Treatment and management of sleep and night-time problems

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 medications do not ease the dystonia, then injections of apomorphine may be prescribed.
• nocturia: medications 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 medications 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 experience 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 medication, such as apomorphine or controlled release levodopa. If related to anxiety, different medication may be required - see anxiety or depression below.

• sleep-disordered breathing: the most common treatment for SDB is Continuous Positive Airway Pressure (CPAP) which ensures that the airway is kept open so that continuous breathing is maintained. Along with this daytime alerting medications such as modafinil may be required or sodium oxybate in very selected cases.

• anxiety or depression: if depression seems to be causing sleep problems, then treatments may include antidepressant medication and psychological approaches, such as counselling.
• 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, medication that promote wakefulness, e.g. selegiline, amantadine or modafinil, may be used, but this requires specialist approval.