Sleep Disturbances in Parkinson’s

Angela Anagnos, MD

Board Certified in Sleep Medicine and Neurologywww.sleepmedicineandneurology.com

Rigid musclesTremors or stiffnessUnable to roll over in bedFrequent urge to urinateVivid dreams, hallucinations, violent

nightmaresActing out dreams(RBD) can precede PD by

decades

Introduction most people with PD find it difficult to sleep through the night

Daytime Sleepiness

Due to sleep disturbances Due to medication side effects Due to Parkinson’s disease itself End result: Interferes with daily life

Step 1: Find Root CauseSeek professional help in early or mid-stage

PD for:InsomniaExcessive daytime sleepinessRestless legs syndromeREM behavior disorderPoor sleep due to depression

InsomniaInability to get a good night’s sleepTrouble falling/staying/falling back to sleepFragments of sleep a few hours at a timeSleep studies (PSG) in PD show:

Less deep sleep (S3)More light sleep (S1S2)Increased sleep fragmentationMultiple night awakenings

Sleep Hygiene and InsomniaMaintain a regular schedule for waking/sleepingAvoid excessive time in bedAvoid naps during the day and early eveningUse bed for sleeping (not reading or watching TV)Do not watch the clock in bedTry to relax before bedtime: environmental cuesTimed light exposure in the am

Sleep HygieneKeep the bedroom dark, cool and comfortableBlock out noises that disturb sleepAvoid caffeinated beverages or alcohol w/in 6 hrs of

bedtimeExercise early in the day, not two hours before bedtimeGo to another room if you cannot sleepAvoid going to bed hungry

Light Therapy

Do not underestimate the power of natural sunlight in helping circadian rhythm disorders and common insomnia!

Excessive Daytime Sleepiness in PD

Common in early and mid-PDCan be related to insomniaCan be related to other sleep disturbances

Sleep apneaRLS/PLMDRBD

Or related to medicationsHigh doses of dopaminergic medications like

pramipexole and ropinirole can contribute but rare

RLS- Restless Legs Syndrome5-10% of general populationCommon in PD but not predictive of PDCan predate PD by many years/decadesCommon, underdiagnosed, hyperkinetic

movement disorder

RLSFour diagnostic criteria

Do you have an uncomfortable or unpleasant sensation that causes an urge to move your legs?

Are your symptoms worse during periods of rest or inactivity such as lying or sitting?

Are your symptoms temporarily relieved by movement, such as walking or stretching?

Are your symptoms worse in the evening or at night? As symptoms get worse, can occur during the day

Key ?: “Do you have a creepy, crawly, or restless feeling in your legs at night that improves when you move around?”

RLSUsually primary/hereditary (possible loci

chromosomes 9,12,14)Secondary causes due to iron deficiency, ESRD,

Medications (neuroleptics=DA antagonists like Reglan) or antidepressants, peripheral neuropathy

Prevalence increases with age over 40, F>MCan be mistaken for ADHD, especially in childrenMore common in Parkinson’s Disease

PLMS-Periodic Limb Movements in Sleep

80% of those with RLS also have PLMSSlow, involuntary, stereotypic movements,

usually involving flexing the leg at the hip, knee, and ankle. May involve arms.

Reported by bed partner or found on sleep study.

Causes daytime sleepiness and/or insomnia

RLS/PLMD Work-UpLabs tests for blood count, ferritin and

iron studies, folate, glucose, renal screen; EMG/NCV if suspect neuropathy

Sleep study to rule out sleep apnea and look for PLMD

TREATMENT RLS/PLMD

Avoid alcohol, caffeine; regular sleep hygieneStop problematic medications like antihistamines,

tricyclic antidepressantsDopamine agonists help >70% of patients ; first

line therapy : ropinirole (Requip) pramipexole (Mirapex), Levodopa (Sinemet)

anticonvulsants like gabapentin, carbamazepinenarcotics, iron tid with Vit C if ferritin < 50 mcg/dL

or iron saturation <16%

REM Behavior Disorder (RBD)A disorder of dissociation of muscle atonia during

REM sleepBreakthrough behaviors during REM described as

acting out dreamsAbrupt emotional vocalizations, swearing,

injurious/violent behaviorsDisruption of sleep continuityAppx 50% of PD patients have partial or complete

loss of muscle atonia in REM sleep

REM Behavior Disorder (RBD)Male predominance > 45 yrsAssociated neurodegenerative diseases, PDMorbidity

Self injury 1/3 of casesInjury to others 2/3 of casesDaytime sleepiness in ¾ of cases (often

due to other associated sleep problems)

Treatment of RBDBehavioral

Safe environmentReduce disruptive events Reduce anxietyGood sleep hygiene

PharmacologicalClonazepam (80% of patients reported

benefit)Parkinson’s Treatment with

Dopaminergics

Obstructive Sleep Apnea (OSAS)Symptoms

SnoringWitnessed apneasDaytime fatigue/SleepinessMoodiness, irritabilityConcentration/ memory complaintsDepressionInsomniaExacerbated pain symptoms

Whose at Risk?Men> premenopausal womenMicrognathia, overbiteObesity, hypothyroidismEnlarged adenoids, tonsillar tissueExacerbated by supine sleep, gravityDeviated septum, allergies with mouth breathingMacroglossia, enlarged uvulaDecreased muscle tone with aging, testosteroneHigher incidence in PD related autonomic dysfunction

Diagnosis of OSAS by PSGApneas- cessation of airflow >10 secHypopneas- 50% reduction in airflow with

3% reduction in oxygen, or EEG arousalRERAS- EEG arousals with increased

respiratory effortAHI> 5/hrRDI > 40/hr, severe

Treatment of OSAS CPAP/BIPAP/ AutoPAP +/- oxygen Weight loss Mandibular Advancement Appliance Surgery overall, 50-70% improvement

UPPP Septoplasty, turbinate reduction Maxillomandibular advacement Somnoplasty (RF) Pillar procedure tracheostomy

Sleep and DepressionDepression in appx 40% of PD

patients Associated with sleep disturbancesUnrefreshing sleepEarly morning awakeningsIrregular dreams

Sleep in Later Stages of PD33% of PD patients in mid-late

stages experience hallucinations related to higher doses of medications

Visual, not auditoryAssociated with vivid dreams