How to improve sleep with Parkinson’s disease?
Non-motor symptoms of Parkinson’s disease, such as autonomic dysfunction, sleep disturbances, and neuropsychiatric manifestations, can precede movement disorders by years and even decades before diagnosis.
Parkinson’s disease is accompanied not only by motor symptoms but also by non-motor manifestations such as anxiety, apathy, mood changes, cognitive impairments, and emotional instability. These symptoms significantly reduce the quality of life for patients. Sleep disturbances are also a common companion of Parkinson’s disease. They may be related to the disease itself, side effects of medications, or motor problems such as tremor and rigidity.
Sleep disturbance is one of the most common non-motor symptoms, occurring in 60-90% of patients and manifesting as insomnia, sleep-disordered breathing, excessive daytime sleepiness, and behavioral disorder in REM-sleep phase, movement disorders occurring during sleep, such as restless legs syndrome, and circadian rhythm disruption
The pathophysiology of sleep disorders in Parkinson’s disease is complex and involves multiple factors, including movement complications and side effects of medications. However, the disintegration of sleep-regulating pathways by the neurodegenerative process likely plays a key role, especially in the early stages of the disease.
Feedback between neurodegeneration and sleep is also possible, as disruption of the regular sleep pattern and circadian rhythm leads to its aggravation through altered synaptic homeostasis, reduction of slow-wave sleep and REM-sleep, impaired function of the glymphatic system, leading to the accumulation of neurotoxic proteins – alpha-synuclein and beta-amyloid
For sleep assessment, polysomnography is performed and two scales are used: Scales for Outcomes in PD Sleep (SCOPASLEEP) и Parkinson’s Disease Sleep Scale (PDSS-2), other questionnaires are also used: Epworth Sleepiness Scale, Stanford Sleepiness scale, International Restless legs Symptoms Severity Scale (IRLSS), PSQI for insomnia, REM Sleep Behavior Disorder Screening Questionnaire (RBDSQ), RBD single-question-questionnaire, the PD NMS questionnaire.
Causes and Treatment Methods for Specific Types of Sleep Disorders:
Insomnia:
- causes: neurodegenerative processes, akinesia, dyskinesias, motor fluctuations, side effects of dopaminergic drugs and amantadine, psychiatric symptoms (anxiety), autonomic disorders (nocturia, blood pressure fluctuations)
- treatment: sleep hygiene, cognitive-behavioral therapy, light therapy, treatment of movement complications (long-acting medications), antidepressants (doxepin, trazodone, venlafaxine, nortriptyline) z-medications, including eszopiclone, short-term (up to 4 weeks), the antipsychotic pimavanserin, melatonin, and orexin antagonists (research is needed)
Excessive daytime sleepiness:
- causes: neurodegeneration in the brainstem, basal ganglia, and hypothalamus affecting the GABAergic, serotonergic, and orexinergic systems, sleep-related breathing disorders, motor complications of Parkinson’s disease – akinesia, non-motor symptoms of the disease: anxiety, depression, dopamine agonists, and levodopa medications
- treatment: correction of motor and non-motor complications – use of long-acting drugs, assessment of timing and dosage of dopamine agonists, sleep hygiene, increased physical activity (physical therapy), light therapy, caffeine up to 200 mg twice a day, istradefylline approved for dyskinesia correction, methylphenidate, modafinil, atomoxetine, sodium oxybate (GABA) – further research is needed to confirm the effectiveness of these medications
Sleep Breathing Disorder:
- treatment: CPAP/BiPAP – therapy, positional therapy, and mandibular advancement device for obstructive sleep apnea, hypoglossal nerve stimulation, for central sleep apnea – treatment of the underlying condition (lung diseases, heart diseases, kidney diseases, opioid addiction)
Behavioral disorders in REM-sleep phase
- treatment: melatonin, clonazepam, studies are being conducted on ramelteon, nelotanserin, zopiclone, rivastigmine, sodium oxybate (GABA), discontinuation/replacement of antidepressants
Movement disorders occurring during sleep. Restless legs syndrome:
- causes: disruption of dopamine and iron metabolism, genetic risk factors ( MEIS1, BTBD9), Vitamin B12 deficiency, folic acid deficiency, diabetes mellitus, pregnancy, chronic kidney disease, spinal cord injury, polyneuropathies, use of antagonists and SSRIs.
- treatment: iron supplements (ferritin above 75), dopamine agonists, gabapentin/pregabalin, oxycodone-naloxone
Circadian Rhythm Disruption:
- treatment: sleep hygiene, light therapy, treatment of anxiety, depression, hallucinations, melatonin
The impact of sleep deprivation on intellectual activity
Lack of sleep can exacerbate memory problems and cause emotional disturbances in patients with Parkinson’s disease due to changes in dopamine metabolism. Sleep is an important physiological process, the lack of which leads to fatigue, mood swings, decreased concentration, learning, and memory. It has previously been shown that sleep deprivation in healthy individuals reduces the number of dopamine receptors, which can negatively affect cognitive functions.
To study the impact of sleep deprivation on cognitive and emotional impairments in Parkinson’s disease, a group of scientists conducted an experiment on Danio fish. The animals were induced with parkinsonism symptoms using rotenone, a substance that disrupts mitochondrial function and leads to cell death. It is known that people exposed to rotenone have an increased risk of developing Parkinson’s disease. The fish were then deprived of sleep for four weeks by creating constant lighting. Typically, these fish “sleep” about 10 hours a day in dark places. The results were compared with a control group that maintained a normal sleep schedule.
The experiment showed that fish with parkinsonism and sleep deprivation exhibited significant problems with memory and object recognition, indicating the impact of sleep deprivation on cognitive functions. These fish also showed increased anxiety and depressive behavior. Scientists linked these changes to dopamine metabolism—a key neurotransmitter whose deficiency is characteristic of Parkinson’s disease. Although the dopamine level in the brains of fish with parkinsonism was reduced, sleep-deprived animals showed a decrease in the number of dopamine receptor types D2 и D3. This confirms the hypothesis that lack of sleep does not reduce dopamine levels but decreases the number of receptors it interacts with.
Adequate sleep plays an important role in maintaining cognitive functions and emotional state in patients with Parkinson’s disease. It helps preserve dopamine receptors, which helps reduce the severity of cognitive impairments. If you have sleep problems, it is important to consult a neurologist for correction.
Sources
Research “Sleep Deprivation Exacerbates Mental and Emotional Disorders in Parkinson’s Disease” // Journal Behavioural Brain Research.06.2019. URL: https://www.sciencedirect.com/research/article/pii/S0166432819301949 Volkow, N. (2012). Evidence That Sleep Deprivation Downregulates Dopamine D2R in Ventral Striatum in the Human Brain. of Neuroscience, 32 (19), 6711-6717
Schütz L., Sixel-Döring F. et al. Review Managemeф nt of Sleep Disturbances in Parkinson’s Disease. J Parkinsons Dis. 2022;12(7):2029-2058. doi: 10.3233/JPD-212749.