Herbie Murray
Sleep issues are common in people with Parkinson's disease, with up to 2 in 3 people suffering from sleep problems. The disease itself may cause some sleep issues, such as REM sleep disorder, insomnia, or excessive daytime sleepiness. Sleep issues can also be caused by medications used to treat Parkinson's, which can cause side effects such as sleep attacks, hallucinations, and vivid dreams. Other factors, such as emotional challenges and pain, can also contribute to sleep disturbances. Sleep is crucial for people with Parkinson's as the body needs more time to restore and repair itself.
| Characteristics | Values |
|---|---|
| Sleep issues | Sleep problems occur at any point before or after a Parkinson’s disease diagnosis |
| Sleep-related symptoms | Thrashing while asleep, tremors, vivid dreams, nocturia, insomnia, daytime sleepiness, REM sleep disorder, sleep apnea, hallucinations, confusion, psychosis, and more |
| Sleep medications | Clonazepam, bupropion, sertraline, dopaminergic medications, oxybutynin, tolterodine, trospium, tofenacin succinate, darifenacin, mirabegron, phenoperidine fumarate, anticholinergic medications, ddAVP nasal spray, and more |
| Sleep recommendations | Avoid over-the-counter sleep medications, alcohol, caffeine, heavy exercise before bedtime, screen time, and loud noises; maintain a regular sleep schedule, a cool bedroom temperature, and good oral and sleep hygiene |
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What You'll Learn
Sleep fragmentation and REM sleep disorders
Sleep fragmentation is the most common nocturnal complaint in Parkinson's disease. Studies have found that sleep patterns are more frequently interrupted, and the amount of time spent in slow-wave and REM sleep (the deepest and most restorative phases of sleep) is significantly less than in age-matched adults without Parkinson's. This type of sleep disturbance may be associated with a greater susceptibility to medication-induced hallucinations and excessive daytime sleepiness. Excessive daytime sleepiness is a common problem in Parkinson's, with up to one-third of patients experiencing disabling sleepiness, and it can have a significant impact on their quality of life.
Sleep fragmentation can be treated with the long-acting sedative clonazepam, which is effective in 75-90% of cases and helps regulate sleep, allowing for a more normal nighttime sleeping pattern. Other alternatives include treating excessive daytime sleepiness, which often goes hand-in-hand with sleep disturbance, and cognitive behavioural therapy (CBT), which can help change patterns of negative thinking and behaviour.
REM sleep behaviour disorder (RBD) is also a common issue in Parkinson's disease. It is a parasomnia that can lead to self-injury and/or injury to partners at night. RBD is often described as "thrashing about" in sleep or "acting out" of dreams, and it is a result of impaired sleep paralysis that can manifest in Parkinson's patients and other neurodegenerative conditions. It is more frequently encountered in males with Parkinson's.
Medications can also play a role in sleep disturbances in Parkinson's disease. Certain medications can negatively influence sleep quality, and dopaminergic medications that help alleviate motor symptoms may cause sleepiness. Additionally, some patients may experience sleep attacks or increased sleepiness with certain medications. It is important to establish the relationship between increased sleepiness and medication initiation before making any changes.
Other factors that can contribute to sleep disturbances in Parkinson's include nocturia (excessive urination at night), tremors, vivid dreams, pain, difficulty getting comfortable, and mental health disorders such as depression. Sleep hygiene practices, such as maintaining a regular sleep schedule and avoiding stimulants, can help improve sleep quality.
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Medication side effects and interactions
While Parkinson's disease (PD) is predominantly a motor dysfunction, non-motor symptoms, including sleep disturbances, are also common. The impact of PD on sleep is related to motor and non-motor symptoms, as well as the disruption of pathways regulating sleep due to central nervous system pathology. Sleep issues can occur at any point before or after a PD diagnosis, and researchers estimate that up to 2 in 3 people with PD experience sleep problems.
Several medications used to manage PD can have side effects that negatively impact sleep. Levodopa-based medications, such as Sinemet, can cause vivid dreams, disturbing sleep. Amantadine, another medication used in PD management, is associated with sleepiness due to its anticholinergic properties. Dopaminergic medications can also cause sleepiness, and younger patients tend to tolerate dopamine agonists better than older patients. If daytime sleepiness occurs, a doctor may recommend decreasing the dosage of these medications.
Additionally, certain sleep medications can have serious drug interactions with PD medications, and over-the-counter sleep aids may worsen sleep problems. Therefore, it is crucial to consult a healthcare provider before taking any new medication, especially sleep aids.
On the other hand, some medications can help alleviate sleep disturbances in PD. Clonazepam, a long-acting sedative, is effective in 75-90% of cases and helps regulate sleep patterns. Anticholinergic medications, such as darifenacin (Enablex) and oxybutinin (Ditropan), can be useful for nighttime urinary frequency, a common issue in PD that disrupts sleep. For individuals with REM behavioural disorder (RBD), dopaminergic medications can resolve sleep disturbances.
Strategies for Better Sleep
In addition to medication adjustments, there are several strategies that can improve sleep for people with PD:
- Maintaining good "sleep hygiene" practices, such as waking up and going to bed at the same time each day, limiting daytime naps, and avoiding stimulants like caffeine and screens before bed.
- Relaxing activities, such as reading or listening to music, can signal to the body that it's time to settle down for sleep.
- Regular exercise can help deepen sleep, but it's important to avoid heavy exercise close to bedtime.
- Cognitive behavioural therapy (CBT) can help change negative thinking and behaviour patterns that may contribute to insomnia.
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Emotional challenges and mental health
Sleep problems are common in people with Parkinson's disease (PD), with up to 2 in 3 people experiencing some form of sleep disruption. The connection between Parkinson's and sleep is complex and not yet fully understood by scientists. However, it is known that the disease itself can cause sleep issues, such as REM sleep disorder, insomnia, and excessive daytime sleepiness. The same changes in the brain that lead to motor symptoms in PD can also affect the sleep-wake cycle, mood, and thinking.
The emotional challenges and mental health aspects of PD can significantly impact sleep. The disease can cause mood disorders, anxiety, and depression, which are often interconnected with sleep disturbances. For example, depression related to PD can lead to a loss of interest in activities and a numb feeling towards life, further exacerbating sleep problems. Additionally, the impact of sleep deprivation can extend beyond the individual with PD, as their caregivers and partners may also experience disrupted sleep patterns.
The complex interplay between PD and mental health can create a cycle that affects sleep. Sleep disturbances can contribute to the onset or worsening of mental health issues, which in turn can make it even harder to get a good night's rest. This bidirectional relationship underscores the importance of addressing both the physical and mental aspects of PD when treating sleep problems.
Medications used to manage PD symptoms can also have an impact on sleep. Dopaminergic medications, for instance, may cause hallucinations, confusion, and psychosis, particularly in combination with sleep deprivation. Additionally, certain antidepressants can influence sleep, with some aiding sleep while others may worsen sleep symptoms. The challenge lies in finding the right balance of medications that effectively manage PD symptoms without unduly disrupting sleep.
The emotional challenges associated with PD can further compound the difficulties in achieving restful sleep. The disease can bring about feelings of anxiety and depression, which are themselves associated with sleep disturbances. Managing these emotional challenges is crucial not only for overall well-being but also for improving sleep quality. This may involve seeking support from mental health professionals or support groups, engaging in therapeutic activities, or exploring medication options specifically targeting mental health concerns.
In summary, the emotional challenges and mental health aspects of PD play a significant role in sleep disturbances. The disease's impact on mood, anxiety, and depression can disrupt sleep patterns, and the resulting sleep deprivation can further exacerbate these mental health issues. Addressing these emotional challenges and mental health concerns is essential for improving sleep quality and enhancing overall well-being in individuals with PD.
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Nocturia and urinary frequency
Nocturia, or excessive urination at night, is one of the most common non-motor symptoms in Parkinson's disease (PD), affecting up to 60% of patients. It can have a significant negative impact on the quality of life of both patients and their caregivers. Nocturia is characterised by waking up from sleep more than once to pass urine. While the causes of nocturia in PD are not well understood, it is often associated with reduced functional bladder capacity or nocturnal polyuria, and its prevalence increases with the progression of PD.
Lower urinary tract (LUT) symptoms are common in PD, and nocturia is one of them. Other LUT symptoms include storage symptoms such as urinary urgency and increased daytime frequency, and voiding symptoms such as urinary hesitancy, interrupted or poor stream, and double voiding. The prevalence of LUT symptoms ranges from 38% to 71%, and their severity increases as PD progresses. Urinary symptoms can have a devastating impact on the quality of life of individuals with PD, affecting their health, mood, and overall well-being.
The management of nocturia in PD requires an individualised approach. Evaluating nocturia typically involves history-taking, medication review, and maintaining a bladder diary to record fluid intake, urinary output, and timing of voids. Standardised questionnaires such as the Urinary Symptom Profile (USP) and the International Prostate Symptom Score (IPSS) can also be used to assess LUT symptoms and their severity. Additionally, urinalysis, ultrasonography, and urodynamic studies can help assess the cause of LUT symptoms and exclude other pathologies, such as bladder outlet obstruction.
There are several medications available to manage nocturia, including oxybutynin (Ditropan), tolterodine (Detrol), trospium (Sanctura), tofenacin succinate (VESIcare), darifenacin (Enablex), mirabegron (Myrbetriq), and phenoperidine fumarate (Toviaz). In some cases, individuals with PD and nocturia may be referred to a bladder specialist (urologist) for further evaluation and management.
Nocturia can be a bothersome symptom for individuals with PD, disrupting their sleep and affecting their overall quality of life. By understanding the impact of nocturia and seeking appropriate management strategies, individuals with PD can aim to improve their sleep quality and overall well-being.
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Sleep apnea and breathing issues
Sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing. The muscle tone of the body relaxes during sleep, and at the level of the throat, the human airway is composed of collapsible walls of soft tissue. These can obstruct breathing during sleep. Sleep apnea can be seen in up to 40% of people with Parkinson's Disease (PD), compared to less than 5% of older adults without PD. Unlike the general population, people with PD who have sleep apnea may not be overweight.
People with PD often experience excessive daytime sleepiness, which negatively impacts their quality of life and increases the risk of falls. PD patients may also experience sleep fragmentation, or nocturnal sleep fragmentation, which can cause chronic sleep deprivation. This can lead to insomnia and further contribute to daytime sleepiness and fatigue. Up to one-third of PD patients experience disabling sleepiness, and this incidence increases as the disease advances.
Several studies have found that the sleep pattern of people with PD is more frequently interrupted, and the amount of time spent in slow-wave and REM sleep (the deepest and most restorative phases of sleep) is significantly less than that of age-matched adults without PD. This type of sleep disturbance may be associated with a greater susceptibility to medication-induced hallucinations and excessive daytime sleepiness.
There are several factors that can contribute to sleep issues in people with PD. Chemical changes in the brain can disrupt sleep-wake cycles, and certain medications can negatively influence sleep quality and cause sleepiness. Additionally, nocturia, or excessive urination at night, can disrupt sleep. Tremors, pain, and rigidity can also wake people up and impact sleep continuity.
To improve sleep quality, people with PD can try various strategies such as maintaining good sleep hygiene, including waking up and going to bed at the same time every day, eating regular, healthy meals at the same time, and limiting daytime naps. It is also important to avoid stimulants like caffeine and alcohol before bed, as well as heavy exercise within two hours of bedtime. Regular exercise earlier in the day can help deepen sleep.
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Frequently asked questions
REM sleep disorder, or REM behavioural disorder (RBD), is a parasomnia that can lead to self-injury and/or injury to partners at night. It is a result of impaired sleep paralysis that can manifest in patients with Parkinson's Disease and other neurodegenerative conditions. It is often described as "thrashing about" in sleep or "acting out" of dreams.
Sleep-related symptoms of Parkinson's can include thrashing while asleep, insomnia, excessive daytime sleepiness, and frequent awakenings during the night.
Sleep disturbances in Parkinson's can be caused by several factors, including chemical changes in the brain, medication side effects, emotional challenges, and circadian rhythm dysfunction.
There are several strategies that can help improve sleep for people with Parkinson's, such as maintaining good sleep hygiene, keeping a regular sleep schedule, limiting screen time and stimulants before bed, and engaging in relaxing activities before bedtime. In addition, certain medications and therapies can be prescribed by a healthcare provider to address specific sleep disorders and improve sleep quality.
