Acknowledgement
We would also like to acknowledge the use of information from the Parkinson’s Disease Society fact sheet Sleep and Night-time Problems in Parkinson’s
Our thanks also to Professor K Ray Chaudhuri1and Dr Sharon Muzerengi2for their help in reviewing this article.
If you are experiencing sleep or night-time problems, you should discuss these with your doctor or Parkinson's disease Nurse Specialist. They will need to check if your anti-Parkinson’s medication is the cause, and if your existing drug regime requires adjustment, such as follows:
Medication: if sleep deficiency is a result of symptoms caused ‘off’ periods (such as tremor and rigidity at night), your doctor may prescribe a longer acting anti-Parkinson medication to be taken before bedtime, such as controlled release levodopa. Alternatively, you may be prescribed a rotigotine skin patch which has a long duration of action and appears to have a positive effect on sleep. Cabergoline may also help although there is a risk of valvulopathy (formation of fibrous tissue of the heart valves) so it may not be suitable for everyone. If these medications do not last you through-out the night, you may be referred for apomorphine injections which provide continuous infusion through a waist-held pump with a needle inserted under the skin.
Early morning dystonia : controlled release levodopa, a longer acting dopamine agonists, such as cabergoline, or rotigotine can be helpful in avoiding dystonia at the end of the night. Again, if these drugs do not ease the dystonia, then injections of apomorphine may be prescribed.
Nocturia : drugs such as oxybutynin or tolterodine can be useful, but so will reducing your evening fluid in-take and ensuring you go to the toilet before bedtime. If nocturia causes postural hypotension, a significant drop in blood pressure when standing, you may feel giddy or light-headed when getting up in the morning. In such a case, you may be prescribed a nasal spray to reduce urination at night. If possible, avoid drugs that lower blood pressure, such as antidepressants, as they can promote night-time urination – but you must consult your doctor before altering your medication regime. To alleviate light-headedness make sure that you get up slowly, sitting for a minute or two before standing fully.
Insomnia : if difficulty sleeping is caused by ‘off’ periods during the night, medication may be altered to include dopaminergic drugs such as apomorphine or controlled release levodopa. If insomnia is related to anxiety or depression (see below ).
Parasomnias : if you suffer from parasomnias, such a sleep talking, which affect you and/or your bed partner, you may be referred to a doctor with a specialist interest in Parkinson’s or in some cases to a neurologist with a special interest in sleep disorders. As hallucinations at night may be a side effect of certain anti-Parkinson’s medications, your doctor may alter your drug regime.
Leg movements: over-production of dopamine or over-stimulation of the cells that produce dopamine can cause abnormal, involuntary movements of the arms, legs and body (dyskinesia ). In such cases, the dosage of levodopa taken at night may need to be adjusted or a longer-acting dopamine agonist, such as cabergoline, may be helpful to control dopamine levels and such movements.
Rapid Eye Movement Behaviour Disorder (RBD): it is important to tell your doctor if you or your bed partner sleep walk, talk, shout or are violent when sleeping so that appropriate medication can be prescribed or specialist advice sought.
Panic attacks: if related to ‘off’ periods, panic attacks may be treated by using dopaminergic drugs, such as apomorphine or controlled release levodopa. If related to anxiety, different medication may be required - see anxiety or depression below.
Anxiety or depression: if depression seems to be causing sleep problems, then treatments may include antidepressant medication and psychological approaches, such as counseling.
Pain: standard painkillers may be helpful in controlling any pain due to night-time akinesia (lack of movement).
Excessive daytime sleepiness (EDS): if you are experiencing EDS, it is important that you discuss this with your doctor. In some cases, drugs that promote wakefulness, e.g. selegiline, amantadine or modafinil, may be used, but this requires specialist approval.
A study by Oxford University researchers in 2002 concluded that the practice of counting sheep does not help in overcoming insomnia. On the contrary, it can be so boring that other problems or worries inevitably surface disturbing sleep further.
Rhythmic shaking of part of the body. It is one of the main symptoms of Parkinson's disease, although it is not experienced by everyone.
Stiffness of the limbs, joints or body that make movement and bending difficult.
The main type of drug prescribed to treat Parkinson's disease and has been in use since the late 1960s. The aim is to increase the levels of dopamine in the brain. Dopamine cannot be directly replaced because it cannot cross the blood-brain barrier that prevents potentially harmful substances in the blood from entering the brain. Levodopa is a chemical compound that can cross this barrier and is then converted into dopamine.
See also Types of medication available.
A dopamine agonist used to treat Parkinson's disease that is administered via a transdermal (skin) patch.
See also Types of medication available.
A dopamine agonist used to treat Parkinson's disease.
See also Types of medication available.
Involuntary sustained muscle contractions causing abnormal movements and postures.
See section on Dystonia.
A dopamine agonist drug used to treat Parkinson's disease, which is usually given by injection.
Dopamine agonists have structures that are very similar to dopamine. It imitates the action of dopamine rather than replace it, in the same way levodopa does.
See also Types of medication available
Waking at night with the urge to urinate.
Low blood pressure caused by a change in a person’s body position. For example, when a person moves from sitting to standing quickly.
Sleep disorder causing inability to fall asleep or to enjoy uninterrupted sleep.
See section on Sleep
A general name given to drugs that work by increasing the level and promoting the action of dopamine.
A parasomnia is any sleep-related disorder such as sleep walking, sleep talking (somniloquy), sleep eating, sleep sex, teeth grinding, night terrors, rhythmic movement disorder, REM behaviour disorder, restless legs syndrome, as well as seizures (convulsions), respiratory dyskinesia (difficulty in performing respiratory movements), arrhythmias (abnormal heart rhythms), and gastroesophageal reflux (food or liquid regurgitating from the stomach into the foodpipe).
Parasmnias are characterized by partial arousals during sleep or during transitions between wakefulness and sleep, meaning that the person exhibits symptoms of being both asleep and awake at the same time, and undesirable physical or verbal behaviors or experiences.
Physicians specializing in the field of neurology (a branch of medicine dealing with disorders of the nervous system ) are called neurologists and are trained to diagnose, treat, and manage patients with neurological disorders. Most neurologists are trained to treat and diagnose adults with neurological disorders.
Pediatric neurologists, nearly always a subspecialty of pediatrics, treat neurological disease in children.
Neurologists may also be involved in clinical research, clinical trials, as well as basic research and translational research.
A symptom that can be produced by Parkinson's disease or the medications used to treat it. They cause people to believe they are seeing, hearing or feeling things that are not really there.
A neurotransmitter produced in the substantia nigra, which forms part of the basal gangia in the brain. It sends messages from the brain to other parts of the body and has a major role in the control of movement. There is a shortage of dopamine in the brains of people with Parkinson's disease.
A general name given to drugs that work by increasing the level and promoting the action of dopamine.
A class of drugs that work by stimulating the parts of the brain (know as dopamine receptors ) where dopamine works. Unlike levodopa, they don’t need to be converted by the brain cells first. They may be given as a first treatment to delay the need for levodopa or used in combination with levodopa to treat the side effects caused by long-term treatment.
See also Types of medication available.
A type of medication used to treat Parkinson's disease.
See also Types of medication available
A mental state of melancholia, unhappiness or sadness characterized by decreased energy, reduced interest in sex, suppressed appetite, too much sleep or sleep disturbance, a pessimistic sense of inadequacy, a despondent lack of activity, despair, and discouragement.
Involuntary movements that tend to occur in people who have had Parkinson's disease for some years as a side effect of long-term use of Parkinson's medication.
A medication / drug or other substance (nutrient or herb) used for to alleviate depression.
