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June: Sleep and Rest


Written By: Dr. Caitlin A. Bender, OTR/L

Dopamine’s Role 

Nearly a third of our lifetime is spent asleep, and during this critical window the brain is hard at work disposing of toxic byproducts that have accumulated throughout the day. Sleep is also neuroprotective in that during this time the brain is reorganizing processed information to form and maintain the pathways that help us create new memories, or react quickly. With Parkinson’s Disease however this process may become disrupted, with one study surveying individuals with Parkinson’s Disease reporting 90% had experienced disabilities at night since the onset of the disease¹. Sleep regulation relies on complex pathways and neurotransmitters integrated throughout the brain, many of which are also involved in Parkinson’s Disease. Dopamine, the predominant neurotransmitter affected by Parkinson’s Disease, is also of major importance within the suprachiasmatic nucleus (SCN), which establishes our circadian rhythm. In synchrony with the solar time, the circadian system dictates the 24 hour rhythmicity in rest–activity behavior, feeding, body temperature, and hormonal levels. Any disruption of this system can, therefore, negatively affect sleep quality, alertness, cognitive performance, motor control, mental health and metabolism². Dopamine’s involvement within the circadian system may be evidenced by symptoms or behaviors associated with Parkinson’s Disease such as, disruptions in motor activity, autonomic function, visual performance, sleep-wake cycles, and responsiveness to dopaminergic treatment which show diurnal fluctuations³. While there is clear evidence of dopamine’s involvement in the circadian system, the etiology of sleep disturbance is likely to be multifactorial, and to include the effects of Parkinson’s Diseased-associated motor features on sleep, adverse effects of anti-parkinsonian medications, and changes of central areas that regulate sleep.


Daily Impact

Compared to the general population, individuals with Parkinson’s Disease experience more sleep fragmentation, and have overall reduced total sleep time⁴. Sleep disturbances for individuals with Parkinson’s Disease are numerous and varied, but may include:

  • Sleep apnea

  • Difficulty falling asleep (insomnia)

  • Frequent awakening (sleep fragmentation)

  • Nighttime urinary frequency

  • Vivid dreams/nightmares often accompanied by physical action (REM behavioral disorder)

  • Nighttime confusion

  • Hallucinations and delusions.

As stated earlier, sleep disturbances for individuals with Parkinson's disease are common and multifactorial, however they frequently go undertreated. This can compound and result in difficulty engaging in tasks such as concentrating on work, staying physically active, socializing, or managing your mood, and ultimately lead to a reduced quality of life⁵.


Management

Sleep disruption is a commonly reported non-motor symptom of those diagnosed with Parkinson’s Disease, and may be further impacted by anti-parkinsonian medications. Studies show Levodopa and other dopaminergic agonists can disrupt nocturnal sleep either by direct effect on the sleep/wake regulation or because of end of dose symptoms⁴.  As stated earlier, sleep disturbances for those with Parkinson’s Disease are potentially wide and varied, but medication management can help to reduce the number of sleep disturbances you experience.

Management of chronic sleep-onset insomnia may include:

  • Melatonin 1-2 hours before bedtime

  • A short acting non-benzodiazepine drug such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta)

  • A benzodiazepine such as temazepam (Restoril), or alprazolam (Xanax)

  • Low dose of a sedating antidepressant medication such as amitriptyline or trazodone

Management of sleep fragmentation may include:

  • Long-acting sedative clonazepam (Klonopin) taken at bedtime

  • Stimulants such as modafinil (Provigil)

Management of REM behavioral disorder may include:

  • Clonazepam

  • Certain antidepressants, such as bupropion (Wellbutrin) and sertraline (Zoloft) may be helpful in some individuals

Management of nighttime urinary frequency may include:

  • Anticholinergic medications such as darifenacin (Enablex), solifenacin (Vesicare), tolterodine (Detrol) and oxybutinin (ditropan)

  • In some cases the hormone ddAVP taken as a nasal spray at bedtime has been used with good effects

Proper medication management and scheduling with Parkinson’s Disease is critical for optimizing the sleep-wake cycle⁶, so bring up your sleep difficulties to your physician or neurologist to see if potentially adjusting medications or scheduling will reduce the number of sleep disturbances you experience. 


OT Tips and Tricks


Energy conservation: poor sleep quality can lead to excessive daytime sleepiness (EDS) or fatigue. 

  • Plan daily tasks around when you usually have the most energy or when medication is “on”

  • Schedule demanding or strenuous chores evenly throughout your week

  • Give yourself ample time to complete a task at a slower pace

  • Build in rest breaks throughout the day

  • Store commonly used items in areas that are easily accessible.

  • Sit when possible for tasks like showering or cooking


Create a sleep routine: creating a routine can help to establish circadian rhythm, and reduce anxiety 

  • Don’t use your bed for anything, but sleeping at night

  • Avoid eating within 2 hour of bedtime, try smaller meals throughout the day

  • Avoid screen time 2 hours before bedtime, try reading or light stretching

  • Try silk/satin pajamas or bed sheets which can reduce reduce friction and overheating silk pajamas AND bed sheets may offer too much glide and increase sliding out of bed while asleep

  • Exercise throughout the day

  • Get sun throughout the day 

  • Create a sleep journal to track how much your are sleeping, waking up in the night, and why for your doctor visits

  • 15 minute rule: If you have not been able to go to fall asleep for 15 minutes or think you are unable to fall asleep in the next 15 minutes, then you need to get out of bed and do something undemanding (reading, listening to music, breathing exercises, etc) until you feel tired again


Create a safe bedroom: REM disturbances can lead to kicking or flailing during sleep, which leads to poorer sleep quality and potentially be unsafe. Urinary frequency can also lead to safety risks while navigating through the environment.

  • Use a bed rail to help getting in and out of bed to conserve energy and increase safety.

  • Use a border around the bed such as pillows or pool noodles underneath the fitted sheets to reduce slipping out of bed while asleep

  • Lower the bed if needed and keep pathways surrounding the bed clear

  • Use a bedside commode to reduce trips to the bathroom at night

  • If nighttime disturbances are too physical, the care partner/spouse may need to sleep in a different bed, and furniture may need to be moved away from the bed to reduce injury


References


  1. Raggi A, Bella R, Pennisi G, Neri W, Ferri R. Sleep disorders in Parkinson’s disease: a narrative review of the literature. Rev Neurosci. 2013;24:279–291. 

  2. Videnovic, A., Lazar, A. S., Barker, R. A., & Overeem, S. (2014). 'The clocks that time us'--circadian rhythms in neurodegenerative disorders. Nature reviews. Neurology, 10(12), 683–693. https://doi.org/10.1038/nrneurol.2014.206

  3. Videnovic, A., & Golombek, D. (2013). Circadian and sleep disorders in Parkinson's disease. Experimental neurology, 243, 45–56. https://doi.org/10.1016/j.expneurol.2012.08.018 

  4. Bollu, P. C., & Sahota, P. (2017). Sleep and Parkinson Disease. Missouri medicine, 114(5), 381–386.

  5. Pandey, S. Impact of sleep quality on the quality of life of patients with Parkinson’s disease: a questionnaire based study, Clinical Neurology and Neurosurgery, Volume 148, 2016, Pages 29-34, ISSN 0303-8467, https://doi.org/10.1016/j.clineuro.2016.06.014

  6. Samanta, J. Sleep problems in Parkinson’s. American Parkinson Disease Association. 2024.

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