1. Parkinson’s Disease and Sleep Disorders Juan A. Albino, MD, FCCP Village Sleep Lab 751-4955 August, 2007 August, 2007

2. Thank You !!! Bill Gray, Parkinson’s Support Group Bill Gray, Parkinson’s Support Group Heather Ellington, Office Manager Heather Ellington, Office Manager Normarie M. Albino, MD, President Normarie M. Albino, MD, President John Crawford, Technical Director John Crawford, Technical Director Thomas Chaput, Sleep Technologist Thomas Chaput, Sleep Technologist Michael Summers, Sleep Technologist Michael Summers, Sleep Technologist Miyoshi Scott, Nurse Miyoshi Scott, Nurse Shunta McKinney, Receptionist Shunta McKinney, Receptionist

3. 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

4. Good Sleep Hygiene: Basics 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

5. Parkinson’s & Sleep Problems Insomnia Insomnia Daytime Sleepiness Daytime Sleepiness Disruptions during Sleep Disruptions during Sleep

6. Parkinson’s & Insomnia Primary Insomnia: present before PD Primary Insomnia: present before PD 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)

7. Insomnia Due to Parkinson’s: Causes Lack of muscle and mental relaxation Lack of muscle and mental relaxation Stiffness, restlessness, and difficulty of moving into comfortable positions Stiffness, restlessness, and difficulty of 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

8. 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

9. 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, June K. Wharton (259-0979) Restless Legs Syndrome Foundation, June K. Wharton (259-0979)

10. 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

11. 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

12. 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

13. Drugs and Insomnia Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or add sedating one at night: trazodone Anti-depressants: Prozac, Celexa, Zoloft, Paxil, take in the morning or add sedating one at night: trazodone Anti-Parkinson’s: Selegiline Anti-Parkinson’s: Selegiline Drugs for emphysema or COPD Drugs for emphysema or COPD Coffee, alcohol, tobacco Coffee, alcohol, tobacco

14. Primary Insomnia: Before Parkinson’s Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Acute Insomnia (<4 weeks): stress, illness Acute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stage Sleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often years Chronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychological Treat basic problem: >60% psychological Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychologists, Psychiatrists, PCP Psychologists, Psychiatrists, PCP

15. Treatment of Chronic Insomnia Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before bed Sleep Hygiene: avoid coffee & alcohol, sleep in a quiet, dark, cool room, eat lightly before bed regular sleep hours, avoid day naps, exercise regular sleep hours, avoid day naps, exercise Restriction: only go to bed when ready to sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 min Restriction: only go to bed when ready to sleep, if in bed sleep 90% of the time; out of bed and bedroom if awake over 20 min Stimulus control: simple bedroom furniture and bedroom strictly for sleep Stimulus control: simple bedroom furniture and bedroom strictly for sleep Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the problem Proper perspective: good if adequate sleep over 75% of the time, don’t exaggerate the problem

16. Treatment of Chronic Insomnia: Sleeping Pills Anti-histamines: available over the counter Benadryl (diphenhydramine) Anti-histamines: available over the counter Benadryl (diphenhydramine) Sedating anti-depressants: trazodone Sedating anti-depressants: trazodone Sedatives: temazepam (Restoril), triazolam (Halcion), flurazepam (Dalmane) Sedatives: temazepam (Restoril), triazolam (Halcion), flurazepam (Dalmane) Specific drugs: Ambien (generic), Ambien CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming) Specific drugs: Ambien (generic), Ambien CR (not generic), Lunesta, short acting but expensive; Rozerem (not habit forming) Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they help, side effects Natural Substances: melatonin, valerian root, chamomile tea, lavender, kava, jazmine scent, little to no proof that they help, side effects

17. Day Time Sleepiness Insomnia due to Parkinson’s: sleep deprivation because disease not controlled at night and worsened by anti-PD drugs in the morning that finally relax the patient Insomnia due to Parkinson’s: sleep deprivation because disease not controlled at night and worsened by anti-PD drugs in the morning that finally relax the patient Drugs: all anti-PD drugs may cause sleepiness but not common, other drugs Drugs: all anti-PD drugs may cause sleepiness but not common, other drugs Sleep Apnea Sleep Apnea Restless Legs Syndrome / Periodic Leg Movement Disorder: sleep deprivation Restless Legs Syndrome / Periodic Leg Movement Disorder: sleep deprivation

18. Drugs and Daytime Sleepiness Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin) Anti-anxiety: alprazolam (Xanax), clonazepam (Klonopin) Narcotics Narcotics Muscle Relaxants: cyclobenzaprine (Flexeril) Muscle Relaxants: cyclobenzaprine (Flexeril) Seizure Drugs: phenytoin (Dilantin), gabapentin (Neurontin) Seizure Drugs: phenytoin (Dilantin), gabapentin (Neurontin) Drugs for hallucinations and psychosis: quetiapine (Seroquel), olanzapine (Zyprexia), resperidone (Resperdal) Drugs for hallucinations and psychosis: quetiapine (Seroquel), olanzapine (Zyprexia), resperidone (Resperdal)

19. 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

20. 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

21. Sleep Apnea: Consequences During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During day: sleepy, tired, depressed, irritabile, impotent, forgets, sometimes few complaints During day: sleepy, tired, depressed, irritabile, impotent, forgets, sometimes few complaints More accidents: work, home, motor vehicle More accidents: work, home, motor vehicle Higher death rates with severe sleep apnea Higher death rates with severe sleep apnea 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 Problems: at night, during day, risk factor Problems: at night, during day, risk factor

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

23. 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 (Bob Eisenhauer, 259-1485) Bariatric Surgery: banding, bypass (Bob Eisenhauer, 259-1485) Dental appliances: also pull forth mandible or tongue; expertise necessary Dental appliances: also pull forth mandible or tongue; expertise necessary

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

25. 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, also Benefits of treatment: sleep better at night, also 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 and strokes Reduce risk factor for heart disease and strokes Control better: obesity, diabetes, hypertension Control better: obesity, diabetes, hypertension Bed partner sleeps better: less noise and less worry (but dog is scared of CPAP) Bed partner sleeps better: less noise and less worry (but dog is scared of CPAP)

26. 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 or Seizures Sleep Apnea or Seizures

27. 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

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