Sleep is integral in forming our memories and helping our brain learn new skills and information. However, some Parkinson's medications can disrupt sleep while other medications can make people sleepy during the day. More than 75% of people with Parkinson's have reported sleep-related symptoms.
Symptoms of lack of sleep:
Poor memory.
Trouble focusing.
Altered mood.
Poor balance.
Excessive fatigue.
Weight gain.
Low sex drive.
Headaches.
Negative side effects of lack of sleep:
Our body will create fewer endogenous opioids, our natural pain killers.
Our body may have higher counts of inflammation.
Increased rates of depression.
Increased rates of high blood pressure
Increased rates of kidney disease.
Increased blood sugar.
Did you know that sleep has a huge effect on pain? There have been several studies that show poor sleep is predictive of an increase in next day pain, next month pain, headaches, and chronic pain, and up to 14 missed days from work per year.
Types of sleep disturbances
1. REM Sleep Behavioral Disorder (RBD)
REM stands for rapid eye movement and it is the part of our sleep cycle where we dream. Typically, only our eyes are moving when we are in this cycle of sleep. When people have RBD, they do not have normal relaxation of muscles during their dreams. This causes them to act out their dreams. People with RBD may hit, kick, shout, or grind their teeth. Some people can even be aggressive and violent, but this usually occurs with more moderate to severe RBD. Around 50% of people with PD also have RBD. In most cases, RBD starts 5-10 years before their diagnosis.
2. Insomnia
Insomnia refers to difficulty falling asleep, staying asleep, and waking up too early. Insomnia is another sleep disorder that is common in people with PD, especially in women and elderly. People with insomnia may experience pain, tremor, and rigidity that returns when you wake up during the night. It is important to note that there is no definitive diagnostic test for insomnia.
3. Restless legs syndrome (RLS)
RLS is common in people with Parkinson’s and is described as unpleasant feelings in the legs when not moving that is usually relieved with movement. Usually, the restlessness goes away during the latter portion of the night and is gone by morning. RLS can be a symptom of other medical conditions such as iron deficiency, neuropathy, and renal failure.
4. Trouble moving in bed.
Sometimes, motor symptoms such as stiffness or slowness of movement may make it hard to move around in bed.
5. Nighttime trips to the bathroom.
This is called nocturia and about 35% of people with PD experience it. Many people wake up multiple times per night to use the bathroom. This can have a serious impact on your sleep cycle and number of hours you are sleeping.
Treatments of sleep disorders
1. Improving your quality of sleep
Try to keep it consistent with when you go to bed and when you wake up, even on the weekends or days off. This helps keep our internal clock in tune and helps us fall into deep sleep quicker.
Avoid naps. If you do need to nap, try to limit it to 30 minutes.
Go outside when the sun first comes out for 15 minutes. Getting sunshine first thing in the morning helps regulate the melatonin secretion and helps set our internal clock. It is important to actually be outside and not look outside through a window. The rays from the sun that help regulate our internal clock cannot pass through windows.
Have a relaxing bedtime routine. Avoid screen time 90 minutes before bed and take a hot shower before bed.
Reserve your bed for sleep and sex only. It is important to not do work in bed! Subconsciously, we will create stressful connections with our bed which can make it harder to fall asleep.
No caffeine after 2pm, avoid alcohol within 3 hours of sleeping, and avoid smoking (especially in the evening). It takes 7-8 hours after we ingest caffeine for it to stop affecting us.
Avoid heavy meals before bed. If we eat too close to bedtime, the gut-brain connection will prevent our brain from entering deep sleep if it is trying to digest a big meal.
Minimize any light, noise, and excessive temperatures in the bedroom.
Hide your clock if you are always watching it. This applies to phones too.
If you are having a hard time falling asleep after 10-15 minutes, don’t force it. Leave the room and sit in the dark or read a book. Do not look at your phone, laptop, TV, or other screens.
2. Treatments for RBD
Change the sleep environment to reduce risk of injury. Paddling the floor, creating a barrier between partners sharing a bed, or sleeping in separate beds/rooms may be helpful to keep everyone safe.
Over-the-counter sleep aid melatonin may help. Doses up to 12mg one hour before bedtime have been shown to improve symptoms. Before you try, talk with your neurologist.
When melatonin is not effective, Clonazepam is often prescribed. 0.5mg to 1.0mg of clonazepam has been shown to improve symptoms in 80-90% of cases. However, there are negative side effects such as nocturnal confusion, daytime sedation, and exacerbation of obstructive sleep apnea.
3. Treatments for insomnia
Cognitive behavioral therapy (CBT) has been found to be effective in treating insomnia in those with Parkinson's. Talk with your neurologist about therapists in the New York Capital District Area that they recommend for insomnia!
Light therapy. Being exposed to a light that is brighter than indoor light but not as bright as direct sunlight may be helpful. Talk with your neurologist before trialing light therapy.
4. Restless leg syndrome
Talk with your neurologist about what medications are most appropriate for you. Dopamine agonists and long-acting levodopa have been helpful for people with RLS. Gabapentin, gabapentin enacarbil and pregabalin can also be effective.
Make sure you talk about the risks associated with these medications. Some medications can cause confusion and hallucinations, especially older adults or those with more advanced PD. Others can lead to worsening of PD symptoms, making them appear earlier in the day, or migrating to the upper body in addition to the legs.
5. Treatments for trouble moving in bed.
Talk with your neurologist about medication changes to help manage "off" times when you are sleeping.
Visit a Physical Therapist to discuss what movements are difficult and see how they can help you move better.
6. Treatments for nighttime trips to the bathroom
Reducing fluid intake, caffeine, alcohol, and large meals a few hours before going to bed.
In those with lower leg swelling, increasing exercise and physical activity levels, elevating the legs in the afternoon to a level above the heart, and use of compression stockings have been shown to be helpful. Talk with your doctor before trying.
If you are taking diuretics (water pills), talk with your doctor about changing the timing of the medication.
Visit a Pelvic Floor Therapist to determine if there are any bladder habits or muscle dysfunctions that are impacting your bathroom trips.
References
The Association of Sleep and Pain: An Update and a Path Forward- Finan 2013
Depner CM, Melanson EL, Eckel RH, et al. Ad libitum Weekend Recovery Sleep Fails to Prevent Metabolic Dysregulation during a Repeating Pattern of Insufficient Sleep and Weekend Recovery Sleep. Curr Biol. 2019;29(6):957-967.e4. doi:10.1016/j.cub.2019.01.069
Lamon S, Morabito A, Arentson-Lantz E, et al. The effect of acute sleep deprivation on skeletal muscle protein synthesis and the hormonal environment. Physiol Rep. 2021;9(1):e14660. doi:10.14814/phy2.14660