Problems in falling or staying asleep are common in people with Parkinson’s disease. Symptoms such as rigidity (muscle resistance to movement) and bradykinEsia (slowed muscle response and movement) make turning over in bed and finding comfortable positions difficult. Sometimes these symptoms cause aching and even pain as muscles held in the same position too long become cramped and exhausted. An uncomfortable feeling in the legs as one lies in bed trying to fall asleep that is at least partially relieved with movement. It is known as restless leg syndrome and is common in those with Parkinson’s and is often a precursor to actual Parkinson’s in some cases. Once asleep, the person often thrashes around. Many people with Parkinson’s have extraordinarily vivid dreams and nightmares. The reasons for these disturbances seem to be a combination of factors related to the disease process of Parkinson’s, the effects of anti-parkinson’s medications, and normal changes in sleep patterns that take place with increasing age.
Consequences of Inadequate Sleep
Although researchers do not fully understand what happens during sleep or why sleep is essential, they do know that the consequences of sleep deprivation can be severe and may include physical as well as cognitive and psychological impairment. Studies of extended sleep deprivation in healthy volunteers reveal significant disruptions of concentration, ability to think, and reason, and even seizures, which suggest strong connections between physical and cognitive functioning in the brain.
Sleep is the body’s time to slow its functions, allowing cells the opportunity to repair and recover from the stresses of daily activity. When the rest the body receives is inadequate, cells (and accordingly tissues and structures) must continue functioning at full activity, and after a time, they wear out. This may contribute to oxidative stress, and other destructive conditions may occur, in theory causing cells to become damaged or die. The neurodegenerative disease process of Parkinson’s magnifies the consequences of inadequate rest. The body’s attempts to compensate result in uncontrollable urges to fall asleep at inappropriate times. Anti-Parkinson’s medications, because they alter the biochemical balance of the brain, further contribute to this condition. Inadequate rest stresses the already dysfunctional neuromuscular processes that characterize Parkinson’s, worsening symptoms.
Sleep Pattern Changes with Age
Changes in sleep patterns are normal as people grow older. They likely are due to a combination of factors that accompany aging such as slowing of metabolism, decline in hormone levels, reduction of activity, and alterations in brain biochemical processes with apoptosis (programmed, normal cell death) and perhaps other kinds of damage to neurons aside from that of Parkinson’s (such as oxidation) that affect their functions or cause their death. Researchers are uncertain whether less sleep indicates a diminished need for sleep or difficulty in sleeping that arises from these physiological changes.
Whatever the causative factors, many people find that as they get older they sleep less they go to bed later or take longer to fall asleep, wake up more frequently throughout the night, and wake earlier in the morning. Most nonetheless feel rested, suggesting that their bodies either adjust to the shortened hours of sleep or do not need them. This is not the case for people with Parkinson’s, however, who typically find that the disease magnifies these patterns and creates disturbances that leave them unrested. People who have early-onset Parkinson’s who are generally not yet old enough to be experiencing sleep changes related to aging experience Parkinson-related sleep disturbances as well, although they seem better able to cope with them until later in the disease process.
Insomnia and Nighttime Waking
Insomnia is the inability to fall asleep. Often the person is tired, even so tired that he or she finds it impossible to stay awake, but nonetheless just lies in bed unable to fall asleep. This pattern generates further distress and anxiety. By the middle stages of the disease, many people with Parkinson’s have shifted their anti-Parkinson’s medication regimens to provide maximal relief of neuromuscular symptoms during waking hours, so the reduced medication coverage during the night allows muscles spasms and dystonic events to emerge.
Nighttime waking is another dimension of insomnia in which, after finally falling asleep, the person awakens and then cannot fall asleep again. Many of the factors that originally prevented sleep motor symptoms, anxiety, “busy” thoughts contribute again. nocturia (the urge to urinate) interrupts sleep for many people with Parkinson’s. Nocturia is a consequence of Parkinson’s disease’s disruption of smooth muscle function affecting the bladder. When neuromuscular symptoms make it a struggle to get up and go to the bathroom, and then get back into bed and get comfortable enough to fall back to sleep, nocturia can create disturbances that last an hour or longer. Nocturnal myoclonus jerking of muscle groups is another physical disturbance that can awaken a person from sleep.
Sleeping during the day disrupts nighttime sleep patterns as well. Many anti-Parkinson’s medications cause drowsiness. The person with Parkinson’s may take brief or even extended naps during the day as a result, unable to stay awake because of the drug’s effect. This napping contributes to the body’s “sleep bank,” however, and can reduce the need for nighttime sleep because the body’s sleep needs are being met throughout the day. Sometimes altering the dosages and schedules of medications can lessen this effect. The medication modafinil (Provigil) is a nonamphetamine stimulant that increases wakefulness and alertness when medication adjustments are ineffective for reducing episodes of sleepiness. Restoring the body’s normal cycle of daytime wakefulness improves the ability to sleep at night.
Dreams and Nightmares
Shakespeare’s wistful “To sleep, perchance to dream” is not a wish but a dread of many people who have Parkinson’s. For them, vivid dreams and nightmares frequently disturb restful sleep. Researchers are unsure why this is, although most believe it is a combination of continued cell death, which alters brain perceptions and activity, and continually fluctuating neurotransmitter levels in the brain. The brain is designed to “expect” certain
cycles of physiological events a predictable rise and fall of biochemical activity. This pattern becomes chaotic in Parkinson’s, creating widespread disturbances in brain functions beyond the disruptions of motor function that are the core of the disease. Researchers speculate that this effect contributes to both hallucinations and enhanced dream experiences.
Anti-Parkinson’s medications, particularly dopaminergics such as lEvodopa and dopamine agonists (pErgolidE, pramipExolE) that incidentally activate dopamine receptors in areas of the brain other than the basal ganglia, trigger brain activity that otherwise would not occur during rest. This effect is manifested through vivid and sometimes frightening or disturbing dreams and nightmares. At times the person with Parkinson’s may have a problem distinguishing between dreaming and being awake. The reality of being immobilized by the symptoms of Parkinson’s further compounds the sensation of being “frozen” in a dream state. This perception can create considerable anxiety until the person becomes oriented and fully awake. After such experiences, of course, returning to sleep is difficult.
REM Sleep Behavior Disorder (RBD)
Normal sleep occurs in identifiable stages. The stage in which dreams primarily take place is called rapid eye movement (REM). In people with normal brain function, the brain suppresses muscle activity during REM sleep. This mechanism prevents the body from acting out the events of dreams. In people with Parkinson’s, this mechanism becomes dysfunctional and the body acts out dreams, sometimes with great physical energy expressed through kicking, thrashing, swinging of the arms, and other actions that can actually be harmful to the person or to a partner who is sharing the bed. Medications that relax the muscles can help to reduce RBD. RBD sometimes emerges or intensifies when the anti-Parkinson’s medication regimen is adjusted to mediate increased daytime symptoms, thereby reducing medication coverage at night.
Improving the Potential for Restful Sleep
Finding the optimal blend of conditions to support restful sleep is highly individualized and often
requires flexibility to accommodate day-to-day changes in symptoms and activity levels. It generally is helpful to
• Stay awake during the day
• Go to bed and get up at the same times each day regardless of sleep quality
• Establish a routine of diminishing activity and concentration in the evenings to prepare the body and mind for rest and sleep
• Reduce outside distractions, such as light and noise, as much as possible
• Limit fluid intake after the evening meal to reduce problems with nocturia
• Consider medication for depression, if symptoms of depression are present
• Consider sleep medication, if disturbed sleep persists longer than two weeks
Because pharmacotherapy is the primary therapeutic approach for Parkinson’s disease at present, the person with Parkinson’s typically takes a number of medications. As there generally are choices among the drugs within a particular classification, finding medications that can accomplish more than one mission makes sense. There are, for example, more than a dozen drugs that act as muscle relax-ants. These produce varying degrees of sedation. For the person who has trouble sleeping at night because of nocturnal myoclonus and restless muscle activity, choosing a nighttime muscle relaxant with a high sedative effect is helpful. Conversely, it is important to look at the sedative effects of drugs taken during the day, to try to schedule them, or activities, to minimize drowsiness. A person who knows that the morning dose of levodopa causes sleepiness may consider taking a brisk walk at the time drowsiness is most likely to occur, helping to keep the body busy and the mind occupied until the drowsiness passes.