Whilst most adults experience difficulty sleeping or disturbed nights with fragmented sleep at some point in their lives, sleep problems and night-time difficulties are very common for people with Parkinson’s. In fact, it has been estimated that almost 90% of those with Parkinson’s experience sleep difficulties and these often affect bed partners too.
There are several possible reasons for this, the most common of which are outlined below.
Medication: changes in sleep patterns can occur in response to anti-Parkinson’s medication in a number of ways.
- when levodopa, or other dopamine–replacement medications, start to wear off at night, they lose their effectiveness before the next dose is due. This causes symptoms such as tremor, rigidity, pain and turning over in bed to worsen resulting in disturbed sleep and frequent waking
- other anti-Parkinson’s medications can also interfere with sleep. For example amantadine and selegiline can keep people awake at night (insomnia), particularly when taken in the evening. In some people with advanced Parkinson’s, high doses of levodopa or dopamine agonists can also cause insomnia
- other medications and substances can interfere with sleep, too, such as caffeine, diuretics (tablets to promote urine production and flow) and ephedrine (a stimulant used to treat postural hypotension ).
Early morning dystonia : these painful muscle spasms disturb sleep, particularly very late at night or in the early hours of the morning. Dystonia at this time is usually a sign of Parkinson’s medication wearing off. It often affects the feet and hands and may cause the feet to turn inwards resulting in a painful cramp.
Nocturia: many people wake at night with the urge to urinate. Not only does this interrupt sleep, but for people with Parkinson’s experiencing an ‘off’ period, it can also cause urinary incontinence, due to a lack of mobility and not being able to get to the toilet in time. Increased urination at night can also lead to reduced levels of minerals in the blood which can in turn cause light-headedness when trying to stand up. This is caused by an abnormal drop in blood pressure on standing, also known as postural hypotension.
Insomnia: difficulty in falling asleep or staying asleep can be caused by the symptoms of ‘off’ periods, such as rigidity and tremor, or by anxiety and depression.
Parasomias: disorders that are experienced just prior to waking, or when light sleep changes to deep sleep, can disrupt sleep considerably. Such disorders include hallucinations, nightmares, vivid dreaming, sleep-walking, sleep-talking. Hallucinations may be a side effect of certain anti-Parkinson’s medications.
Leg movements: Restless leg syndrome (RLS), an irresistible desire to move the legs, is a common cause of sleeplessness in Parkinson’s. Periodic Limb Movement Disorder, with which legs, arms and body jump and twitch, can disrupt sleep for both you and your bed partner. Pins and needles in the calf muscles is also very common and this may make bedclothes uncomfortable. This may be relieved by walking around, but such a solution obviously interferes with sleep, too.
Rapid Eye Movement Behaviour Disorder (RBD): during rapid eye movement (REM) sleep, the deepest phase of our sleep cycle, some people are particularly active. This ultimately results in waking and sleep deficiency. Some people may act out violent dreams, and falling out of bed becomes a risk. Others shout, cry or thrash about, sometimes unwittingly harming their bed partner.
Panic attacks: a sense of panic during the night, often related to ‘off’’ periods or to anxiety or depression, can interfere with sleep.
Sleep-disordered breathing: sleep disordered breathing
(SDB), also called sleep apnoea, means that a person stops breathing for a
short-period, usually a few seconds. Typically loud snoring is a problem. It is
thought that as many as 20-30% of people with Parkinson’s experience SDB and
some believe that this leads to day-time difficulties with drowsiness or sleepiness, and
memory. A sleep study called polysomnography is essential for
diagnosis.
Anxiety or depression: anxiety, depression and other psychological problems, including dementia, can disturb sleep. Lack of sleep can also exacerbate such problems so it is important to get help if you think you may be anxious or depressed.
Pain: pain may sometimes be caused by akinesia (a lack of movement) at night and results in frequent waking.
Excessive daytime sleepiness (EDS)
People with Parkinson’s can also experience excessive daytime sleepiness which causes them to fall asleep or doze frequently during normal waking hours. In extreme cases, such as narcolepsy, sleep may overcome the individual with no warning. In addition to such pathological abnormalities, there are several reasons for EDS, including:
- insufficient or poor quality sleep at night
- the use of medications which increase sleepiness, e.g. sedatives, antidepressants and hypnotic
- high dose levodopa treatment and stimulants, such as amantadine, which interrupt night-time sleep due to their stimulant effect
- anti-Parkinson’s medication such as dopamine agonists and levodopa may actually cause EDS.
