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By: Ken Bernstein, Last modified, April 16, 1995


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For people suffering from Parkinson's disease sleep can be a brief escape
from the hampering
effects of their illness. The major signs of illness, tremor and rigidity
are quieted. In their dreams
patients may dance, swim and run with their former ease and grace, however
bittersweet that may
be. Dreams of flying push the reality of the need for medication to induce
daily movement into a
far and distant corner.<P>Even this last place of peace is vulnerable, for
studies report that 74%-
96% of all Parkinson's disease patients have some sleep disturbance. The
causes for this are
unclear. Aging brings on more difficulties with sleep, even in healthy
adults (see article below on
Facts about Sleep and Normal Aging). Sleep disorders generally fall into
three -major categories:
problems with sleep initiation or maintenance, excessive daytime sleepiness,
and parasomnias
(behavioral events during sleep that nightmares, night terrors, sleep
walking and talking).<P>A
recent report by Hilten et al in 1993, studied sleep disorders in 90
nondepressive Parkinson's
patients and 71 healthy controls. The object of this questionnaire-based
inquiry was to ascertain
the prevalence and cause of sleep problems in<P>Parkinson patients. Most
previous studies
lacked a healthy control population to which the Parkinsonian patient could
be compared.<P>The
vast majority (81%) of the Parkinson's patients and 92% of the healthy
controls admitted to having
disturbed sleep. Statistically, there was no difference between both groups
with sleep initiation,
maintenance, or with problems on awakening. There was no difference between
the two groups in
the length of time their disturbed sleep had occurred. Can one simply
conclude that Parkinson's
patients have the same sleep disabilities that other healthy older people
have?<P>Restless legs,
nocturia (having to urinate frequently at night), stiffness and problems
turning over in bed were
reported by patients and controls, as reasons that they were awakened. The
difference between
the two groups was not significant. There was also no difference in the
frequency of occurrence of
disturbed sleep maintenance. But in the people who did experience sleep
maintenance difficulties,
i.e.. they were waking up during the night, the Parkinson's patients
reported a much greater
number of awakenings. Additionally, the women patients had (87.5%) more
problems with waking
then men, (64%). In the control group there was no difference between the
sexes when night time
waking was questioned.<P>Is there something unique to this disease that
would cause easy
arousal? Causality is difficult to determine. Perhaps patients only notice
their stiffness, or their
frustrated desire to turn over because they are awake, and perhaps patients
make frequent trips
to the bathroom because they are already aroused. Urodynamic evaluations of
patients with
Parkinson's disease commonly find detrusor hyperreflexia (the detrusor
urinae are the longitudinal
muscle fibers along the walls of the bladder) causing urinary frequency,
urge incontinence, and
urgency. Whether this is unique to PD patients is questionable, what is
certain is that these people
are awake and active in the dark much more often than others who had also
reported problems
maintaining sleep.<P>Taken to an extreme, this continual night time waking
can result in sleep
fragmentation. Commonly, the patient begins to feel increasingly sleepy
during the day and will
resort to taking several naps to recoup. Over a twenty four hour period this
patient will sleep as
much as any other person, whose nocturnal sleep patterns have not broken
down.<P>This study
showed no difference between controls and patients in regard to the
existence or duration of
excessive daytime sleepiness. Both patients and controls stated that they
were most sleepy
around noon and in 65% of the patients and 85.5% of the controls, a nap
helped them recoup their
former energy.<P>Unlike daytime sleepiness, daytime fatigue has no diurnal
pattern. This finding
contrasts to other studies in the past that linked fatigue with a circadian
factor. For the Parkinson
patient fatigue can be incessant and may interfere with physical and social
functioning. Excessive
daytime fatigue was reported in 43% of the patients. Most of these patients
associated fatigue
with exertion. When asked to compare fatigue with their other symptoms,
patients responded as
follows: 15% ranked fatigue as their worst symptom, 54% ranked fatigue equal
to other symptoms
and 31% ranked fatigue as their worst complaint. Researchers were unable to
find any
relationship between fatigue and clinical characteristics or the use of
common Parkinson
medications. This finding supports the assumption made in the past that
fatigue is probably
related to the motor deficits of Parkinson's disease.<P>There was a
remarkable difference
between controls and patients concerning altered dream experiences. Almost
exclusively, patients
reported more unpleasant, more frightening and more intense dreams. A
greater number of
women (68.4%) reported excessive dreaming than men (31%), while the controls
showed no sex
differences. Past studies have reported nightmares, night terrors and vivid
dreams occur in 30.7%
of all Parkinson's patients. These are believed to be brought on by chronic
levodopa therapy. Past
data also suggests that the emergence of terrifying or bizarre nightmares
may be the hallmark of a
hallucinatory syndrome and that further psychiatric symptoms will increase
with an increasing
dosage of levodopa. However, patients with Parkinson's disease were
experiencing hallucinations
and wild nightmares before the advent of levodopa in 1960. Occasionally
nightmares and
hallucinations may occur in drug-free PD patients but the frequency of these
phenomena increase
with use of many other medications besides levodopa. For example, the
belladonna alkaloids
(drugs similar to trihexyphenidyl or benztropine) had been in use in the
treatment of Parkinson's
disease since the nineteenth century and these are well known to induce
nightmares and
hallucinations in some patients. To blame drugs as the only cause is perhaps
too simple an
answer. Most likely, the inter action of these drugs with the underlying
neurochemical imbalance
inherent in PD is responsible for these psychiatric complications<P>Another
question in the
survey asked the participants whether they had a preference for waking early
and retiring early, or
whether they preferred to sleep late and retire late at night. The other
alternative was that they
had no preference. A difference between controls and patients was apparent
here. Fifty seven
percent of the patients revealed themselves to be morning types, when 40.8%
of the controls
preferred the morning. Past studies have discovered some interesting clues
into what this might
indicate. In sleep studies, morning type people have a shorter rapid eye
movement latency (REM)
and a different disbursement of slow wave activity across the first four
sleep cycles, than evening
people. Studies have shown this shortened latency is also a sign of
depression. In another
previous study 94% of the depressed Parkinson's patients had shortened REM
latencies and 52%
of<P> the nondepressed Parkinson's patients also had a diminished latency.
Why do some non
depressed Parkinson's patients share sleep study results that mimic
depressed patients? What is
the link between morning people, their typical shortened REM latency and
depression?<P>In
summary, it seems that Parkinson's patients share a lot of the same sleep
problems that their
aging healthy partners also experience. It is true that patients are waking
more frequently during
the night and the cause is still unclear although possibilities include
medication, and detrusor
hyperreflexia. Sleep maintenance can be improved in some by augmenting the
daily dose of
levodopa. Daytime fatigue can plague the PD patient often resulting in
daytime drowsiness. The
majority of patients ranked fatigue equal in its debilitating effects to
their other symptoms. This
sense of fatigue is probably linked to the motor deficits of the disease.
Unfortunately, even the
dream life of Parkinson patients is not spared. They reported more
harrowing, intense dreams. A
few studies found no relationship between any clinical or medication
variable and altered dream
experience while most studies suggested that levodopa (or other anti-PD
medications) caused
many dream aberrancies. Lastly, PD patients rated themselves morning types
significantly more
often than did controls. Further research in sleep studies needs to
elucidate the link between
morning type people, patients with shortened REM latencies, and
depression.'<HR>

There are many Old-wives tales" about improving sleep. Should we sleep in a
cold or warm room,
on a hard or a soft mattress, on an empty stomach or with a glass of warm
milk and honey, alone
or with a partner? The following is a list of the rules of good sleep
hygiene. Many individuals with
mild to moderate problems with sleep may be able to solve their problems
following some simple
suggestions.<P>

1. Don't sleep too much. Sleep as much as needed to feel refreshed and
healthy during the
following day, but not more. Limiting the time in bed seems to solidify
sleep. Excessively long
times in bed is related to fragmented and shallow sleep.<P>

2. Rise each morning at a regular time. This strengthens the circadian
cycling and tends to result
in regular times of sleep onset at night.<P>

3. A steady daily amount of exercise most likely deepens sleep. Occasional
or spotty exercise
does not necessarily improve sleep the following night.<P>

4. Loud noises disturb sleep even in people who are not awakened by noises
and cannot
remember them in the morning. If a person must sleep in a noisy environment,
soundattenuated
rooms may help sleep maintenance.<P>

5. Excessively warm rooms may disturb sleep, but there is no evidence that
an excessively cold
room solidifies sleep.<P>

6. Hunger may interfere with sleep. A light snack may help sleep. Drinks
that contain milk seem to
improve sleep. Some researchers advise taking cheese and crackers on the
theory that the
tryptophan in milk products helps to induce sleep and that its transport
into the brain is facilitated
by the carbohydrates in crackers. Similarly, warm milk and honey serves the
same purpose.<P>

7. Caffeine in the evening disturbs sleep, even in those who claim it does
not.<P>

8. Alcohol helps tense people fall asleep, but then the ensuing sleep is
fragmented.<P>

9. People who become frustrated because they can't fall asleep should not
try harder to fall
asleep, but instead should turn on the light and do something different.<P>

10. The chronic use of tobacco disturbs sleep.

Sleeping medications (hypnotics) are useful in the short-term management of
insomnia to help the
patient through a limited crisis. Prolonged use of hypnotics is very rarely
desirable and may lead
to tolerance and increasing demands for escalating dosages. When a
particular hypnotic
medication is effective in a given patient, it should not be increased in
dose. If effectiveness of the
medication is diminishing it is better to discontinue the drug for a while
and then use it again later
if needed. Restoration of its effectiveness will then be more likely.<P>Many
hypnotics maintain
their usefulness when used intermittently (once or twice a week). Used this
way, the occasional
hypnotic may restore some of the insomniacs reserves when experiencing a run
of sleepiness
nights, and helps to avoid panic and maladaptive sleeping habits. Caution
must be used when
prescribing these medications to individuals with liver or kidney disease,
to the elderly, and to
those who are heavy snorers. Heavy snorers are at risk because these
medications may
decrease ventilatory drive and may worsen nocturnal breathing
problems.<P>All currently
available hypnotics and minor tranquilizers are additive with each other and
with alcohol. Cross-
tolerance also develops between these drugs. This means that if a patient is
no longer responsive
to one specific sleeping medication, he will most likely not be responsive
to another
one.<P>Benzodiazepines are currently the drugs of choice in the short term
treatment of
insomnia. The reasons for preference of this class of hypnotics over others
includes the following:
a) prolonged effectiveness (for up to one month) has been demonstrated for
some
benzodiazepines, but for no other sleeping pills, b) benzodiazepines are
less potent respiratory
depressants than barbiturates, c) fatal overdosage with benzodiazepines are
rare (although in
combination with other hypnotics or alcohol, fatalities have been reported).
There are many other
hypnotics that have been and continue to be used, but for various reasons
are less desirable than
benzodiazepines. These include glutethimide, methyprylon, ethchlorvynyl,
chloral hydrate and
barbiturates. These drugs may be as effective as benzodiazepines, but side
effects and problems
with dependence seem more severe.<P>In the case of Parkinson's disease
patients, low doses of
the anti-depressant, amitriptyline ( 10 to 50 mg) are often effective. This
is especially true if
depression is a major factor in the insomnia. Diphenhydramine (benadryl) is
an antihistamine that
is useful for short periods in the induction of sleep and also helps PD
patients because of
inhibition of excessive salivation that may occur at bedtime. Also,
diphenhydramine has some
beneficial effects in attenuating tremor that may interfere with the
transition into sleep. Although
levodopa may increase the risk of vivid dreams and nightmares, sometimes
patients find it useful
in the induction of sleep. More recently the use of controlled release
Sinemet (CR) before bedtime
has been advocated, but this is more helpful for waking up the next morning
without excessive
rigidity and akinesia.<P>In summary, properly used hypnotics may be useful
in treatment of
insomnia. Judicious use of antidepressants and anti-PD medications may help
some PD patients
improve the quality of sleep.

Regards,
Margaret Tuchman