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Sleep disturbances in patients with parkinsonism

Abstract

Altered sleep and vigilance are among the most frequent symptoms, besides parkinsonism, in movement disorders. As many as 60% of patients with Parkinson's disease (PD) experience insomnia, 15–59% show rapid eye movement (REM) sleep behavior disorders (RBDs), and 30% show excessive daytime sleepiness. Insomnia is a distressing difficulty to maintain sleep, which is exacerbated by motor disability, painful dystonia, restless legs, dysuria, anxiety and depressed mood. Improving night-time motor control by overnight treatment with levodopa, transdermal or long-acting dopamine agonists, or bilateral subthalamus stimulation, can improve sleep continuity. RBDs are violent, enacted dreams that expose the patient or their sleeping partner to night-time injuries. A striking improvement of parkinsonism is observed during these behaviors in PD. RBDs are thought to be caused by lesions in the REM sleep atonia system, and can, in association with other early markers of neurodegenerative diseases, such as olfactory, cognitive and autonomic disturbances, precede parkinsonism by several years. Daytime sleepiness, often with a narcolepsy-like phenotype, is a common occurrence in PD, owing to lesions in the arousal systems of the brain. The use of dopamine agonists increases the risk of sleep attacks, especially when driving, suggesting a drug–disease interaction.

Key Points

  • As many as 60% of patients with Parkinson's disease (PD) experience insomnia, 15–60% exhibit rapid eye movement (REM) sleep behavior disorders (RBDs), and 30% show excessive daytime sleepiness

  • Insomnia in PD is a distressing symptom that can be improved by better control of night-time disability, restless legs syndrome and dystonia

  • RBDs are characterized by violent enacted dreams; this condition might act as a harbinger of parkinsonism several years before disease onset

  • A striking disappearance of parkinsonism is observed during RBD in PD, suggesting a restoration of motor control during sleep

  • In patients with PD, daytime sleepiness can culminate in sleep attacks that can impair driving ability; a narcolepsy-like phenotype is observed in one-third of patients

  • Sleepiness is caused by a disease–drug interaction, with specific lesions in arousal (noradrenergic, serotonergic and orexinergic) systems; dopamine agonists expose patients to a twofold increase in the frequency of sleep attacks

  • Stridor is the main nocturnal complication in multiple system atrophy, and patients with this condition can benefit from continuous positive airway pressure

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Figure 1: Sleep histograms from patients with parkinsonism.
Figure 2: Rapid eye movement sleep behavior disorder.
Figure 3: Brain pathology in rapid eye movement sleep behavior disorders.
Figure 4: Key components of the ascending arousal systems in the human brain.

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Acknowledgements

The sleep studies performed by the authors in patients with parkinsonism were in part financed by grants from Inserm, Fondation Lilly, Fédération pour la Recherche sur le Cerveau, and France-Parkinson.

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Correspondence to Isabelle Arnulf.

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Supplementary Movie 1

Rapid eye movement sleep behavior disorder. Example of abnormal, violent behavior during rapid eye movement (REM) sleep behavior disorder in a 68-year-old man with advanced Parkinson's disease. The patient dreams that he is arguing and fighting with a stranger. He has imperfect muscle atonia during REM sleep and is therefore able to move, but he does not stand up. Note that his movements are extremely fast and coordinated, and his face is expressive with no evidence of parkinsonism, despite the fact that he has been weaned from levodopa for 12 hours. (MPG 8329 kb)

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De Cock, V., Vidailhet, M. & Arnulf, I. Sleep disturbances in patients with parkinsonism. Nat Rev Neurol 4, 254–266 (2008). https://doi.org/10.1038/ncpneuro0775

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