Talk To Your Doctor About Sleep
Here are some questions to ask yourself:
If so, this might be a good time to approach a neurologist with your concerns. You might have a medication side effect to address, a hidden sleep disorder, or other health condition that needs treatment.
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
Long Naps And Parkinsons Risk Factor
Research published in Innovation in Aging in 2017 looked at unplanned naps among people aged 65 or older and found that almost 60 percent of those surveyed took unplanned naps. Almost 20 percent of the same baseline population took long naps of more than 1 hour. Both groups napping behaviors were associated with poorer self-reported health and a higher number of chronic conditions.2
Some research also points to naps as being associated with a higher risk for developing PD among older men.3 The International Journal of Epidemiology published a study that found that men who napped at least an hour every day were more likely to develop PD. Fortunately, it appears that napping for 30 minutes or less did not result in the same risk factors for PD.
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Periodic Limb Movement Disorder And Restless Legs Syndrome
Do you often feel the irresistible urge to move your legs around during the night in order to get comfortable? If so, you might have restless legs syndrome . This condition can be associated with PLMD . PLMD causes slow rhythmic movements of the legs and feet, whereas restless legs syndrome causes more twitchy unpleasant sensations in the legs. Naturally, if you are frequently moving your legs, you are likely to wake up throughout the night, limiting your ability to get a good nights sleep. Periodic limb movements are quite common in older adults as well as those with Parkinson’s. Restless legs syndrome frequently affects middle-aged and older adults in addition to people with PD.
Strategies That Improve Wakefulness During The Day
Non-pharmacologic interventions for EDS
- Encourage daily exercise and activities a person without an activity planned is much more likely to doze than one who is engaged in an activity. Be realistic about scheduling a person with advanced PD, but aim for at least one scheduled activity a day
- Light therapy Light therapy, in which a person is exposed to bright light via a light box, is used as a treatment modality for sleep disorders and psychiatric disorders not associated with PD. A small clinical trial testing its efficacy in PD was conducted and demonstrated an improvement in sleep and in excessive daytime sleepiness.
Pharmacologic interventions for EDS
There are no FDA approved medications for EDS in the context of PD. However, clinicians sometimes prescribe medication off-label for EDS. These include modafinil, methylphenidate, and caffeine. Istradefylline is a medication approved to treat motor symptoms of PD. A small trial demonstrated its potential improvement of EDS as well. Talk with your physician about the possibility of using a medication to maintain wakefulness during the day.
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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.
Nighttime Tips For Better Sleep
For more insights on this topic, listen to our podcast episodeParkinsons Disease and Sleep.
*Please note that not all content is available in both languages. If you are interested in receiving Spanish communications, we recommend selecting both” to stay best informed on the Foundation’s work and the latest in PD news.
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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.
Rem Sleep Behavioral Disorder
Rapid eye movement, or REM, sleep is a normal part of the sleep cycle when people dream. Usually the only part of the body that moves during REM is the eyes, thus the name.
- People with rapid eye movement sleep behavior disorder do not have the normal relaxation of the muscles during their dreams. Therefore, they act out their dreams during REM sleep.
- People with RBD may shout, kick their bed partner or grind their teeth. Sometimes, in moderate to severe RBD, people may have aggressive, violent behaviors, like getting out of bed and attacking their bed partner.
- About half of people with PD suffer from RBD. It may develop after or along with the disease, but in most cases, it precedes the PD diagnosis by five to 10 years.
RBD Treatment
- Consider making environmental adjustments to protect the person with RBD and bed partner from injury. This may include padding the floor, using bed rails or sleeping in separate rooms.
- Clonazepam has been shown in large case series to improve RBD in 80 to 90 percent of cases. The dose of clonazepam required is low, usually from 0.5 mg to 1.0 mg. The adverse effects of clonazepam include nocturnal confusion, daytime sedation, and exacerbation of obstructive sleep apnea, if present. It is in generic form and not expensive.
- Talk to your doctor about the over-the-counter sleep aid Melatonin. Doses up to 12 mg at night one hour before can improve RBD.
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If You Live In South Jersey And Have Questions About The Final Stages Of Parkinsons Disease Or Hospice Care For Your Loved One Please Call Samaritan At 229
Samaritan is a member of the National Partnership for Healthcare and Hospice Innovation, a network of not-for-profit hospice and palliative providers across the country. If you know someone outside of our service area who is living with advanced illness and can benefit from hospice or palliative care, please call 1 -GET-NPHI for a referral to a not-for-profit provider in your area.
When To Seek Hospice Care
When you or your loved one have a life expectancy of six months or less, you become eligible for hospice care a type of comfort care provided at the end of life for someone living with end-stage Parkinsons disease. Hospice provides extra support so your loved one can live as comfortably as possible.
If you have experienced a significant decline in your ability to move, speak, or participate in activities of daily living without caregiver assistance, its time to speak with a hospice professional.
Read more: What is hospice care?
Some of the things that determine whether your loved one with end-stage Parkinsons is eligible for hospice include: difficulty breathing, bed bound, unintelligible speech, inability to eat or drink sufficiently, and/or complications including pneumonia or sepsis.
If you live in South Jersey, our nurse care coordinator can answer your questions and decide if your loved one is ready for hospice care. Call us 24/7 at 229-8183.
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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 ).
Why Do Parkinsons Patients Have Trouble Sleeping
Despite having daytime tremors, Parkinsons patients do not shake in their sleep. However, both Parkinsons disease itself and the medications used to treat it can give rise to a number of sleep problems that lead to insomnia and excessive daytime sleepiness.
Patients with motor symptoms may have trouble adjusting sleeping positions to get comfortable. Others may experience distressing nocturnal hallucinations when trying to fall asleep. These may be a result of medications or cognitive impairment.
In turn, excessive daytime sleepiness may occur as a consequence of sleeping poorly at night. It may also be triggered by medications. Parkinsons patients who suffer from EDS may be at a higher risk of accidents and unable to safely carry out activities such as operating a motor vehicle.
Since insomnia frequently goes hand-in-hand with anxiety and depression, it may be a contributing factor to sleep problems in people with Parkinsons disease. For that reason, doctors often look for mental health disorders in people with Parkinsons disease who have sleep problems.
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Whats The Relationship Between Parkinsons And Sleep
Parkinsons disease and sleep are connected in complex ways that not even scientists completely understand quite yet.
Sometimes, Parkinsons disease directly causes sleep problems. According to one study, sleep-related symptoms may be one of the earliest signs of Parkinsons disease. These signs may include things like thrashing while youre asleep.
Other factors can also play a role. One thing is clear: For many people with Parkinsons disease, a restful nights sleep can be hard to find.
The Treatment Of Sleep Disorders In Parkinsons Disease: From Research To Clinical Practice
- 1Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- 2Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
Sleep disorders are one of the most frequent non-motor symptoms of Parkinsons disease , usually increasing in frequency over the course of the disease and disability progression. SDs include nocturnal and diurnal manifestations such as insomnia, REM sleep behavior disorder, and excessive daytime sleepiness. The causes of SDs in PD are numerous, including the neurodegeneration process itself, which can disrupt the networks regulating the sleepwake cycle and deplete a large number of cerebral amines possibly playing a role in the initiation and maintenance of sleep. Despite the significant prevalence of SDs in PD patients, few clinical trials on SDs treatment have been conducted. Our aim is to critically review the principal therapeutic options for the most common SDs in PD. The appropriate diagnosis and treatment of SDs in PD can lead to the consolidation of nocturnal sleep, the enhancement of daytime alertness, and the amelioration of the quality of life of the patients.
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Tips For Better Sleep
- Keep a regular sleep schedule go to bed at the same time and get up at the same time.
- Choose your bedtime based on when you want to get up. Plan to spend seven to eight hours a night in bed.
- Make a bedtime routine for example, snack, bath, tooth-brushing, toileting and follow it every evening.
- Spend time outdoors and exercise every day, in the morning if possible. Avoid exercise after 8:00 p.m.
- If you cant get outdoors, consider light therapy sitting or working near a light therapy box, available at drug stores and department stores.
- If you nap, try to do so at the same time every day, for no more than an hour, and not after 3:00 p.m.
- Sleep in a cool dark place and use the bed only for sleeping and sexual activity.
- Do not read or watch television in bed.
- Use satin sheets and pajamas to make moving in bed easier.
- Minimize drinking liquids for three hours before bedtime to avoid frequent nighttime urination.
- Go to the bathroom immediately before retiring.
- Place a commode next to the bed, to minimize the effort, and light to get up during the night.
- 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
- Clock watching
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Mechanism Of Arousal In Parkinsons Disease And Dementia With Lewy Bodies
Lewy body disease affects the brainstem and hypothalamic sleep-wake centers, and the pathology affects multiple neurotransmitter systems . Saper et al. have provided data and a theoretical framework for a neuroanatomic flip-flop switch that regulates the transition from sleep to wakefulness. It includes mutually inhibitory elements responsible for sleep initiation, and brainstem nuclei that promote arousal. One hypothesis for the daytime somnolence in PD and DLB may be associated with the disruption of the wakefulness centers, but perhaps also to damage to the mechanism that switches and maintains wakefulness, presumed to reside in the hypothalamic hypocretin neurons. Involvement of the latter may lead to difficulty keeping the arousal switch in place, which may result in trouble maintaining wakefulness and/or frequent brief transitions of sleep into wakefulness, or microsleeps.
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Parkinsons Sleep Problems: Diagnosis And Treatment
Parkinsons disease is chronic and progressive, meaning it tends to get worse over time. However, there are treatment options that can help manage symptoms and allow patients to get more restful sleep.
The simplest way to start sleeping better with Parkinsons disease is by adopting healthy sleep habits. Sleep hygiene tips for Parkinsons disease sufferers include:
- Sticking to regular bedtimes
- Following a consistent bedtime routine with soothing activities such as listening to music or reading a calming book
- Getting regular exercise, preferably early in the day
- Getting adequate exposure to light, whether outdoors or through light therapy
- Avoiding long naps and naps late in the day
- Creating a cool, dark, and comfortable sleeping environment
- Restricting bedtime activities to sex and sleep only
- Turning off screens an hour before bedtime
- Reducing liquid intake before bedtime
- Avoiding caffeine, alcohol, and tobacco
- Eating a healthy diet and avoiding large meals at night
Light therapy, exercise, and deep brain stimulation have been successfully used to improve overall sleep quality and to treat specific conditions, such as REM sleep behavior disorder, in patients with Parkinsons disease. Cognitive behavioral therapy for insomnia has proven effective at reducing insomnia in healthy adults, although further research is needed on the effects of CBT in patients with Parkinsons disease.
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Solutions For Daytime Sleepiness
The Michael J. Fox foundation offers some simple solutions in sleep hygiene that may help improve nighttime sleep, which by default can help prevent daytime sleepiness:4
- Plan your daytime naps, and limit them to less than 30 minutes. Longer and later naps disrupt circadian rhythms and make it harder to fall asleep at night.
- Stick to a bedtime routine that includes sleep-friendly activities that help you relax, and maintain a consistent bedtime and wake time, even on the weekends.
- Avoid blue spectrum light exposure at night by turning off computers and handheld electronic devices an hour before bedtime. The light emitted from these screens suppresses the melatonin production in the brain which is necessary to help the brain and body transition to sleep.
- Try not to drink too much fluid before bedtime to prevent the need for nighttime trips to the bathroom.
- Avoid caffeine after lunch and alcohol at bedtime. Both will disrupt your ability to fall asleep and stay asleep.
- Daytime exercise can help the circadian system stay on track and usually leads to better sleep at night.
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