1. Parkinson’s Disease and Sleep Disorders Juan A. Albino, MD Board Certified in Sleep Medicine Village Sleep Lab 751-4955 November, 2015

2. Common Sleep Disorders Insomnia: wants to sleep but cannot Insomnia: wants to sleep but cannot Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep Deprivation: does not want to sleep but can; problem of sleep quantity SLEEP APNEA: during day, snores at night because of obstruction in throat; problem of sleep quality SLEEP APNEA: sleepy during day, snores at night because of obstruction in throat; problem of sleep quality Restless Legs Syndrome: leg discomfort, relieved by movement that hinders sleep Restless Legs Syndrome: leg discomfort, relieved by movement that hinders sleep Parasomnia: disruptive behavior of sleep Parasomnia: disruptive behavior of sleep

3. Good Sleep Habits Regular times for sleeping and awakening Regular times for sleeping and awakening Maintain bedroom dark, quiet, cool Maintain bedroom dark, quiet, cool Use bed only for sleep and sex Use bed only for sleep and sex Avoid late daytime naps Avoid late daytime naps Avoid at night: alcohol, caffeine, nicotine Avoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every night Sleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bednight Avoid stressful situations at bednight

4. Parkinson’s & Insomnia Insomnia due to Parkinson’s: improves with better treatment of PD at night Insomnia due to Parkinson’s: improves with better treatment of PD at night Depression: before or after Parkinson’s Depression: before or after Parkinson’s Urge to urinate: bladder, prostate, etc. Urge to urinate: bladder, prostate, etc. Medications: some antidepressants, selegiline (Deprenyl, Eldeprl) Medications: some antidepressants, selegiline (Deprenyl, Eldeprl)

5. Insomnia Due to Parkinson’s: Causes Lack of muscle and mental relaxation Lack of muscle and mental relaxation Stiffness, restlessness, and difficulty moving into comfortable positions Stiffness, restlessness, and difficulty moving into comfortable positions Tremor can be bothersome Tremor can be bothersome Medications wear off during the night Medications wear off during the night Insufficient medications during the night Insufficient medications during the night

6. Insomnia Due to Parkinson’s Stage 1: Difficulty falling asleep: need to take PD meds 1 to 3 hours before bedtime Stage 1: Difficulty falling asleep: need to take PD meds 1 to 3 hours before bedtime Stage 2: Waking up early part of night: take long acting medicine at bedtime Stage 2: Waking up early part of night: take long acting medicine at bedtime Stage 3: Waking up latter part of the night : take medicine when wake up Stage 3: Waking up latter part of the night : take medicine when wake up

7. Restless Legs Syndrome (RLS) Leg discomfort, worse at night, relieved by movement, affects 5-10% of population Leg discomfort, worse at night, relieved by movement, affects 5-10% of population Familial, begins in childhood Familial, begins in childhood Associated with iron deficiency, drugs, Periodic Limb Movement Disorder, PLMD Associated with iron deficiency, drugs, Periodic Limb Movement Disorder, PLMD Easily treatable with medicines Easily treatable with medicines Restless Legs Syndrome Foundation Restless Legs Syndrome Foundation

8. Treatment of RLS/PLMD Restless Legs Syndrome is diagnosed by history: exlude leg cramps Restless Legs Syndrome is diagnosed by history: exlude leg cramps Periodic Leg Movement Disorder is diagnosed by a sleep study Periodic Leg Movement Disorder is diagnosed by a sleep study Treatment is the same and effective Treatment is the same and effective Luckily the same medicines to treat PD: Mirapex and Requip, also sedatives, and narcotics, seizure drugs Luckily the same medicines to treat PD: Mirapex and Requip, also sedatives, and narcotics, seizure drugs

9. Frequent Urination Causes: light sleep, bladder problem, prostate problem, drugs, infections, other Causes: light sleep, bladder problem, prostate problem, drugs, infections, other Light sleep: PD, Sleep Apnea, PLMD Light sleep: PD, Sleep Apnea, PLMD Consider urological evaluation Consider urological evaluation Avoid too much fluids, salt, diuretics, alcohol, caffeine Avoid too much fluids, salt, diuretics, alcohol, caffeine Control Parkinson’s better; do sleep study Control Parkinson’s better; do sleep study Medicines for bladder or prostate Medicines for bladder or prostate

10. Depression and Anxiety Anxiety: difficulty going to sleep, worries Anxiety: difficulty going to sleep, worries Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun Depression: before or after Parkinson’s; problem recognizing, admitting to illness Depression: before or after Parkinson’s; problem recognizing, admitting to illness Drugs are effective in treating both Drugs are effective in treating both Beware: anti-anxiety drugs & sleepiness; anti-depressants & insomnia Beware: anti-anxiety drugs & sleepiness; anti-depressants & insomnia

11. Disruptions During the Night Vivid dreams and nightmares Vivid dreams and nightmares REM Sleep Behavior Disorders: unique to Parkinson’s Disease: acting out dreams REM Sleep Behavior Disorders: unique to Parkinson’s Disease: acting out dreams Hallucinations and Delusions at Night: patient is awake not asleep Hallucinations and Delusions at Night: patient is awake not asleep Confusion at night: Sundowning, part of dementia of advanced Parkinson’s, reverse day/night cycle Confusion at night: Sundowning, part of dementia of advanced Parkinson’s, reverse day/night cycle Sleep Apnea Sleep Apnea

12. Disruptions During the Night Often disruptive to family Often disruptive to family Important cause of institutionalization Important cause of institutionalization Difficult to distinguish among: REM Sleep Behavior Disorder, Sleep Apnea, and Hallucinations Difficult to distinguish among: REM Sleep Behavior Disorder, Sleep Apnea, and Hallucinations Sleep study often indicated Sleep study often indicated Medicines control REM Sleep Behavior Disorder, and Hallucinations Medicines control REM Sleep Behavior Disorder, and Hallucinations Familiar surroundings, lighting for confusion Familiar surroundings, lighting for confusion

13. Day Time Sleepiness Insomnia due to Parkinson’s Insomnia due to Parkinson’s Drugs: all anti-PD drugs may cause sleepiness but not common Drugs: all anti-PD drugs may cause sleepiness but not common Sleep Apnea Sleep Apnea Restless Legs Syndrome / Periodic Leg Movement Disorder Restless Legs Syndrome / Periodic Leg Movement Disorder Sleep deprivation Sleep deprivation

14. Pseudo-Sleepiness Low blood pressure can mimic sleepiness Low blood pressure can mimic sleepiness Parkinson’s and drugs to treat it can lead to low BP, especially in the morning Parkinson’s and drugs to treat it can lead to low BP, especially in the morning Clue: patient feels faint when standing up Clue: patient feels faint when standing up May lose consciousness and mistakenly thought to be asleep May lose consciousness and mistakenly thought to be asleep Clue: after breakfast Clue: after breakfast Confirm: take blood pressure lying down, sitting, and standing Confirm: take blood pressure lying down, sitting, and standing

15. Sleep Apnea: Risk Factors Affects: 4 to 5% of population: common Affects: 4 to 5% of population: common Family history, Sleep maintenance insomnia Family history, Sleep maintenance insomnia Obesity: 80 % of sleep apnea patients; central (visceral, apples) obesity Obesity: 80 % of sleep apnea patients; central (visceral, apples) obesity Increasing age, Male gender Increasing age, Male gender Large tonsils / adenoids in children Large tonsils / adenoids in children Small mandible, large neck Small mandible, large neck Smoking, alcohol, sedatives, nasal allergies Smoking, alcohol, sedatives, nasal allergies

16. Sleep Apnea: Consequences During night: snoring, snorting, gasping, stops breathing, restless, wakes up During night: snoring, snorting, gasping, stops breathing, restless, wakes up During day: sleepy, tired, depressed, irritable, impotent, forgets During day: sleepy, tired, depressed, irritable, impotent, forgets Accidents: work, home, motor vehicle Accidents: work, home, motor vehicle Hypertension, Congestive Heart Failure Hypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial Fibrillation Heart Attacks, Strokes, Atrial Fibrillation Promotes Obesity and Diabetes Promotes Obesity and Diabetes

17. What is OSA? Cessation of airflow with ongoing respiratory effort NORMALSNORINGSLEEP APNEA Obstructive Sleep Apnea

18. Sleep Apnea: Treatment Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, Avoid sedatives Behavioral: Weight Loss, Sleep Position (Sleep on side, head raised), Oxygen, Avoid sedatives CPAP: proven therapy, needs motivation: widely available, 70%: patients adapt well CPAP: proven therapy, needs motivation: widely available, 70%: patients adapt well Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongue Surgery: tracheostomy, tonsillectomy, pull forth mandible or tongue Bariatric Surgery: banding, bypass Bariatric Surgery: banding, bypass Dental appliances: also pull forth mandible or tongue; expertise necessary Dental appliances: also pull forth mandible or tongue; expertise necessary

19. Treatment -CPAP treatment –Positive pressure keeps airway open –100% effective CPAP therapy Treatment Options: CPAP

20. Summary: Sleep Apnea Very common and dangerous Very common and dangerous Easily diagnosed and treated Easily diagnosed and treated Benefits of treatment sleep better at night Benefits of treatment sleep better at night Feel better during the day: less sleepiness and fatigue, more energy, less accidents Feel better during the day: less sleepiness and fatigue, more energy, less accidents Reduce risk factor for heart disease & strokes Reduce risk factor for heart disease & strokes Control better: obesity, diabetes, hypertension Control better: obesity, diabetes, hypertension Bed partner sleeps better: less noise & worry Bed partner sleeps better: less noise & worry

21. Stem Cell Treatments At best: a for profit experimental procedure At best: a for profit experimental procedure At worst: fraud and abuse of patients that are hopeful At worst: fraud and abuse of patients that are hopeful History of experimental procedures: about one third help, one third have no effect, and one third hurt History of experimental procedures: about one third help, one third have no effect, and one third hurt

22. Stem Cell Treatments: 6 False Hope Warning Signs The International Society for Stem Cell Research lists these warning signs that a stem cell treatment is not legitimate The International Society for Stem Cell Research lists these warning signs that a stem cell treatment is not legitimate It makes claims based on patient testmonials It makes claims based on patient testmonials The same stem cells are used to treat many diseases The same stem cells are used to treat many diseases The source of the stem cells is not clearly documented The source of the stem cells is not clearly documented

23. Stem Cell Treatments: 6 False Hope Warning Signs There is no clear protocol or detailed guide to treatment There is no clear protocol or detailed guide to treatment Claims that there is no risk; all medical procedures carry risk Claims that there is no risk; all medical procedures carry risk High cost or hidden costs; legitimate clinical trials do not charge patients, and may even pay them High cost or hidden costs; legitimate clinical trials do not charge patients, and may even pay them

24. Stem Cell Clinics: Comments October 15 th, 2015: Medical News http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unr egulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx October 15 th, 2015: Medical News http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unr egulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unr egulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx http://journals.lww.com/neurotodayonline/Fulltext/2015/10220/Unr egulated_Stem_Cell_Clinics_Proliferate_in_the.1.aspx May 18 th, 2015: San Jose Newspaper: http://www.mercurynews.com/business/ci_28139232/stem-cell- clinics-run-amok-amid-lack-regulation May 18 th, 2015: San Jose Newspaper: http://www.mercurynews.com/business/ci_28139232/stem-cell- clinics-run-amok-amid-lack-regulation http://www.mercurynews.com/business/ci_28139232/stem-cell- clinics-run-amok-amid-lack-regulation http://www.mercurynews.com/business/ci_28139232/stem-cell- clinics-run-amok-amid-lack-regulation Mayo Clinic: overview of stem cells: http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/in- depth/stem-cells/ART-20048117?pg=1 Mayo Clinic: overview of stem cells: http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/in- depth/stem-cells/ART-20048117?pg=1 http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/in- depth/stem-cells/ART-20048117?pg=1 http://www.mayoclinic.org/tests-procedures/stem-cell-transplant/in- depth/stem-cells/ART-20048117?pg=1 September 10, 2015: Medical Journal: Medicine’s Wild West- Unlicensed Stem Cell Clinics http://www.nejm.org/doi/full/10.1056/NEJMp1504560?query=TOC September 10, 2015: Medical Journal: Medicine’s Wild West- Unlicensed Stem Cell Clinics http://www.nejm.org/doi/full/10.1056/NEJMp1504560?query=TOC http://www.nejm.org/doi/full/10.1056/NEJMp1504560?query=TOC International Society for Stem Cell Research: Patient Handbook on Stem Cell Therapies, http://www.isscr.org/home/publications/patient-handbook International Society for Stem Cell Research: Patient Handbook on Stem Cell Therapies, http://www.isscr.org/home/publications/patient-handbook

25. Placebo Effect Fascinating part of medicine and healing Fascinating part of medicine and healing Traditionally studied with true pain: about one third to half of all patients controlled with placebo or sugar water/pill Traditionally studied with true pain: about one third to half of all patients controlled with placebo or sugar water/pill FDA demands that all new medicines be tested against placebo FDA demands that all new medicines be tested against placebo Since so many patients controlled or even cured with placebo there will be many testimonials for any pill Since so many patients controlled or even cured with placebo there will be many testimonials for any pill

26. References: Placebo Dr Ted Kaptchuk, Director of the Program in Placebo Studies at Harvard Medical School: Dr Ted Kaptchuk, Director of the Program in Placebo Studies at Harvard Medical School: Interview: http://www.npr.org/2012/01/06/144794035/one- scholars-take-on-the-power-of-the-placebo Interview: http://www.npr.org/2012/01/06/144794035/one- scholars-take-on-the-power-of-the-placebo http://www.npr.org/2012/01/06/144794035/one- scholars-take-on-the-power-of-the-placebo http://www.npr.org/2012/01/06/144794035/one- scholars-take-on-the-power-of-the-placebo Article: http://harvardmagazine.com/2013/01/the- placebo-phenomenon Article: http://harvardmagazine.com/2013/01/the- placebo-phenomenonhttp://harvardmagazine.com/2013/01/the- placebo-phenomenonhttp://harvardmagazine.com/2013/01/the- placebo-phenomenon Placebo Effect in Knee Surgery: YouTube https://www.youtube.com/watch?v=HqGSeFOUsLI Placebo Effect in Knee Surgery: YouTube https://www.youtube.com/watch?v=HqGSeFOUsLI https://www.youtube.com/watch?v=HqGSeFOUsLI Placebo Effect at Stanford Medical School: https://www.youtube.com/watch?v=udJ31KKXBKk Placebo Effect at Stanford Medical School: https://www.youtube.com/watch?v=udJ31KKXBKk

27. Websites National Center on Sleep Disorders: www.nhlbi.nih.gov/health/resources/sleep/ National Center on Sleep Disorders: www.nhlbi.nih.gov/health/resources/sleep/ Insomnia: Cognitive Behavioral Therapy cbtforinsomnia.com and uwhealth.org/health/topic/mini/insomnia/uh1001.html Insomnia: Cognitive Behavioral Therapy cbtforinsomnia.com and uwhealth.org/health/topic/mini/insomnia/uh1001.html Commercial: www.MyResmed.com Commercial: www.MyResmed.com Commercial: www.Respironics.com Commercial: www.Respironics.comwww.Respironics.com Buyer Beware!!! Buyer Beware!!!

28. Websites The Movement Disorder Society: www.wemove.org The Movement Disorder Society: www.wemove.org www.wemove.org The American Academy of Neurology: The American Academy of Neurology:www.thebrainmatters.com American Sleep Apnea Association: www.sleepapnea.org American Sleep Apnea Association: www.sleepapnea.org Restless Legs Syndrome Foundation: www.rls.org Restless Legs Syndrome Foundation: www.rls.org National Sleep Foundation: www.sleepfoundation.org National Sleep Foundation: www.sleepfoundation.org

29. Books The Parkinson’s Disease Treatment Book by J. Eric Ahlskog, Mayo Clinic The Parkinson’s Disease Treatment Book by J. Eric Ahlskog, Mayo Clinic The Promise of Sleep by William Dement The Promise of Sleep by William Dement Sleeping Well by Michael Thorpy Sleeping Well by Michael Thorpy No More Sleepless Nights by Peter Hauri No More Sleepless Nights by Peter Hauri A Woman’s Guide to Sleep Disorders by Meir H. Kryger A Woman’s Guide to Sleep Disorders by Meir H. Kryger Restless Legs Syndrome by Robert H. Yoakum Restless Legs Syndrome by Robert H. Yoakum Say Good Night to Insomnia by Gregg D. Jacobs Say Good Night to Insomnia by Gregg D. Jacobs