Are disturbances of sleep and wakefulness common in Parkinson’s disease?

Yes.

Patients with Parkinson’s disease can have problems while sleeping. They can also have excessive sleepiness/drowsiness during waking hours.

What problems can I have while sleeping?

There are 3 major problems that patients with Parkinson’s disease may have while sleeping:

Major Sleep problems in Parkinson's disease
1. REM behavior disorder (RBD)
2. OFF-dystonia
3. Obstructive Sleep Apnea (OSA)

Other problems such as Restless Leg Syndrome / Periodic Leg Movement disorder are described elsewhere.

Restless Leg Syndrome – RLS = Very unpleasant tingling and occasionally painful sensations in the legs during the late evening and when trying to sleep.

What is REM Behavior disorder (RBD) & how is it treated?

Usually, when we dream, the body does not move. In patients with Parkinson’s disease, the body is not paralyzed during the dream, so that the person “acts out” what they are dreaming.

Patients with Parkinson’s disease may talk, move excessively while sleeping, and sometimes hit their bed partner while sleeping.

Some patients have only mild symptoms such as talking in their sleep or some movements resembling restlessness while sleeping. But occasionally patients may have dramatic movements – they may start running in bed, or have trashing movements. Sometimes these movements can be so violent that the person may fall off from the bed. Rarely the kicking and thrashing movements may hurt the patient’s partner in bed.

Melatonin is a natural hormone that helps the brain to sleep. Melatonin is exceptionally safe and very effective in treating mild to moderate REM behaviour disorder. It is taken orally before going to bed.

Melatonin is a natural chemical that helps us to sleep soundly.

In severe cases, a sedative medication may help. Usually Clonazepam is given – it is exceptionally effective and resolves RBD in almost all patients. But excessive sedation can be problematic (see below), and Clonazepam can be habit-forming. Therefore, melatonin is much more preferable.

Other medications such as Memantine (a drug usually given for dementia) may be effective in RBD, but they are generally not used for this purpose. If a patient has both dementia and RBD, it may be worth trying.

Which other sleep events can be confused with REM Behavior Disorder?

The diagnosis of RBD is usually easy to make. The following conditions, which can happen in any individual, may occasionally cause confusion:

Sleep Problems Mimicking Seizures

What happens?

Confusional ArousalsThe child suddenly wakes up confused and disoriented
Sleep TerrorsThe child wakes up screaming & crying and is difficult to console
NightmaresBad, bad dreams that wake you up, and are remembered
NarcolepsyThe child can abruptly nod off to sleep & may drop down to the ground
Hypnagogic & Hypnopompic HallucinationsVisual hallucinations can happen as the patient is sleeping (-gogic) or when the patient is waking up (-pompic)

Occasionally, a sleep study (see below) may be needed to correctly identify your problem.

What is OFF-dystonia and how is it treated?

OFF-dystonia at night happens because the effect of Levodopa wears off. It prevents deep sleep.

Let us say you take a dose of Levodopa before dinner at 7 PM. You go to bed at 10 PM and wake up at 8 AM. Then, from 7 PM to 8 AM – a duration of 13 hours – your body is not getting any dopamine! Therefore, in the early morning, you are in an “OFF state”!

You may have difficulty turning around in bed if the effect of levodopa wears off in the middle of the night,

Your body becomes stiff. It becomes difficult to change your position or turn from one side to another in bed. Your muscles – especially those in your legs – may cramp up. This cramping up of muscles is called OFF-dystonia.

The feeling of Levodopa wearing off can be very uncomfortable for some patients. You may wake up multiple times in the night – this is called Maintenance Insomnia.

The solution is to take a dose of Levodopa (preferably the controlled release or CR formulation) just before you go bed. Do it as the last thing you do, just before you close your eyes.

Taking a dose of levodopa just before you close your eyes at night may prevent OFF-dystonia in the night.

If that doesn’t work, then you may need to start taking a long-acting dopamine agonist (e.g. Pramipexole ER or Ropinirole XL) to prevent going into an OFF-state at night.

Deep Brain Stimulation (DBS) may help to reduce OFF-dystonia and also improve the quality of sleep. While at King’s College, I had the opportunity to research this topic with the world-renowned expert of Parkinson’s disease – Dr Kallol Ray Chaudhuri (see below).

Relevant references:

  1. Changes in Parkinson’s disease sleep symptoms and daytime somnolence after bilateral subthalamic deep brain stimulation in Parkinson’s disease. Kharkar S et al NPJ Parkinsons Dis. 2018 May 25;4:16

What is Obstructive Sleep Apnea (OSA) and how is it treated?

Our muscles relax when we sleep. Our throat muscles and tongue relax as well. If you are sleeping on your back, your tongue can fall back and hinder the flow of air into your lungs. If incomplete, this causes heavy snoring. If the tongue almost completely obstructs the airflow, it produces choking. This obstruction to breathing during sleep is called Obstructive Sleep Apnea (OSA).

Your tongue may fall backwards during deep sleep, and obstruct the flow of air to your lungs.

Patients or their companion may complain of heavy snoring. The patient may wake up in the middle of the night with a choking sensation. The patient complains that he/she never gets deep sleep and wakes up frequently. Because he never gets deep sleep, he may be very sleepy during the day. Because sleep is crucial for thinking and memory, he may have trouble concentrating and remembering things.

Obstructive Sleep Apnea can cause difficulties in concentration and forgetfulness.

OSA is common even in patients who don’t have Parkinson’s disease, especially if the bodyweight is on the higher side. Physical inactivity and weight gain may contribute to its occurrence.

OSA is common in Parkinson’s disease. Problems with breathing during sleep (related to, but not the same as OSA) are even more common in Parkinson’s plus syndromes, especially Multiple System Atrophy (MSA).

The first step in treating OSA is to verify the diagnosis by doing a sleep study (technical name – Polysomnography). Occasionally, symptoms of RBD, OFF-dystonia and OSA may be difficult to distinguish from each other without a sleep study.

Multiple measurements are done as part of a Sleep Study.

You can do the following things:

  • Sleep on your side – so that your tongue doesn’t fall backwards.
  • Gradually reduce your weight – as mentioned previously, brisk walking may be one of the best exercises for Parkinson’s disease.
  • Avoid alcohol & smoking – especially close to bed time.
  • Use a device – You can use a machine which maintains a constant pressure of air inside your airways so that they don’t collapse – this is called a CPAP machine.

    Sleeping on your side & using a CPAP machine keeps the airway to your lungs open.

    If you cannot afford a CPAP machine, a simple silicone jaw advancement device that you place over your teeth while sleeping may relieve symptoms tremendously. The jaw advancement device may be as effective as CPAP. Some people may find it uncomfortable.

    A Mandibular Advancement Device (or MAD) slightly protrudes your lower jaw while sleeping, so that your airway remains open.

     

How can I find out if I have excessive daytime sleepiness?

Some studies indicate that up to 1/2 of all patients with Parkinson’s disease may have daytime sleepiness.

Patients with Parkinson’s disease can doze off at inopportune times due to excessive daytime sleepiness.

You can measure your own daytime sleepiness by answering the Epworth Sleepiness Questionnaire:

What are the reasons & treatment for Excessive Daytime Sleepiness in Parkinson’s disease?

There are multiple reasons:

  1. Lack of good sleep – as described above.
  2. Medications – some medications given for Parkinson’s disease, especially the dopamine agonists (Pramipexole, Ropinirole) can cause you to become drowsy during the day.

    Some Parkinson’s medications may produce sleepiness.

  3. Depression – Depression, which is very common in Parkinson’s disease may alter your sleep-wake rhythm and make you more lethargic during the day.

    Depression can cause you to become lethargic and sleepy during the day.

The first step when you are faced with excessive day time sleepiness is to find out if you are sleeping well at night. If you think you may have RBD, or OFF-dystonia or RBD, talk to your neurologist about these problems because they are easily treatable.

In some patients, it may be necessary to discontinue or decrease the dose of Dopamine agonists.

Occasionally we may face a hard situation where decreasing the dose causes unacceptable OFF symptoms & increasing the dose causes unacceptable drowsiness. DBS bails us out in this situation – medication doses can be reduced by half (on average) after the most commonly performed DBS surgery (STN-DBS). At the same time, DBS itself takes over the work of relieving Parkinson’s symptoms.

Deep Brain Stimulation Surgery may help to reduce the dose of sedating medications.

Depression itself is very common in Parkinson’s disease. I have described depression, and it’s treatment in another article here.

 


Dr. Siddharth Kharkar

Dr. Kharkar is a Neurologist, Epilepsy specialist & Parkinson’s disease specialist in Mumbai, Maharashtra, India. He has trained in the best institutions in India, US and UK including KEM hospital in Mumbai, Johns Hopkins University in Baltimore, University of California at San Francisco (UCSF), USA & Kings College in London.

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