Board Certified in Sleep Medicine and Neurology www.sleepmedicineandneurology.com

most people with PD find it difficult to sleep through the night
 Rigid muscles
 Tremors or stiffness
 Unable to roll over in bed
 Frequent urge to urinate
 Vivid dreams, hallucinations, violent nightmares
 Acting out dreams(RBD) can precede PD by decades

 Due to sleep disturbances
 Due to medication side effects
 Due to Parkinson’s disease itself
 End result: Interferes with daily life

 Seek professional help in early or mid-stage
PD for:
 Insomnia
 Excessive daytime sleepiness
 Restless legs syndrome
 REM behavior disorder
 Poor sleep due to depression

 Inability to get a good night’s sleep
 Trouble falling/staying/falling back to sleep
 Fragments of sleep a few hours at a time
 Sleep studies (PSG) in PD show:
 Less deep sleep (S3)
 More light sleep (S1S2)
 Increased sleep fragmentation
 Multiple night awakenings

 Maintain a regular schedule for waking/sleeping
 Avoid excessive time in bed
 Avoid naps during the day and early evening
 Use bed for sleeping (not reading or watching TV)
 Do not watch the clock in bed
 Try to relax before bedtime: environmental cues
 Timed light exposure in the am

 Keep the bedroom dark, cool and comfortable
 Block out noises that disturb sleep
 Avoid caffeinated beverages or alcohol w/in 6 hrs of bedtime
 Exercise early in the day, not two hours before bedtime
 Go to another room if you cannot sleep
 Avoid going to bed hungry

 Do not underestimate the power of natural sunlight in helping circadian rhythm disorders and common insomnia!

Excessive Daytime Sleepiness in PD
 Common in early and mid-PD
 Can be related to insomnia
 Can be related to other sleep disturbances
 Sleep apnea
 RLS/PLMD
 RBD
 Or related to medications
 High doses of dopaminergic medications like pramipexole and ropinirole can contribute but rare

 5-10% of general population
 Common in PD but not predictive of PD
 Can predate PD by many years/decades
 Common, underdiagnosed, hyperkinetic movement disorder

 Four diagnostic criteria
 Do you have an uncomfortable or unpleasant sensation that causes an urge to move your legs?
 Are your symptoms worse during periods of rest or inactivity such as lying or sitting?
 Are your symptoms temporarily relieved by movement, such as walking or stretching?
 Are your symptoms worse in the evening or at night? As symptoms get worse, can occur during the day
 Key ?: “Do you have a creepy, crawly, or restless feeling in your legs at night that improves when you move around?”

RLS
 Usually primary/hereditary (possible loci chromosomes 9,12,14)
 Secondary causes due to iron deficiency, ESRD,
Medications (neuroleptics=DA antagonists like
Reglan) or antidepressants, peripheral neuropathy
 Prevalence increases with age over 40, F>M
 Can be mistaken for ADHD, especially in children
 More common in Parkinson’s Disease

PLMS-Periodic Limb Movements in Sleep
 80% of those with RLS also have PLMS
 Slow, involuntary, stereotypic movements, usually involving flexing the leg at the hip, knee, and ankle. May involve arms.
 Reported by bed partner or found on sleep study.
 Causes daytime sleepiness and/or insomnia

 Labs tests for blood count, ferritin and iron studies, folate, glucose, renal screen; EMG/NCV if suspect neuropathy
 Sleep study to rule out sleep apnea and look for PLMD

TREATMENT RLS/PLMD
 Avoid alcohol, caffeine; regular sleep hygiene
 Stop problematic medications like antihistamines, tricyclic antidepressants
 Dopamine agonists help >70% of patients ; first line therapy : ropinirole (Requip) pramipexole
(Mirapex), Levodopa (Sinemet)
 anticonvulsants like gabapentin, carbamazepine
 narcotics, iron tid with Vit C if ferritin < 50 mcg/dL or iron saturation <16%

REM Behavior Disorder (RBD)
 A disorder of dissociation of muscle atonia during
REM sleep
 Breakthrough behaviors during REM described as acting out dreams
 Abrupt emotional vocalizations, swearing, injurious/violent behaviors
 Disruption of sleep continuity
 Appx 50% of PD patients have partial or complete loss of muscle atonia in REM sleep

REM Behavior Disorder (RBD)
 Male predominance > 45 yrs
 Associated neurodegenerative diseases, PD
 Morbidity

Self injury 1/3 of cases

Injury to others 2/3 of cases

Daytime sleepiness in ¾ of cases (often due to other associated sleep problems)

 Behavioral

Safe environment

Reduce disruptive events

Reduce anxiety

Good sleep hygiene
 Pharmacological

Clonazepam (80% of patients reported benefit)

Parkinson’s Treatment with Dopaminergics

Obstructive Sleep Apnea (OSAS)
Symptoms
 Snoring
 Witnessed apneas
 Daytime fatigue/Sleepiness
 Moodiness, irritability
 Concentration/ memory complaints
 Depression
 Insomnia
 Exacerbated pain symptoms

 Men> premenopausal women
 Micrognathia, overbite
 Obesity, hypothyroidism
 Enlarged adenoids, tonsillar tissue
 Exacerbated by supine sleep, gravity
 Deviated septum, allergies with mouth breathing
 Macroglossia, enlarged uvula
 Decreased muscle tone with aging, testosterone
 Higher incidence in PD related autonomic dysfunction

 Apneas- cessation of airflow >10 sec
 Hypopneas- 50% reduction in airflow with 3% reduction in oxygen, or EEG arousal
 RERAS- EEG arousals with increased respiratory effort
 AHI> 5/hr
 RDI > 40/hr, severe

 CPAP/BIPAP/ AutoPAP +/- oxygen
 Weight loss
 Mandibular Advancement Appliance
 Surgery overall, 50-70% improvement






UPPP
Septoplasty, turbinate reduction
Maxillomandibular advacement
Somnoplasty (RF)
Pillar procedure tracheostomy

 Depression in appx 40% of PD patients
 Associated with sleep disturbances
 Unrefreshing sleep
 Early morning awakenings
 Irregular dreams

 33% of PD patients in mid-late stages experience hallucinations related to higher doses of medications
 Visual, not auditory
 Associated with vivid dreams