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Downloaded from: http://neuro-chief-e.mgh.harvard.edu/parkinsonsweb/Main/PDmain.html By: Ken Bernstein, Last modified, April 16, 1995 * * * * * * 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