Sleep and parkinsonism

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By Stefano Zanigni MD PhD and Federica Provini MD PhD

The significant impact of Parkinson disease on sleep was clearly noted in James Parkinson’s remarkable description of the illness in his 1817 monograph, “An Essay on the Shaking Palsy.” He correctly noted that the motoric symptoms of Parkinson disease, such as severe nocturnal emergent tremor or nocturnal immobility, have great potential to interrupt sleep. Today, we are aware that the sleep-Parkinson disease interaction takes many other forms, including the effect of Parkinson drugs or Parkinson-associated behavioral symptoms (depression and psychosis) on sleep, and the (mostly beneficial) effect of sleep on the symptoms of the disease. The authors highlight the common sleep disorders found in Parkinson disease, looking at both the potential etiologies and treatment options. One of the most striking sleep problems in Parkinson disease is excessive daytime sleepiness, which is in part due to medication side effects, but also highly correlated with age and duration of disease. We have also learned that many sleep disorders that are moderately common in the general population, such as restless legs syndrome and REM sleep behavior disorder, are even more prevalent among Parkinson patients, the latter condition sometimes antedating clinical Parkinson disease by years. Finally, this update discusses the role of circadian disruption in the development of Parkinson disease, an exciting new area of research and potential intervention.

Key points

  • REM sleep behavior disorder is one of the most common sleep disorders associated with Parkinson disease and often antedates the motoric features of Parkinson disease by years.
  • Daytime sleepiness and fatigue are common complaints in Parkinson disease patients, especially in the elderly and in men.
  • Circadian dysfunction is an important emerging component of sleep dysfunction in Parkinson disease, with recent demonstration of changes in melatonin release patterns and potential benefits seen from timed bright light exposure.
  • The common notion that parkinsonian tremor disappears entirely during sleep is not completely true as tremor can re-emerge, sometimes significantly, during sleep arousals.
  • Bedtime dosages of dopaminergic medications, especially long-acting preparations, are very useful to combat nocturnal re-emergent parkinsonian symptoms, such as high-amplitude tremor or severe akinesia, while in bed, which can significantly disrupt sleep.

In This Article

Historical note and nomenclature
Clinical manifestations
Clinical vignette
Pathogenesis and pathophysiology
Differential diagnosis
Diagnostic workup
Prognosis and complications
References cited