Sleep Disorders

A good night’s sleep is critical to our health and well-being. However, for people with Parkinson’s disease (PD), sleep becomes even more important as the body needs more time to restore and repair itself. The brain changes that are part of PD can also cause sleep difficulties and some people have problems sleeping even before movement symptoms develop and PD is diagnosed.

Some PD medications can disrupt sleep. Others make people sleepy during the day. Not surprisingly, sleep-related symptoms are reported by more than 75% of people with PD.

Disrupted sleep can affect your health, mood and overall quality of life. Furthermore, when people with PD don’t sleep well, their care partner’s sleep is disrupted, too. Caregivers also need restful sleep to stay healthy and be at their best.

Most Common Sleep Issues

Difficulty falling and staying asleep
Excessive daytime sleepiness
Talking, yelling out or physically acting out while asleep
Vivid dreaming
Leg movements, jerking, cramping (restless leg syndrome)
Difficulty turning over in bed
Waking up to go to the bathroom

Tips for Better Sleep

Keep a regular sleep schedule — go to bed at the same time and get up at the same time.
Choose your bedtime based on when you want to get up. Plan to spend seven to eight hours a night in bed.
Make a bedtime routine — for example, snack, evening medication, tooth-brushing, using the restroom — and follow it every evening.
Spend time outdoors and exercise every day, in the morning if possible. Avoid exercise after 8:00 p.m.
If you can’t get outdoors, consider light therapy — sitting or working near a light therapy box, available at drug stores and department stores.
If you nap, try to do so at the same time every day, for no more than an hour, and not after 3:00 p.m.
Sleep in a cool dark place and use the bed only for sleeping and sexual activity.
Do not read, watch television, or use electronic devices in bed.
If turning in bed is difficult: use a satin fitted sheet and pajamas; use a light quilt instead of an easily tangled bedsheet.
Minimize drinking liquids for three hours before bedtime to avoid frequent nighttime urination.
Go to the bathroom immediately before retiring.
Consider a soft, rather than bright, light to illuminate your path to the bathroom.
Place a portable commode next to the bed to minimize effort, if needed.

If you are experiencing sleep problems, you should avoid:

Alcohol, caffeine and other stimulants such as nicotine
Heavy late-night meals (although a light snack at bedtime may be helpful)
Heavy exercise within six hours of bedtime
Thoughts or discussions before bedtime about topics that cause anxiety, anger or frustration
Clock watching
“Screen time” — television, phones, tablets — one or two hours before bed.

Certain antidepressants, such as mirtazapine (Remeron) may help with sleep while others — the SSRIs — can make other sleep symptoms worse. Also, if you are unsure, check with your doctor or pharmacist to ensure alerting medications are being taken in the morning and sedating medications are being taken at night.

If urinary frequency keeps you up at night, be sure your doctor rules out causes other than PD. In addition, there are several medications that can be helpful, including oxybutynin (Ditropan®), tolterodine (Detrol®), trospium (Sanctura®), tofenacin succinate (VESIcare®), darifenacin (Enablex®), mirabegron (Myrbetriq®) and phenoperidine fumarate (Toviaz®). You may be referred to a bladder specialist (urologist).

Excessive Daytime Sleepiness

Sleepiness during the day is seen in about 30 to 50% of people with PD and it is more prominent as the disease advances. Daytime sleepiness related to PD may arise for many reasons, including getting a poor night’s sleep or the use of dopaminergic medications, especially dopamine agonists like pramipexole (Mirapex), ropinirole (Requip) and rotigotine (Neupro).

NOTE: dopamine agonist medications like pramipexole and ropinirole can cause sudden "sleep attacks" while driving. This is a potential cause of motor vehicle accidents and should be monitored.

Consider making certain lifestyle modifications, such as:
- Establish good sleep hygiene, including a set bedtime and wake-up time.
- Get exposure to adequate light during the day and darkness at night.
- Remember indoor lighting may not be sufficient to promote a normal circadian rhythm.
- Avoid sedentary activities during the day.
- Participate in activities outside the home. They may help provide stimulation to prevent daytime dozing.
- Get physical exercise appropriate to your level of functioning, which may also promote daytime wakefulness. Strenuous exercise, however, should be avoided six hours before sleep.
- Do NOT drive while sleepy if you experience excessive daytime sleepiness. Motor vehicle accidents increase during periods of drowsiness and may be associated with sudden onset of sleep (sleep attacks).
- Talk to your doctor about possibly decreasing the dosage of dopamine agonists if you experience daytime sleepiness or sleep attacks.
- If you snore or stop breathing at night, tell your doctor so that you can be evaluated for sleep apnea.
- Talk to your doctor about stimulants like caffeine, modafinil (Provigil) and methylphenidate (Ritalin).

Problems with Sleep at Night

There are several problems that people with PD may experience during the night:

Sleep Apnea

Sleep apnea can be seen in up to 40% of people with PD. Common symptoms include:

Loud snoring
Pause in breathing during night sleep
Restless sleep
Sleepiness during the daytime

Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is the most common category of sleep-disordered breathing. The muscle tone of the body relaxes during sleep and at the level of the throat the human airway is composed of collapsible walls of soft tissue. These can obstruct breathing during sleep.

Unlike the general population, people with PD who have sleep apnea may not be overweight.

A continuous positive airway pressure (CPAP) machine, a machine that blows air into your airway (through a mask) at a pressure that is sufficient to keep the airway open during sleep, is the most consistently effective treatment for obstructive sleep apnea. The CPAP machine is connected by a tube to a face mask worn when sleeping through the night. It controls pressure in one’s throat to prevent the walls of the throat from collapsing, creating better sleep quality. CPAP should be worn for the entire night and for naps.

REM Sleep Behavioral Disorder

Rapid eye movement, or REM, sleep is the part of the sleep cycle when dreaming occurs. Usually the only part of the body that moves during REM sleep is the eyes.

People with rapid eye movement sleep behavior disorder (RBD) do not have the normal relaxation of the muscles during their dreams. Therefore, they act out their dreams during REM sleep.
People with RBD may shout, hit or kick their bed partner or grind their teeth. Sometimes, in moderate to severe RBD, people may have aggressive, violent behaviors, like getting out of bed and attacking their bed partner.
About half of people with PD suffer from RBD. It may develop after or along with the motor symptoms, but in most cases, it precedes the PD diagnosis by five to 10 years.

- Consider making environmental adjustments to protect the person with RBD and bed partner from injury. This may include padding the floor, creating a barrier between bed partners, or sleeping in separate beds or rooms.
- Talk to your doctor about the over-the-counter sleep aid melatonin. Doses up to 12 mg one hour before bedtime can improve RBD symptoms.
- Clonazepam has been shown in large case series to improve RBD in 80 to 90% of cases. It is often used when melatonin is not effective. 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.

Insomnia

Insomnia is the inability to sleep. It includes difficulty falling asleep and staying asleep, as well as waking up too early. About one-third of the adult population has some symptoms of insomnia, and it is even more common in people with PD. Problems with sleep maintenance — such as frequently waking throughout the night with difficulty falling back to sleep — are the most common type of insomnia in PD. There are many causes of insomnia in general. When it comes to people with Parkinson’s:

Women and elderly people are more likely to experience insomnia.
People with more advanced PD have more prominent insomnia compared to those with milder symptoms.
Other medical and psychiatric conditions contribute to insomnia in people with PD. For example, anxiety and depression can lead to difficulties falling asleep.
Undiagnosed sleep disorders may cause insomnia.
Symptoms — including rigidity, pain and tremor that returns when you wake during the night — can impact sleep continuity.
Certain medications can also negatively influence sleep quality.

Like Parkinson’s, there is no definitive diagnostic test for insomnia. To establish an accurate diagnosis, talk to your doctor, who will most likely ask questions to get a detailed medical and sleep history. Share your sleep schedule, how often you have problems sleeping and what you do when you are unable to fall asleep. Your doctor may ask you to start a sleep diary or refer you to a sleep laboratory for an overnight sleep study.
There can be many insomnia triggers, so treatment depends largely on what is causing it. The treatment approach should be tailored for each person.

Cognitive behavioral therapy (CBT) is a technique that helps people change patterns of negative thinking and behavior. It is commonly used to treat mood disorders such as depression and anxiety, but it can also target thoughts and actions that are disruptive to sleep. CBT has been studied in people with PD and found to be effective in treating insomnia. CBT can include many strategies, such as stimulus control, relaxation, sleep hygiene and sleep restriction.

Light therapy is another treatment option, where you are exposed to light that is brighter than indoor light but not as bright as direct sunlight. Because of its effectiveness, low cost and excellent safety profile, light therapy is a promising treatment not only for impaired sleep and alertness but also for other aspects of PD, such as depression. Like any treatment, do not start light therapy without consulting your healthcare provider.

Other strategies can include:
- Relaxation therapy: This might include deep breathing, meditation, guided imagery, biofeedback, progressive muscle relaxation and more.
- Sleep restriction: This intervention initially limits the number of hours you sleep, then gradually increases sleep time until a normal night’s sleep is achieved.
- Reconditioning: Encourages use of your bed for the sole purposes of sleep and sex. Only get in bed when sleepy or for intimate purposes. If you cannot fall asleep, leave the bedroom and return when you are sleepy again.
Medications may also be considered as a treatment. Talk to your doctor before taking any medication. Only as a last resort should sedatives such as zolpidem (common brand: Ambien) be used. These drugs can be addictive, so that you are not able to fall asleep without them. They can also contribute to grogginess during daytime and lead to troubling behaviors, such as nighttime eating disorders.

Page reviewed by Dr. Addie Patterson, Movement Disorders Neurologist at the Norman Fixel Institute for Neurological Diseases at the University of Florida, a Parkinson’s Foundation Center of Excellence.