Sleep & Parkinson’s Disease

Today the American Academy of Neurology published new guidelines for treating nonmotor symptoms of Parkinson’s disease. The section on sleep dysfunction was endorsed by the AASM board of directors.

The NINDS reports that Parkinson’s disease is a motor system disorder. These disorders involve problems with muscle control.

One of the primary motor symptoms of PD is tremor. This is trembling or shaking in the hands, arms, legs, jaw or face.



But there are other nonmotor symptoms of PD. These include a variety of sleep-related problems.

The AAN guidelines report that people with PD often struggle with insomnia. They may be unable to fall asleep. They also may wake up frequently during the night.

Sleep aids such as melatonin may improve the perception of sleep quality in people with PD. But it is unclear if they produce an objective sleep improvement.

Deep brain stimulation also may cause sleep to improve. DBS is a surgical procedure that is used to treat the motor symptoms of PD.

Both restless legs syndrome and periodic limb movements are common in people with PD. These problems are classified as sleep related movement disorders.

Treating PD with carbidopa and levodopa may improve the symptoms of RLS and PLM. The drugs ropinirole (Requip) and pramipexole (Mirapex) are FDA-approved to treat PD and RLS. But it is unclear if they reduce RLS symptoms in people who also have PD.

The parasomnia REM sleep behavior disorder often occurs in people with PD. People who have RBD act out vivid dreams and nightmares as they sleep.

RBD can be treated with clonazepam or melatonin. But research needs to evaluate the treatment of RBD in people with PD.

People with PD often struggle with excessive daytime sleepiness. The stimulant modafinil (Provigil) may help them feel more awake. But it may not produce actual improvements in alertness.

Read a patient summary of the new guidelines on the AAN Web site. Get help for a sleep problem at an AASM-accredited sleep center.

Restless Legs & Impulse Control Disorders

A new study examined the frequency of impulse control disorders in people being treated for restless legs syndrome. The results were published in the Jan. 1 issue of the journal Sleep.

The study involved 100 people with RLS who were seen at the Center for Sleep Medicine at Mayo Clinic. All of them were being treated or had been treated with “dopaminergic” drugs.

These drugs stimulate the dopamine receptors in the brain. Dopamine is a chemical that acts as a neurotransmitter. It is believed that RLS may involve a dysfunction in the brain’s dopamine system.

The study group completed questionnaires about impulse control disorders. Phone interviews also were conducted.

They were compared with two control groups. One group consisted of 52 people with RLS who had never been treated with a dopaminergic drug. The other group had 275 people with obstructive sleep apnea who did not have RLS.

Results show that impulse control disorders occurred in 17 percent of people with RLS who were treated with dopaminergic drugs. They occurred in eight percent of the RLS control group and six percent of the OSA control group.

Nine percent of the RLS treatment group reported compulsive shopping. Five percent reported pathologic gambling.

Seven percent reported “punding.” This involves purposeless, repetitive actions. Examples include sorting objects and excessive grooming or cleaning.

These rates were significantly higher than in people with OSA. The rate of compulsive shopping was higher than in the RLS control group.

People being treated for RLS were most likely to have impulse control disorders while taking pramipexole (Mirapex). Some RLS patients also struggled with impulse control while taking ropinirole (Requip).

Eight people stopped taking a medication due to an impulse control disorder. Within several weeks the problem ended or improved in all of them.

The authors noted that dopamine plays a role in the brain’s “reward system.” In some people dopaminergic drugs may overstimulate brain areas involved in this system.

They added that doctors treating people with RLS should monitor them for symptoms of an impulse control disorder. These disorders can have devastating effects.

In May 2008 the FDA approved the first generic versions of ropinirole for RLS. Learn more about RLS.

Image by Kevin Labianco

Hypersomnia: Common Features & Effective Treatments

A new study examined the common features of hypersomnia and effective treatment options. The results were published in the Dec. 15 issue of the Journal of Clinical Sleep Medicine.

The study involved 85 people who had been diagnosed with hypersomnia at the Center for Sleep Medicine at Mayo Clinic. They were followed up for an average of 2.4 years. Their medical charts and clinical notes were reviewed and analyzed.

Sixty-five percent of the patients were women. Symptoms tended to begin when they were in their late teens. But typically they weren’t diagnosed with hypersomnia until they were in their mid-30s. Thirty-seven percent reported that at least one family member had excessive sleepiness.

Patients reported sleeping for an average of eight hours per day. Nineteen percent of patients reported sleeping for more than 10 hours per day. But the average sleep time measured by actigraphy was 7.5 hours per day. During an overnight sleep study they fell asleep after an average of seven minutes.

Seventy-three percent of patients reported taking naps. The mean nap duration was one hour and 28 minutes. But in most cases the naps were considered to be unrefreshing.

The authors reported that the majority of patients responded well to treatment with medication. A complete response to treatment was reported by 65 percent of patients.

Twenty-six percent had a partial response to treatment. Only nine percent reported a poor response.

The two medications that were most often prescribed were modafinil and methylphenidate. Both medications are recommended as a treatment option in AASM practice parameters.

Modafinil was most often taken once a day in the morning. The average total daily dose was 367 mg. “High cost” was a common complaint of people who were using modafinil.

Methylphenidate was often taken three to four times per day. The average total daily dose was 60 mg.

Amphetamines were prescribed less often. And one patient reported a complete response to treatment with 200 mg of caffeine per day.

Forty-two percent of patients tried more than one medication. Eight percent were being treated with a combination of medications at their last visit.

Read more about hypersomnia. Learn more about idiopathic hypersomnia with long sleep time and idiopathic hypersomnia without long sleep time on SleepEducation.com.

Get help for hypersomnia at an AASM-accredited sleep center near you.

Sleep Deprivation: A Memory-Enhancing Drug?

Researchers report that they have identified the molecular mechanism by which sleep deprivation causes memory problems. They also suggest that drug treatment may be able to prevent the cognitive effects of sleep deprivation.

Their letter was published today in the journal Nature.

“Millions of people around the world suffer from a lack of sleep,” study co-author George S. Baillie said in a University of Glasgow news release. “This research opens the door for effective treatment of the memory loss associated with this debilitating condition."

The research team studied mice that had been deprived of sleep for five hours, reports NatureNews. They detected increased levels and activity of the “PDE4” enzyme in sleepy mice.

Then they treated sleep-deprived mice with the drug rolipram. It is a PDE4 inhibitor. The treatment prevented memory deficits that normally would have appeared after sleep deprivation.

Study co-author Christopher G. Vecsey cautioned that drugs like rolipram do have side effects. He also said that the study targets only one of the negative effects that sleep deprivation can have on the brain.

Study co-author Miles D. Houslay noted that sleep deprivation has many causes.

“People suffer sleep loss not only from disease but also jet lag, looking after young babies, getting old and through types of lifestyle,” he said. “This discovery offers hope for a simple and effective treatment.”

But sleep specialist Dr. Neil Stanley expressed concerns about the potential treatment. He worries that some people may take a drug for sleep loss when lifestyle changes would be a better solution.

“We really need to be thinking about ways to achieve adequate sleep in the first place - not how to deal with the consequences," Stanley told BBC News.

"We are always going to need drugs for people with serious disorders,” Stanley added. “But we don't want to end up medicalising lifestyles. We need to go back to basics and think about the way we as a society lead our lives, and the impact this has on our sleep, rather than looking for a cure."

In March the Sleep Education Blog reported on concerns that many healthy people are taking some medications as “smart drugs.” Learn more about sleep deprivation, and sleep and memory.

Michael Jackson’s Death & Prescription Drug Abuse

Soon after Michael Jackson’s death questions arose about his possible abuse of prescription drugs. Five days later those questions remain. Investigators recently took more medications from the rented house where Jackson collapsed.

The controversy has focused attention on the nationwide problem of prescription drug abuse. The risk of addiction extends far beyond the rich and famous.

The National Institute on Drug Abuse reports that millions of people in the U.S. abuse prescription drugs each year. The NIDA estimates that 48 million people have abused or misused prescription drugs in their lifetime.

Which drugs are most likely to be abused? The NIDA warns that three classes of drugs carry the greatest risk.

Opioids are commonly abused. These drugs are used to treat pain. Examples include morphine, codeine, OxyContin, Vicodin and Demerol.

Stimulants also may be abused. These drugs are used for problems such as narcolepsy. Examples include dextroamphetamine and methylphenidate.

Central nervous system depressants also are commonly abused. This class of drugs includes barbiturates such as Nembutal. It also includes benzodiazepines such as Valium and Xanax.

Some benzodiazepines are used to treat insomnia. Examples include Dalmane, Doral, Halcion, Prosom and Restoril.

But newer “nonbenzodiazepines” have a lower risk of addiction. Examples include Ambien, Lunesta and Sonata.

Another low-risk sleep aid is ramelteon. It is marketed as Rozerem. This drug is a melatonin receptor agonist. It targets the part of the brain that regulates the sleep-wake cycle.

The AASM offers these Guidelines for Taking Sleep Medications. Contact your doctor or pharmacist if you have any other questions about taking sleeping pills. You also should ask your doctor about cognitive behavioral therapy for insomnia. It is a safe and effective treatment option.

The NIDA reports that drug addiction is a brain disease that can be treated effectively. Treatments include detoxification, counseling and drug therapy.

To get help call 1-800-662-HELP or go online to http://findtreatment.samhsa.gov/.

Learn more about prescription drug abuse on SleepEducation.com.

Image by LainerJeanTater

Taming Violent Dreams: Treating REM Sleep Behavior Disorder

A new study in the Journal of Clinical Sleep Medicine reports that there are effective treatment options for people with REM sleep behavior disorder.

People who have RBD act out vivid, action-packed dreams while remaining asleep. Injuries to the dreamer or a bed partner are common.

RBD often is treated with clonazepam, a long-acting sedative. But the study reports that some side effects of this drug may be more prominent in older adults. Since RBD usually emerges after the age of 50 years, treatment can be problematic.

The small study involved a review of 39 people with confirmed RBD who were treated at a sleep center in the U.K.; 38 of the patients were men. They had an average age of 66 years; the youngest patient was 34 years old.

Thirty-six of the patients began treatment with clonazepam. Fifty-four percent took the medication successfully; but 58 percent reported moderate or severe side effects. The most common side effects were morning grogginess, confusion and cognitive impairment.

Zopiclone, a shorter-acting hypnotic, was used by 11 patients; nine used it alone, while two used it together with another medication. It was effective and well tolerated in eight of the 11 cases.

Two patients used melatonin; one used it while taking two other medications. Both people found it to be effective.

The authors conclude that it is important to consider the potential side effects when treating RBD in older adults. Shorter-acting hypnotics may be a useful treatment option.

Learn more about medications for sleep disorders on SleepEducation.com.

Contact an AASM-accredited sleep center if you or someone you know acts out dreams during sleep.

More Young Adults Using Sleeping Pills

The New York Times reports that the use of sleeping pills by young adults has risen dramatically. The biggest increase from 1998 to 2006 came among adults between the ages of 18 and 24.

The report is based on an analysis by Thomson Reuters. It examined drug claims by adults under the age of 45. Overall sleeping pill use was highest among adults between the ages of 35 and 44.

The most popular sleeping pills were Ambien CR and Lunesta. The drugs were prescribed for an average of 93 days.

AASM president Dr. Mary Susan Esther told the Times that chronic insomnia often is linked to other problems. These include depression and anxiety. In these cases a sleeping pill won’t address the related problem.

Insomnia also can be caused by disruptions to the sleeping environment. This is called environmental sleep disorder. Dr. Esther pointed out that a noisy dorm is a common sleep disrupter for college students.

The report did not examine the use of other treatments for insomnia. One of the most effective treatments is cognitive behavioral therapy. Following the tips of good sleep hygiene also helps some people with insomnia.

Like any other drug, sleeping pills may cause some side effects. These side effects can include sleepwalking, sleep eating and other complex sleep behaviors. Some people also may experience memory problems.

The AASM offers these Guidelines for Taking Sleep Medications. Contact your doctor or pharmacist if you have any other questions about taking sleeping pills.

How Much Does Insomnia Cost?

Insomnia is the most common sleep complaint. The burden of insomnia often includes anxiety and frustration. It also involves a high economic cost.

A study in the Jan. 1 issue of the journal Sleep examines the economic burden of insomnia. The study found that the indirect costs of untreated insomnia are much greater than the direct costs of treating it. The specific results may surprise you.

The study shows that the highest cost of insomnia is in lost hours of productivity at work. This accounts for 76 percent of all insomnia costs. The study estimates that a person with insomnia loses a whopping 27.6 days worth of productivity each year.

The second-highest cost of insomnia is attributed to absences from work. The study estimates that people with insomnia miss 4.36 days of work per year because of the disorder.

What about the direct costs of treating insomnia? Again the results are surprising. The study found that the highest direct cost is related to using alcohol as a sleep aid. Alcohol accounts for five percent of all insomnia costs.

(By the way: Alcohol is a terrible sleep aid. It may make you sleepy at first. But it will lead to disrupted sleep during the night.)

Consultations with a doctor account for about three percent of all insomnia costs. In the study less than one percent of the total annual cost of insomnia is related to prescription medications.

Here it is important to put the results in context. The study was conducted in Quebec, Canada. The authors report that Quebec’s centralized health-care system keeps medical costs low. The study also states that most medications used for sleep in Canada are inexpensive generic drugs.

Yet it is clear that the overall economic impact of insomnia is great. So what do you think? Does insomnia cause you to underperform at work?