The Parkinson Association of Northern California (PANC) hosted a virtual conference on Parkinson’s disease (PD) in late October. Erica Byrd, MD, movement disorder specialist at Sutter Roseville, spoke about sleep and PD. Dr. Byrd discussed several sleep problems that can occur in PD patients, including excessive daytime somnolence, sleep apnea, restless leg syndrome, insomnia, and REM sleep behavior disorder. She also addressed treatment for these problems.

Dr. Byrd offered some sleep hygiene tips, including:

• Go to bed at the same time and wake up the same time everyday
• Keep naps short and before 3 pm
• Get sunlight exposure during daytime
• Purchase satin sheets to move better in bed

You can find lots more resources on sleep issues in PD on the Stanford Parkinson’s Community Outreach website here.

We’ve been told that eventually the links to the conference talks will be available online. For the next two months, only conference registrants can view the recordings.

In the meantime, I listened to this webinar and am sharing a summary of the talk below. 

– August Besser

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“Sleep in Parkinson’s” – Lecture Notes

Speaker: Erica Byrd, MD, movement disorder neurologist, Sutter Roseville

Conference Host: Parkinson Association of Northern California

October 24, 2020

Summary by August Besser, Stanford Parkinson’s Community Outreach

Importance of Sleep

• Sleep affects many aspects of our wellness: cognition, mood, general wellbeing, energy to do daily activities
• Poor sleep can affect caregivers- correlates with greater caregiver burden and quality of life

What is Normal Sleep?

• Sleep latency: amount of time it takes to fall asleep after the lights are turned off
• Normal: 10-20 minutes
• Different stages of sleep: REM and non-REM

Sleep in PD

•  One of the most common non-motor symptoms of PD
• Majority of PD patients will have at least one sleep complication
• Insomnia
• Excessive daytime sleepiness
• Restless leg syndrome
• Behavioral

Sleep Disturbance in PD

• Symptoms include: excessive daytime somnolence, sleep apnea, restless leg syndrome, insomnia, poor sleep hygiene, REM sleep behavior disorder

Insomnia

• >75% prevalence
• Difficulty falling or staying asleep
• Results in daytime impairment
• Most commonly issues with staying asleep (sleep maintenance)
• Multiple potential causes: motor off symptom, night-time urination, anxiety, medication effects, sleep apnea, restless leg syndrome, REM sleep behavior disorder, poor sleep hygiene

Insomnia Treatment

• Find reversible or treatable causes, such as:
• Motor off state (tremor, pain)
• Anxiety/depression
• Medication side effects (amantadine, selegiline, dopamine drugs)
• Night-time urination
• Sleep apnea
• Restless leg syndrome
• REM sleep behavior disorder
• Sleep hygiene issues
• Limited drug treatments
• Adjust sleep schedule
• ]Cognitive behavioral therapy

Cognitive Behavioral Therapy for Insomnia (CBTI)

• Structured program to identify behaviors affecting sleep and replace with healthier sleeping habits
• Works by helping you to overcome the underlying sleep problem
• How to do?
• Cognitive behavioral therapist
• Apps also available:
  • CBT-I Coach
  • Calm (meditation and sleep stories)

Restless Leg Syndrome (RLS)

• RLS is common in the general population
• Increased prevalence in PD 15-20%
• More common with duration of disease
• Most likely due to medication effect
• RLS criteria
• Urge to move legs
• Worsened by rest
• Improved with activity
• Worse in evening

Restless Leg Syndrome Treatment

• Rule out mimickers (joint or muscle pain, cramps, circulation problems)
• Look for triggers (antidepressants)
• Evaluation for low iron
• Reduce dopamine medication (often not possible)
• Gabapentin/Lyrica

Excessive Daytime Somnolence

• Excessive daytime somnolence is not fatigue (fatigue = drained, exhausted)
• Somnolence = sleepiness
• Very common in PD, over 1/3 of patients (range 15-75%)
• May be prodromal symptom of PD
• May be due to medications early in disease
• Sleep attacks may be caused by dopamine agonists
• Associated with advanced motor impairment/progression of disease, males, and use of PD meds

Excessive Daytime Somnolence Treatment

• Treat sleep apnea if present
• Adjust/reduce any contributing medications
• Limited medication options (stimulants, caffeine)
• Caution must be used for stimulants due to cardiovascular side effects
• Light therapy can be beneficial

REM Sleep Behavior Disorder (RBD)

• Approximately half of patients with PD
• During REM sleep muscles should be paralyzed; loss of muscle paralysis leads to dream enactment
• Dreams can be vivid or life threatening
• Can lead to injury for patient or hitting of bed partner
• May be under recognized in women with PD
• Usually less aggressive dream enacting behaviors and fewer injuries

REM Sleep Behavior Disorder Treatment

• Number one goal is to prevent injury during sleep
• Bedroom safety: remove firearms or large objects that could be used as weapons during dream enactment, lower height of bed, sleep separately from bed partner, bed rail
• Melatonin (before bedtime)- primary purpose is for dream enactment not insomnia
• A low dose of Clonazepam (benzodiazepine)
• Have a bed alarm- voice recording of familiar voice providing reassurance
• Can be exacerbated by certain medications (antidepressants)

Obstructive Sleep Apnea (OSA)

• Common in general population (25% prevalence)
• People with Parkinson’s disease and OSA tend to be thinner
• Screening for OSA is done with a questionnaire, but daytime somnolence is not specific
• Sleep study can be offered but not necessarily routine
• Consider especially if witnessed apnea, stroke history and willing to undergo test/treatment
• Treatment: positive airway pressure (CPAP/biPAP)
• Work with sleep specialist for other options if the person is unable to tolerate CPAP/biPAP

Sleep Hygiene

• Sleep hygiene is improving sleep practices and behaviors
  • Go to bed at the same time and wake up the same time everyday
  • Keep naps short and before 3 pm
• Most people typically need 7-9 hours per night
• Make sure to get sunlight exposure during daytime

Sleep Hygiene Tips

• Purchase satin sheets to move better in bed
• Have bed space conducive to sleep
• Avoid electronics
• Don’t stay in bed longer than 15-20 mins if you can’t sleep 
• Avoid stimulation right before bed (i.e., caffeine, nicotine, alcohol, food, and vigorous exercise)

Sleep and Exercise

• There was a recent study of people with PD not in a regular exercise program
• Two groups
  • Exercise group: supervised exercise 3 times a week for 16 weeks (exercised prior to 2 pm)
  • Sleep hygiene, no-exercise control group: in-person discussion, monthly phone calls
• Results: exercise group showed improvement in sleep efficiency and improvements in other sleep parameters
• High intensity exercise may improve sleep too

In Summary

• Sleep disturbances are intrinsic to PD
• REM sleep disorder and excessive daytime somnolence are more specific to PD
• Poor sleep hygiene, sleep apnea, insomnia, restless leg syndrome are more common in the general population
• Many of these disorders can be treated and/or improved upon

Questions

Q.   What are the best sleep aids for people with Parkinson’s disease?A.   Low doses of melatonin. Mirtazapine.

Q.   What about CBD or THC for sleep?
A.   THC is not recommended due to side effects. Not opposed to CBD, need more research. Purchase from a trusty source and watch for side effects.

Q.   Why is Benadryl not good for PD patients?
A.  Even though it’s over the counter, it’s not safe for people with Parkinson’s disease. It affects the neural pathways.

Q.   Is it possible to get 8 straight hours of sleep for PD patients?
A.   It may not always be possible. It’s more important to get good quality sleep over 8 straight hours of sleep.