Sleep Disturbances

 Key Facts

  • Sleep disturbances are common in PD even before motor symptoms.
  • Parkinsonian medications can also cause sleep disturbances.
  • Diagnosis usually requires a family member.
  • Any sleep medication may result in morning sedation and should be used with caution.

Clinical Best Practices

  • Ask your PD patient/caregiver about sleep disorders.
  • Revise medication schedule in your patient with sleep disorder.

Sleep disturbances with PD patients are common for a variety of reasons. One early symptom of PD is REM sleep behavior sleep disorder (RBD). This typically manifests itself years before the clinical diagnosis of PD based on motor symptoms is made. Sleep disruption, secondary insomnia, restless legs syndrome (RLS), and other sleep issues may be exacerbated by PD medications.

Presentations

  • Insomnia (may be secondary to medications)
  • Frequent night time wakening (nocturia, delirium)
  • Non-restorative sleep
  • RBDi
  • Daytime somnolence
  • Sleep apnea

Common Causes

Diagnosis

  • History
  • Polysomnography
  • Multiple Sleep Latency Testi
  • Epworth Sleepiness Scalei

Barriers to Diagnosis

  • High index of suspicion
  • For REM sleep behavior disorder, spouse or family member often required for history

Treatment Options

  • Insomnia: Ensure that exacerbating medications are minimized or taken earlier in the day; increase exercise, encourage good sleep hygiene, try melatonin 3-18 mg/night.
  • Frequent night time wakening: Try melatonin, tricyclic antidepressants; address nocturia;
  • Non-restorative sleep: Ensure that patient does not have RBD or depression; try exercise, melatonin.
  • RBD: Try melatonin 3-18 mg/night, clonazepam 0.5 mg qhs; check for depression and treat.
  • Daytime somnolence: Minimize/stop dopamine agonists; minimize levodopa; increase activity to keep patient engaged during the day; check for dementia, orthostatic hypotension.

Important Caveats to Therapy

  • Always be cautious with clonazepam–may result in morning “hangover” feeling, confusion, or grogginess and thereby increase risk of falling.
  • Any sleep medication may result in morning sedation and should be used with caution.
  • Modafinil may improve perception of wakefulness but does not improve objective measures of wakefulness.
  • Subthalamic nucleus deep brain stimulation (STN DBS) improves sleep–in those requiring STN DBS for motor control.
References: 

Zesiewicz TA, Sullivan KL, Arnulf I, et al. Practice Parameter: treatment of nonmotor symptoms of Parkinson disease: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2010;74(11):924-931.