Parkinson’s DiseaseParkinson’s Disease& Sleep Disorders& Sleep Disorders

The Village Sleep LabThe Village Sleep LabAccredited By theAccredited By the

American Academy of Sleep MedicineAmerican Academy of Sleep Medicine

Juan A Albino MDJuan A Albino MDBoard Certified in Sleep MedicineBoard Certified in Sleep Medicine

751-4955751-4955April, 2009April, 2009

Thank You !!!Thank You !!!Bill Gray, Parkinson’s Support GroupBill Gray, Parkinson’s Support GroupHeather Ellington, Office Manager Heather Ellington, Office Manager Jim Grazis, Sleep TechnologistJim Grazis, Sleep TechnologistMelyssa Rivera, Sleep TechnologistMelyssa Rivera, Sleep TechnologistMiyoshi Scott, NurseMiyoshi Scott, NurseAWAKE Group of The VillagesAWAKE Group of The VillagesLois Brach, CoordinatorLois Brach, Coordinator

Common Sleep DisordersCommon Sleep Disorders

InsomniaInsomnia: wants to sleep but cannot : wants to sleep but cannot Sleep DeprivationSleep Deprivation: does : does notnot want to sleep want to sleep

but can; problem of sleep but can; problem of sleep quantityquantity Sleep ApneaSleep Apnea: sleepy during day, snores : sleepy during day, snores

(throat obstruction) problem of sleep (throat obstruction) problem of sleep qualityquality Restless Legs SydromeRestless Legs Sydrome: leg discomfort, : leg discomfort,

relieved by movement, symptoms day and relieved by movement, symptoms day and night night

Parasomnias: Parasomnias: abnormal sleep behaviorsabnormal sleep behaviors Circadian Rhythm Disorders: Circadian Rhythm Disorders: sleep clock sleep clock

not in harmony with the environmentnot in harmony with the environment

Good Sleep HabitsGood Sleep Habits

Regular times for sleeping and Regular times for sleeping and awakeningawakening

Maintain bedroom dark, quiet, coolMaintain bedroom dark, quiet, cool Use bed only for sleep and sexUse bed only for sleep and sex Avoid late daytime napsAvoid late daytime naps Avoid at night: alcohol, caffeine, nicotineAvoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every nightSleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bednightAvoid stressful situations at bednight Test: spontaneous bedtime and rise timeTest: spontaneous bedtime and rise time

Parkinson’s & Sleep Parkinson’s & Sleep ProblemsProblems

InsomniaInsomniaDisruptions during SleepDisruptions during SleepDaytime SleepinessDaytime Sleepiness

Parkinson’s & InsomniaParkinson’s & Insomnia

Primary InsomniaPrimary Insomnia: present before PD: present before PDInsomnia due to Parkinson’sInsomnia due to Parkinson’s: improves : improves

with better treatment of PD with better treatment of PD Depression:Depression: before or after Parkinson’s before or after Parkinson’sUrge to urinate:Urge to urinate: bladder, prostate, etc. bladder, prostate, etc.Medications:Medications: some antidepressants, some antidepressants,

selegiline (Deprenyl, Eldeprl)selegiline (Deprenyl, Eldeprl)Sleep apneaSleep apnea can cause insomnia can cause insomnia

Insomnia Due to Insomnia Due to Parkinson’s: CausesParkinson’s: Causes

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 nightInsufficient medications during the Insufficient medications during the

nightnight

Insomnia Due to Insomnia Due to Parkinson’sParkinson’s

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

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

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

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

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

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

Periodic Limb Movement Disorder, Periodic Limb Movement Disorder, PLMDPLMD

Easily treatable with medicinesEasily treatable with medicinesRestless Legs Syndrome FoundationRestless Legs Syndrome Foundation

Treatment of RLS/PLMDTreatment of RLS/PLMD

Restless Legs Syndrome is diagnosed Restless Legs Syndrome is diagnosed by history: exclude leg crampsby history: exclude 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, anti-seizure sedatives, and narcotics, anti-seizure drugsdrugs

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: Primary Insomnia: Before Parkinson’sBefore Parkinson’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 HabitsSleep Habits: avoid coffee & alcohol, sleep : avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before in a quiet, dark, cool room, eat lightly before bedbed

regular sleep hours, avoid day naps, regular sleep hours, avoid day naps, exercise exercise

Restriction:Restriction: only go to bed when ready to 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 controlStimulus control: simple bedroom : simple bedroom furniture and bedroom strictly for sleepfurniture and bedroom strictly for sleep

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

Treatment of Chronic Treatment of Chronic Insomnia: Sleeping PillsInsomnia: Sleeping Pills

Anti-histamines: available over the counter Anti-histamines: available over the counter Benadryl (diphenhydramine), Tylenol PMBenadryl (diphenhydramine), Tylenol PM

Anti-depressants: trazodoneAnti-depressants: trazodone Sedatives: temazepam (Restoril)Sedatives: temazepam (Restoril) Specific drugs: Ambien (generic: zolpidem), Specific drugs: Ambien (generic: zolpidem),

Ambien CR (not generic), Lunesta Ambien CR (not generic), Lunesta 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

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

Disruptions During the Disruptions During the NightNight

REM Sleep Behavior DisorderREM Sleep Behavior Disorder: : acting out dreams, associated with PDacting out dreams, associated with PD

Hallucinations and DelusionsHallucinations and Delusions at at Night: patient is awake not asleepNight: patient is awake not asleep

ConfusionConfusion: Sundowning, advanced : Sundowning, advanced Parkinson’s dementia, reversed Parkinson’s dementia, reversed day/night cycle (wandering at night)day/night cycle (wandering at night)

Sleep ApneaSleep Apnea and restless sleep and restless sleep

Disruptions During the Disruptions During the NightNight

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, Behavior Disorder, Sleep Apnea, Hallucinations, Delusions, NightmaresHallucinations, Delusions, Nightmares

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

Day Time SleepinessDay Time Sleepiness

Insomnia due to Parkinson’sInsomnia due to Parkinson’s: : uncontrolled disease at night leads to uncontrolled disease at night leads to sleep deprivation then anti-PD drugs in the sleep deprivation then anti-PD drugs in the morning relax the patientmorning relax the patient

Anti-PD DrugsAnti-PD Drugs: all may cause sleepiness : all may cause sleepiness Other DrugsOther Drugs: sedatives, anti-depressants: sedatives, anti-depressants Restless Legs Syndrome / Periodic Leg Restless Legs Syndrome / Periodic Leg

Movement DisorderMovement Disorder: sleep deprivation: sleep deprivation Sleep ApneaSleep Apnea leads to sleep leads to sleep

fragmentationfragmentation

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 Elderly & women: little snoring & not obeseElderly & women: little snoring & not obese

Sleep Apnea: Sleep Apnea: ConsequencesConsequences

NightNight: snoring, stops breathing : snoring, stops breathing snorting, gasping, bed partner worriessnorting, gasping, bed partner worries

DayDay: sleepy, tired, depressed, irritable, : sleepy, tired, depressed, irritable, impotent, forgets, ? few complaintsimpotent, forgets, ? few complaints

AccidentsAccidents: work, home, motor vehicle: work, home, motor vehicleHypertensionHypertension, Heart Failure, Heart , Heart Failure, Heart

Attacks, Higher death rates Attacks, Higher death rates StrokesStrokes, Atrial Fibrillation, Atrial FibrillationPromotes Promotes ObesityObesity and and DiabetesDiabetes

What is OSA?•NO AIRFLOW DESPITE RESPIRATORY EFFORT

•NORMAL SNORING SLEEP APNEA

Obstructive Sleep Apnea

Sleep Apnea: TreatmentSleep Apnea: Treatment

BehavioralBehavioral: : Weight LossWeight Loss, , Sleep PositionSleep Position (Sleep on side, head raised), (Sleep on side, head raised), OxygenOxygen, Avoid , Avoid sedatives sedatives

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

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

Bariatric SurgeryBariatric Surgery: banding, bypass (Bob : banding, bypass (Bob Eisenhauer 259-1485; Lewis Jones 753-3459)Eisenhauer 259-1485; Lewis Jones 753-3459)

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

Continuous Positive

Airway Pressure:

CPAP Keeps airway open

100% effective, simple

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)

WebsitesWebsites

The Movement Disorder Society: The Movement Disorder Society: www.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: www.rls.orgRestless Legs Syndrome Foundation: www.rls.org National Sleep Foundation: National Sleep Foundation:

www.sleepfoundation.org The Village Sleep Lab: The Village Sleep Lab: www.villagesleeplab.com American Academy of Sleep Medicine: American Academy of Sleep Medicine:

www.sleepeducation.comwww.sleepeducation.com

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