Sleep Disturbances in Parkinson’s

Sleep disturbances are a common and significant problem for individuals with Parkinson’s disease (PD), sometimes greatly affecting quality of life. These issues often exacerbate the motor and non-motor symptoms of PD, creating a cycle of discomfort and fatigue. The causes are multifaceted, involving both the neurodegenerative processes of PD itself and the side effects of medications used to manage the condition. However, by understanding how these problems arise and what can be done about them, people with Parkinson’s can improve their overall wellbeing and get a good night’s sleep.

Causes of Sleep Disturbances

Multiple brain areas and neurotransmitters that are impacted by Parkinson’s are involved in regulating sleep and wakefulness, which explains why sleep disorders are very prevalent amongst people with PD. In fact, one frequently-cited study found that up to 98% of people diagnosed with the disease had some form of sleeping problem, with 30% experiencing issues maintaining normal levels of alertness and wakefulness during the day (Stefani & Högl, 2019). Another study stated that individuals with Parkinson’s disease averaged only five hours of sleep per night and experienced twice as many awakenings compared to age-matched individuals without the disease (American Parkinson Disease Association, n.d).

Additionally, the medications used to treat PD can disturb sleep. In particular, the timing of dopaminergic medication seems to matter – one study found that taking it right before sleep resulted in less rapid eye movement (REM) sleep – the stage of sleep in which we dream (Chahine et al., 2013). This is problematic because the benefits of REM sleep include improved mood and memory, healthy brain development, protection against dementia, and a boost in problem-solving skills (Levine, 2024). 

People with Parkinson’s also experience a reduction in something called sleep spindles, which are short bursts of brain activity during non-REM sleep. While these bursts of activity have not always been understood, new research is emerging that shows they might be quite important in memory consolidation, learning, and protecting sleep from external disturbances by shutting off a part of the brain called the thalamus, which processes information from our senses. Reduced sleep spindles leave people with PD vulnerable to more frequent wake ups, as well as cognitive decline (Summer & Rehman, 2023).

Types of Sleep Disturbances

Common sleep issues in PD include:

1. Insomnia: This sleep condition makes falling, staying, or going back to sleep hard. It is one of the most common sleep problems, with 30% of all adults reporting some degree of it; however, people with PD are even more likely to experience insomnia (Parkinson’s Foundation, n.d.).
2. Excessive daytime sleepiness (EDS): As its name suggests, EDS can result in undesirable sleepiness during hours you may prefer to be awake. It affects around half of people with PD with considerable impacts on quality of life. EDS can be triggered by a class of medications commonly used to treat PD called dopamine agonists, though it can also occur with levodopa (Knie et al., 2011).
3. REM sleep behaviour disorder (RBD): This sleep disorder is common in people with Parkinson’s. Those with RBD lack the normal muscle paralysis that prevents most people from acting out their dreams during REM sleep. While this paralysis sounds scary, it actually keeps us safe. Without it, people with RBD may kick, shout, or punch during sleep. In severe cases, they may need to sleep alone to avoid harming their bed partner (Mahmood et al., 2020).
4. Sleep apnea: Sleep apnea is characterized by irregular breathing patterns during sleep, such as pauses in breathing or shallow breaths. It may be caused by the disease’s impact on the upper airway (Maggi et al., 2023).
5. Sleep fragmentation: This occurs when sleep is frequently broken up, resulting in an individual being unable to get enough deep, restorative sleep. Research comparing sleep stages between people with PD and age-matched controls shows that those with the disease spend significantly less time in both slow-wave (the deepest stage of sleep) and REM sleep, as mentioned above. The impact can be serious, as fragmented sleep is associated with medication-induced hallucinations and increased daytime sleepiness (American Parkinson Disease Association, n.d.).
6. Frequent urination at night (nocturia): Nocturia is one of the most common non-motor symptoms amongst people with PD, with over 50% of those with the disease needing to urinate at least twice per night (Batla et al., 2016).

Strategies for Improving Sleep

• Optimize your medication: With guidance from your neurologist or doctor, switching to a longer-lasting or extended-release form of medication may help manage your symptoms throughout the night. Some individuals may need to switch to a different class of medications altogether; for example, people with excessive daytime sleepiness caused by dopamine agonist use may need to try other drugs with less risk of EDS, such as MAO-B inhibitors (Di Laudo et al., 2023). Always speak with your doctor to get the best advice for your situation.
• Avoid blue light in the evening: Experts have been warning about the impact electronics are having on our sleep for a good reason – the blue light emanating from our screens has a profound effect on our 24-hour cycle, also called the circadian rhythm. The content we consume electronically can also be very stimulating, revving up our minds right when they need to get ready for bed. Opt instead for a relaxing, old-fashioned book before sleep (Newsom & Singh, 2024).
• Stick to a routine – even on weekends: Maintaining a consistent routine might be one of the most important ways to get a restorative night’s sleep because it helps tune our body’s internal clock. In fact, one study found that a routine could lower your chances of dying from all causes by 30%, and that sleep regularity is even more important than sleep duration (Zuraikat et al., 2023)!
• Tap into the power of exercise: You may have already heard that exercise can boost sleep quality, as well as making it easier to fall asleep. However, a 2022 study was the first to find that high-intensity exercise, including resistance and body-weight interval training, could improve sleep spindle density in people with Parkinson’s, which was associated with improved memory. These findings suggest that exercise may have potential benefits for both sleep quality and cognitive function in PD (Memon et al., 2022). No matter how you choose to move, just get moving (your body and mind will thank you!), though it is best to avoid strenuous exercise right before bed, as it can raise your core temperature and make it hard to fall asleep.
• Take charge of your mental health: Many individuals with PD experience mental health challenges, such as depression and anxiety, which can interfere with sleep quality and quantity. These conditions are treatable, so make sure to speak with your doctor, or get in touch with Parkinson Society BC’s counsellors for confidential, free counselling. Learn more at www.parkinson.bc.ca/counselling 

Sleep disturbances are a common and challenging issue for people with Parkinson’s disease, significantly impacting their overall wellbeing. The complex interaction between the disease itself and the medications used to treat it can worsen problems like insomnia, excessive daytime sleepiness, and fragmented sleep. However, there are practical steps that can help. By understanding these challenges and applying targeted strategies, individuals with Parkinson’s can work towards better sleep and an overall improved quality of life.

Sources

American Parkinson Disease Association (n.d.). Sleep Problems. https://www.apdaparkinson.org/what-is-parkinsons/symptoms/sleep-problems/ 

Batla, A., Phé, V., De Min, L., & Panicker, J. N. (2016). Nocturia in Parkinson's Disease: Why Does It Occur and How to Manage? Mov Disord Clin Pract, 3(5), 443–451. https://doi.org/10.1002/mdc3.12374 

Chahine, L. M., Daley, J., Horn, S., Duda, J. E., Colcher, A., Hurtig, H., Cantor, C., & Dahodwala, N. (2013). Association between dopaminergic medications and nocturnal sleep in early-stage Parkinson's disease. Parkinsonism & Related Disorders, 19(10), 859-863. https://doi.org/10.1016/j.parkreldis.2013.05.009 

Di Laudo, F., Baldelli, L., Mainieri, G., Loddo, G., Montini, A., Pazzaglia, C., Sala, M., Mignani, F., & Provini, F. (2023). Daytime sleepiness in Parkinson's disease: A multifaceted symptom. Frontiers in Sleep, 2, Article 1302021. https://doi.org/10.3389/frsle.2023.1302021

Knie, B., Mitra, M. T., Logishetty, K., & Chaudhuri, K. R. (2011). Excessive daytime sleepiness in patients with Parkinson's disease. CNS Drugs, 25(3), 203–212. https://doi.org/10.2165/11539720-000000000-00000 

Levine, H. (2024). REM sleep: What is it, why is it important, and how can you get more of it? https://www.health.harvard.edu/staying-healthy/rem-sleep-what-is-it-why-is-it-important-and-how-can-you-get-more-of-it 

Mahmood, Z., Van Patten, R., Nakhla, M. Z., Twamley, E. W., Filoteo, J. V., & Schiehser, D. M. (2020). REM sleep behavior disorder in Parkinson’s disease: Effects on cognitive, psychiatric, and functional outcomes. Journal of the International Neuropsychological Society, 26(9), 894–905. https://doi.org/10.1017/S1355617720000430

Memon, A. A., Catiul, C., Irwin, Z., Pilkington, J., Memon, R. A., Joop, A., Wood, K. H., Cutter, G., Bamman, M., Miocinovic, S., & Amara, A. W. (2022). Effects of exercise on sleep spindles in Parkinson's disease. Frontiers in Rehabilitation Sciences, 3, Article 952289. https://doi.org/10.3389/fresc.2022.952289

Newsom, R. & Singh, A. (2024). Blue Light: What It Is and How It Affects Sleep. https://www.sleepfoundation.org/bedroom-environment/blue-light 

Parkinson’s Foundation (n.d.). Sleep Disorders. https://www.parkinson.org/understanding-parkinsons/non-movement-symptoms/sleep-disorders 

Stefani, A., & Högl, B. (2020). Sleep in Parkinson’s disease. Neuropsychopharmacology Reviews, 45, 121–128. https://doi.org/10.1038/s41386-019-0448-y 

Summer, J. & Rehman, A. (2023). Sleep Spindles. https://www.sleepfoundation.org/how-sleep-works/sleep-spindles 

Zuraikat, F. M., Aggarwal, B., Jelic, S., & St-Onge, M.-P. (2024). Consistency is key: Sleep regularity predicts all-cause mortality. Sleep, 47(1), zsad285. https://doi.org/10.1093/sleep/zsad285

This content was published in the Winter 2024 edition of our quarterly magazine, Viewpoints. The content was accurate as of this publication date.