1. Sleep Disturbances in Parkinson’s Angela Anagnos, MD Board Certified in Sleep Medicine and Neurology www.sleepmedicineandneurology.com

2. Rigid muscles Tremors or stiffness Unable to roll over in bed Frequent urge to urinate Vivid dreams, hallucinations, violent nightmares Acting out dreams(RBD) can precede PD by decades Introduction most people with PD find it difficult to sleep through the night

3. Daytime Sleepiness  Due to sleep disturbances  Due to medication side effects  Due to Parkinson’s disease itself  End result: Interferes with daily life

4. Step 1: Find Root Cause Seek professional help in early or mid-stage PD for: Insomnia Excessive daytime sleepiness Restless legs syndrome REM behavior disorder Poor sleep due to depression

5. Insomnia Inability to get a good night’s sleep Trouble falling/staying/falling back to sleep Fragments of sleep a few hours at a time Sleep studies (PSG) in PD show: Less deep sleep (S3) More light sleep (S1S2) Increased sleep fragmentation Multiple night awakenings

6. Sleep Hygiene and Insomnia Maintain a regular schedule for waking/sleeping Avoid excessive time in bed Avoid naps during the day and early evening Use bed for sleeping (not reading or watching TV) Do not watch the clock in bed Try to relax before bedtime: environmental cues Timed light exposure in the am

7. Sleep Hygiene Keep the bedroom dark, cool and comfortable Block out noises that disturb sleep Avoid caffeinated beverages or alcohol w/in 6 hrs of bedtime Exercise early in the day, not two hours before bedtime Go to another room if you cannot sleep Avoid going to bed hungry

8. Light Therapy Do not underestimate the power of natural sunlight in helping circadian rhythm disorders and common insomnia!

9. Excessive Daytime Sleepiness in PD Common in early and mid-PD Can be related to insomnia Can be related to other sleep disturbances Sleep apnea RLS/PLMD RBD Or related to medications High doses of dopaminergic medications like pramipexole and ropinirole can contribute but rare

10. RLS- Restless Legs Syndrome 5-10% of general population Common in PD but not predictive of PD Can predate PD by many years/decades Common, underdiagnosed, hyperkinetic movement disorder

11. RLS Four diagnostic criteria Do you have an uncomfortable or unpleasant sensation that causes an urge to move your legs? Are your symptoms worse during periods of rest or inactivity such as lying or sitting? Are your symptoms temporarily relieved by movement, such as walking or stretching? Are your symptoms worse in the evening or at night? As symptoms get worse, can occur during the day Key ?: “Do you have a creepy, crawly, or restless feeling in your legs at night that improves when you move around?”

12. RLS Usually primary/hereditary (possible loci chromosomes 9,12,14) Secondary causes due to iron deficiency, ESRD, Medications (neuroleptics=DA antagonists like Reglan) or antidepressants, peripheral neuropathy Prevalence increases with age over 40, F>M Can be mistaken for ADHD, especially in children More common in Parkinson’s Disease

13. PLMS-Periodic Limb Movements in Sleep 80% of those with RLS also have PLMS Slow, involuntary, stereotypic movements, usually involving flexing the leg at the hip, knee, and ankle. May involve arms. Reported by bed partner or found on sleep study. Causes daytime sleepiness and/or insomnia

14. RLS/PLMD Work-Up Labs tests for blood count, ferritin and iron studies, folate, glucose, renal screen; EMG/NCV if suspect neuropathy Sleep study to rule out sleep apnea and look for PLMD

15. TREATMENT RLS/PLMD Avoid alcohol, caffeine; regular sleep hygiene Stop problematic medications like antihistamines, tricyclic antidepressants Dopamine agonists help >70% of patients ; first line therapy : ropinirole (Requip) pramipexole (Mirapex), Levodopa (Sinemet) anticonvulsants like gabapentin, carbamazepine narcotics, iron tid with Vit C if ferritin < 50 mcg/dL or iron saturation <16%

16. REM Behavior Disorder (RBD) A disorder of dissociation of muscle atonia during REM sleep Breakthrough behaviors during REM described as acting out dreams Abrupt emotional vocalizations, swearing, injurious/violent behaviors Disruption of sleep continuity Appx 50% of PD patients have partial or complete loss of muscle atonia in REM sleep

17. REM Behavior Disorder (RBD) Male predominance > 45 yrs Associated neurodegenerative diseases, PD Morbidity Self injury 1/3 of cases Injury to others 2/3 of cases Daytime sleepiness in ¾ of cases (often due to other associated sleep problems)

18. Treatment of RBD Behavioral Safe environment Reduce disruptive events Reduce anxiety Good sleep hygiene Pharmacological Clonazepam (80% of patients reported benefit) Parkinson’s Treatment with Dopaminergics

19. Obstructive Sleep Apnea (OSAS) Symptoms Snoring Witnessed apneas Daytime fatigue/Sleepiness Moodiness, irritability Concentration/ memory complaints Depression Insomnia Exacerbated pain symptoms

20. Whose at Risk? Men> premenopausal women Micrognathia, overbite Obesity, hypothyroidism Enlarged adenoids, tonsillar tissue Exacerbated by supine sleep, gravity Deviated septum, allergies with mouth breathing Macroglossia, enlarged uvula Decreased muscle tone with aging, testosterone Higher incidence in PD related autonomic dysfunction

21. Diagnosis of OSAS by PSG Apneas- cessation of airflow >10 sec Hypopneas- 50% reduction in airflow with 3% reduction in oxygen, or EEG arousal RERAS- EEG arousals with increased respiratory effort AHI> 5/hr RDI > 40/hr, severe

22. Treatment of OSAS  CPAP/BIPAP/ AutoPAP +/- oxygen  Weight loss  Mandibular Advancement Appliance  Surgery overall, 50-70% improvement  UPPP  Septoplasty, turbinate reduction  Maxillomandibular advacement  Somnoplasty (RF)  Pillar procedure  tracheostomy

23. Sleep and Depression Depression in appx 40% of PD patients Associated with sleep disturbances Unrefreshing sleep Early morning awakenings Irregular dreams

24. Sleep in Later Stages of PD 33% of PD patients in mid-late stages experience hallucinations related to higher doses of medications Visual, not auditory Associated with vivid dreams