sleep So Much

Parkinson’s patients experience difficulties with their sleep due to the disease itself and the medications that treat it. This can lead to increased sleepiness during the day.

Parkinsons disease can cause problems with sleep, and the medications used to treat it can cause even more. Difficulties sleeping during the night can cause daytime sleepiness, and the medications can also cause drowsiness. This disruption to the circadian rhythms can lead to more frequent, lower quality sleep.

Associations Of Insomnia And Subjective Sleepiness With Motor And Non

Multivariate logistic regression models showed that part I of MDS-UPDRS rather than parts II or III mainly contributed to subjective insomnia assessed using the ISI . However, none of the MDS-UPDRS parts were significantly associated with subjective daytime sleepiness assessed using the ESS.

Table 1 Results of multivariate logistic regression analysis

Table 1 Results of multivariate logistic regression analysis

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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.

Rem Sleep Behavior Disorder

(PDF) Daytime Sleepiness and Alertness in Patients with ...

REM sleep is characterized by rapid eye movements and skeletal muscle atonia. Respiration is diaphragmbased during REM sleep. Dreaming during REM sleep tends to be vivid and detailed, compared to vague content of Non-REM sleep. Muscle atonia is mediated by brainstem centers, pedunculopontine nucleus and locus ceruleus, and serves as a protective mechanism preventing dream enactment during REM. However, conditions resulting in disruption of this protective mechanism can lead to physical enactment of dream content during REM. This phenomenon is called REM Sleep Behavior Disorder .

Parkinson disease is very strongly associated with RBD. In fact, RBD can predate the initial motor symptoms by years and is one of the best known biomarkers for PD. RBD is present in 2550% of PD patients and is even more frequent in multiple system atrophy and Lewy body dementia,. Forty percent of the patients with idiopathic RBD develop a parkinsonian syndrome within a decade, and two-thirds within two decades. Mild cognitive impairment and dysautonomia were seen in these patients with idiopathic RBD.

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Dyskinesia: Track It To Hack It

Dyskinesia is a common side effect of some medications used to treat PD. The resulting jerky, involuntary movements may be mild or severe, and can impact daily life. But you will probably find that being on the medication and having dyskinesia is better than being off the medication.

Since dyskinesia is a symptom of PD medication, talking to your health care professional is the best option for figuring out clinical ways to manage it. However, there are some things you can do on your own.

For example, tracking the time and frequency of your dyskinesia can help you and your health care team know if the medication is working. Logging those moments will also tell you the times when movement is easier , which you can use to your advantage. You can enlist your caregiver or a family member to help you keep track.

Once youre aware of the times of day when you experience fewer dyskinesia episodes, you can schedule activities around those periods. Physical activity might even help you deal with dyskinesia. One MyParkinsonsTeam member put it this way: Exercise helps me when my body is doing the dyskinesia dance.

Whether you exercise to go with the flow of dyskinesia or only exercise during those in-between times, movement can build and maintain your strength, which may reduce overall exhaustion from dyskinesia.

Associations Of Insomnia And Subjective Sleepiness With Specific Pd Features And Comorbidities

For the 128 subjects, insomnia severity as reflected by ISI score correlated significantly with age, levodopa equivalent dose, Beck Depression Inventory, Trait Anxiety Score, Fatigue Severity Scale, Survey of Autonomic Symptoms, 39-item Parkinson Disease Questionnaire, and parts I and II subcategories of the MDSUPDRS . Daytime sleepiness as assessed by the ESS was significantly correlated with Hoehn and Yahr stage, duration of illness, levodopa equivalent dose, Beck Depression Inventory, trait score of State Trait Anxiety Inventory, Fatigue Severity Scale, Survey of Autonomic Symptoms, 39-item Parkinson Disease Questionnaire, and each of the 3 assessed components of the MDS-UPDRS. Subjects who were taking dopamine agonists alone and those who took levodopa alone showed no significant differences in ESS scores. The ISI and ESS scores were moderately correlated with each other.

Table 2 Correlation of subjective sleep questionnaire and objective polysomnographic findings with age and measures of Parkinson disease or related symptom severity

Table 2 Correlation of subjective sleep questionnaire and objective polysomnographic findings with age and measures of Parkinson disease or related symptom severity

Table 3 Results of multivariate stepwise logistic regression of insomnia symptoms or sleepiness on specific Parkinson disease features and comorbidities

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Schedule Vocal Rests To Manage Communication Issues

PD can affect nerves and muscles that are necessary for clear, easy speech. Voice problems are common among people living with PD and can make communication difficult and laborious as the disease progresses. You might have a soft, breathy, and strained voice that gets thinner as the day goes on, or even as you speak. This may mean people have a hard time understanding you, which can be frustrating.

Just as communication is key to social relationships, so is feeling heard. In addition to meeting with a speech therapist or speech pathologist, there are other ways you can improve your ability to communicate.

For example, try to meet people in quiet spaces to have conversations. And make sure whoever is listening to you can see your face . While it may seem awkward at first, speak in short phrases so that you arent trying to say a lot in one breath. And, as strange as it may be to schedule vocal rest, doing so before you know you will speak with someonesuch as on the phonecan make your side of the conversation flow more easily.

You might also consider practicing vocal exercises. I have been doing music therapy and vocal exercises, one MyParkinsonsTeam member wrote. Even doing just a few even just singing karaoke can help keep the muscles going!

Potential Ways To Reduce Excessive Daytime Sleepiness

Excessive daytime sleepiness in Parkinson’s
  • Assess the underlying cause
  • Improve nocturnal sleep through medications, cognitive behavioral therapy, diet, light therapy and more
  • Evaluate all medicines being takensome have hypersomnia as a side effectand adjust as needed
  • If taking dopaminergic medications, consider dose adjustment
  • Watch consumption of alcohol or sleep-inducing foods/ingredients
  • Experiment with caffeine

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Researchers Say That Their Sample Size Is Insufficient To Support Conclusions About The Treatments Safety

Neurology Reviews

Sodium oxybate effectively treats excessive daytime sleepiness and nocturnal sleep disturbance in patients with Parkinsons disease, according to research published in the January issue of JAMA Neurology. Patients receiving this therapy should be monitored with follow-up polysomnography to rule out treatment-related complications, the investigators said.

Many patients with Parkinsons disease have excessive daytime sleepiness and disturbed sleep, but few treatments are available for them. An open-label study found that sodium oxybate, a first-line therapy for narcolepsy type 1, improved sleep and reduced daytime sleepiness in Parkinsons disease.

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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How Are Sleep Problems Diagnosed In People With Parkinsons Disease

If youre having problems sleeping, sit down with your healthcare provider to discuss the issue in detail. Your provider will ask you questions to better understand your symptoms.

Be prepared to explain when sleep disruptions happen and how they affect your life. Keeping a sleep journal for a few weeks can help you remember the details.

If your provider suspects you may have a sleep disorder, they may recommend you have a sleep study. This overnight test uses electrodes attached to your skin to track how your body functions when youre sleeping.

Conflict Of Interest Statement

(PDF) Daytime Sleepiness in Parkinson

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.

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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.

Nonpharmacologic Therapies For Excessive Daytime Sleepiness

Because drug therapies have the potential for adverse side effects, nonpharmacologic treatment approaches offer a promising alternative for preventing and managing EDS in PD.

Cognitive behavioral therapy

Cognitive behavioral therapy for insomnia is extensively used to treat insomnia in non-PD populations. It consists of behavioral and psychological approaches to teaching patients how to change their dysfunctional behaviors and thinking patterns. One small study found that the Insomnia Severity Index, PD Sleep Scale, and examiner-reported clinical global impression improved in PD patients who received CBT-I combined with light therapy. Therefore, in accordance with CBT-I, clinicians could recommend that patients strictly follow sleep hygiene rules such as having regular nap times and daytime physical activity and avoiding vigorous physical activity 34 h before sleeping. Efficacy conclusion for CBT is under investigation. CBT-I is simple to administer, but there remains insufficient evidence for its effective management of EDS in PD patients.

Light therapy

Repetitive transcranial magnetic stimulation

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What Else Can I Do To Sleep Better With Parkinsons Disease

Practicing healthy sleep hygiene habits may also promote more restful sleep.

  • Get outside during the day. Bright light tells your body its time to be awake.
  • Keep your body moving during the day. Even if all you feel up to is a short walk or two, all physical activity offers benefits.
  • Try at-home remedies, such as massage or a warm bath. Relaxing your mind may help your body fall asleep.


  • Take long naps during the day.
  • Use stimulants, such as caffeine, within six hours of bedtime.
  • Use your bedroom for activities other than sleeping. Go to another room to read, watch TV or work.

Lessons Ive Learned On My Parkinsons Journey

Sleep and Parkinson’s Disease

Cannabis has two main active components: tetrahydrocannabinol , which is the main chemical that induces a high, and cannabidiol , which doesnt induce a high but may have numbing or anti-inflammatory properties.

Cannabis has not been rigorously studied in Parkinsons, but many patients are interested in its potential benefits, and with increasing availability of a number of cannabis-based products, many have tried them. In lieu of scientific studies, learning from these patients experiences could help patients and clinicians to understand the potential benefits and risks of using various cannabis products for Parkinsons patients.

To this end, researchers at the University of Colorado conducted a survey through Fox Insight, an online platform run by the Michael J. Fox Foundation for Parkinsons Research.

The survey was answered by 1,881 people with Parkinsons who reported having used cannabis products since they were diagnosed. Most respondents were men , and more than half had been diagnosed with Parkinsons for less than three years. The vast majority were white , and the respondents generally were highly educated, with nearly two-thirds having at least a college degree and 33.6% with graduate or professional degrees.

In general, the overall magnitude of both positive and negative effects was small, the researchers noted. Notably, patients who took a product with high THC were generally more likely to experience an effect whether positive or negative.

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Restless Legs Syndrome And Periodic Leg Movements In Sleep

Restless Legs Syndrome is associated with urge to move the legs due to unpleasant and uncomfortable sensations. These sensations begin or worsen during periods of rest or inactivity and are partially or totally relieved by movement. The symptoms occur mainly in the evening or nighttime. Sometimes, symptoms may involve arms and very rarely, the whole body. RLS can result in significant distress to the patients. It can interfere with sleep onset and cause insomnia. Daytime fatigue and sleepiness are common associated complaints with restless leg syndrome.

Prevalence of RLS is estimated to be 510% of adult population in North America. It is twice as prevalent in women as in men. Prevalence increases with age. Iron deficiency, certain medications , pregnancy, chronic renal failure, and prolonged immobility are associated with increased risk of RLS. There is a strong familial association especially with early onset RLS.

Multiple studies show higher RLS prevalence in PD patients than in general population. RLS profile of PD patients, however, is different from general population. RLS in PD tends to start relatively late, tends to be milder with most patients having no family history of RLS. The overall impact of RLS on PD patients seems modest in terms of day time sleepiness and quality of life.

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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Figuring Out Causes Of Fatigue

The first step in easing the fatigue associated with Parkinsons disease is to rule out other causes of tiredness, says Liana Rosenthal, M.D., assistant professor of neurology at the Johns Hopkins University School of Medicine and director of clinical core at the Morris K. Udall Center Parkinsons Disease Research Center of Excellence. We evaluate patients to see if there are other things contributing to the fatigue besides their disease, she says.

Sometimes patients may be referred to a sleep specialist for an evaluation. That can help identify causes of tiredness, like sleep apnea. Rosenthal says: Our aim is to first treat any sleep issues, like insomnia, sleep apnea or other causes of poor sleep. Once we treat and address those issues, we can see if fatigue still persists.

What Types Of Sleep Problems Do People With Parkinsons Disease Have

Sleep and Fatigue in Parkinson

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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