In mid-March, the Parkinson Association of the Rockies hosted a webinar on “Sleep and Fatigue in Parkinson Disease” with Dr. Alexander Baumgartner. He is a movement disorder fellow at the University of Colorado’s Movement Disorders Center.  Dr. Baumgartner indicated that as many as 90% of those with Parkinson’s Disease (PD) have a sleep disorder.  He contrasted sleepiness and fatigue.  Sleepiness is the tendency or ability to fall asleep. Fatigue is similar, and is associated with excessive tiredness and mental or physical exertion. 

Common sleep issues in PD are REM sleep behavior disorder, restless leg syndrome, periodic limb movement disorder, insomnia, daytime sleepiness, and sleep apnea. Most sleep problems are treatable in multiple ways including medication. Dr. Baumgartner went over different symptoms and their possible impact on daily activities for those with PD. Dr. Baumgartner recommended speaking to a general practitioner or sleep specialist for more information. 

For more resources, please see the Stanford Parkinson’s Community Outreach pages: 

• Sleep
• Fatigue

Please see below for notes on the March 19th webinar.

Regards, 

– Joëlle Kuehn

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“Sleep and Fatigue in Parkinson Disease”

Speaker: Alexander Baumgartner, MD, fellow in movement disorders, University of Colorado’s Movement Disorders Center

Host: Parkinson Association of the Rockies (PAR)

Webinar Date: March 19, 2021 

Summary by Joëlle Kuehn, Stanford Parkinson’s Community Outreach

 Fatigue vs. Sleepiness:

• Sleepiness:
  • Tendency or ability to fall asleep
• Fatigue:
  • No universal definition of fatigue specific to PD
  • Excessive tiredness associated with mental or physical exertion 
  • Other terms: exhausted, drained, lack of energy 
  • Peripheral:
    • Measurable lock of muscle strength with repetition
  • Central:
    • A state of feeling exhausted, drained, wiped, etc.
    • Can have both mental or physical manifestations
  • People with PD usually have peripheral and central

Causes of Fatigue:

• Depression
• Sedating effects of medication
• Poor sleep (insomnia, frequent urination, sleep apnea, other sleep disorders)
• Dementia (mild cognitive impairment)
• Anemia
• Orthostatic hypotension (blood pressure drops when changing position from sitting to standing
• Thyroid disorders
• Progression of PD itself

Treatment of Fatigue:

• Managing the time you have energy during the day
  • Utilize best times: Get exercise or errands during the time when your energy is at its maximum
  • Budget energy over the day
  • Power naps (20-30 min)
• Exercise regularly
• Maintain a stimulating environment
  • Having bright and natural light
  • Not staying in the same room with the same background noises
  • Add lights to dark areas
  • Bright light therapy
  • Doing crossword puzzles or other things that keep your brain active and engaged
• Removing sedating and fatigue-inducing medications
• The use of stimulants is still unclear

Sleep Disorders:

• Everyone needs high quality sleep.  It comes down to hours and quality, which should be consistent
• Why is sleep important?
  • Memory consolidation 
  • Energy levels
  • Thinking/cognition
  • Mood
  • Physical performance
  • Alertness
• Very common in PD – as high as 90% of PD patients may have some form of sleep disorders
• Silver lining: most are treatable

Effects of Sleep Deprivation:

• Cognitive: 
  • Irritability
  • Cognitive impairment
  • Memory lapses or loss
  • Impaired moral judgement
  • Severe yawning
  • Hallucinations
  • Symptoms similar to ADHD
• Impaired immune system
• Risk of type 2 diabetes
• Heart:
  • Increased heart rate variability
  • Risk of heart disease
  • High cholesterol 
• Muscles:
  • Increased reaction time
  • Decreased accuracy
  • Tremors
  • Aches
• Other:
  • Growth suppressor
  • Risk of obesity
  • Decreased temperature

REM Sleep Behavior Disorder (RBD):

• REM – Rapid eye movement deep sleep where people have dreams
• Abnormal movements during REM sleep
  • Acting out dreams
  • Normally muscles are paralyzed during REM sleep
• Potential harm to individual with RBD and bed partner
• Occurs typically 90 minutes after sleep onset
• Seen in 25-50% of patients with PD
• May be one of the first symptoms of PD and can be there years or decades before the other symptoms
• As many as 90% of people who have REM sleep behavior disorder will develop PD or other similar conditions.  This fact could be useful in the future for treatments to slow or prevent PD?
• Symptoms
  • People usually don’t notice symptoms because they are in a deep sleep, but the person sharing a bed will notice
  • Yelling or talking during sleep
  • Having conversations with bed partner
  • Movements, often violent or defensive
  • Almost never sleep walking
  • Dreams of situations where they are under duress or attack

RBD Treatments:

• Safety precautions:
  • Lower the bed
  • Move things out of the way that you could hit (nightstands, furniture)
  • Padded side rails; padded floor
  • Sleep in separate beds
  • Sleeping bag with a zipper
• Medications
  • Melatonin
    • Natural sleep-promoting hormone
    • Helps fall asleep and stay in deep REM sleep
    • Talk to doctor about dosing
  • Clonazepam (Klonopin)
    • Initially a anti-seizure / anti-anxiety medication
    • Slows down signalling in brain
    • Be aware of side effects: drowsiness, falls, poor memory / thinking

Restless Leg Syndrome:

• Common in general population but more common with people with PD
• Urge to move or unpleasant sensation
• Beginning or worsening during periods of rest or inactivity (laying down or sitting)
• Partially or totally relieved by movement such as walking or stretching, at least as long as the activity continues
• Worse in the evening or night, or only occur in the evening or night
• In PD:
  • Occurs in 15-30% of people with PD
  • May be associated with low iron, end stage renal disease, neuropathy, kidney disease, and pregnancy
  • Diagnosis typically made by a physician. In some cases if there is uncertainty a sleep study is needed

Restless Leg Syndrome Treatments:

• Look for conditions that may be making it worse 
• Consider stopping antidepressants or antihistamines
• Avoid nicotine, caffeine, alcohol
• Exercise or warm bath before bed
• Eat an iron-rich diet: enriched breakfast cereals/grains, beans, tofu, seeds (pumpkin, sesame), nuts, broccoli, spinach, beef, chicken, mussels, oysters
• Iron therapy (even if iron levels are “normal”)
• Medication:
  • Gabapentin, Pregabalin
    • Side effects: sleepiness, grogginess, swelling
  • Dopamine Agonists – affect signalling of dopamine in the brain
    • Pramipexole, Ropinirole, rotigotine patch
      • Side effects: Sleep attacks, impulse control disorders, augmentation (can cause even worse RLS symptoms: early start of onset, increase intensity, and involvement other body regions)
  • Opiates: Tramadol, Oxycodone, Methadone

Periodic Limb Movements in Sleep:

• Repetitive, highly stereotyped limb movements (bending hip or knee, periodical (every 10-15 seconds)
• May occur in healthy individuals
• Prevalence increases with age
• Associated with several sleep disorders but especially RLS
  • Also associated with heart disease, kidney disease, and medication use (antidepressants)

Periodic Limb Movement Disorder:

• PLMS index (number of PLMS per hour) is 15 or more
• Clinical sleep disturbance or daytime fatigue – symptoms in day to day life
• Treatment: benzodiazepines, dopaminergic medications

Hypnic Jerks / Sleep Starts:

• Jerky movements usually involve different and isolated body segments.  Can involve the whole body, not just limbs
• A feeling of “shock” or “falling into the void”
• Happens during the transition between being awake to sleep
• Triggered by fatigue, stress, sleep deprivation, vigorous exercise (especially before bed), caffeine, and nicotine
• 70% of adult population has them

Sleep Apnea:

• Back of the tongue collapse against the palate blocking the airway
• Happens during deeper sleep
• Witnessed breathing interruptions or awakening due to gasping or choking for air with greater than 5 events/hour
• Brain naturally wakes you up
• Very short awakenings: usually not noticeable
• Snoring is not normal in sleep – snoring can be an indicator that some degree of apnea is happening
• Has a host of affect on neurologic health and general health:
  • Increased risk of impotence, hypertension, obesity, drowsiness, fatigue, diabetes, car accidents, job impairment, arrhythmia, heart attack, headache, stroke, lung hypertension, dementia and memory loss
• How do you diagnose it:
  • Polysomnography (sleep study)
  • Can be at hospital or at home
• Treatment:
  • CPAP: positive pressure ventilation
  • Oxygen
  • Devices to pull jaw forward

Insomnia:

• Inability to fall asleep within 30 minutes
• Long periods of wakefulness during the night
• Waking up too early in the morning
• Most common sleep disorder in PD (37-88%)
• Causes:
  • Going to bed too early or too late (dysregulated sleep cycles)
  • Naps
  • Anxiety, depression
  • Inconsistent schedule
  • Restless legs
  • Sleep apnea
  • Medication side effects
  • Worsened PD symptoms: rigidity/wearing off of medications, discomfort from decreased movement

Treatments of Insomnia:

• Sleep hygiene – keeping excellent sleep routine/schedule
  • Exercise
  • Avoid caffeine and alcohol after 4PM
  • Avoid late evening meals
  • Minimize napping (no more than 20-30 minutes)
  • Avoiding screens
  • Peaceful routine before bedtime
  • Establish bedtime routine
  • If unable to sleep within 15 minutes, get out of bed, read, walk around.  Try to designate the bed just for sleeping
  • Make the bedroom comfortable
• Medical Treatments:
  • Melatonin – natural hormone to help with sleep
  • Rotigotine 24-hour patch
  • Long-acting carbidopa/levodopa
  • Deep brain stimulation.  May improve sleep time and quality though results are somewhat mixed

Excessive Daytime Sleepiness:

• Tendency to fall asleep more than desired during the daytime
• Good sleep is about quantity, quality and timing
• If none of the above are problematic, also consider:
  • Medication side effects (dopamine agonists)
  • Mental health issues
  • Seeing a sleep specialist
• Medical treatments:
  • Caffeine
  • Modafinil: a stimulant with similar efficacy as caffeine, minimal side effects

Question & Answer:

Question: Someone gets panic attacks when they lay down at night. Any thoughts on that?

Answer:  This isn’t something we typically think about as a sleep issue. It could be a part of a hypnic sleep jerk. They could also be true panic attacks that happen to come on at night.

Question: Does dreaming mean you are getting REM sleep?

Answer: For the most part yes. Dreams that are vivid and complex and there’s talking and realistic are REM sleep. Simple dreams may not be REM.

Question: Can melatonin be taken nightly long-term?

Answer: Yes, we don’t know of any addictive effects. 

Question: Does melatonin affect your ability to drive the next day?

Answer: Sometimes when people start melatonin they can feel groggy or sleepy the next day, but if you wake up feeling refreshed the next day feel free to drive. 

Question: How do you manage restless legs with PD patients taking Sinemet, in particular avoiding augmentation of  RLS while achieving the right Sinemet dose for PD symptom control? 

Answer: Sometimes they are in conflict. We have to be cautious and judicious about timing and dosing of Sinemet, and usually try to make an effort to make sure that people aren’t experiencing the early signs of augmentation because that’s the time to catch it before things get out of hand. We’d try a patch or other medications that don’t carry the risk of augmentations and we’ll look at iron supplementation or exercise instead. 

Question: Is heartburn typical for PD?

Answer: It’s typical for so many people that it’s hard to say it’s more common for people with PD. It’s very common for the general population.

Question: What is your recommendation for an average amount of sleep for PD patients?

Answer: It varies person to person. Typically we don’t think they need more sleep than the general population. Generally people need about 7-8 hours of sleep to feel refreshed and restored. As people age, the structure of sleep changes (less time in REM), and people’s sleep needs may change. Whether it’s due to PD or aging can be difficult to say. 

Question: After a sleepless night how do you catch up on lost sleep without nap?

Answer: Try to maintain a wakefulness-promoting environment as best you can. Try to not spend the whole day on the couch. Get natural light and some exercise. Try to change the environment (different rooms). Short power naps can be helpful but don’t think of catching up for lost time.

Question: Is REM sleep the same as deep sleep?

Answer: No, REM sleep is this strange in-between stage and has features of both light and deep sleep, but it usually follows the deepest sleep stage.    

Question: What is the normal amount of deep sleep during the night?

Answer: This changes as people age, so someone in their 30-40s might get 2 hours, and as people age it can be an hour or even less. Some people with disordered sleep might not get any deep sleep.