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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 percent 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 caregiver’s sleep is disrupted, too. Caregivers also need restful sleep to stay healthy and to provide the best care.

Most Common Issues

  • Difficulty falling and staying asleep
  • Excessive daytime sleepiness
  • Talking or yelling 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, bath, tooth-brushing, toileting — 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 or watch television in bed.
  • Use satin sheets and pajamas to make moving in bed easier.
  • Minimize drinking liquids for three hours before bedtime to avoid frequent nighttime urination.
  • Go to the bathroom immediately before retiring.
  • Place a commode next to the bed, to minimize the effort, and light to get up during the night.
  • 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.  
  • 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 (Enables®), mirabegron (Moretti®) 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 percent 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), ropinerole (Requip) and rotigotine (Neupro).

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

How Is Daytime Sleepiness Treated?

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.
  • Talk to your doctor about decreasing 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 percent of people with PD. Common symptoms include:

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

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 are not overweight.

How is sleep apnea diagnosed?

A patient may participate in a “sleep study” or polysomnogram where the number 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 worn when sleeping through the night. It controls pressure in one’s throat to prevent the walls of the throat from collapsing, thus creating better sleep quality.

REM Sleep Behavioral Disorder

Rapid eye movement, or REM, sleep is a normal part of the sleep cycle when people dream. Usually the only part of the body that moves during REM is the eyes, thus the name.

  • 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, 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 disease, but in most cases, it precedes the PD diagnosis by five to 10 years.

RBD Treatment

  • Consider making environmental adjustments to protect the person with RBD and bed partner from injury. 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 percent of cases. 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 in generic form and not expensive.
  • Talk to your doctor about the over-the-counter sleep aid Melatonin. Doses up to 12 mg at night one hour before can improve RBD.  

Page reviewed by Dr. Chauncey Spears, Movement Disorders Fellow at the University of Florida, a Parkinson’s Foundation Center of Excellence.

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