Ask an Expert: Dr. Jason Valerio Discusses Sleep Dysfunction and Disorders in People with Parkinson’s

Dr. Jason Valerio, MD, is a neurologist and sleep specialist at the University of British Columbia (UBC) sleep disorders clinic and a movement disorders specialist at the Pacific Parkinson’s Research Centre. He graduated from the University of Ottawa medical school, following completion of a MSc. in Neuroscience. He completed his neurology training at UBC. This was followed by two fellowships, one in sleep medicine at Stanford University and one in movement disorders at UBC, where he now practices. His clinical focus is on Parkinson’s disease and sleep related pathologies. He has a special interest and research focus on REM sleep behaviour disorder. In 2016, Dr. Valerio spoke at Parkinson Society BC’s Victoria Regional Conference on the interplay between sleep and Parkinson’s disease.

How common are sleep disturbances in people with Parkinson’s disease?

Sleep pathology is one of the most common non-motor symptoms of Parkinson’s disease (PD). Although exact numbers are not known, reports suggest approximately 50% – 70% of people with PD experience a sleep disorder.

Common disorders include insomnia (trouble falling/staying asleep), sleep disordered breathing, circadian rhythm sleep-wake disorders (which impact the timing of sleep), periodic limb movement, and restless leg syndrome. Other disorders often seen in PD are REM sleep behaviour disorder (dream-enacting), vivid nightmares, excessive daytime sleepiness, and sleep maintenance dysfunction due to medication wearing off or disruption from motor symptoms of PD.

What is REM sleep behaviour disorder?

REM sleep behaviour disorder (RBD) is closely associated with PD and other neurodegenerative disorders and can impair quality of sleep for both people with PD and their bed partners. REM or rapid eye movement is a sleep phase in which the body is immobile, often associated with dreaming. In RBD, the paralysis circuit in the brainstem — which should be ‘on’ during REM sleep — is now disrupted so that people with parkinsonism can act out their dreams instead of remaining still.

Oftentimes, people with PD may not recognize that they have RBD unless injury occurs. Falling out of bed, or striking walls or nightstands may result in injuries, which can be unfortunately common in people with RBD. People who experience RBD also have higher rates of periodic limb movement and nocturnal leg cramping, which can lead to further sleep disruptions. Vivid nightmares also coincide with RBD and infrequently can cause anxiety and distress leading to further sleep dysfunction.

What are some effects Parkinson’s can have on sleep quality?

Overnight, people with PD may experience more severe symptoms due to their medications wearing off, or their medication dosage being too low. This can result in stiffness, rigidity, tremors, dystonia, akinesia, pain, and even akathisia-like symptoms (restlessness), all of which can lead to sleep maintenance dysfunction or early-morning awakenings. Bladder issues, which are frequently seen in PD, also result in more trips to the washroom at night, again potentially fragmenting sleep.

When nocturnal sleep begins to be interrupted, as with all the disorders described above, there is a potential for arousals or short awakening periods to become more frequent or longer in duration. This sleep maintenance dysfunction can result in chronic insomnia leading to daytime dysfunction.

How can Parkinson’s medications contribute to sleep dysfunction?

Medications, and their impact on sleep and alertness, are a major consideration when deciding on the best pharmacotherapy for each individual. Most people with PD are on dopaminergic drugs, which can cause disruptions in sleep and wakefulness. Individuals can experience excessive daytime sleepiness, and even sleep attacks, as adverse effects from dopamine agonists, and less commonly from levodopa. Impulse control disorder, another side effect from dopaminergic drugs, can also result in disruption or continuation of sleep disturbances.

One drug, amantadine, can contribute to insomnia if taken too late in the day. Many antidepressants, used commonly in PD, can also trigger or worsen RBD. Medications to treat hallucinations, such as antipsychotics, tend to be very sedating, again resulting in sleep and wakefulness dysfunction, and if taken at night, a morning ‘hangover’ effect can be experienced. Benzodiazepines, which are used less commonly nowadays in PD, can be sedating, but also worsen sleep disordered breathing at night.

What characterizes a sleep disorder?

Sleep dysfunction is very common in society and most people will experience some difficulty with sleep in their lifetime. However, to make the distinction with a sleep disorder, the sleep disturbance has to cause clinically significant dysfunction in social, occupational, educational, or other important areas of functioning. For example, many people who are older experience early morning awakenings, and in turn go to bed earlier.

This sleep-wake pattern is not considered a pathology unless it is interfering with quality of life, causing distress, or resulting in significant dysfunction to daily activities.

What is circadian rhythm?

All humans have roughly a 24-hour internal clock that guides a vast array of biological functions and behaviours; this is the circadian rhythm. During this 24-hour cycle, varying metabolic processes occur and chemicals are released to guide behaviours including sleep. In the mornings, alerting chemicals kick in, assisting with the “wake up switch” in the brain, and another set of chemicals triggers the “sleep switch” of the brain at night. Light is the most important synchronizing agent controlling the body’s circadian rhythm. Although sunlight guides our chronobiology, people may have preferences on an individual level, typically by a couple of hours. This varying chronotype suggests some people are morning types (larks) or evening types (owls) based on their subjective preference.

What are some practical ways to regulate your circadian rhythm?

One of the most important strategies is using sunlight to optimize the circadian rhythm. This means waking up at the same time every day, getting out of bed and exposing yourself to bright light. Going for a walk every morning, or doing other forms of exercise in the sun, can be a great way to regulate the circadian rhythm. In BC, we have reduced sunlight during certain times of the year and during those times a bright light lamp can be used to replicate the sun. Inversely, bright light should be avoided at night; this includes avoiding TVs, computers, and cellphones 60 minutes before bed.

Having a fairly consistent schedule throughout the day with meals, medications, and timing of activity can also help. If a nap is required, 20-30 minutes maximum is suggested between 2pm and 4pm, during which there is natural lull in the circadian rhythm.

What is sleep hygiene?

The most practical way of thinking about sleep hygiene is to think of it as a set of habits that are conducive to getting good sleep regularly. Resources to learn more about this that I commonly recommend to individuals include Quiet Your Mind and Get to Sleep by Carney and Manber as well as Cognitive Behavioural Treatment of Insomnia by Perlis et al. Although these resources are directed towards treating insomnia, learning about your sleep and optimizing sleep hygiene are the pillars of beginning to manage any sleep dysfunctions. Sleep hygiene strategies include:

• Sleep only as much as you need to feel refreshed the next day.
• Only go to bed when sleepy, but wake up at the same time every day, 7 days a week.
• Make sure the bedroom is dark, quiet, and a comfortable temperature (typically cooler temperatures improve sleep).
• Avoid excessive fluids in the evening. Do not eat overnight, but also do not go to bed hungry.
• No napping or only short naps during the day – be mindful if it disrupts your night time sleep.
• Exercise regularly.
• Avoid all activities in bed other than sleep or sex.
• Do not take your problems to bed.
• Avoid electronics with bright light, such as cellphones, a minimum of 30 minutes, but preferably 60 minutes, before bed.

What are common treatment options for more specific sleep disorders, such as insomnia, REM Behaviour Disorder (RBD), or Sleep Apnea?

The preferred treatment for insomnia is Cognitive Behavioural Therapy for insomnia (CBTi). This can be done on your own, using some of the books that are referenced at the end of this article, or with the assistance of a trained psychologist. If CBTi fails, sedating medications can be used, but are typically a last resort.

The approach to treat RBD is twofold. First, conservative measures should be taken to ensure bedroom safety for you and your partner. This includes soft padding on the floors, keeping beds close to the ground, removing night stands and other objects could cause damage if struck, and having bed partners sleep in another room, or at minimum, placing a large body pillow between people. The second step is ensuring no medications are worsening RBD. Healthcare professionals may suggest using melatonin and, if required, clonazepam to treat RBD when the patient is a risk to themselves or others.

Sleep apnea management varies depending on severity, with the gold standard being Continuous Positive Airway Pressure (CPAP) therapy, which uses a machine to increase air pressure in the throat to prevent the airway from collapsing. In some cases, oral appliances or positional therapy may provide benefit as well.

Is there anything else you would like to add?

Sleep is vital for a host of human functions including but not limited to memory consolidation, healing and body repair, and clearing out metabolic waste products from the brain. With advancement in our understanding of the importance of sleep, we also recognize the importance of sufficient sleep. Although this varies, most humans should look to get 6-9 hours of sleep each night.

People with parkinsonism have high rates of sleep dysfunction, however, simple adjustments in medication timing, bright light exposure, exercise, and improved sleep hygiene can make a tremendous difference in improving sleep quality and, in turn, improving daytime functioning.

This content was published in the Spring 2021 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.