Parkinson’s disease is a disorder of the central nervous system caused due to the damage of the dopamine producing nerve cells in the brain. This dopamine deficiency manifests in the form of a constellation of slowly and continually debilitating pre-motor and motor symptoms ranging from sleeping problems, constipation, to tremors, stiffness and the loss of ability to control one’s own bodily movements.
A range of sleeping problems are associated with a large majority (about 96%) of the people suffering from Parkinson’s disease (PD) and unless they are recognized and tackled effectively, they can give rise to serious consequences. Often the sleep disorders are an early indicator of this impending neurodegenerative disorder, even before the appearance of motor symptoms, and can manifest as restless sleep, nightmares, vivid dreams, acting out dreams during sleep, and excessive daytime sleepiness. These sleep-related problems can affect the quality of life in PD patients, resulting in fatigue, poor attention, memory deficits, and predisposition to accidents.
Types of Sleeping Problems
Problems with sleep can be of two types :
- Difficulty in falling asleep – sleep onset problem.
- Inability to continue sleeping without frequent awakenings – sleep maintenance problem or sleep fragmentation. This occurs due to the frequent need to use bathroom during night, adverse effects due to drug wear off, pain, and night sweats.
A third type of sleeping problem – excessive daytime sleepiness – can develop as a result of inadequate sleep at night. This turns into a vicious cycle, with the person unable to sleep at night because of daytime sleeping. Daytime sleepiness can also occur due to the disease itself or due to the effects of Parkinson’s disease medication.
Sudden sleep onset during the day or “sleep attacks”, with the person suddenly falling asleep while driving or operating machinery, can be extremely dangerous. Often, two or more problems can co-exist.
UCLA researchers have found an association between the Parkinson’s disease and narcolepsy. Narcolepsy is a disorder due to the brain’s inability to regulate the sleep/wake cycles in a normal fashion. The patients suffering from both Parkinson’s disease and narcolepsy display a loss of orexin / hypocretin cells in the brain. Striving to maintain a healthy sleep habit might help the Parkinson’s patients with the physical and psychological symptoms.
What are the Sleeping Problems in PD?
- Certain PD medication, especially when initially started and the dose has not been regulated satisfactorily, can lead to the sleeping problems.
- As the disease progresses, muscle rigidity, stiffness, tremors and pain increase, contributing to problems with sleep.
- Insomnia may occur due to akinesia or inability to roll over or turn on sides in bed. Insomnia in Parkinson’s patients is often linked to anxiety and depression. It can also result due to excessive daytime sleeping. Another cause of insomnia includes the initiation of Levodopa therapy, which is usually corrected by adjustment of the medication schedule.
- Lower levels of dopamine during the night can aggravate the symptoms of PD causing more frequent awakenings at night.
- Age related insomnia.
- Dementia, depression, hallucinations.
- Nocturia – frequent urge to pass urine at night can interfere with sleep. In a PD patient, getting out of bed to use the toilet each time can become a task.
- Nightmares, vivid dreams, night terrors, and dream-enacting behavior during sleep are common in PD patients due to a problem known as REM sleep behavior disorder (RBD). It can be one of the earliest symptoms of PD. The patient may kick or punch out if he is dreaming of being attacked and unknowingly harm himself or the person sleeping beside him. A person sleeping alone may not even realize that he is suffering from this condition. On being awake, he will become absolutely normal. Certain PD drugs are associated with causing nightmares too.
- Sleep apnea – It is the most common sleep related breathing disorder and is manifested as the disruption of sleep caused by a medical condition where there is periodic suspension of breathing for a few moments. According to a latest study, average of 20% Parkinson’s patients suffer through sleep apnea.
- Restless leg syndrome (RLS) and periodic leg movement disorder (PLMD) are two similar but different conditions commonly seen in PD patients, which often contribute to sleep disturbance.
- Excessive daytime sleeping.
Management and Treatment of Sleeping Problems in Parkinson’s disease
- Reduction of evening fluid intake.
- The symptoms of the sleep disorders worsens with the enhancement of the disease progression. The severe pain and uncontrollable muscular movements become the route cause of troublesome insomnia. This can be improved by taking Parkinson’s medication late in the day or with the use of hypnotic sleep aids. Also, the insomnia might be a result of the side effect due to certain antiparkinsonian medications. In this case the medication should be taken earlier in the day to improve the sleep cycle. However these necessary changes in the timings of the sleeping aids, must be done under strict supervision of a neuro physician.
- Avoiding diuretics or caffeinated drinks or food at bedtime.
- Emptying the bladder before going to bed.
- Use of bedside commode.
- Avoiding daytime sleeping.
- Treatment related to the cause of insomnia.
- Over-the-counter drugs to aid sleep should not be taken without consulting a doctor. These over the counter drugs usually contain an antihistamine which blocks the absorption of dopamine, thereby resulting in the treatment failure of levodopa.
- The use of stimulant or alerting medications during the daytime might help to prevent sleep attacks and exercise napping. Rectification of the excessive day-time napping will also indirectly rectify the resultant insomnia at night.
- In addition the patient must maintain a regular sleep schedule. The patient must adopt a habit of going to bed and getting up at the same time each day.
- Sedatives and tranquillizers may be prescribed and the dose and time of taking PD drugs may be altered by the doctor.
- Certain behavioral techniques are adopted to regulate the sleep cycle. Also, the patients are advised to spend time outdoors and to exercise in the morning after waking up. In this way, the light therapy may help to normalise the sleep or wake cycles in the patients.
- Also, the patients might join the support groups which procures an opportunity to get introduced to other individuals struggling with Parkinson’s disease, as it offers mutual benefits by sharing the knowledge and personal experiences.