1. Sleep and Parkinson’s Disease
Prof. Sebastiaan Overeem, MD, PhD
Sleep Medicine Center ‘Kempenhaeghe’, Heeze, NL
Eindhoven University of Technology, NL

2. Disclaimer
Goal: give a broad overview of sleep in Parkinson’s Disease (PD)
Broad view of the mechanisms and symptoms of sleep disorders
Some general example of specific disorders and possible treatments
NOT medical advice
Discuss any sleep problems with your physician, PD nurse, etc.
Relatively short overview; most important: interactive discussion 2

3. Sleep

4. 4

5. Sleep is an active and very complex brain process5

6. Sleep is an active and very complex brain process6

7. So.. plenty of reasons for things to go wrong..
We sleep 1/3 of our lives
Sleep regulated by many different brain regions
Sleep disorders are very prevalent
More than 10% of the population
Extensive spectrum of different sleep disorders 7

8. Parkinson’s Disease (PD)

9. PD is (much) more than just a movement disorder
Besides the motor symptoms
tremor
rigidity
posture and balance problems
Spectrum of non-motor symptoms
Psychiatric (e.g. depression)
Urologic
Sexual
Memory
Hypersalivation
Sleep disorders! 9

10. Sleep disorders in PD 10

11. Sleep versus other non-motor symptoms
nocturia %
urinary urgency %
constipation %
mood disorders %
insomnia %
concentration %
anxiety %
memory %
restlessness %
dribbling %
REM Sleep Behavior Disorder %
Excessive Daytime Sleepiness %
Clayton et al Park & Rel Dis 2006 11

12. Sleep versus other non-motor symptoms
nocturia %
urinary urgency %
constipation %
mood disorders %
insomnia %
concentration %
anxiety %
memory %
restlessness %
dribbling %
REM Sleep Behavior Disorder %
Excessive Daytime Sleepiness 30.0%
Clayton et al Park & Rel Dis 2006 12

13. Sleep disorders in PD How often do sleep disorders occur in PD?
Very much depends on the definition
Very much depends on the diagnostic method
60 - >90% has some disruption/disorder of sleep (!) 13

14. Reduced quality of life; also for partners!14

15. Sleep disorders in PD Many different sleep disorders / sleep symptoms
Difficulties initiating sleep
Difficulties maintaining sleep
Sleep related movement disorders
Etc
Complex (and often combined) causes
Damage to sleep regulating brain areas
Secondary to (motor) symptoms
Medication side-effects 15

16. Secondary to PD symptoms
Tremor
Rigidity
Akinesia / bradykinesia
Cramps
Pain
Nocturia … 16

17. Damage to sleep related brain regions
REM sleep behaviour disorder
Insomnia
Restless legs
Hallucinations
Sleep related breathing disorders
Sleep related stridor
Excessive daytime sleepiness 17

18. Medication related Too short acting PD medication (‘nocturnal off’)
Hyperkinesias at night
Insomnia
Hallucinations
Excessive daytime sleepiness
(dopamine agonists) 18

19. Examples

20. Excessive daytime sleepiness
15-50% of people with PD
All kinds of situations
‘Sleep attacks’ due to dopamine agonists
Often secondary to disturbed nocturnal sleep
Sometimes secondary to depression 20

21. Sleep disruption secondary to motor symptoms
Tremor, muscle/joint paints
Difficulties turning around in bed!
When this is not possible anymore; then it becomes clear how important it is to have a comfortable sleep position 21

22. Sleep problems due to motor symptoms
Difficulties turning around in bed
Degree of sleep disruption
Never
Seldom
Regularly
Most of the time
Always 5 6 7 8 9 10
Maartje Louter et al JAGS (2012) 22

23. Sleep disorders due to the PD disease process23

24. Muscle activity during REM sleep
During dreaming sleep (REM sleep): complete muscle paralysis
This is actively regulated by the brain, from the brainstem
This exact region is affected very early in the PD disease process 24

25. REM sleep behavior disorder (RBD)
What if the muscle weakness during REM sleep does not occur?
This would result in ‘dream enactment’
RBD present in more than 60% of PD patients 25

26. Treatment

27. Treatment of sleep disorders in PD
Sometimes: easy to treat
Often, it can be a complex situation
Crucial (in my view)
Attention to sleep by every PD caregiver
Sleep’interview’ in every PD patient
Help from a sleep medicine specialist can be very helpful
Dedicated PD-sleep clinic at Kempenhaeghe sleep center 27

28. Treatment of sleep disorders in PD
Sometimes: easy to treat
Often, it can be a complex situation
Crucial (in my view)
Attention to sleep by every PD caregiver
Sleep’interview’ in every PD patient
Help from a sleep medicine specialist can be very helpful
Dedicated PD-sleep clinic at Kempenhaeghe sleep center
 treatment start with a precise sleep diagnosis 28

29. General aspects: good sleep ‘hygiene’
Regular bedtimes
Comfortable bed and bedroom
Do not spend too long in bed
Mind stimulants (caffeine, strenuous exercise before bedtime..)
Do not sleep too long during the day
Etc. 29

30. Treatment: medication review
Always important to critically review all medication
Increase ‘dopaminergic control’ at night
Reduce or stop ‘sleep offending’ medication 30

31. Examples of specific treatments
Nocturia: behavioural, catheter, medication
Insomnia: medication changes, behavioural treatment, medication
REM Sleep Behavior Disorder: medication
Restless Legs: iron, specific medication
Excessive Daytime Sleepiness: medication changes, stimulants 31

32. Examples of specific treatments
Nocturia: behavioural, catheter, medication
Insomnia: medication changes, behavioural treatment, medication
REM Sleep Behavior Disorder: medication
Restless Legs: iron, specific medication
Excessive Daytime Sleepiness: medication changes, stimulants
 Can be difficult
 Sometimes ‘trial & error’, but do not give up!
 Interaction between PD neurologist and sleep medicine specialist! 32

33. Sleep as an ally

34. Sleep benefit in PD
Sleep benefit: temporary improvement in motor function after sleep
Unexpected after night without medication
Sometimes after daytime naps
Merel van Gilst et al JAGS (2012) 34

35. Sleep benefit in PD
Merel van Gilst et al PRD (2013) 35

36. Sleep benefit in PD Mainly based on subjective reports
Objective measurements in clinic: no clear picture
Current research in our group: automated video analysis at home
Merel van Gilst et al PRD (2013) + SLEEP (2015) 36

37. Conclusions

38. Conclusions Sleep disorders are very prevalent in PD
Complex causes, often several factors together
Treatable, given a precise sleep diagnosis
Interaction with sleep medicine specialist can be helpful
 attention to sleep by all PD caregivers! 38