Problems with Sleep at Night
There are several problems that PD patients may experience during the night. For example:
- Obstructive sleep apnea
- Restless legs syndrome
- REM sleep behavioral disorder
- Return of the tremor and rigidity during the night
- Patients may have a combination of a few sleep problems
Sleep apnea can be seen in up to 40% of patients with PD. The common symptoms include:
- Loud snoring
- Restless sleep
- Sleepiness during the daytime
- Pause in breathing during night sleep
Obstructive Sleep Apnea (OSA)
- Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing.
- The muscle tone of the body ordinarily relaxes during sleep and at the level of the throat the human airway is composed of collapsible walls of soft tissue, which can obstruct breathing during sleep.
- What is interesting is that unlike the general population, patients with PD with sleep apnea are not overweight.
How is sleep apnea diagnosed?
- A patient may participate in a “sleep study” or polysomnogram where the patient’s amount of pauses in breathing and oxygen level in blood are monitored throughout the night at a sleep clinic.
How is sleep apnea treated?
Continuous positive airway pressure (CPAP) is the most consistently effective treatment for obstructive sleep apnea. CPAP is a machine connected to a facemask that is worn by the patient through the night and controls the pressure in one’s throat to prevent the walls of the throat from collapsing, thus creating better quality of sleep.
REM – sleep behavioral disorder
REM is a normal part of the sleep during which people dream. Usually the only part of the body that is moving during REM is the eyes, thus the name rapid–eye movement sleep.
- Patients with rapid-eye movement behavior disorder (RBD) do not have the normal relaxation of the muscles during their dreams. Therefore, they act out their dreams during rapid-eye movement (REM) stage sleep.
- During RBD patients may: shout, kick their bed partner, grind their teeth and sometimes in moderate to severe RBD may have aggressive, violent behaviors, like getting out of bed and attacking their bed partner.
- About half of people with PD suffer from RBD — which may develop after or along with the disease, or in most cases, actually precedes the PD diagnosis by 5-10 years.
What is the treatment for RBD?
- Environmental adjustments to protect the patient and bed partner from injury are important. This may include padding the floor, using bed rails, or sleeping in separate rooms.
- Clonazepam has been shown in large case series to improve RBD in 80% to 90% of patients. The dose of clonazepam required is low, usually from 0.5 mg to 1.0 mg.
- The adverse effects of clonazepam include nocturnal confusion, daytime sedation, and exacerbation of obstructive sleep apnea, if present. It is available in generic form and is not expensive.
- Melatonin in doses up to 12 mg at night one hour before bedtime was shown to improve RDB in a small study.
- Adverse effects reported include: morning headaches, morning sleepiness, and delusions/hallucinations.
Return of the usual Parkinsonian symptoms at night
- It is not unusual for tremor and rigidity to return in the middle of the night
- Many times, patients take their last dose of anti-Parkinsonism medication before going to sleep, which lasts only up to 5-6 hours.
Some of the signs that Parkinsonian symptoms are causing the patient to wake up are:
- Waking up at the same time in the middle of the night
- Frequency of urination because of the rigidity of the bladder and lack of dopamine
- Feeling tremor or rigidity coming back,
- Inability to turn in bed.
How are Parkinsonian symptoms treated at night?
- Using a long acting dopaminergic medications like Sinemet CR and Requip XL had been helpful in alleviating Parkinsonian symptoms in the middle of the night.
- It is not unusual for some patients to take additional Sinemet 25/100 mg ½ tab – 1 tab in the middle of the night to help decrease the rigidity and fall back to sleep.
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Medical content reviewed by: Nina Browner, MD—Medical Director of the NPF Center of Excellence at the University of North Carolina at Chapel Hill in North Carolina and by Fernando Pagan, MD—Medical Director of the NPF Center of Excellence at Georgetown University Hospital in Washington, D.C.