What Is A Resting Tremor
A Parkinsons tremor differs from most other types of tremor because it is a resting tremor. It happens most often when a body part is relaxed rather than in motion. For a Parkinsons patient, a hand may quiver when resting in a lap or when holding a utensil to the mouth while eating.
Most tremors are action tremors where the shaking happens when a person moves their muscles. These may occur when holding arms outstretched, holding a heavy item in one position, or reaching slowly and purposefully toward an object.
Limit Drugs That Disrupt Sleep
If you are suffering from muscle spasms caused by the long-term use of levodopa , then you should talk to your neurologist in regards to replacing these drugs with extended-release preparations and/or taking amantadine to control the dyskinesia.
The effect of drugs in PD are very unpredictable, especially in the late stages of the disease.
Long-term use of levodopa can cause a side-effect called dyskinesia.
Dyskinesias are uncontrollable, dance-like movements due to the fluctuation of the drugs concentration in blood.
Adding dopamine agonists like MAO-B or COMT inhibitors to levodopa can worsen these movements.
Violent dyskinesia can prevent you from falling asleep.
Remove these drugs and use extended-release preparations to decrease dyskinesia.
Another drug called amantadine is also useful in the control of dyskinesia.
Due to the higher age of patients with PD, they are also likely to be on other drugs which can disrupt sleep.
These include beta-blockers and diuretics , corticosteroids, caffeine, anti-depressants, and anti-anxiety drugs.
You should inform your neurologist about these medicines to avoid sleep-related side-effects.
Assessment Of Impact Of Nocturnal Symptoms On Excessive Daytime Sleepiness
To investigate the impact of nocturnal disabilities on excessive daytime sleepiness, the ESS was administered to the Parkinsons disease group, and 103 patients completed the scale satisfactorily during the same visit as the PDSS , 37 women mean age 66.9 years mean duration of disease 5.6 years mean Hoehn and Yahr score 2.7 ).
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Administration And Repeatability Of The Pdss
We found the scale easy to administer and to comprehend. It can be completed by patient or caregiver with occasional proxy, as is commonplace with most scales employed in chronic neurodegenerative disorders. There was high intrapatient and interpatient reliability. The time interval between the two administrations was relatively short to try to ensure stable conditions however, we do not feel that bias caused by remembering previous scores was likely to have been introduced. The visual analogue system is advantageous in this respect.
Beating The Lockdown Blues
Did you knowBodily functions are heavily influenced by biological clocks which are distributed throughout your body . Your clocks primary role is timing and orchestrating your bodys everyday vital functions and aligning these to geophysical and social schedules. Disruptions to your daily routine derail your clock which reflects negatively on your mood, energy, sleep, digestion, heart and immune system, just to name a few!
With COVID-19-related lockdowns causing unanticipated disruptions to our routine, Researchers at the University of Queensland have developed some guidelines to stay on a schedule to improve sleep and support your health and wellbeing.
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Favor Sleep Therapy Over Sleep Medication
Patients with Parkinsons disease may develop a multitude of sleep problems.
Whilst not all patients need drugs, it is still necessary to identify and treat sleep dysfunction at the earliest.
Treatment of sleep dysfunction begins with the observance of good sleep hygiene practices.
If you still have difficulty falling asleep, try behavioral modification techniques.
These include relaxation techniques such as progressive muscle relaxation, hypnosis, and guided imagery.
If you are having problems getting to sleep due to anxiety, then follow the sleep hygiene practices and other techniques in my guide to getting to sleep with OCD thoughts here.
3.1: Try Sleep Therapy
You can also try other techniques such as sleep restriction therapy and cognitive behavioral therapy.
These are especially useful if your sleep schedule is very erratic.
On day one of sleep restriction therapy, you have to stay out of the bedroom till 3 AM.
On subsequent nights, go to bed 15 minutes earlier until the target bedtime is reached.
In cognitive-behavioral therapy, a psychotherapist will help you replace unwanted thoughts with positive ones.
3.2: Only Use Sleep Medications as a Last Resort
If you are non-responsive to sleep therapy, sleep medicines may be useful.
Over-the-counter medicine such as melatonin taken 1-2 hours before bedtime may useful for some patients.
In severe cases, your doctor may prescribe a short-term course of sleep drugs.
Bladder Issues And Waking Up To Use The Restroom
Bladder issues are common in people with PD, and some survey respondents shared that they often wake up with the urge to urinate. Studies show that anywhere from 30 to 40 percent of people with PD have urinary problems.5
One respondents experience included:
The 4th Annual Parkinsons Disease In America survey was conducted online from May to August 2020. 1,472 people completed the survey.
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Diagnosis Of Parkinsons Disease
There are currently no blood or laboratory tests to diagnose non-genetic cases of Parkinsons. Doctors usually diagnose the disease by taking a persons medical history and performing a neurological examination. If symptoms improve after starting to take medication, its another indicator that the person has Parkinsons.
A number of disorders can cause symptoms similar to those of Parkinsons disease. People with Parkinsons-like symptoms that result from other causes, such as multiple system atrophy and dementia with Lewy bodies, are sometimes said to have parkinsonism. While these disorders initially may be misdiagnosed as Parkinsons, certain medical tests, as well as response to drug treatment, may help to better evaluate the cause. Many other diseases have similar features but require different treatments, so it is important to get an accurate diagnosis as soon as possible.
Effect Of Melatonin On Insomnia
Three studies used the PSQI scale to assess the subjective sleep quality of patients with PD. However, only two studies reported the mean and SD of PSQI scores at the end of treatment. One study showed that compared with baseline and the placebo group, the PSQI score significantly improved in patients with PD treated with 4 weeks of 2 mg prolonged-release melatonin . These results showed that in the PRM group, the mean change in the PSQI score at the end of treatment was 1.75 . We also found that in the PRM group, the PSQI subcomponents improved, including subjective sleep quality , sleep latency , and sleep disturbance . However, in the Ahn et al. study, the mean and SD of PSQI scores after treatment could not be extracted. Therefore, we performed a qualitative analysis in our study.
Two studies reported the mean and SD of PSQI scores. Our meta-analysis results showed that compared with the placebo group, the subjective sleep quality of patients with PD had a significant improvement after receiving melatonin treatment . A fixed-effects model was applied.
Figure 3. Forest plot of the efficacy of melatonin on the subjective sleep quality of patients with PD.
The results of TSA on the data of PSQI scores at the end of treatment are shown in Figure 4. The accumulated Z value of the meta-analysis crossed both the TSA boundary value and the traditional boundary value before the required information size of 140 was reached.
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If You Are Experiencing Sleep Problems You Should Avoid:
- Alcohol, caffeine and other stimulants such as nicotine
- Heavy late-night meals
- Heavy exercise within six hours of bedtime
- Thoughts or discussions before bedtime about topics that cause anxiety, anger or frustration
- Screen time television, phones, tablets one or two hours before bed.
Certain antidepressants, such as mirtazapine may help with sleep while others the SSRIs can make other sleep symptoms worse. Also, if you are unsure, check with your doctor or pharmacist to ensure alerting medications are being taken in the morning and sedating medications are being taken at night.
If urinary frequency keeps you up at night, be sure your doctor rules out causes other than PD. In addition, there are several medications that can be helpful, including oxybutynin , tolterodine , trospium , tofenacin succinate , darifenacin , mirabegron and phenoperidine fumarate . You may be referred to a bladder specialist .
Parkinsons Symptoms Including Pain And Frequent Urination
Pain is a common cause of sleep disturbances in Parkinsons, says Horvat. A study published in June 2019 in the Journal of Pain Research found that about one-third of people with Parkinsons had clinically relevant sleep disturbances, and that central parkinsonian pain was the pain subtype that was most often associated with sleep issues.
Central pain can vary widely from person to person. It can feel like a constant burning or tingling that affects the whole body or it can be an intermittent sharp episode of pain, according to the Parkinsons Foundation.
You should definitely talk to your doctor if pain or Parkinsons symptoms are waking you up or keeping you up at night, to see what your treatment options may be, says Horvat.
Frequent urination can be a sign of several different things, and so its important to pay attention to any other symptoms you may also be having, she says.
Autonomic instability is often present in Parkinsons disease, which basically means the autonomic system is not firing regularly, as it should be, says Horvat. The autonomic system controls functions that keep you alive, including your heartbeat, breathing, and digestion.
This condition can lead to incontinence or urinary retention, she says. This is something to talk with your doctor about there are some medications that can be helpful.
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Changes In Sleep With Aging
As people age, they experience a number of changes in their circadian rhythms, and among the most noticeable are the changes in the sleep-wake cycle. Older people tend to wake up earlier and go to bed earlier than they did when they were younger. They wake up more often during the night and have more difficulty going back to sleep than younger people. They also tend to sleep more during the daytime hours. Therefore, if one looks at total sleep time over the 24-hour day, the total time spent sleeping changes very little but the distribution of sleep may be quite different. Younger people experience a consolidated nighttime episode with little or no daytime sleep, whereas older individuals experience sleep episodes throughout the 24-hour day. Daytime sleepiness is affected by two major factors: the amount and quality of nighttime sleep, and the strength of the circadian rhythm. In addition, older people tend to have a reduced amount of N3 or deep slow wave sleep.
Nighttime Hallucinations Psychosis & Confusion
Nighttime hallucinations and confusion may result from any combination of cognitive impairment, dopaminergic medications, age and PD-related vision changes and lack of sleep. Psychosis may first appear after infection, trauma, surgery or prolonged hospitalization. Symptoms may range from a sensation that someone or something is standing at the side of or behind the person, to very detailed and often frightening visions. Delusions may occur as well.
Treating Parkinsons Psychosis
The first-line approach to treatment of PD psychosis involves simplification of the anti-PD medication regimen and adjusting dose timing , treating other sleep disturbances, providing a consistent and familiar sleep environment , and in more severe cases, the use of atypical antipsychotic drugs.
Most of the available anti-psychotics are always avoided in PD psychosis because they block dopamine receptors and can cause significant problems with movement. However, two anti-psychotic medications, quetiapine and clozapine, are sometimes used as they have less of an ability to worsen motor symptoms. However, data for the use of quetiapine is limited and clozapine requires the patient to undergo frequent blood draws to monitor blood counts. A newer medication pimavanserin, was approved by the FDA to treat PD psychosis. It has a different mechanism of action, and does not block the dopamine system, but rather the serotonin system, and therefore does not increase motor symptoms.
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Studies On The Activity Of Melatonin In Animal Models Of Parkinsons Disease
Besides the degeneration of DA-containing neurons in the substantia nigra pars compacta , PD is considered a progressive disease that affects various neurotransmitter systems. A major argument in this respect is the demonstration that Lewy bodies are located not only in DA neurons but also in raphe nuclei serotonergic neurons, in brainstem noradrenergic neurons and in specific cholinergic neurons all over the CNS . Non-motor symptoms in PD, like gastrointestinal, genitourinary and cardiorespiratory disorders, neuropsychiatric, visual, and sleep-related disorders and anosmia can thus be explained. In fact, since the preclinical non-motor phase of PD can span more than 20 years, the importance of neuroprotection in this regard is evident.
Microglial activation, astrogliosis, and lymphocytic infiltration are the inflammatory patent of PD . The aggregation of fibrillar -synuclein is typical of PD and other Lewy body diseases . Mitochondrial dysfunction plays a role in this process, as free radicals promote protein folding and aggregation.
TABLE 1. Effects of melatonin in animal models of PD.
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Limitations Of The Pdss
There are limitations of this scale like any subjective semiquantitative scale which attempts to provide a holistic and clinical assessment of the complex aetiology of sleep problems in Parkinsons disease.
First, we have not validated this instrument against a gold standard measurement of sleep architecture such as polysomnography. However, we feel that a complete validation of the PDSS is impossible, as several of the 15 items have no gold standards that could be validated polysomnographically. Our aim is to provide a simple, clinical, inexpensive bedside tool for semiquantitative evaluation of sleep problems in Parkinsonian syndromes.
Second, we are unable to comment on the confounding impact of concomitant medical conditions upon the PDSS scores obtained for individual items. The age matched controls, however, may have suffered from a similar amount of concomitant disorders. It would be necessary to control for depression, psychosis, and other disorders such as arthritis that may have a confounding influence on sleep in future studies.
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Rapid Eye Movement Sleep Behavior Disorder
Rapid eye movement sleep behavior disorder is a parasomnia that arises out of REM sleep and leads to a loss of paralysis of skeletal muscles where patients may exhibit dream enactment behavior . These behaviors during sleep may range from mild muscle twitches to vocalizations to violent and complex motor behaviors. This can lead to falling out of bed, self-injury, or injury to bed partners . In fact, bed partners may be the first to note these types of complex behaviors during sleep, as patients themselves are unaware of most episodes . The prevalence of RBD is estimated to be 0.51% of the general population, but up to 50% in the PD population . A diagnosis of probable RBD can be made clinically based on the presence of nocturnal behaviors associated with vivid or violent dreams . A definitive diagnosis requires polysomnography confirmation of abnormal tonic elevation and/or bursts of muscle tone measured by electromyography , termed loss of REM atonia . The underlying mechanism leading to loss of REM atonia in PD is likely mediated by accumulation of alpha-synuclein in pontine nuclei such as the sublaterodorsal nucleus and ventral medial medulla, which send inhibitory projections to the spinal motor neurons during REM sleep . For a number of patients with PD, the symptoms of RBD precede motor manifestations and a formal diagnosis of PD by a median time of 10 years, providing an opportunity for early diagnosis and neuroprotective interventions .
Fig. 2
Excessive Daytime Sleepiness And Fatigue
Tiredness during the day is one of the more common difficulties experienced by people with PD. EDS should be differentiated from fatigue . While it can be difficult to clinically distinguish fatigue and tiredness, the distinction is possible with Multiple Sleep Latency Test done in a sleep lab. Estimates of the occurrence of EDS range from 1550%31 and fatigue is found in up to 59% of patients.32 The presence of both EDS and fatigue are significantly correlated with more severe disease, more disability, cognitive decline and depression.33
Treatment may also include a variety of environmental and behavioral approaches that, while not studied in PD, have been found to be helpful in other populations. Regular mild exercise is a mainstay of the treatment of fatigue and should usually be recommended. A stimulating daytime environment and exposure to intense light in early morning may be of use. Stimulant medications should be considered in refractory situations. Small controlled trials of modafinil have found a modest effect on EDS in PD patients.34 Other stimulants, such as methylphenidate, may improve EDS and fatigue, though there are no controlled studies addressing this issue.
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Good Night: Sleep And Parkinsons Disease
Lack of good sleep can worsen Parkinsons symptoms. In this 45-minute lecture, Dr. Rafael Zuzuárregui addresses causes of sleep loss and the latest treatments for: insomnia, restless leg syndrome, REM sleep behavior disorder, nocturnal urination, hallucinations, wearing off of medication, dystonia and sleep apnea.
Sleep And Parkinsons Disease
The Palo Alto Parkinsons Disease support group February 2020 meeting featured Dr. Emmanuel During, a Stanford sleep medicine neurologist. During the meeting, Dr. During discusses sleep disturbances that can occur in PD, such as insomnia, restles legs syndrome, sleep apnea, and REM sleep behavior disorder , along with available treatments. There’s a question and answer session.
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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.