Re:  Sleep disorders and PD
From:  Brian Symonds   <[log in to unmask]>
 
Insomnia is now being recognised as a common symptom in family medical
practice, and one that can have a significant impact on the quality of life,
and diseases. Although an estimated 1/3 of the general population has sleep
difficulties, a US National Commission Report found that 75% of patients said
their doctor had never asked them about their sleeping difficulties, and a
1991 Gallup poll found that 1/3 of patients with insomnia were not diagnosed
by their physician. This is probably because sleeping disorders have been
given little if any attention in medical schools until the last couple of
years. Insomnia is not a diagnosis. It is a symptom of many disorders and it
has to be assessed like any other symptom. Assessment should follow a
management plan comprising documentation of the nature and duration of the
sleep complaint (sleep diary), improvement in sleep hygiene, and possibly
intervention with other techniques and medications.
 
Insomnia can be defined simply as an inability to achieve restful, night time
sleep. This may mean that you cannot fall asleep within a reasonable period;
cannot stay asleep without waking during the night; or that you cannot get
back to sleep easily if you awake during the night or awaken too early.
People also often complain of fatigue, drowsiness, or an inability to
function adequately during the day, although daytime performance may not be
impaired. Insomnia is a nonspecific symptom and should be investigated
thoroughly to determine its cause.
 
Much research has gone into the question of why we sleep, but the answer is
still unknown. It appears that our brain needs sleep, but the rest of the
body doesnUt. The effect of sleep deprivation in the short run is to cause
sleepiness. There is little other effect on physiological and psychological
processes. After two nights of sleeplessness, tasks that require a high level
of alertness are impaired unless sufficient interest and stimulation can be
maintained while doing them. Boring and routine tasks suffer when the person
is tired. Prolonged deprivation of sleep produces periods of visual
hallucinations and intermittent minor clumsiness with slurred speech. Studies
have shown that while insomnia may leave you feeling groggy and clumsy, so do
many of the sleeping medications (hypnotics).
 
It is important to remember that insomniacs are extremely unreliable in their
ability to assess time. Most insomniacs will overestimate the time taken to
go to sleep by as much as three times. This is not an intended mistake but a
genuine misperception of time. In 1979, the National Academy of Sciences
showed that most insomniacs obtain six hours of sleep a night, most are
asleep within 30 minutes of going to bed, and most have less than 30 minutes
of wakefulness during their sleep without using hypnotic drugs. When
hypnotics were used, the reduction in time taken to fall asleep was less than
15 minutes, and there was no more than a 30 minute increase in overall sleep
length.
 
Transient or short term insomnia (present for less than one month) is
generally easy to recognize as people complain of poor sleep performance in
the past few days or weeks.
Common precipitants of short-term insomnia include:
% Short term stressors such as examinations, meetings, moving to a new house,
a recent hospital stay, etc. Therapy involves sleep hygiene measures,
relaxation techniques, and possibly the short term use of a sleeping
medication.
% Poor sleep hygiene. Environmental factors that disrupt normal sleep, such
as caffeine or alcohol consumption, tobacco smoking, late-night exercise, and
so on. Insomnia will often resolve spontaneously with the proper sleep
hygiene measures if the person makes an adequate attempt.
% Psychophysiological. This is a conditioned phenomenon caused by a crisis in
which sleep patterns are disrupted and cannot be re-established by the
person.
% Circadian rhythm disorders: delayed (go to sleep late, wake up late) and
advanced (go to sleep early, wake up early) sleep-wake problems. Sleep often
improves with a gradual return to a normal sleep-wake cycle. Light therapy
may be employed to RresetS the biological clock.
% Shiftwork sleep disorders. Caused by evening or night time shiftwork. This
may be managed short term with sleeping medications to facilitate sleep
during the shift work period, and generally resolves with a return to normal
daytime work.
 
Persistent or chronic insomnia can cause people to suffer from a greatly
diminished quality of life. Disturbed motor, cognitive, and emotional
functioning during the day after a poor nightUs sleep adversely affects
performance at work, family life, and social relationships. It may suggest a
more significant underlying problem. Improved sleep hygiene measures may help
if they are maintained. Chronic insomnia may be due to:
% Drug dependency. A complete review of the personUs alcohol and drug use is
required. In addition to street drugs such as alcohol, POT, and cocaine, some
of the common drugs that cause sleep difficulties include: Theobromine (in
chocolate preparations and prescription drugs), CNS stimulants (e.g.,
pseudoephedrine and phenylpropanolamine, etc.), respiratory muscle
spasmolytics (e.g., aminophyliline, theophyline, etc.), amphetamines,
nonamphetamines (diethylpropion, fenfluramine, pemoline, etc.),
antidepressants (imipramine, amitriptyline, desipramine, nortriptyline,
maprotiline, tranylcypromine, isocarboxazide, trazodone, clomipramine,
fluoxetine, sertaline, buspirone, etc), anticonvulsants (e.g., clonazepam,
phenytoin), cardiovascular drugs (e.g., propranolol, atenolol, metoprolol,
captopril, verapamil, etc.), antiinflammatory/analgesic drugs (e.g., ASA,
diclofenac, ibuprofen, piroxicam, etc.), corticosteroids (e.g., prednisone),
major tranquillizers or neuroleptics (e.g., perphenazine, chlorpromazine,
haloperidol, etc.), thyroid medications in excess (e.g., levothyroxine,
thyroid, etc.), and antiparkinson drugs (e.g., levodopa, selegiline).
% Co existing medical conditions. A number of medical conditions including
ParkinsonUs Disease can disturb sleep, such as cardiovascular disease,
obstructive sleep apnea, and periodic limb movement disorder. Migraine or
other headaches, back pain, fibromyalgia, or other pain syndromes should be
managed with sufficient pain medication to enable sleep, and a sleep
medication may be added if required.
% Mood and anxiety disorders. An insomnia complaint may mask depression,
anxiety, or other types of problems, and if such problems exist, they need to
be dealt with by psychological interventions and/or medications.
% Psychosocial factors. Chronic insomnia may be caused by stressors such as
marital discord, spousal abuse, work related problems, and the like. Many
insomniacs have a fear of poor performance the following day, with job and
financial repercussions. Falling asleep becomes a performance challenge.
Often such people will try to sleep without a medication, and then if they
take a medication will fall asleep quickly, long before the pill can work
(the very act of taking a ill is reassuring). Relaxation techniques, marriage
counselling or other intervention may be required.
 
Sleep Clinics teach that there are five main aspects to the management of an
insomnia complaint.
Step 1. The personUs sleeping history must be complete. This may include
having the person complete a sleep diary, which details the personUs habits,
and duration and quality of sleep. Diaries help in providing documentation of
all the possibilities leading to a sleep disorder. The objectives are to:
          Determine the duration of the problem (weeks, months, years).
          Uncover any underlying precipitants such as poor sleep hygiene and
drug
           use.
          Determine if there are any underlying medical or psychiatric
problems
          such as chronic pain, depression, anxiety disorder, chemical
dependency,
          periodic limb movement disorder, sleep apnea, etc. The primary
disorders
          must be managed prior to treating the insomnia.
Step 2. Institute sleep hygiene measures.
Step 3. Counselling and education. This may include time management, stress
reduction, marital therapy, etc. A short term period of insomnia can become
conditioned insomnia, in which the person becomes apprehensive just before
bedtime about being able to get to sleep. So it is important to know that
with relaxation training and proper sleep hygiene they will sleep again.
Step 4. Initiate sleeping medication use if required. The key to drug therapy
as always is to employ the right drug for the right duration for the right
condition. Before you use a drug, you should know what condition you are
treating (so that any underlying physical or psychiatric condition that may
be helping to cause the insomnia does not go untreated or gets worse if the
wrong drug is used), know the aim of the treatment (is it supposed to help
you fall asleep, help you stay asleep, or help you sleep later, or a
combination), know the potential daytime effects of the medication (will it
affect daytime function, cognitive performance, or memory).
Step 5. Behavioural therapies. The person may benefit from relaxation
training, sleep restriction, cognitive restructuring and other techniques.
These can be used in conjunction with medications or instead of them. Some
people paradoxically experience tension and arousal when asked to relax, and
benefit from relaxation therapy. Restricting sleep is sometimes useful since
many insomniacs are found to sleep too long. A short course of sleep
restricted to four hours/night will often result in improved sleep
efficiency. Sleep efficiency is calculated as the total sleep time divided by
the total time in bed multiplied by 100. When sleep efficiency is found to
increase to 85 percent, the time in bed is increased by 30 minutes. Light
therapy is useful for people who receive sufficient sleep but at the wrong
time of day due to dysregulation of circadian rhythm.
 
Medications for sleep
A sedative drug decreases activity, moderates excitement, and calms the
person. A hypnotic drug produces drowsiness and facilitates the onset and
maintenance of a state of sleep that resembles natural sleep. In practice
these terms are often used interchangeably. Hypnotics do work. they guarantee
a night of RsleepS. However, they also change sleep architecture and they
selectively affect REM sleep. Tolerance develops to all hypnotics, usually
within two to four weeks if taken nightly. Some types of hypnotics will cause
disturbed sleep after they are stopped.
 
Drug options include:
 
Over the counter medications. Three antihistamines - diphenhydramine (Nytol;
and others), doxylamine (Unisom; and others) and pyrilamine (Quiet World; and
others) - are currently approved by the US Food and Drug Administration for
sale as hypnotics without a prescription; they are not as effective as the
benzodiazepines and in overdose can cause serious adverse effects, including
delirium, psychosis and dystonic reactions, particularly in the elderly.
These drugs tend to make the person groggy. If the person is worried about
sleeping, then this groggy feeling makes the person feel as if sleep is
coming on, and they relax, and can then fall asleep. Their effect wears away
and tolerance/addiction can become a problem.
 
L-tryptophan is a precursor of serotonin, an inhibitory neurotransmitter
often associated with sleep. Studies about whether or not it helps sleep have
had conflicting results. It comes as 500 mg capsules, and can be tried at
1000 to 5000 mg at night. Some studies have suggested taking it as 2000 mg
nightly for 3 nights and then not taking it for four nights, and following
this pattern over a month, allows a better sleep pattern. Taking it nightly
for a period of time can cause its benefit to wear away. There was a problem
a couple of years ago in the US when this medication caused a serious side
effect, but the problem was apparently traced to an impurity in one companyUs
manufacturing process, and this is no longer a concern. Nausea can occur at
higher doses, and this medication can interfere with, enhance, or cause side
effects if used with antidpressants, especially the newer ones.
 
Older sedative/hypnotics. Agents such as barbiturates, chloral hydrate, and
methaqualone are rarely used anymore due to the risk of fatal overdose, the
problem of side effects, and the problem of withdrawal syndromes. Some
geriatricians claim that chloral hydrate may be useful in people with
dementias. Antihistamines are generally best avoided as the benzodiazepines
induce better sleep with fewer side effects.
 
Benzodiazepines. These agents replaced the use of barbiturates as they are
generally safer, and each member of this class has a varying degree of
hypnotic, muscle relaxant, anti epileptic, and anti anxiety effects. The
longer acting ones such as Flurazepam (Dalmane) may cause persistent early
morning sedation and fatigue, and there is a clear and significant decrease
in psychomotor performance the day after taking one of the longer acting
meds. The very short acting ones such as Triazolam (Halcion) may cause an
increase in wakefulness during the final hours of the night. Rebound insomnia
may be a problem with all of these drugs on their discontinuation, and may
occur up to two weeks after their discontinuation. Temazepam (Restoril) is
intermediate in action. Oxazepam (Serax). nitrazepam (Mogadon), lorazepam
(Ativan), and clonazepam (Rivotril) are occasionally used depending upon the
circumstances. These drugs loose their effectiveness after a few weeks if
used nightly, and thus are only for short term use. Behavioural rather than
physical addiction is the main problem with these drugs. After several weeks
of therapy, people may associate taking a pill at bedtime with falling
asleep, and if they donUt take the pill, they donUt sleep. This ingrained
behaviour is known as behavioural dependence. Additionally, these drugs may
cause memory loss, especially in the elderly, and people with significant
respiratory diseases canUt take them as they can depress the breathing center
in the brain.
 
Cyclopyrrolones. At present in Canada the only available drug in this class
is Zopiclone (Imovane). These drugs are chemically different from the
benzodiazepams, but seem to act through the benzodiazepam receptors in the
brain. It has a medium duration of action, is generally as effective as
benzodiazepine drugs, and may be tolerated better. It improves sleep
duration, quality of sleep, soundness of sleep, and does not tend to cause
morning sleepiness. It does not appear to have an effect on normal sleep
patterns, and has been used to wean patients from dependence on
benzodiazepams. Its most common side effect is a metallic taste in the mouth.
There are claims that it does not cause dependence, but it has not been used
long enough to know for sure.
 
Ambien (zolpidem tartrate), is a non-benzodiazepine hypnotic of the
imidazopyridine class and is available in 5 mg and 10 mg strength tablets for
oral administration. Adverse reactions most commonly associated with
discontinuation from U.S. trials were daytime drowsiness (0.5%), dizziness
(0.4%), headache (0.5%), nausea (0.6%), and vomiting (0.5%). Approximately 4%
of 1,701 patients who received zolpidem at all doses (1.25 to 90 mg) in U.S.
pre-marketing clinical trial discontinued treatment because of an adverse
clinical event. Approximately 6% of 1,320 patients who received zolpidem at
all doses (5 to 50 mg) in similar foreign trials discontinued treatment
because of an adverse event. Events most commonly associated with
discontinuation from these trials were daytime drowsiness (1.6%), amnesia
(0.6%), dizziness (0.6%), headache (0.6%), nausea (0.6%). There are claims
that it does not cause dependence, but it has not been used long enough to
know for sure.
 
Antidepressants. Some types of these are used to induce sleep because of
their side effect of causing sedation, or when the person has a sleep
disorder related to depression. Amitriptyline, trazodone, doxepin, and
trimipramine are the most commonly used. Their major problem is causing low
blood pressure which may lead to falls and fractures during the night. Many
of the newer antidepressants called SSRIs (serotonin reuptake inhibitors)
used for the treatment of depression may actually impair sleep by shortening
the sleep period and causing several awakenings throughout the night. It is
interesting to note that FluoxetinUs (Prozac) deleterious effects on sleep
patterns may be present even one to two years after discontinuation of this
drug suggesting that Fluoxetin produces fairly permanent and profound brain
changes. There is some indication that a new SSRI type drug called Nefazodone
(Serzone) can restore a more normal pattern of sleep. Nefazodone has SSRI
activity (enhances serotonin by inhibiting reuptake of the 5-HT1a receptor),
and also 5HT-2 blockade. It has little effect on muscarinic, histaminic,
adrenergic or dopaminergic receptors. It has virtually no sexual dysfunction
or heart toxicity, few drug interactions, and is useful to treat depression,
including the anxiety and agitation associated with it. Nefazodone (at 200 to
400 mg per day) when given to men who were sleeping normally showed an
increase in the percentage of actual sleep time and a decrease in wakefulness
after sleep onset (a significant increase in the amount and the percentage of
REM sleep and a decrease in REM latency). In depressed patients, Nefazodone
produces a significant decrease in the percentage of time spent awake and in
the number of arousals during the night. Its uncertain yet how long
NefazodoneUs effects will last after discontinuation of the drug. Main
possible side effects are constipation and lightheadedness.
 
Neuroleptics with a tranquillising effect are sometimes used in special
circumstances, but also have the risk of lowering blood pressure, and causing
dyskinesias.
 
ParkinsonUs Disease
Some sleeping difficulties, especially vivid dreaming and myoclonus, are
related to L-dopa. Readjustment of the dose of L-dopa, and eliminating the
evening dose (if possible) may improve the patientUs sleep. On the other
hand, some patients require L-dopa to sleep because a lack of medication
makes them so rigid that they cannot turn in bed.
 
 
Sleep Hygiene Measures
% Most people sleep and dream poorly on the first night in an unfamiliar
environment, but some insomniacs paradoxically sleep better on the first
night in new surroundings. No manipulation should be tried for only one night
because the first night is rarely typical.
% Individual differences are important, and what works for one person may
make things worse for another.
% Self-fulfilling prophecies often determine success or failure. A person who
expects to sleep poorly in a certain environment often worries about it and
as a result sleeps poorly. Anxiety, no matter what the source, interferes
with sleep and must be considered before changing the sleep environment.
% Caffeine in the evening disturbs sleep, even in those who feel it does not.
It should be avoided in all its forms.
% Alcohol helps tense people fall asleep more easily, but the ensuing sleep
is then fragmented. It should be avoided.
% The chronic use of tobacco disturbs sleep. It should be avoided.
% To silence snorers, they should try Dr. FlackUs exercise. They should first
hold a common tongue depressor or something similar firmly between the teeth
for ten minutes after going to bed but before settling down to sleep. The
jaws will probably become tired after about five minutes or so, but this is
normal, so keep going. Next, remove the depressor and for two to three
minutes they should press their fingers firmly against the chin, and the same
time forcing their jaw steadily against the pressure of the fingers. Lastly,
they should close their mouth and firmly press the tongue against their lower
front teeth for three to four minutes. It may take two weeks for these
exercises to cut down and then eliminate the snoring. If it doesnUt work, the
person should be evaluated by their doctor.
 
% Avoid having a bedroom clock within view.
% Use the bedroom as a place reserved for sleeping. DonUt use the bedroom for
work, eating, arguing, television watching, etc.
% Occasional loud noises disturb sleep even in people who are not awakened by
noises and cannot remember them in the morning. Sound attenuated bedrooms may
help those who must sleep close to noise.
% Although excessively warm rooms disturb sleep, there is no evidence that an
excessively cold room solidifies sleep. As light and temperature fluctuations
disturb sleep, people should dim the light, as well as keep the room at a
constant temperature of about 21 {C (70 {F) although room temperatures
between 24 !C (75 !F) and 17 !C (63 !F) may be fine for sleeping.
% Weight gain is associated with a longer less interrupted sleep, and weight
loss with more awakenings especially in the second half of the night. Claims
that some types of diet help sleep are unsubstantiated. High carbohydrate/low
fat diets decreases delta sleep but increases REM sleep.
% Sleeping together may be good for marital bliss, but sleeping apart
eliminates disturbances when the partner changes position.
% There is no evidence that sleeping with the head of the bed elevated or
flat, or on a hard or soft surface makes any difference to sleep once the
sleeper is used to them. Some studies have suggested that water beds may
promote better quality sleep by reducing the number of times the person
awakes during the night.
 
% Do not nap during the daytime.
% Avoid overwork or getting exhausted. Allow a wind down time from the dayUs
turmoil before going to bed. Keep to the same pre sleep routine each night.
Hot baths should be taken about two hours before bedtime.
% A steady daily amount of exercise probably deepens sleep. Occasional
exercise does not necessarily improve sleep the following night. Do not do
heavy exercise just before bedtime. Light exercise is advised about 3 to 6
hours before bedtime.
% Hunger may disturb sleep. A light snack or a glass of milk may help sleep
(the classic snack of hot mild and cookies is still advised and the
carbohydrates in cookies can help the absorption of the tryptophan in milk).
DonUt eat a heavy meal before retiring and do not snack during the night.
 
% People who feel angry and frustrated because they cannot sleep should not
try harder and harder to fall asleep but should turn on the light and do
something different. If unable to sleep, do not remain in bed longer than 20
minutes. Go to another room and do something relatively unstimulating (e.g.,
reading). Return to bed when you feel drowsy.
% Have a plan for when you awaken at night. If you wake up before you wish,
try to fall asleep again by thinking pleasant thoughts, breathing deeply,
reciting a certain word or phrase, or practising some relaxation routine.
Some of the methods that may work include: Rcounting sheepS; going around
your home (in your mindUs eye) straightening all the pictures and when youUve
finished, start again; squint your eyes in the dim light and focus on an
object in the room, try to close your eyes as much as possible while keeping
focused on the object you can barely see, empty your mind of all else but the
object; design your dream house in your mind; think of five things you can
see in your room, five things you can hear, and five things you are aware of,
repeat the above with four items in each category, if you cannot think of new
items, you can reuse the old ones. repeat with three, two, and then one item
in each category; visualize a blackboard, anything that comes on Q rub it
off; light a candle in your mind, focus on the flame, see how each
distracting thought makes it flicker, watch the flame become upright again as
you dismiss all thoughts, from your mind, as the flame burns steadily your
mind becomes more relaxed and serene.
%  Classical (Jacobs) or subliminal relaxation techniques or progressive
muscle relaxation training may help. Acupuncture sometimes helps.
% Curtailing the time in bed seems to solidify sleep. Excessively long times
in bed seems related to fragmented and shallow sleep.
% A regular arousal time in the morning strengthens normal sleep patterns,
and leads to regular times of sleep onset. Establish a fixed wake up time for
every day, and get help maintaining it (alarm clock, another person, etc.).
  % An occasional sleeping pill may be of some benefit, but their chronic use
is ineffective in most insomniacs. Avoid over the counter sleeping aids. The
active ingredient in these drugs is usually an antihistamine, e.g.,
diphenhydramine or doxylamine.
% Sleep as much as needed to feel refreshed and healthy during the following
day, but not more.
 
References:
Sleep/Wake Disorders Canada, P.O. box 223, Station S, Toronto, ON  M5N 4L7.
Better Sleep Foundation publishes a booklet, RGood Night America: A Guide to
Better SleepS
The American Medical Association Guide To Better Sleep, Random House, Inc.
A Good NightUs Sleep: A Step By Step Program For Overcoming Insomnia and
Other Sleep Problems, WW Norton and Company, Inc.