By Amer G. Aboukasm

Although the daytime clinical manifestation of Parkinson's disease have been well recognized for almost two centuries, the nocturnal (nighttime) 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.

Clinical features:

Insomnia with difficulty falling asleep and remaining asleep are the most common sleep-related complaints. Nocturnal vocalization and daytime dozing are also common. The inability to turn over in bed and to get out of bed to go to the bathroom, are especially bothersome complaints.

Sleep disturbances including daytime sleepiness tend to increase with disease progression. Patients with on-off phenomena and hallucinations are particularly likely to have severe sleep disruption. Depression and dementia, which commonly affect late-stage Parkinson's disease, are usually associated with increased severity of sleep disturbances, including nocturnal hallucinations and vocalization, and sometimes the REM sleep behavior disorder (which consists of violent movements related to the patient acting his/her dreams; this is due to lack of the physiologic paralysis of the skeletal muscles during Rapid Eye Movement stage of sleep).

The Sleep-Wake Organization Disturbances, mostly consist of sleep fragmentation. The time to fall asleep and the number of awakenings tend to increase in proportion to the severity of the parkinsonian symptoms. The proportions of lighter stages of sleep are increased and REM sleep is remarkably reduced.

The Motor Activity during sleep: tremors are generally suppressed, although they may appear during stages 1 and 2 of sleep, with awakenings, body movements or during bursts of rapid eye movements or after an REM period. Simple and complex movements are common during sleep in patients with parkinsonism. These include blinking, blepharospasms (spasms of the eyelids), persistent contraction of the muscles in Non-REM and in REM sleep, vocalization, periodic limb movements (resulting in extension of the big toe, foot or fingers) and REM sleep behavior. Furthermore, REM sleep behavior may appear years before the onset of daytime symptoms of Parkinson's disease or other related degenerative disorders. -Sleep-Related Respiratory Disturbances include irregular breathing due to central apnea from lack of the respiratory drive or obstructive sleep apnea due to upper airway closure.

Diagnostic Evaluation:

Clinical history, examination and sleep studies are used to determine the most important factor in the patient sleep disorder. The description from the bedpartner is essential to determine the presence of movements or awakenings and daytime sleepiness. The medication schedule is important. If dopamnergic drugs medication are not taken in the evening, nocturnal rigidity may contribute to sleep disruption; on the other hand the same drugs taken excessively or late may induce sleep-onset insomnia.

Sleep studies are useful when sleep apnea is suspected based on history of snoring, witnessed respiratory difficulties during sleep, or excessive daytime sleepiness. Sleep studies are helpful in documenting abnormal limbs movements or REM sleep behavior disorder.

Treatment:

The treatment of sleep disturbances in patients with parkinsonism is rarely straightforward because treatment of the disease may impact on or result in sleep disorders. The dual action of the dopaminergic drugs must be kept in mind: low doses of these medications may promote sleep, whereas high evening doses may result in sleep disruption in the first half of the night and improve sleep in the second half of the night. When managing the sleep disturbances of parkinsonism, the physician must balance the effects on sleep of changes in medication dosage with the effects of such changes on daytime parkinsonian symptoms.

Improvement of sleep hygiene in addition to simple measures such as placing a portable commode at the bedside may lead to substantial improvements. Concurrent psychiatric disorders should be addressed. In advanced stages of the disease, the patient's spouse should be advised to sleep in a different bed or room; inadequate rest for the spouse or other caregiver may make the patient's sleep disturbances intolerable leading to institutionalization.

For patient with insomnia without nocturnal hallucinations or vocalizations, a small dose of a dopaminergic drug, such as Sinemet 25/100, at bed time with a second similar dose at 2 or 3 AM if needed may be considered. In that regard, Sinemet CR 50/200 is particularly useful. Unfortunately these drugs may results in new sleep problems including vivid dreams, nightmares and night terrors. These occur in up to 30% of patients especially those with dementia. Small dose of short-acting sleep medication (Ambien, Sonata ), for few days or weeks may help normalize the sleep-wake schedule. Antidepressants with sedating properties such as amitriptyline are frequently helpful for sleep-onset insomnia.

Nocturnal vocalization and REM sleep behavior disorder respond to clonazepam (Klonopin). Nocturnal hallucination may require reduction in the dopminergic drugs dosages or the use of antipsychotic drugs such Seroquel or Clozaril.

The treatment of sleep apnea in parkinson's patients is similar to the treatment of such problems in other patients. In patients with sleep apnea, Continuous Positive Airway Pressure is the most effective treatment. Upper airway surgery may help some patients. For patient's with severe vocal cord dysfunction tracheostomy often is necessary.

Tips for Dealing with Sleep Problems

By Linda Mondoux

  • Sleepiness during the day or frequently waking up during the night are signs that you should evaluate your sleep pattern.

  • It would be helpful if you had a diary to share with the physician. You could include the following items:

    1. When do you go to bed and how long you sleep? Is this a consistent pattern?

    2. How long it typically take you to fall asleep?

    3. Describe any rituals that help you to fall asleep or anything that helps if you are awakened during the night.

    4. Do you take any medications routinely that are for sleeping or that you think keep you awake.

    5. Do you worry about things before you fall asleep or if you wake up during the night?

    6. Do you exercise and, if so, when do you exercise?

    7. Do you eat or drink anything just before you go to bed?

    8. Do you feel rested during the day or are you usually tired feeling all day?

  • There are sleep clinics with specialist who can evaluate your sleep pattern and develop specialized plans for you to achieve more restful nights.

  • Psychological and mental health problems like depression, anxiety and stress are often associated with sleeping difficulty. In many cases, difficulty staying asleep may be the only presenting sign of depression. A physician should be consulted about these issues to help determine the problem and the best treatment

  • Work with your physician and pharmacist to determine if any medications can cause insomnia. Both prescription and over-the-counter medications can have side effect of sleeplessness. Check with your doctor to question if any of the medications that you re taking could be potential culprits.

  • Choose a consistent time to go to bed and to wake up. This is important even if you do not have schedules to follow during the day. Your body recognizes that it is time to go to sleep if you can develop a regular time to go to bed. Your "biological clock" gets set with a regular sleep pattern.

  • Try to avoid thinking about troubling thoughts or trying to solve problems after you lie down to go to sleep. Set aside a time earlier in the night to deal with "heavy thinking."

  • Most people function best with 7 ½ -8 hours of sleep a night. If you go to bed after midnight, it is generally harder to get to sleep, as many people start to feel more awake after midnight.

  • Use the bedroom only for sleeping and sex to minimize the association with other activities that do not equate to sleep.

  • If you try to fall asleep and are unsuccessful after 15-20 minutes, then get up and go into another room and read or relax by listening to soothing music or reading light material. You should, however, not expose yourself to extremely bright light, as that gives a message to your body that you are to wake up. Tranquil music with sounds of nature, such as waterfalls and ocean waves, can aide in falling asleep. Don't watch television or engage in any challenging activity or strenuous exercise.

  • Evaluate your bedding to make sure that is comfortable and make changes as you identify areas for improvement. There are many specially contoured pillows to provide neck support depending on whether you are a "side sleeper" or an "on the back" sleeper. There are also pillows that allow you to have your head more elevated if you have any respiratory distress at night or if you have acid reflux (GERD).

  • Be sure that the bedroom's temperature is comfortable for you. Sometimes people sleep better in a cooler room.

  • Eliminate any noises and lights that might cause distractions. Earplugs that can comfortably mold to the ears are sometimes beneficial. Some people find "white noise" machines or a blowing fan noise to be conducive to sleep.

  • Naps are not recommended during the day. If you do take a nap, take it before 3 PM and don't sleep longer than an hour.

  • Rituals that signal that it is soon time to go to sleep have proven helpful. Sometimes a bath just before going to bed can help you to relax and fall asleep more easily. Some people listen to soothing music or drink decaffeinated tea, such as chamomile tea. Before using any herbal teas, you should check with your physician.

  • Getting outdoors daily to be exposed to natural light can help to establish a circadian rhythm.

  • Coffee, colas, and chocolate have caffeine and this can be a stimulant, causing you to stay awake at night. Smoking before bedtime is also detrimental, as nicotine is a stimulant.

  • Alcohol can cause you to feel sleepy; however, during your sleep it might cause you to have a sleepless night.

  • Strenuous exercise less than 3-4 hours before bedtime can cause you to have difficulty falling asleep; however, yoga or relaxation exercises can aid in falling asleep.

  • When the sun goes down, the pineal gland is stimulated and produces a natural chemical called melatonin. Your body needs melatonin to feel sleepy. Melatonin can be found in oats, rice, ginger, tomatoes, bananas, barley and sweet corn. You can also eat foods that help to stimulate the production of melatonin in your body. Such foods include soy nuts, cottage cheese, chicken, pumpkin, and turkey.

  • Small snacks before bed, particularly foods high in the amino acid tryptophan, such as peanut butter and dairy products, can cause sleepiness and help you to fall asleep.

  • For individuals that have allergies to dust or dust mites, paying attention to decreasing allergens by dusting frequently, using vacuum cleaners with HEPA filters, using air conditioners, and replacing old pillows and carpeting. Pets can also interfere with sleep with their dander, but also with their movements on the bed.

  • There are some herbal scents that can induce relaxation and sleep, such as lavender and vanilla.

 

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