Parkinson’s Disease

Parkinson’s disease and sleep disorders

Mr Stewart has Parkinson’s disease (PD). Like so many patients with PD, he suffers from so many sleep problems.  He feels too sleepy during the day. His sleep quality is poor and disrupted. His legs feel restless before bedtime. His wife told his neurologist that he acts out his dreams. Sometimes, she herself wakes up frightened because Mr Stewart kicks and gestures with his hands in a confrontational manner while he is talking angrily during sleep, only to recall a dream of a man who is trying to attack his wife- and, he was defending her. He felt bad for frightening his wife. He is a nice man.  Mr Steward suffers from “REM Behavioral disorder” or RBD.

Mr Steward saw a sleep medicine specialist and had a sleep study. He was diagnosed with obstructive sleep apnea syndrome. He is now in the process of getting a CPAP machine to help him breathe better at night. By treating the sleep apnea, the RBD and restless legs may get better. He will still likely need medication for the RBD (such as clonazepam at bedtime).

What is Parkinson’s Disease? It is a disorder that affects the central nervous system, specifically disrupting movement control. Tremors, slow walking, stiffness, imbalance and coordination problems are common. Patients with more advanced or aggressive disease suffer from difficulty eating, urinary and bowel problems, falls and hallucinations. Depression, anxiety and cognitive (memory, attention) problems are also common. There is no cure for PD, yet. But medications improve symptoms and the quality of life. It is important to include the sleep issues into the treatment plan.

Recap of the sleep problems in Parkinson’s Disease:

  • Excessive daytime sleepiness: the cause is partly due to the loss of brain neurotransmitter, dopamine and the effect of medications. “Sleep attacks” which is a strong urge to fall asleep, possibly during driving can occur though rarely.
  • Insomnia
  • Depression, which is common in PD, can cause unrefreshed sleep and daytime fatigue.
  • REM Behavioral Disorder (RBD): This disorder may precede the diagnosis of PD. Sleep problems such as RBD may be the early signs of PD or dementia. While most of people become relatively paralyzed during sleep, PD patients lose this ability, so they act out the dreams.
  • Nightmares: occurs during sleep
  • Visual hallucinations: occur during the day; they are related to side effects of medications. They see people or animals that are not there.
  • Restless legs syndrome: a twitchy sensation in legs with an urge to move them, typically occurring during rest or evenings and night. They should  improve with movements.
  • Periodic limb movements of sleep: moving legs during sleep
  • Nocturia (frequent urination)
  • Sleep apnea

Tips on Addressing sleep problems in Parkinson’s Disease:

1. Excessive daytime sleepiness:

  • Review the effect of medications. Talk to your neurologist.
  • Exposure to outdoor light during the day. Open the curtains. Sit in the porch.
  • Remain physically active
  • Cautiously consider medications that promote wakefulness or are stimulants such as Wellbutrin, provigil or nuvigil.
  • Do not drive if you are sleepy.

2.  Avoid unintended naps. Take one nap in the early afternoon, no later than 2 pm and no more than 30 minutes to avoid night time insomnia. The nap might give you a refresher for the remainder of the day.

3.  Insomnia:

  • Review the side effect of your medications- any of them may cause insomnia?  Talk to your neurologist
  • Do you experience symptoms of RBD (REM behavioral disorder), nightmares, hallucinations? If so, talk to your doctor to make adjustment of you medications.
  • Discuss the use of a hypnotic (sleeping pill), but be careful of side effects such as hallucinations, drowsiness in the morning and perhaps increased risk of falls and cognitive problems.
  • Be careful using sedating antidepressants for insomnia (example trazodone, remeron, elavil) since they can worsen confusion and hallucinations during the night or even the day. Some of them can also worsen restless legs. If they are needed for depression or anxiety, that is fine but again, side effect needs to be watched closely.
  • It is preferable to use the lowest doses of sedative-hypnotic such as Ambien, Lunesta or Sonata. Again, use caution- they can cause hangover during the day for some folks. These medications are FDA approved for insomnia. In my patients, I use the lowest doses possible and watch them closely.
  • Be careful of over the counter sleeping aid. Some may have contain diphenhydramine, which are known to block the absorption of dopamine.
  • Pain, stress, anxiety and restless legs can cause insomnia. You need to address these issues as well.

4.  REM Behavioral Disorder (RBD) and nightmares:

  • There are effective medications that manage RBD or nightmares. They include clonazpam 0.5 up to 2 mg, Restoril 15-30 mg or melatonin 1 mg or higher (up to 10 mg), typically taken right at bedtime.
  • In my experience with my patients, low dose of gabapentin 100-300 mg at bedtime helps with the RBD and improves the sleep quality.
  • Pay attention to safety issues: ask the spouse to sleep in a separate bed until you feel safe the kicking is diminished to the point of being non-injurious.

5.  Restless legs syndrome (RLS) and periodic limb movements of sleep:

  • There are FDA approved medications for RLS: Requip, mirapex, horizant and patch called Neupro. They can also be used for the leg movements during sleep. Talk to your doctor.
  • Rule out iron deficiency anemia, abnormal thyroid or B12

6.  Sleep apnea is not uncommon in PD patients. Symptoms include snoring, pauses in breathing, frequent awakenings. Treatment can improve your sleep quality and decrease daytime sleepiness. Talk to your doctor to get a sleep study.

7.  Tremors disappear during sleep but stiffness may continue. Pain and stiffness may also affect the sleep quality. This can improve when the PD medication can be given close to bedtime.

8.  “Off periods”– with advanced PD, patients may experience from what is called “off periods”. During the night, as the medicine wears off, they become stiff and immobile. This makes turning in bed or bathroom visits a challenge.

  • May use requip or mirapex at bedtime – consider even the long- acting formulary. Remember, they can also worsen or precipitate nighttime hallucinations, so use the lower doses possible.

9.  Seek psychological support to deal with the effect of the disease on your life. Engage your family. Support group is a great idea.

10.  Follow good sleep habits: keep a regular bed and wake time, avoid alcohol and tobacco. Keep caffeinated food or beverages no later than 12 pm. Keep well hydrated during the day, but avoid liquids and food close to bedtime.

11.  If you need to urinate frequently at night yet it is a challenge to get up at night, consider a bedside commode or urinal. Avoid putting yourself in a situation where you are at a fall risk.

12. Use comfortable and light bedding and clothing so you can change positions more easily at night.

13.  Get outdoor daylight. The best is to take a good walk outside in the morning. Open the curtains in your house and allow light to come through. Sit in your porch when weather permits.

14.  Keep your passion with life and stay engaged with hobbies and fun activities. Parkinson’s disease is a challenge but life is full of challenges anyway. You can stay active and lead a healthy life with minimal limitations. A good night sleep can go a long way to keep you strong and happy.

References

Kumar, S., Bhatia, M., & Behari, M. (2002). Sleep disorders in Parkinson’s disease. Mov Disord, 17(4), 775-781.