Parkinson’s DiseaseParkinson’s Diseaseand Sleep Disordersand Sleep Disorders

Juan A. Albino, MD, FCCPJuan A. Albino, MD, FCCP

Village Sleep Lab 751-4955Village Sleep Lab 751-4955

August, 2007August, 2007

Thank You !!!Thank You !!!Bill Gray, Parkinson’s Support GroupBill Gray, Parkinson’s Support GroupHeather Ellington, Office Manager Heather Ellington, Office Manager Normarie M. Albino, MD, PresidentNormarie M. Albino, MD, President John Crawford, Technical DirectorJohn Crawford, Technical DirectorThomas Chaput, Sleep TechnologistThomas Chaput, Sleep TechnologistMichael Summers, Sleep TechnologistMichael Summers, Sleep TechnologistMiyoshi Scott, NurseMiyoshi Scott, NurseShunta McKinney, ReceptionistShunta McKinney, Receptionist

Common Sleep DisordersCommon Sleep Disorders

Insomnia: wants to sleep but cannot Insomnia: wants to sleep but cannot Sleep Deprivation: does Sleep Deprivation: does notnot want to want to

sleep but can; problem of sleep sleep but can; problem of sleep quantityquantity

SLEEP APNEA: SLEEP APNEA: sleepy during day, during day, snoressnores at night because of obstruction in throat; at night because of obstruction in throat; problem of sleep problem of sleep qualityquality

Restless Legs Syndrome: leg discomfort, Restless Legs Syndrome: leg discomfort, relieved by movement that hinders sleep relieved by movement that hinders sleep

Good Sleep Hygiene: BasicsGood Sleep Hygiene: Basics

Regular times for sleeping and Regular times for sleeping and awakeningawakening

Maintain bedroom dark, quiet, coolMaintain bedroom dark, quiet, coolUse bed only for sleep and sexUse bed only for sleep and sexAvoid late daytime napsAvoid late daytime napsAvoid at night: alcohol, caffeine, nicotineAvoid at night: alcohol, caffeine, nicotineSleep around 7 to 8 hours every nightSleep around 7 to 8 hours every nightPrudent exercise and eating Prudent exercise and eating Avoid stressful situations at bednightAvoid stressful situations at bednight

Parkinson’s & Sleep ProblemsParkinson’s & Sleep Problems

InsomniaInsomniaDaytime SleepinessDaytime SleepinessDisruptions during SleepDisruptions during Sleep

Parkinson’s & InsomniaParkinson’s & Insomnia

Primary Insomnia: present before PDPrimary Insomnia: present before PD Insomnia due to Parkinson’s: improves Insomnia due to Parkinson’s: improves

with better treatment of PD at nightwith better treatment of PD at nightDepression: before or after Parkinson’sDepression: before or after Parkinson’sUrge to urinate: bladder, prostate, etc.Urge to urinate: bladder, prostate, etc.Medications: some antidepressants, Medications: some antidepressants,

selegiline (Deprenyl, Eldeprl)selegiline (Deprenyl, Eldeprl)

Insomnia Due to Parkinson’s: Insomnia Due to Parkinson’s: CausesCauses

Lack of muscle and mental relaxation Lack of muscle and mental relaxation Stiffness, restlessness, and difficulty Stiffness, restlessness, and difficulty

of moving into comfortable positionsof moving into comfortable positionsTremor can be bothersomeTremor can be bothersomeMedications wear off during the nightMedications wear off during the night Insufficient medications during the Insufficient medications during the

nightnight

Insomnia Due to Parkinson’sInsomnia Due to Parkinson’s

Stage 1: Difficulty falling asleep: Stage 1: Difficulty falling asleep: need to take PD meds 1 to 3 hours need to take PD meds 1 to 3 hours before bedtimebefore bedtime

Stage 2: Waking up early part of Stage 2: Waking up early part of night: take long acting medicine at night: take long acting medicine at bedtimebedtime

Stage 3: Waking up latter part of the Stage 3: Waking up latter part of the night : take medicine when wake upnight : take medicine when wake up

Restless Legs Syndrome Restless Legs Syndrome (RLS)(RLS)

Leg discomfort, worse at night, relieved Leg discomfort, worse at night, relieved by movement, affects 5-10% of by movement, affects 5-10% of populationpopulation

Familial, begins in childhoodFamilial, begins in childhoodAssociated with iron deficiency, drugs, Associated with iron deficiency, drugs,

Periodic Limb Movement Disorder, PLMDPeriodic Limb Movement Disorder, PLMDEasily treatable with medicinesEasily treatable with medicinesRestless Legs Syndrome Foundation, Restless Legs Syndrome Foundation,

June K. Wharton (259-0979)June K. Wharton (259-0979)

Treatment of RLS/PLMDTreatment of RLS/PLMD

Restless Legs Syndrome is diagnosed Restless Legs Syndrome is diagnosed by history: exlude leg crampsby history: exlude leg cramps

Periodic Leg Movement Disorder is Periodic Leg Movement Disorder is diagnosed by a sleep studydiagnosed by a sleep study

Treatment is the same and effectiveTreatment is the same and effectiveLuckily the same medicines to treat Luckily the same medicines to treat

PD: Mirapex and Requip, also PD: Mirapex and Requip, also sedatives, and narcotics, seizure drugssedatives, and narcotics, seizure drugs

Frequent UrinationFrequent Urination

Causes: light sleep, bladder problem, Causes: light sleep, bladder problem, prostate problem, drugs, infections, otherprostate problem, drugs, infections, other

Light sleep: PD, Sleep Apnea, PLMDLight sleep: PD, Sleep Apnea, PLMDConsider urological evaluationConsider urological evaluationAvoid too much fluids, salt, diuretics, Avoid too much fluids, salt, diuretics,

alcohol, caffeinealcohol, caffeineControl Parkinson’s better; do sleep Control Parkinson’s better; do sleep

studystudyMedicines for bladder or prostateMedicines for bladder or prostate

Depression and AnxietyDepression and Anxiety

Anxiety: difficulty going to sleep, worriesAnxiety: difficulty going to sleep, worriesDepression: difficulty going or staying Depression: difficulty going or staying

asleep, or waking up early; hopeless, asleep, or waking up early; hopeless, helpless, no fun helpless, no fun

Depression: before or after Parkinson’s; Depression: before or after Parkinson’s; problem recognizing, admitting to illnessproblem recognizing, admitting to illness

Drugs are effective in treating bothDrugs are effective in treating bothBeware: anti-anxiety drugs & sleepiness; Beware: anti-anxiety drugs & sleepiness;

anti-depressants & insomniaanti-depressants & insomnia

Drugs and InsomniaDrugs and Insomnia

Anti-depressants: Prozac, Celexa, Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or Zoloft, Paxil, take in the morning or add sedating one at night: trazodoneadd sedating one at night: trazodone

Anti-Parkinson’s: SelegilineAnti-Parkinson’s: SelegilineDrugs for emphysema or COPDDrugs for emphysema or COPDCoffee, alcohol, tobaccoCoffee, alcohol, tobacco

Primary Insomnia: Before Primary Insomnia: Before Parkinson’sParkinson’s

Insomnia: inability to get to sleep, stay Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime asleep, wakes up early, with daytime impairmentimpairment

Acute Insomnia (<4 weeks): stress, illnessAcute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stageSleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often yearsChronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychologicalTreat basic problem: >60% psychological Psychotherapy and behavioral therapy Psychotherapy and behavioral therapy

better than medicines, not easy to treat better than medicines, not easy to treat Psychologists, Psychiatrists, PCPPsychologists, Psychiatrists, PCP

Treatment of Chronic Treatment of Chronic InsomniaInsomnia

Sleep Hygiene: avoid coffee & alcohol, sleep in Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before beda quiet, dark, cool room, eat lightly before bed

regular sleep hours, avoid day naps, exercise regular sleep hours, avoid day naps, exercise Restriction: only go to bed when ready to Restriction: only go to bed when ready to

sleep, if in bed sleep 90% of the time; out of sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 minbed and bedroom if awake over 20 min

Stimulus control: simple bedroom furniture Stimulus control: simple bedroom furniture and bedroom strictly for sleepand bedroom strictly for sleep

Proper perspective: good if adequate sleep Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the over 75% of the time, don’t exaggerate the problemproblem

Treatment of Chronic Insomnia: Treatment of Chronic Insomnia: Sleeping PillsSleeping Pills

Anti-histamines: available over the counter Anti-histamines: available over the counter Benadryl (diphenhydramine)Benadryl (diphenhydramine)

Sedating anti-depressants: trazodoneSedating anti-depressants: trazodone Sedatives: temazepam (Restoril), Sedatives: temazepam (Restoril),

triazolam (Halcion), flurazepam (Dalmane)triazolam (Halcion), flurazepam (Dalmane) Specific drugs: Ambien (generic), Ambien Specific drugs: Ambien (generic), Ambien

CR (not generic), Lunesta, short acting but CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming)expensive; Rozerem (not habit forming)

Natural Substances: melatonin, valerian Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they jazmine scent, little to no proof that they help, side effectshelp, side effects

Day Time SleepinessDay Time Sleepiness

Insomnia due to Parkinson’s: sleep Insomnia due to Parkinson’s: sleep deprivation because disease not deprivation because disease not controlled at night and worsened by controlled at night and worsened by anti-PD drugs in the morning that finally anti-PD drugs in the morning that finally relax the patientrelax the patient

Drugs: all anti-PD drugs may cause Drugs: all anti-PD drugs may cause sleepiness but not common, other drugssleepiness but not common, other drugs

Sleep ApneaSleep ApneaRestless Legs Syndrome / Periodic Leg Restless Legs Syndrome / Periodic Leg

Movement Disorder: sleep deprivationMovement Disorder: sleep deprivation

Drugs and Daytime Drugs and Daytime SleepinessSleepiness

Anti-anxiety: alprazolam (Xanax), Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin)clonazepam (Klonopin)

NarcoticsNarcotics Muscle Relaxants: cyclobenzaprine Muscle Relaxants: cyclobenzaprine

(Flexeril)(Flexeril) Seizure Drugs: phenytoin (Dilantin), Seizure Drugs: phenytoin (Dilantin),

gabapentin (Neurontin)gabapentin (Neurontin) Drugs for hallucinations and psychosis: Drugs for hallucinations and psychosis:

quetiapine (Seroquel), olanzapine quetiapine (Seroquel), olanzapine (Zyprexia), resperidone (Resperdal)(Zyprexia), resperidone (Resperdal)

Pseudo-SleepinessPseudo-Sleepiness

Low blood pressure can mimic sleepinessLow blood pressure can mimic sleepinessParkinson’s and drugs to treat it can lead Parkinson’s and drugs to treat it can lead

to low BP, especially in the morningto low BP, especially in the morningClue: patient feels faint when standing upClue: patient feels faint when standing upMay lose consciousness and mistakenly May lose consciousness and mistakenly

thought to be asleepthought to be asleepClue: after breakfastClue: after breakfastConfirm: take blood pressure lying down, Confirm: take blood pressure lying down,

sitting, and standingsitting, and standing

Sleep Apnea: Risk FactorsSleep Apnea: Risk Factors

Affects: 4 to 5% of population: commonAffects: 4 to 5% of population: common Family history, Sleep maintenance insomniaFamily history, Sleep maintenance insomnia Obesity: 80 % of sleep apnea patients; Obesity: 80 % of sleep apnea patients;

central (visceral, apples) obesitycentral (visceral, apples) obesity Increasing age, Male genderIncreasing age, Male gender Large tonsils / adenoids in childrenLarge tonsils / adenoids in children Small mandible, large neckSmall mandible, large neck Smoking, alcohol, sedatives, nasal allergiesSmoking, alcohol, sedatives, nasal allergies

Sleep Apnea: ConsequencesSleep Apnea: Consequences During During nightnight: snoring, snorting, gasping, : snoring, snorting, gasping,

difficult or stops breathing, wife worriesdifficult or stops breathing, wife worries During During dayday: sleepy, tired, depressed, : sleepy, tired, depressed,

irritabile, impotent, forgets, sometimes few irritabile, impotent, forgets, sometimes few complaintscomplaints

More More accidentsaccidents: work, home, motor vehicle: work, home, motor vehicle Higher death rates with severe sleep apneaHigher death rates with severe sleep apnea Hypertension, Congestive Heart FailureHypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial FibrillationHeart Attacks, Strokes, Atrial Fibrillation Promotes Promotes ObesityObesity and and DiabetesDiabetes Problems: at night, during day, risk factorProblems: at night, during day, risk factor

What is OSA?•Cessation of airflow with ongoing respiratory effort•NORMAL SNORING SLEEP APNEA

Obstructive Sleep Apnea

Sleep Apnea: Treatment Sleep Apnea: Treatment

Behavioral: Weight Loss, Sleep Position Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, (Sleep on side, head raised), Oxygen, Avoid sedatives Avoid sedatives

CPAPCPAP: proven therapy, needs motivation: : proven therapy, needs motivation: widely available, 70%: patients adapt wellwidely available, 70%: patients adapt well

Surgery: tracheostomy, tonsillectomy, pull Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongueforth mandible or tongue

Bariatric Surgery: banding, bypass (Bob Bariatric Surgery: banding, bypass (Bob Eisenhauer, 259-1485)Eisenhauer, 259-1485)

Dental appliances: also pull forth mandible Dental appliances: also pull forth mandible or tongue; expertise necessaryor tongue; expertise necessary

Treatment -CPAP treatment–Positive pressure keeps airway open–100% effective

CPAP therapy

Treatment Options: CPAP

Summary: Sleep ApneaSummary: Sleep Apnea Very common and dangerousVery common and dangerous Easily diagnosed and treatedEasily diagnosed and treated Benefits of treatment:Benefits of treatment: sleep better at sleep better at

nightnight, also, also Feel better during the dayFeel better during the day: less sleepiness : less sleepiness

and fatigue, more energy, less accidentsand fatigue, more energy, less accidents Reduce risk factorReduce risk factor for heart disease and for heart disease and

strokesstrokes Control betterControl better: obesity, diabetes, : obesity, diabetes,

hypertensionhypertension Bed partner sleeps betterBed partner sleeps better: less noise and : less noise and

less worry (but dog is scared of CPAP)less worry (but dog is scared of CPAP)

Disruptions During the NightDisruptions During the Night

Vivid dreams and nightmaresVivid dreams and nightmaresREM Sleep Behavior Disorders: unique REM Sleep Behavior Disorders: unique

to Parkinson’s Disease: acting out to Parkinson’s Disease: acting out dreamsdreams

Hallucinations and Delusions at Night: Hallucinations and Delusions at Night: patient is awake not asleeppatient is awake not asleep

Confusion at night: Sundowning, part Confusion at night: Sundowning, part of dementia of advanced Parkinson’s, of dementia of advanced Parkinson’s, reverse day/night cycle reverse day/night cycle

Sleep Apnea or SeizuresSleep Apnea or Seizures

Disruptions During the NightDisruptions During the Night

Often disruptive to family Often disruptive to family Important cause of institutionalizationImportant cause of institutionalization Difficult to distinguish among: REM Sleep Difficult to distinguish among: REM Sleep

Behavior Disorder, Sleep Apnea, and Behavior Disorder, Sleep Apnea, and HallucinationsHallucinations

Sleep study often indicatedSleep study often indicated Medicines control REM Sleep Behavior Medicines control REM Sleep Behavior

Disorder, and HallucinationsDisorder, and Hallucinations Familiar surroundings, lighting for confusionFamiliar surroundings, lighting for confusion

WebsitesWebsites

The Movement Disorder Society: The Movement Disorder Society: www.wemove.orgwww.wemove.org

The American Academy of Neurology: The American Academy of Neurology: www.thebrainmatters.comwww.thebrainmatters.com

American Sleep Apnea Association: American Sleep Apnea Association: www.sleepapnea.orgwww.sleepapnea.org

Restless Legs Syndrome Foundation: Restless Legs Syndrome Foundation: www.rls.orgwww.rls.org

National Sleep Foundation: National Sleep Foundation: www.sleepfoundation.orgwww.sleepfoundation.org

BooksBooks

The Parkinson’s Disease Treatment Book The Parkinson’s Disease Treatment Book by J. by J. Eric Ahlskog, Mayo ClinicEric Ahlskog, Mayo Clinic

The Promise of SleepThe Promise of Sleep by William Dement by William Dement Sleeping WellSleeping Well by Michael Thorpy by Michael Thorpy No More Sleepless NightsNo More Sleepless Nights by Peter Hauri by Peter Hauri A Woman’s Guide to Sleep DisordersA Woman’s Guide to Sleep Disorders by by

Meir H. KrygerMeir H. Kryger Restless LegsRestless Legs SyndromeSyndrome by Robert H. Yoakumby Robert H. Yoakum Say Good Night to InsomniaSay Good Night to Insomnia by Gregg D. by Gregg D.

JacobsJacobs