Parkinson's disease Clinical treatment strategies for sleep disorders in Parkinson's disease

Sleep disturbance is one of the common non-motor symptoms in
people with Parkinson's disease (PD).
Sleep disturbances can occur as a preclinical symptom of PD, as part of disease progression, or as a side effect
of symptomatic treatment medications.
Common sleep disorders in patients with PD include insomnia, excessive daytime sleepiness (EDS), rapid eye movement sleep behavior disorder (RBD), restless legs syndrome (RLS), and sleep-disordered breathing (SDB).

Key points to recommend

1.
Clarify the type of PD sleep disorder;
2.
Pay attention to PD nocturnal motor symptoms;
3.
Adjust PD's own medication;
4.
Reasonable choice of sleep disorder drug treatment;
5.
Pay attention to non-drug treatment
of sleep disorders.

insomnia

27%~80% of PD patients have insomnia, of which the proportion of insomnia in Chinese PD patients is 30%~86.
8%.

Causes of insomnia in patients with PD include:

(1) Female sex, course of disease, depression and anxiety, other factors (such as cough, hot and cold, pain);

(2) Nocturnal motor dysfunction, difficulty turning over, tremor, pain and nocturia;

(3) Drugs (such as entacapone, selegiline, rasagiline) may increase the risk of
insomnia.

Recommended by the Expert Consensus on the Management of Sleep Disorders in Patients with Parkinson's Disease

3.
Changes in insomnia with dopaminergic preparations may be beneficial
if sleep disturbances in PD patients are associated with uncontrollable motor symptoms at night.
(Recommended by experts)

4.
Drug treatment for insomnia in PD patients includes the treatment of insomnia itself and the treatment
of insomnia secondary to motor symptoms in the PD process.
The drug treatment of insomnia itself in PD patients can refer to the FDA-approved drug treatment principles
for simple insomnia disorder.
At present, only dexzopiclone, melatonin, and doxepin have been studied
for the treatment of PD with insomnia.
Depression and anxiety caused by the progression of PD disease can also induce and aggravate insomnia symptoms in PD patients, and the use of antidepressant and anxiolytic therapy for them can also improve PD comorbid insomnia
.
(Recommended by experts)

Excessive daytime sleepiness

The diagnosis of EDS should be made with detailed questions about the sleep of the patient and family, including daytime and nighttime sleepiness, medication history, comorbidities, and other possible influencing factors
.

Phototherapy has become a new treatment option
for patients with PD with EDS.
A randomized, placebo-controlled, clinically interventional study of 31 patients with PD with EDS who were randomized to receive bright light therapy (N=16) and dark red light therapy (placebo-controlled) (N=15) as the primary efficacy measure was the change
in Epworth Drowsiness Scale (ESS) scores from baseline to treatment endpoint.
The results of the study showed that bright light therapy significantly improved the patient's ESS scale score (P<0.
05).
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Recommended by the Expert Consensus on the Management of Sleep Disorders in Patients with Parkinson's Disease

3.
Modafinil, adenosine receptor inhibitors (caffeine and itraphylline), sodium oxybate, methylphenidate may have a relieving effect on daytime sleepiness in PD patients, but large-scale double-blind studies are needed to further confirm.

(Recommended by experts)

4.
Cognitive behavioral therapy, phototherapy, repetitive transcranial magnetic stimulation, and deep brain stimulation may alleviate EDS
in patients with PD.
(Recommended by experts)

REM sleep behavior disorder

The incidence of RBD is 0.
4%~0.
5% in the general population and 7%~8%
in people over 70 years old.
RBD has important early warning significance
for neurodegenerative diseases.

ICSD-3 diagnostic criteria for RBD are:

(1) Skeletal muscle retardation (RWA) during REM sleep;

(2) have a definite dream behavior deduction (DEB), a history of clinical seizures, or standard polysomnography (PSG) recording definite seizures;

(3) No epileptiform discharge of EEG during REM sleep;

(4) Symptoms cannot be explained by other causes, including other types of sleep behavior abnormalities, neurological/psychiatric disorders, drugs, medical medical diseases, or substance abuse
.

Among them, RWA (PSG monitoring) + DEB (clinical symptoms) are the most important diagnostic criteria
for RBD.

Recommended by the Expert Consensus on the Management of Sleep Disorders in Patients with Parkinson's Disease

3.
Melatonin has obvious advantages in the treatment of RBD in patients with PD and can be considered as the preferred drug treatment
.
The dopamine agonists pramipexole and rotigotine may be effective in RBD in patients with PD and, given their role in PD therapy, may be considered as a higher priority for RBD therapy in patients with PD
.
(Evidence-based evidence)

4.
Clunitrazepam is the most effective drug in idiopathic RBD, but its efficacy in patients with PD and RBD has not been fully demonstrated
.
Given the potential impact of clonazepam's fall risk in patients with PD, clonazepam can be used as an alternative
when other agents are ineffective.
(Recommended by experts)

Restless legs syndrome

The clinical manifestations of RLS are usually extreme discomfort in both lower limbs during night sleep, forcing patients to constantly move or walk on the ground, resulting in severe sleep disturbance
.
RLS occurs in both normal and Parkinson's patients, and its core feature is that symptoms worsen
at night.

General treatment of PD with RLS includes:

1.
Stop drugs that induce or aggravate RLS: such as anti-dopaminergic drugs;

2.
Exclude related factors and accompanying symptoms: metabolic disorders, end-stage renal disease, diabetes, pregnancy, and use of serotoninergic antidepressants;

3.
Treatment of iron deficiency;

4.
Behavioral therapy (for patients with mild RLS).

Sleep-disordered breathing

SDB can be divided into habitual snoring, upper airway resistance syndrome and sleep apnea-hypopnea syndrome, and its evaluation scales include the STOP-BANG questionnaire and the Berlin questionnaire
.
PSG is the gold standard
for diagnosing SDB.

Pre-treatment evaluation:

1.
An ESS scale is recommended to assist in assessing the degree of
daytime sleepiness.

2.
The evaluation of etiology and complications should include: the presence of related diseases, such as hypothyroidism, acromegaly, otolaryngology and stomatology diseases; Complications and comorbidities, such as metabolic syndrome, diabetes, hypertension, pulmonary hypertension, pulmonary heart disease, arrhythmia, cerebrovascular accident, polycythemia, etc.
; The presence or absence of other sleep disorders
.

Recommended by the Expert Consensus on the Management of Sleep Disorders in Patients with Parkinson's Disease

3.
Continuous positive airway pressure (CPAP) is the gold standard of treatment
for patients with PD and SDB.
(Grade A recommendation)