Daytime REM sleep in Parkinson's disease

Sleepiness in neurological disorders

Sleepiness is a frequent and underrecognized symptom in neurological disorders, that impacts functional outcomes and quality of life. Multiple and potentially additive factors might contribute to sleepiness in neurological disorders, including sleep quality alterations, circadian rhythm disorders, drugs, and sleep disorders including sleep apnea or central disorders of hypersomnolence. Physician awareness of the possible symptoms of hypersomnolence, and associated causes is of crucial importance to allow proper identification and treatment of underlying causes. This review first provides a brief overview on clinical aspects of excessive daytime sleepiness, and diagnosis tools, then examines its frequency and mechanisms in various neurological disorders, including neurodegenerative disorders, multiple sclerosis, autoimmune encephalitis, epilepsy, and stroke.

Sleep and wakefulness disturbances in Parkinson's disease: A meta-analysis on prevalence and clinical aspects of REM sleep behavior disorder, excessive daytime sleepiness and insomnia

Sleep disorders (SDs) are common non-motor symptoms of Parkinson's disease (PD) with wide variability in their prevalence rates. The etiology of SDs in PD is multifactorial because the degenerative processes underlying the disease and their interaction with drugs and clinical features may promote REM sleep behavior disorder (RBD), excessive daytime sleepiness (EDS) and insomnia. Therefore, we designed a meta-analytic study to provide a reliable estimate of the prevalence and associated clinical and neuropsychiatric aspects of SDs in PD. A systematic literature search was performed up to February 2022. Pooled RBD prevalence was 46%, and its occurrence was associated with older age, lower education, longer disease duration, higher levodopa equivalent daily dose (LEDD), worse motor and autonomic manifestations, poorer quality of life and autonomy, and more severe neuropsychiatric symptoms. The pooled prevalence of EDS was 35% and was associated with older age, longer disease duration, worse motor and autonomic symptoms, higher LEDD, reduced autonomy, and more severe neuropsychiatric symptoms. Insomnia was reported in 44% of PD patients and was related to longer disease duration, higher LEDD, and more severe depression. SDs are associated with a more severe PD clinical phenotype; further studies should explore the pathophysiological mechanisms underlying SDs and develop targeted therapeutic strategies.

Behavioral validation of the University of Michigan REM behavior disorder questionnaire in the synucleinopathies

Many questionnaires have been proposed to collect data related to dream enactment. These are typically validated by reference to objective measurements of polysomnography, which incorporate physiologic recording of muscle activity during sleep. Another approach to such questionnaire validation would be the direct behavioral observations of patients' sleep. In the course of an ongoing study, we examined the association between sleep technologists' observations of dream enactment on two consecutive sleep laboratory nights and patients' and bedpartners' responses on the University of Michigan REM Behavior Disorder Questionnaire (UMRBDQ). Results suggested good correspondence between laboratory-based observations and questionnaire responses that did not appear to be impacted by whether the patient or the bedpartner completed the questionnaire. These results suggest utility of the UMRBDQ to identify individuals who have dream enactment during sleep.

[Speech and behavioral contaminations as non-epileptic automatic behavior in Parkinson's disease]

Parkinson's disease is characterized by a variety of motor and non-motor symptoms. More than two hundred years have passed since its description, but we still discover its new manifestations. Abnormal behaviors include impulse control disorders, dopamine dysregulation syndrome, psychotic disorders and others. However, two new phenomena have been recently described in patients with PD. It can manifest in the form of doing inappropriate actions which patient doesn't recognize, or pronouncing/writing unsuitable words and phrases. Patients can't remember such episodes, but find «signs» of their unconscious activity or hear about it from attestors. This article represents a review of literature on unrelated communication interlude and automatic behavior in Parkinson's disease and discusses its possible reasons.

Orexin and Parkinson's disease: A protective neuropeptide with therapeutic potential

Parkinson's disease (PD) is the second most common neurodegenerative disease caused by the progressive loss of dopaminergic neurons in the substantia nigra pars compacta. PD is characterized by motor dysfunctions as well as non-motor disorders. Orexin (also known as hypocretin) is a kind of neuropeptide involved in the regulation of motor control, the sleep/wake cycle, learning and memory, gastric motility and respiratory function. Several lines of evidence suggest that the orexinergic system is involved in the manifestations of PD, especially the non-motor disorders. Recent studies have revealed the protective actions and potential therapeutic applications of orexin in both cellular and animal models of PD. Here we present a brief overview of the involvement of the orexinergic system in PD, including the pathological changes in the lateral hypothalamus, the loss of orexinergic neurons and the fluctuation of orexin levels in CSF. Furthermore, we also review the neuroprotective effects of orexin in cellular and animal models of PD.

Cortical Phase-Amplitude Coupling in a Progressive Model of Parkinsonism in Nonhuman Primates

Parkinson's disease is associated with abnormal oscillatory electrical activities of neurons and neuronal ensembles throughout the basal ganglia-thalamocortical network. It has recently been documented in patients with advanced parkinsonism that the amplitude of gamma-band oscillations (50-200 Hz) in electrocorticogram recordings from the primary motor cortex is abnormally coupled to the phase of beta band oscillations within the same signals. It is not known when in the course of the disease the abnormal phase-amplitude coupling (PAC) arises, and whether it is influenced by arousal or prior exposure to dopaminergic medications. To address these issues, we analyzed the relationship between the severity of parkinsonian motor signs and the extent of PAC in a progressive model of parkinsonism, using primates that were not exposed to levodopa prior to testing. PAC was measured in electrocorticogram signals from the primary motor cortex and the supplementary motor area in 3 monkeys that underwent weekly injections of small doses of the neurotoxin 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine, rendering them progressively parkinsonian. We found that parkinsonism was associated with increased coupling between the phase of low-frequency (4-10 Hz) oscillations and the amplitude of oscillations in the high gamma band (50-150 Hz). These changes only reached significance when the animals became fully parkinsonian. The increased PAC was normalized after levodopa treatment. We also found a similar increase in PAC during sleep, even in normal animals. The identified PAC was independent of concomitant changes in spectral power in the 2.9-9.8Hz or 49.8-150.4 Hz ranges. We conclude that PAC is predominately a sign of advanced parkinsonism, and is, thus, not essential for the development of parkinsonism. However, increased PAC appears to correlate with the severity of fully developed parkinsonism.

REM sleep behavior disorder in narcolepsy: A secondary form or an intrinsic feature?

Disrupted nighttime sleep is one of the pentad of symptoms defining Narcolepsy. REM sleep behavior disorder (RBD) largely contributes to night sleep disruption and narcolepsy is the most common cause of secondary RBD. However, RBD linked to narcolepsy (N-RBD) has been insufficiently characterized, leaving unsolved a number of issues. Indeed, it is still debated whether N-RBD is an intrinsic feature of narcolepsy, as indubitable for cataplexy, and therefore strictly linked to the cerebrospinal fluid hypocretin-1 (CSF hcrt-1) deficiency, or an associated feature, with a still unclear pathophysiology. The current review aims at rendering a comprehensive state-of-the-art of N-RBD, highlighting the open and unsettled topics. RBD reportedly affects 30-60% of patients with Narcolepsy type 1 (NT1), but it may be seen also in Narcolepsy type 2 (NT2). When compared to idiopathic/isolated RBD (iRBD), N-RBD has been reported to be characterized by less energetic and quieter episode, which however occur with the same probability in the first and the second part of the night and sometime even subcontinuously. N-RBD patients are generally younger than those with iRBD. N-RBD has been putatively linked to wake-sleep instability due to CSF hcrt-1 deficiency, but this latter by itself cannot explain completely the phenomenon as N-RBD has not been universally linked to low CSF hcrt-1 levels and it may be observed also in NT2. Therefore, other factors may probably play a role and further studies are needed to clarify this issue. In addition, therapeutic options have been poorly investigated.

Excessive Daytime Sleepiness in Parkinson's Disease: Clinical Implications and Management

Objective

Excessive daytime sleepiness (EDS) is one of the most common sleep abnormalities in patients with Parkinson's disease (PD), yet its multifactorial etiology complicates its treatment. This review summarized recent studies on the epidemiology, etiology, clinical implications, associated features, and evaluation of EDS in PD. The efficacy of pharmacologic and non-pharmacologic treatments for EDS in PD was also reviewed.

Data Sources

English language articles indexed in PubMed and Cochrane databases and Chinese-language papers indexed in Wanfang and National Knowledge Infrastructure databases that were published between January 1987 and November 2017 were located using the following search terms: "sleepiness", "sleep and Parkinson's disease", and "Parkinson's disease and treatment".

Study Selection

Original research articles and critical reviews related to EDS in PD were selected.

Results

EDS is a major health hazard and is associated with many motor and nonmotor symptoms of PD. Its causes are multifactorial. There are few specific guidelines for the treatment of EDS in PD. It is first necessary to identify and treat any possible factors causing EDS. Recent studies showed that some nonpharmacologic (i.e., cognitive behavioral therapy, light therapy, and repetitive transcranial magnetic stimulation) and pharmacologic (i.e., modafinil, methylphenidate, caffeine, istradefylline, sodium oxybate, and atomoxetine) treatments may be effective in treating EDS in PD.

Conclusions

EDS is common in the PD population and can have an immensely negative impact on quality of life. Its causes are multifactorial, which complicates its treatment. Further investigations are required to determine the safety and efficacy of potential therapies and to develop novel treatment approaches for EDS in PD.

Disturbances of Sleep and Alertness in Parkinson's Disease

PURPOSE OF REVIEW

Parkinson's disease (PD) is the second most common neurodegenerative disorder. Sleep dysfunction is one of the most common non-motor manifestations of PD that has gained significant interest over the past two decades due to its impact on the daily lives of PD patients, poorly understood mechanisms, and limited treatment options. In this review, we discuss the most common sleep disorders in PD and present recent investigations that have broadened our understanding of the epidemiology, clinical manifestations, diagnosis, and treatment of disturbed sleep and alertness in PD.

RESENT FINDINGS

The etiology of impaired sleep-wake cycles in PD is multifactorial. Sleep dysfunction in PD encompasses insomnia, REM sleep behavior disorder, sleep-disordered breathing, restless legs syndrome, and circadian dysregulation. Despite the high prevalence of sleep dysfunction in PD, evidence supporting the efficacy of treatment strategies is limited. We are at the opportune time to advance our understanding of sleep dysfunction in PD, which will hopefully lead to mechanisms-driven interventions for better sleep and allow us to approach sleep as a modifiable therapeutic target for other non-motor and motor manifestations in PD.

A systematic review of the literature on disorders of sleep and wakefulness in Parkinson's disease from 2005 to 2015

Sleep disorders are among the most common non-motor manifestations in Parkinson's disease (PD) and have a significant negative impact on quality of life. While sleep disorders in PD share most characteristics with those that occur in the general population, there are several considerations specific to this patient population regarding diagnosis, management, and implications. The available research on these disorders is expanding rapidly, but many questions remain unanswered. We thus conducted a systematic review of the literature published from 2005 to 2015 on the following disorders of sleep and wakefulness in PD: REM sleep behavior disorder, insomnia, nocturia, restless legs syndrome and periodic limb movements, sleep disordered breathing, excessive daytime sleepiness, and circadian rhythm disorders. We discuss the epidemiology, etiology, clinical implications, associated features, evaluation measures, and management of these disorders. The influence on sleep of medications used in the treatment of motor and non-motor symptoms of PD is detailed. Additionally, we suggest areas in need of further research.

Nonmotor Subtyping in Parkinson's Disease

Nonmotor symptoms are integral to Parkinson's disease. Several subtypes dominated by specific nonmotor symptoms have emerged. In this chapter, the rationale behind nonmotor subtyping and currently proposed nonmotor subgroups within Parkinson's disease based on data-driven cluster analysis and clinical observations will be summarized. Furthermore, the concept of seven clinical nonmotor subtypes will be discussed in detail including the clinical presentation, potential biomarkers, and the clinical relevance. In future, nonmotor subtypes will possibly play a major role within the aim to achieve personalized medicine.

Hypersomnia in Neurodegenerative Diseases

Hypersomnia is a common complaint in many patients with neurodegenerative diseases and a major cause of decreased quality of life. This article discusses the prevalence and factors associated with hypersomnia in patients with a variety of neurodegenerative diseases affecting the central nervous system, including tauopathies, synucleinopathies, and other conditions. Common nocturnal sleep problems that may result in daytime hypersomnia are delineated. A clinical approach to hypersomnia in patients with neurodegenerative diseases, recommended diagnostic testing, and available treatment options are also discussed.

EuroInf: a multicenter comparative observational study of apomorphine and levodopa infusion in Parkinson's disease

Subcutaneous apomorphine infusion (Apo) and intrajejunal levodopa infusion (IJLI) are two treatment options for patients with advanced Parkinson's disease (PD) and refractory motor complications, with varying cost of treatment. There are no multicenter studies comparing the effects of the two strategies. This open-label, prospective, observational, 6-month, multicenter study compared 43 patients on Apo (48.8% males, age 62.3 ± 10.6 years; disease duration: 14 ± 4.4 years; median H & Y stage 3; interquartile range [IQR]: 3-4) and 44 on IJLI (56.8% males, age 62.7 ± 9.1 years; disease duration: 16.1 ± 6.7 years; median H & Y stage 4; IQR, 3-4). Cohen's effect sizes (≥0.8 considered as large) were "large" with both therapies with respect to total motor, nonmotor, and quality-of-life scores. The Non-Motor Symptoms Scale (NMSS) with Apo showed moderate improvement, whereas sleep/fatigue, gastrointestinal, urinary, and sexual dimensions of the NMSS showed significantly higher improvement with IJLI. Seventy-five percent on IJLI improved in their quality-of-life and nonmotor symptoms (NMS), whereas in the Apo group, a similar proportion improved in quality of life, but 40% in NMS. Adverse effects included peritonitis with IJLI and skin nodules on Apo. Based on this open-label, nonrandomized, comparative study, we report that, in advanced Parkinson's patients, both IJLI and Apo infusion therapy appear to provide a robust improvement in motor symptoms, motor complications, quality-of-life, and some NMS. Controlled, randomized studies are required.