Evaluation of cutoff scores for the Parkinson's disease sleep scale-2

Sex differences in Parkinson's disease-related non motor symptoms: a focus on sleep problems

Parkinson's disease (PD) symptomatology differs between females and males, yet the contribution of sex on sleep problems needs further analysis. Here, we aimed to investigate sex-specific patterns in the relationship between sleep problems, assessed using the Parkinson's disease sleep scale (PDSS-2), non motor symptoms (NMS), measured by the NMS scale (NMSS), and health-related quality of life (HR-QoL), evaluated by the Parkinson's disease questionnaire (PDQ-39), in a large cohort of PD patients. One-hundred-fifty-four PD patients were included in the study. Female PD patients (n = 62) exhibited a higher prevalence of sleep problems than males (n = 92), with nocturnal motor-related sleep issues being the most frequent. Sleep disturbances differently correlated with a range of NMS between the two sexes. In females, sleep problems mostly correlated with pain; on the other hand, sleep disturbances were linked to a frailer phenotype characterized by global dysautonomia, perception disturbances, and impaired cognitive function in males. Whether female PD patients experienced a lower HR-QoL than males, sleep disturbances were associated with a worse HR-QoL in both sexes. In conclusion, sleep problems in PD differently burden the two sexes, suggesting possible different etiopathogenesis, diagnostic investigations, and possibly tailored approaches.

The Effect of Different Types of Exercise on Sleep Quality and Architecture in Parkinson Disease: A Single-Blinded Randomized Clinical Trial Protocol

OBJECTIVES

The purpose of this trial is to (1) determine the best exercise modality to improve sleep quality and sleep architecture in people with Parkinson disease (PD); (2) investigate whether exercise-induced improvements in sleep mediate enhancements in motor and cognitive function as well as other non-motor symptoms of PD; and (3) explore if changes in systemic inflammation after exercise mediate improvements in sleep.

METHODS

This is a multi-site, superiority, single-blinded randomized controlled trial. One hundred fifty persons with PD and sleep problems will be recruited and randomly allocated into 4 intervention arms. Participants will be allocated into 12 weeks of either cardiovascular training, resistance training, multimodal training, or a waiting list control intervention. Assessments will be conducted at baseline, immediately after each intervention, and 8 weeks after each intervention by blinded assessors. Objective sleep quality and sleep architecture will be measured with polysomnography and electroencephalography. Motor and cognitive function will be assessed with the Unified PD Rating Scale and the Scale for Outcomes in PD-Cognition, respectively. Subjective sleep quality, fatigue, psychosocial functioning, and quality of life will be assessed with questionnaires. The concentration of inflammatory biomarkers in blood serum will be assessed with enzyme-linked immunosorbent assays.

IMPACT

This study will investigate the effect of different types of exercise on sleep quality and architecture in PD, exploring interactions between changes in sleep quality and architecture with motor and cognitive function and other non-motor symptoms of the disease as well as mechanistic interactions between systemic inflammation and sleep. The results will provide important practical information to guide physical therapists and other rehabilitation professionals in the selection of exercise and the design of more personalized exercise-based treatments aimed at optimizing sleep, motor, and cognitive function in people with PD.

Non-Motor Symptom Management: Insights into Adherence to Treatment Guidelines in Parkinson's Disease Patients

Background

Non-motor symptoms (NMS) reduce quality of life in Parkinson's disease (PD) patients, who experience three times more NMS than individuals without PD. While there are international and national NMS treatment guidelines, their implication in clinical practice remains unclear.

Objective

This study aimed to investigate the adherence to pharmacological NMS treatment guidelines in patients with mild to moderately severe PD.

Methods

220 PD patients with ≥1 NMS based on the Non-Motor Symptom Questionnaire and a Hoehn and Yahr stage ≤4 were randomly selected from the Swedish Parkinson registry and screened for inclusion. NMS were evaluated using the International Parkinson and Movement Disorder Society-Non-Motor Rating Scale (MDS-NMS), Parkinson's Disease Sleep Scale 2, Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. Treatment was compared with Swedish national guidelines and international guidelines from the MDS Evidence-Based Medicine Committee.

Results

Among 165 included patients, the median number of NMS was 14, and in median 7 symptoms were estimated to require treatment. The most common NMS requiring treatment were pain (69%) and urinary problems (56%). Treatment of depression and constipation demonstrated the highest adherence to guidelines (79% and 77%), while dysphagia and excessive daytime sleepiness exhibited the lowest adherence (0% and 4%). On average, only 32% of NMS were treated in accordance with guidelines.

Conclusions

Adherence to pharmacological guidelines for NMS in patients with mild to severe PD was low. This study highlights the need for improved evaluation and treatment of NMS to enhance symptom management and quality of life among PD patients.

Relationship Between Sleep Quality and Constipation Severity in Patients With Parkinson Disease: A Cross-sectional Study

ABSTRACT

BACKGROUND: Constipation in patients with Parkinson disease (PD) adversely affects motor symptoms, making defecation management critical. Sleep disturbance is another common complaint in patients with PD (PWP). Associations between sleep disturbances and constipation have been reported in recent studies on PD. If improving sleep quality is useful for managing constipation in PWP, it might serve as a new method of constipation management that is less physically and mentally distressing than laxatives. This study aimed to examine the relationship between sleep quality and constipation severity in PWP. METHODS: We administered a questionnaire on sleep and constipation to 1048 PWP. Constipation severity was assessed using Constipation Assessment Scale Japanese version 2 (CAS). General sleep quality was estimated using the Japanese versions of the Pittsburgh Sleep Quality Index (PSQI) and Athens Insomnia Scale. Sleep quality due to PD-specific nighttime problems was estimated using the Parkinson's Disease Sleep Scale-2 Japanese version (PDSS-2). We conducted a multiple regression analysis using the forced entry method to identify the variables that influenced CAS. RESULTS: We analyzed 350 PWP. Overall, 94.9% of PWP had constipation symptoms. The percentages of PWP with poor sleep were as follows: PSQI, 74.7%; Athens Insomnia Scale, 69.8%; and PDSS-2, 73.8%. Furthermore, 17.6% of the patients with constipation and 35.3% with sleep problems did not consult a healthcare provider. Multivariate analysis revealed that CAS was significantly associated only with PDSS-2 (standardized partial regression coefficient, 0.217; 95% confidence interval, 0.030-0.111). CONCLUSION: Poor sleep quality, related to PD-specific nighttime problems, was found be associated with worsening constipation severity. Nursing activities that help PWP with PD-specific nighttime problems have a more comfortable night's sleep would be key to alleviating constipation severity.

Factors contributing to sleep disturbances and excessive daytime sleepiness in patients with Parkinson's disease

Background

Sleep disturbances and excessive daytime sleepiness (EDS) are common non-motor symptoms in patients with Parkinson's disease (PD). The purpose of this study was to identify the contributors to sleep disturbances, including insomnia, restless legs syndrome, rapid eye movement sleep behavior disorder (RBD), sleep-disordered breathing, nocturnal akinesia and EDS, in patients with PD.

Methods

We conducted a cross-sectional study including 128 consecutive Japanese patients with PD. Sleep disturbances and EDS were defined as a PD Sleep Scale-2 (PDSS-2) total score ≥15 and an Epworth Sleepiness Scale (ESS) score >10, respectively. The patients were divided into four groups according to the presence or absence of sleep disturbances and EDS. We evaluated the disease severity, motor symptoms, cognition, olfactory test, the Scales for Outcomes in PD-Autonomic dysfunction (SCOPA-AUT), the Beck Depression Inventory-II (BDI-II), and the RBD Screening Questionnaire Japanese version (RBDSQ-J).

Results

Of 128 patients, 64 had neither EDS nor sleep disturbances, 29 had sleep disturbances without EDS, 14 had EDS without sleep disturbances, and 21 had both EDS and sleep disturbances. Patients with sleep disturbances had higher BDI-II scores than those without sleep disturbances. Probable RBD was more frequent in patients with both sleep disturbances and EDS than in those with neither EDS nor sleep disturbances. The SCOPA-AUT score was lower in patients with neither EDS nor sleep disturbances than in patients in the other three groups. Using multivariable logistic regression analysis with neither sleep disturbances nor EDS as a reference group, that the SCOPA-AUT score was an independent contributor to sleep disturbances (adjusted OR, 1.192; 95% CI, 1.065-1.333; P = 0.002) or EDS (OR, 1.245; 95% CI, 1.087-1.424; P = 0.001) and that the BDI-II (OR, 1.121; 95% CI, 1.021-1.230; P = 0.016) and RBDSQ-J scores (OR, 1.235; 95% CI, 1.007-1.516; P = 0.043) as well as the SCOPA-AUT score (OR, 1.137; 95% CI, 1.006-1.285; P = 0.040) were independent contributors to both sleep disturbances and EDS.

Conclusions

Autonomic symptoms were associated with patients with sleep disturbances or EDS, and depressive and RBD symptoms in addition to autonomic symptoms were associated with patients with both sleep disturbances and EDS.

Evaluation of Nocturnal Symptoms in Chinese Parkinson's Disease Patients Based on the PDSS-2 Scale: A Multicenter Cross-Sectional Study

BACKGROUND

Nocturnal symptoms have a significant effect on the quality of life in Parkinson's disease (PD) patients.

OBJECTIVE

This study aimed to investigate the prevalence and associated factors of nocturnal symptoms in Chinese PD patients.

METHODS

This multicenter cross-sectional study included 1,500 patients with primary PD from 18 centers in China was carried out between February 2019 and February 2020. Questionnaires including Parkinson's disease sleep scale 2 (PDSS-2), Parkinson's disease questionnaire 8 (PDQ-8), Beck depression inventory (BDI), and generalized anxiety disorder scale 7 (GAD-7) were used to assess nocturnal symptoms, quality of life, depression, and anxiety.

RESULTS

Among 1,500 Chinese PD patients, 576 (38.4%) reported nocturnal symptoms. Of them, 59.2% were older than 65 years. The PDQ-8 total score was higher in patients with nocturnal symptoms (p < 0.01). Moderate and severe depression was reported more often in patients with nocturnal symptoms (p < 0.01), and the occurrence and severity of anxiety were higher as well (p < 0.01). Longer disease duration and higher Hoehn-Yahr (HY) stage were independently associated with nocturnal symptoms (p < 0.01). Education level, depression, disease course, HY stage, and nocturnal symptoms were related to the quality of life in Chinese PD patients (p < 0.01).

CONCLUSION

Our study found that 38.4% of Chinese PD patients have nocturnal symptoms, even in early and mid-stage PD. Nocturnal symptoms were associated with worse quality of life and higher incidences of depression and anxiety. Nocturnal symptoms should be included in the assessment and care plan, especially in patients with longer disease courses and higher HY stages.

The Effect of Rotigotine on Cognitive Function, Daytime Sleepiness, and Sleep Problems in Parkinson Disease: An Open-Label Pilot Study

BACKGROUND

We hypothesized that rotigotine may have a positive effect on cognitive function in patients with Parkinson disease (PD) by improving daytime motor function and sleep status.

METHODS

Fifteen PD patients with sleep disturbances, defined as a PD Sleep Scale (PDSS)-2 score of 15 or greater, were included in this single-center, 3-month open-label study. Participants received 2 to 4 mg/24 h (patch content: 4.5-9 mg) rotigotine for a 3-month period. At baseline and 3 months, the patients were evaluated on the Movement Disorder Society Revision of the Unified PD Rating Scale (MDS-UPDRS) parts III and IV and cognitive assessments, such as the Mini-Mental State Examination, frontal assessment battery, and Montreal Cognitive Assessment (MoCA). The Epworth Sleepiness Scale (ESS) and PDSS-2 were administered at baseline and at 1, 2, and 3 months.

RESULTS

At 3 months, the MDS-UPDRS part III (-11.1, P < 0.0001) and MDS-UPDRS part IV (-1.1, P = 0.0013) scores significantly decreased, and off time significantly decreased (-34.6 minutes, P = 0.0085) from baseline. The PDSS-2 scores significantly decreased from baseline at 1 month (-4.2, P < 0.01), 2 months (-7.7, P < 0.0001), and 3 months (-7.3, P < 0.0001). The ESS also decreased at 1 month (-2.5, P < 0.05) and 3 months from baseline (-4.5, P < 0.01). The MoCA scores (1.6, P = 0.0029) significantly improved, but the Mini-Mental State Examination or frontal assessment battery scores did not significantly change. The mean changes from baseline to 3 months in the MoCA were negatively correlated with mean changes in the ESS scores.

CONCLUSIONS

We suggest that rotigotine could improve cognitive function by improving motor symptoms, sleep disturbance, and daytime sleepiness in patients with PD.

Diffusion Tensor Imaging Reveals Deep Brain Structure Changes in Early Parkinson's Disease Patients with Various Sleep Disorders

Parkinson’s disease (PD) is a progressive age-related movement disorder caused by dopaminergic neuron loss in the substantia nigra. Diffusion-based magnetic resonance imaging (MRI) studies—namely, diffusion tensor imaging (DTI)—have been performed in the context of PD, either with or without the involvement of sleep disorders (SDs), to deepen our understanding of cerebral microstructural alterations. Analyzing the clinical characteristics and neuroimaging features of SDs in early PD patients is beneficial for early diagnosis and timely invention. In our present study, we enrolled 36 early PD patients (31 patients with SDs and 5 patients without) and 22 healthy controls. Different types of SDs were assessed using the Rapid Eye Movement Sleep Behavior Disorder Questionnaire—Hong Kong, Epworth Sleepiness Scale, International Restless Legs Scale and PD Sleep Scale-2. Brain MRI examinations were carried out in all the participants, and a region-of-interest (ROI) analysis was used to determine the DTI-based fractional anisotropy (FA) values in the substantia nigra (SN), thalamus (Thal) and hypothalamus (HT). The results illustrate that SDs showed a higher prevalence in the early PD patients than in the healthy controls (86.11% vs. 27.27%). Early PD patients with nighttime problems (NPs) had longer courses of PD than those without (5.097 ± 2.925 vs. 2.200 ± 1.095; p < 0.05), and these patients with excessive daytime sleepiness (EDS) or restless legs syndrome (RLS) had more advanced Hoehn and Yahr stages (HY stage) than those without (1.522 ± 0.511 and 1.526 ± 0.513, respectively; both p < 0.05). Compared with the early PD patients without probable rapid eye movement sleep behavior disorder (pRBD), those with pRBD had longer courses, more advanced HY stages and worse motor and non-motor symptoms of PD (course(years), 3.385 ± 1.895 vs. 5.435 ± 3.160; HY stages, 1.462 ± 0.477 vs. 1.848 ± 0.553; UPDRS, 13.538 ± 7.333 vs. 21.783 ± 10.766; UPDRS, 6.538 ± 1.898 vs. 7.957 ± 2.345; all p < 0.05). In addition, the different number of SD types in early PD patients was significantly inversely associated with the severity of damage in the SN and HT. All of the early PD patients with various SDs had injuries in the SN, in whom the damage was more pronounced in patients with NP than those without. Moreover, early PD patients with NP, RLS or pRBD had worse degrees of HT damage than those without. The current study demonstrated the pathophysiological features and neuroimaging changes in early PD patients with various types of sleep disorders, which will help in early diagnosis and therapy.

Two-Channel Portable Biopotential Recording System Can Detect REM Sleep Behavioral Disorder: Validation Study with a Comparison of Polysomnography

Background

Sleep disorders are frequent nonmotor symptoms of Parkinson's disease (PD). Polysomnography (PSG) has been the gold standard for its assessment. However, it requires patients to stay overnight in a hospital or sleep center. The mobile two-channel electroencephalography (EEG)/electrooculography (EOG) recording system is a self-applicable and affordable method to objectively assess sleep at home. We aimed at evaluating patients with PD to confirm the difference in sleep parameters between the portable recording system and PSG.

Methods

PSG and the portable recording system were simultaneously performed on a similar night in eight patients with PD. We compared the difference in sleep parameters between them using nonparametric tests.

Results

All patients displayed a score of both PDSS −2 ≥ 15 and PSQI ≥ 5, respectively, which revealed poor sleep quality. There was no difference in the sleep parameters between the portable recording system and PSG, except for the percentage of sleep stage N3. Regarding the detection of REM sleep without atonia, we observed accordance between the portable recording system and PSG in six patients (P=0.686).

Conclusions

The portable EEG/EOG recording system may gain an advantage from home-based evaluations for habitual sleep at home. Our study on device validation may contribute to measuring natural sleep, including rapid eye movement (REM) sleep behavioral disorder (RBD), in an outpatient care setting.

Personalized Assessment of Insomnia and Sleep Quality in Patients with Parkinson's Disease

Sleep disturbances are more common in patients with Parkinson’s disease (PD) than in the general population and are considered one of the most troublesome symptoms by these patients. Insomnia represents one of the most common sleep disturbances in PD, and it correlates significantly with poor quality of life. There are several known causes of insomnia in the general population, but the complex manifestations that might be associated with PD may also induce insomnia and impact the quality of sleep. The treatment of insomnia and the strategies needed to improve sleep quality may therefore represent a challenge for the neurologist. A personalized approach to the PD patient with insomnia may help the clinician to identify the factors and comorbidities that should also be considered in order to establish a better individualized therapeutic plan. This review will focus on the main characteristics and correlations of insomnia, the most common risk factors, and the main subjective and objective methods indicated for the assessment of insomnia and sleep quality in order to offer a concise guide containing the main steps needed to approach the PD patient with chronic insomnia in a personalized manner.

Melatonin Treatment for Sleep Disorders in Parkinson's Disease: A Meta-Analysis and Systematic Review

Objective

The efficacy of melatonin on sleep disorders in Parkinson's disease (PD) is still unclear. The purpose of this study was to investigate the efficacy of melatonin on sleep disorders in PD by summarizing evidence from randomized clinical trials (RCTs).

Methods

PubMed, Cochrane Library, EMBASE, and Web of Science databases were searched for studies published before 20 August 2021. Results were analyzed using Review Manager 5.2 software. We used Trial Sequential Analysis (TSA) software to avoid false-positive results caused by random errors.

Results

We included 7 studies in this systematic review and meta-analysis. The results of the meta-analysis showed that compared with placebo, the subjective sleep quality of patients with PD significantly improved after melatonin treatment (MD = −2.19, 95% CI: −3.53 to −0.86, P = 0.001). In the systematic review, we qualitatively analyzed the efficacy of melatonin on the objective sleep quality of patients with PD, and the results showed that melatonin exerted a positive effect with good safety and tolerability. However, there was no significant improvement in excessive daytime sleepiness assessed by the Epworth Sleepiness Scale (ESS).

Conclusion

We found that melatonin can significantly improve the subjective and objective sleep quality of patients with PD with good safety and tolerability. Melatonin could be considered an effective treatment for insomnia in patients with PD.

Current Update on Clinically Relevant Sleep Issues in Parkinson's Disease: A Narrative Review

Sleep disturbances are among the common nonmotor symptoms in patients with Parkinson’s disease (PD). Sleep can be disrupted by nocturnal motor and nonmotor symptoms and other comorbid sleep disorders. Rapid eye movement sleep behavior disorder (RBD) causes sleep-related injury, has important clinical implications as a harbinger of PD and predicts a progressive clinical phenotype. Restless legs syndrome (RLS) and its related symptoms can impair sleep initiation. Excessive daytime sleepiness (EDS) is a refractory problem affecting patients’ daytime activities. In particular, during the COVID-19 era, special attention should be paid to monitoring sleep problems, as infection-prevention procedures for COVID-19 can affect patients’ motor symptoms, psychiatric symptoms and sleep. Therefore, screening for and managing sleep problems is important in clinical practice, and the maintenance of good sleep conditions may improve the quality of life of PD patients. This narrative review focused on the literature published in the past 10 years, providing a current update of various sleep disturbances in PD patients and their management, including RBD, RLS, EDS, sleep apnea and circadian abnormalities.

Association between sleep disorders and cognitive dysfunctions in non-demented patients with advanced Parkinson's disease

Background

Parkinson’s disease (PD) is increasingly recognized as a multidimensional disorder, characterized by several non-motor symptoms, including disturbances of sleep and cognition. Current studies on the relationship between sleep problems and neuropsychological functions, mainly conducted in early to moderate PD patients, outline mixed results. In this study, we analysed the relationship between subjectively reported sleep alterations and cognitive functions in a large cohort of 181 advanced PD patients.

Methods

All consecutive, non-demented, advanced PD patients candidates for device-aided therapy completed two self-administered sleep questionnaires—the Parkinson’s Disease Sleep Scale (PDSS-2) and the Epworth Sleepiness Scale (ESS)—and underwent a comprehensive battery of neuropsychological tests encompassing five cognitive domains (reasoning, memory, attention, frontal executive functions, and language).

Results

Patients showed mild to moderate sleep problems (PDSS-2 score: 23.4 ± 1.2) and mild daytime sleepiness (ESS 8.6 ± 5.1). A significant correlation was found between PDSS-2 total score and non-verbal reasoning, as well as attentive skills, executive functions, and language abilities. No correlations were found between sleep measures and memory tests scores. Patients with clinically relevant sleep disturbances performed worse on attention, executive functions, and language. No significant correlations were found between daytime sleepiness and any neuropsychological test.

Conclusions

In advanced PD patients, sleep disturbances selectively correlate with specific neuropsychological functions and not with short-term memory and consolidation. Even if confirmations by means of longitudinal studies are needed, our observations suggest the importance of considering treatment of sleep disturbances to minimize their potential impact on cognition.

Prevalence and profile of nocturnal disturbances in Chinese patients with advanced-stage Parkinson's disease: a cross-sectional epidemiology study

Background

The impact of nocturnal disturbance (ND) in Parkinson’s disease on quality of life of patients in Western Countries is increasingly understood. Our study aimed to investigate ND prevalence and its quality of life impact in patients with advanced Parkinson’s disease in China.

Methods

In a multicenter, tertiary-care hospital, outpatient-based, cross-sectional study, patients with advanced Parkinson’s disease (Modified Hoehn & Yahr [H&Y] Stage II–IV with ≥3 h awake “off” time/day) from 10 tertiary hospitals throughout China completed the Parkinson’s Disease Sleep Scale-2 (PDSS-2) and Parkinson’s Disease Questionnaire-39 (PDQ-39). The primary endpoint was the percentage of patients with significant ND (PDSS-2 total score ≥ 15). Additional endpoints were demographic and clinical characteristics, PDSS-2 and PDQ-39 total and subscale scores, correlation between PDSS-2 and PDQ-39, and risk factors for ND and higher PDSS-2 or PDQ-39 scores.

Results

Of 448 patients analyzed (mean age 63.5 years, 47.3% female), 70.92% (95% confidence interval: 66.71, 75.13) had significant ND. Presence of ND and higher PDSS-2 scores were associated with longer disease duration and higher H&Y stage. Presence of ND was also associated with more awake “off” time/day and female sex. PDQ-39 scores were significantly worse for patients with ND versus those without ND; worse scores were associated with more awake “off” time/day, female sex, and higher H&Y stage. PDSS-2 and PDQ-39 total scores were associated: Pearson correlation coefficient 0.62 (p < 0.001).

Conclusions

In China, ND was highly prevalent in patients with advanced Parkinson’s disease and adversely impacted quality of life. This study highlights the importance of early diagnosis and optimized management of ND in patients with Parkinson’s disease in China.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02217-5.

Multiple comorbid sleep disorders adversely affect quality of life in Parkinson's disease patients

Sleep disorders are common non-motor symptoms in patients with Parkinson’s disease (PD). The characteristics and impact of multiple comorbid sleep disorders remain to be elucidated. Our goal was to investigate the characteristics of various sleep disorder comorbidities, and their association with motor complications and the impact on the quality of life in PD patients. In this multicenter, observational, cross-sectional study, data concerning the clinical characteristics of complicated sleep disorders were collected from PD patients treated at 40 different hospitals in Shanghai. Sleep disorders were evaluated using the PD Sleep Scale-2, Epworth Sleepiness Scale, Rapid Eye Movement Sleep Behavior Disorder Questionnaire-Hong Kong, and the International Restless Legs Scale. Among the 1006 subjects evaluated, 77.53% exhibited signs of sleep disorders, and most had multiple sleep disorders (n = 502, 49.9%). A smaller percentage of patients with sleep disorders had a single disorder (n = 278, 27.6%). Furthermore, an increased number of sleep disorders, including nighttime problems, excessive daytime sleepiness, rapid eye movement sleep behavior disorder, and restless legs syndrome was a significant contributor to a poor quality of life (β = 4.33, CI: 3.33–5.33, P for trend <0.001), even when controlling for multiple factors. Moreover, motor complications partially mediated this relationship (indirect effect: β = 0.355, 95% boot CI: 0.134, 0.652).Our study showed that a large proportion of PD patients suffer from multiple comorbid sleep disorders, which greatly decreases the quality of life in PD patients and is partially mediated by motor complications.

The effects of exercise on sleep quality in persons with Parkinson's disease: A systematic review with meta-analysis

We conducted a systematic review with meta-analysis to determine the evidence in support of exercise to improve sleep quality assessed subjectively and objectively in Parkinson's Disease (PD). Standardized mean differences (SMD) comparing the effects of exercise and control interventions on sleep quality with 95% confidence intervals (CI) were calculated. Data from 10 randomized and 2 non-randomized controlled trials, including a total of 690 persons with PD were included. Exercise had a significant positive effect on sleep quality assessed subjectively (SMD = 0.53; 95% CI = 0.16-0.90; p = 0.005). However, the methodological quality of the studies showing positive effects on sleep quality was significantly poorer than the studies showing no effects. Only one study assessed the impact of exercise on objective sleep quality, showing improvements in sleep efficiency assessed with polysomnography (SMD = 0.94; 95% CI = 0.38-1.50; p = 0.001). Exercise performed at moderate to maximal intensities (SMD = 0.46; 95% CI = 0.05-0.87; p = 0.03) had significant effects on subjective sleep quality. In contrast, exercise performed at mild to moderate intensities showed non-significant effects (SMD = 0.76; 95% CI = -0.24-1.76; p = 0.14). These results support the use of exercise to improve sleep quality in persons with PD and reinforce the importance of achieving vigorous exercise intensities. Biases, limitations, practice points and directions for future research are discussed.

Can Qigong improve non-motor symptoms in people with Parkinson's disease - A pilot randomized controlled trial?

Non-motor symptoms (NMS) including sleep disorders, anxiety, depression, fatigue, and cognitive decline can significantly impact quality of life in people with PD. Qigong exercise is a mind-body exercise that shows a wide range of benefits in various medical conditions. The purpose of this study was to investigate the effect of Qigong exercise on NMS with a focus on sleep quality. Seventeen participants completed a 12-week intervention of Qigong (n = 8) or sham Qigong (n = 9). Disease severity, anxiety and depression levels, fatigue, cognition, quality of life, and other NMS of the participants were evaluated prior to the intervention and at the end of the 12-week intervention. After the intervention, both Qigong and sham-Qigong group showed significant improvement in sleep quality (p < 0.05) and overall NMS (p < 0.05). No significant difference was found between groups. Qigong exercise has the potential as a rehabilitation method for people with PD, specifically alleviating NMS in PD. However, this finding needs to be carefully considered due to the small sample size and potentially low intervention fidelity of this study.

Practical Evaluation and Management of Insomnia in Parkinson's Disease: A Review

Background

Insomnia is one of the most common nonmotor features of Parkinson's disease (PD). However, there are few practical guidelines for providers on how to best evaluate and treat this problem.

Methods and Findings

This review was developed to provide clinicians with a pragmatic approach to assessing and managing insomnia in PD. Recommendations were based on literature review and expert opinion. We addressed the following topics in this review: prevalence of insomnia in PD, sleep-wake mechanisms, theoretical models of insomnia, risk factors, assessment, pharmacologic and nonpharmacologic treatments. Insomnia treatment choices may be guided by PD severity, comorbidities, and patient preference. However, there is limited evidence supporting pharmacotherapy and nonpharmacologic treatments of insomnia in PD.

Conclusions

We provide a pragmatic algorithm for evaluating and treating insomnia in PD based on the literature and our clinical experience. We propose personalized insomnia treatment approaches based on age and other issues. Gaps in the existing literature and future directions in the treatment of insomnia in PD are also highlighted.

Subtypes of Sleep Disturbance in Parkinson's Disease Based on the Cross-Culturally Validated Korean Version of Parkinson's Disease Sleep Scale-2

BACKGROUND AND PURPOSE

This study aimed to determine the clinimetric properties of the Korean version of Parkinson's Disease Sleep Scale-2 (K-PDSS-2) and whether distinct subtypes of sleep disturbance can be empirically identified in patients with Parkinson's disease (PD) using the cross-culturally validated K-PDSS-2.

METHODS

The internal consistency, test-retest reliability, scale precision, and convergent validity of K-PDSS-2 were assessed in a nationwide, multicenter study of 122 patients with PD. Latent class analysis (LCA) was used to derive subgroups of patients who experienced similar patterns of sleep-related problems and nocturnal disabilities.

RESULTS

The total K-PDSS-2 score was 11.67±9.87 (mean±standard deviation) at baseline and 12.61±11.17 at the retest. Cronbach's α coefficients of the total K-PDSS-2 scores at baseline and follow-up were 0.851 and 0.880, respectively. The intraclass correlation coefficients over the 2-week study period ranged from 0.672 to 0.848. The total K-PDSS-2 score was strongly correlated with health-related quality of life measures and other corresponding nonmotor scales. LCA revealed three distinct subtypes of sleep disturbance in the study patients: "less-troubled sleepers," "PD-related nocturnal difficulties," and "disturbed sleepers."

CONCLUSIONS

K-PDSS-2 showed good clinimetric attributes in accordance with previous studies that employed the original version of the PDSS-2, therefore confirming the cross-cultural usefulness of the scale. This study has further documented the first application of an LCA approach for identifying subtypes of sleep disturbance in patients with PD.

Anxiety and Levodopa Equivalent Daily Dose Are Potential Predictors of Sleep Quality in Patients With Parkinson Disease in Taiwan

Background and Purpose: Non-motor symptoms of Parkinson disease (PD) have a strong negative impact on the health-related quality of life (QoL) of patients with PD. Sleep disturbance is an important non-motor symptom because of its high prevalence. However, previous studies investigating the determinants of sleep quality in patients with PD have revealed inconsistent results. Our study evaluated the correlations between sleep quality in patients with PD and disease-related variables, medications used depression, anxiety, and QoL and identified the determinants of sleep disturbance in people with PD in Taiwan.

Methods: A total of 134 patients with PD were recruited from the outpatient clinic. We examined the correlations between the Parkinson disease sleep scale-2 (PDSS-2) scores and different variables, namely the Unified Parkinson Disease Rating Scale, Parkinson disease questionnaire, Beck Depression Inventory, and Beck Anxiety Inventory (BAI). Logistic regression analysis was used to assess the potential predictive variables for sleep quality in patients with PD.

Results: Among our participants, 47.8% were classified as poor sleepers (PDSS-2 = 15–60). Correlation analysis demonstrated that poor sleepers exhibited longer disease durations, higher levodopa equivalent daily doses (LEDDs), higher PD severity, more depression and anxiety symptoms, poorer QoL, more frequent unemployed status, higher hypnotics use, higher dependency for activities of daily living, more motor impairments, and more therapy-related complications. Logistic regression revealed that the LEDD was a significant predictive factor of sleep quality.

Conclusion: Poor sleepers constituted approximately half of our patients with PD. The participants experienced more favorable sleep if they were currently working. Increased PD duration, severity, depression or anxiety symptoms, and doses of dopaminergic therapy were significantly associated with poor sleep quality. Continued working, attempts to treat comorbid anxiety or depression, and avoidance of overdosage of dopaminergic treatments may improve sleep quality in patients with PD.

Efficacy of Yokukansankachimpihange on sleep disturbance in Parkinson's disease: A study protocol of a randomized, double blind, placebo-controlled pilot trial

INTRODUCTION

Parkinson's disease (PD) is a progressive neurodegenerative disorder that includes motor and nonmotor symptoms. Sleep disturbance is known to decrease the quality of life in patients with PD, and there are limitations to the pharmacotherapy currently in use. Therefore, complementary treatment therapies are required to address these limitations. The traditional herbal medicines Yokukansan (YKS) and Yokukansankachimpihange (YKSCH) have been used to treat insomnia and night crying in children, suggesting their effectiveness against sleep disturbance in patients with PD. We will evaluate whether YKSCH improves sleep disturbance in PD and will identify YKS-related changes in hemodynamic parameters, and neurotransmitter and hormone levels in patients with PD experiencing sleep disturbance.

METHODS

We will conduct a randomized, double-blinded, placebo-controlled parallel trial in 34 patients with PD and sleep disturbance, randomly allocating the patients to either placebo-control (n = 17) or treatment groups (n = 17). The total study period will be 16 weeks; administration of YKSCH or placebo, as intervention, will be performed for a 12-week period, and follow-up will be performed over a 4-week period. All subjects will undergo conventional treatment, and be required to maintain a regular medication schedule throughout the study period. The primary outcome measure will be the Scales for Outcomes in PD-Sleep Scale score, and the secondary outcome measures will be polysomnography results, findings from instruments related to sleep disorders, neurotransmitter and hormone levels, and hemodynamic changes in the brain cortex.

DISCUSSION AND CONCLUSIONS

This trial will evaluate the effectiveness and safety of YKSCH for sleep improvement in PD with sleep disturbance, and investigate the underlying mechanism of action. We expect improvement in the scores for subjective and objective sleep scales, hemodynamic changes in prefrontal cortical activity, and changes in neurotransmitter and hormone levels. The findings will provide insight into the mechanism underlying the therapeutic effect of YKSCH in PD, and lay the foundation for further studies on whether YKSCH improves sleep disturbance in PD.

TRIAL REGISTRATION NUMBER

Clinical Research Information Service (KCT0002869).

Decreased sleep quality in Parkinson's patients is associated with higher anxiety and depression prevalence and severity, and correlates with pain intensity and quality

OBJECTIVE

Pain, poor sleep quality, restless legs syndrome (RLS), and other symptoms are frequently reported by patients with Parkinson's disease (PD). However, the impact that pain severity and interference has on non-motor symptoms (NMS) has not been extensively studied. The objective of the present study is to explore the relationship between sleep quality in PD to pain and other NMS that affect quality of life.

METHODS

The study included 100 PD patients and 100 age and gender-matched controls assessed for pain severity and pain interference using the Brief Pain Inventory and sleep quality using the Pittsburgh Sleep Quality Index. Participants were also evaluated for their subjective levels of anxiety and depression using the Hospital Anxiety and Depression Scale.

RESULTS

PD patients with poor sleep quality had greater pain severity and pain interference than controls and PD patients with good or borderline sleep quality. PD patients with poor sleep quality also had the greatest case-ness and severity for depression and anxiety. However, RLS was not significantly correlated with depression, anxiety or pain.

DISCUSSION

Poor sleep quality in PD patients is related to greater pain severity, pain interference, and more radiating and paresthestic pain that is independent of RLS. There is a higher prevalence of depression and anxiety in PD patients compared to controls, especially in PD patients with poor sleep quality. Our findings suggest a relationship between poor sleep quality in PD with pain, anxiety and depression. Prospective studies are warranted to investigate the causal relationship.

The use of accelerometry as a tool to measure disturbed nocturnal sleep in Parkinson's disease

Sleep disturbances are common in Parkinson’s disease (PD). We used the Parkinson’s KinetiGraph (PKG), an objective movement recording system for PD to assess night time sleep in 155 people aged over 60 and without PD (controls), 72 people with PD (PwP) and 46 subjects undergoing a Polysomnogram (PSG: 36 with sleep disorder and 10 with normal sleep). The PKG system uses a wrist worn logger to capture acceleration and derive a bradykinesia score (BKS) every 2 min over 6 days. The BKS ranges from 0–160 with higher scores associated with lesser mobility. Previously we showed that BKS > 80 were associated with day time sleep and used this to produce scores for night time sleep: Efficiency (Percent time with BKS > 80), Fragmentation (Average duration of runs of BKS > 80) and Sleep Quality (BKS > 111 as a representation of atonia). There was a fair association with BKS score and sleep level as judged by PSG. Using these PKG scores, it was possible to distinguish between normal and abnormal PSG studies with good Selectivity (86%) and Sensitivity (80%). The PKG’s sleep scores were significantly different in PD and Controls and correlated with a subject’s self-assessment (PDSS 2) of the quality, wakefulness and restlessness. Using both the PDSS 2 and the PKG, it was apparent that sleep disturbances were apparent early in disease in many PD subjects and that subjects with poor night time sleep were more likely to have day time sleepiness. This system shows promise as a quantitative score for assessing sleep in Parkinson’s disease.

A movement recording system reveals the occurrence of sleep disturbances in the early stages of Parkinson’s disease (PD). Malcolm Horne, a movement disorders expert at the University in Melbourne, and colleagues assessed night time sleep in 72 patients with PD using a wrist-worn device that captures movement patterns. The Parkinson’s KinetiGraph (PKG) system derives scores that are associated with sleep stages and correlate with patients’ self-assessment of sleep quality, wakefulness and restlessness. Significant differences between the PKG sleep scores of PD patients and age-matched healthy controls confirmed that night time sleep disturbances and day time sleepiness worsen as the disease progresses. Abnormal PKG scores were found in patients affected by the disease for only 3 years highlighting the extent to which sleep is disrupted in early-stage PD.

Impact of inability to turn in bed assessed by a wearable three-axis accelerometer on patients with Parkinson's disease

Background

Difficulty turning over in bed is a common night-time symptom in Parkinson’s disease (PD). We aimed to quantitatively evaluate overnight turnover movements using a three-axis accelerometer and to investigate whether inability to turn in bed is related to daytime sleepiness, sleep quality, and depressive mood in PD patients.

Methods

We examined 64 patients with PD (mean age, 73.3±8.21 years; modified Hoehn-Yahr [mH-Y] stage, 3.0±1.0; disease duration, 7.2±6.3 years; unified Parkinson's disease rating scale [UPDRS], 36.9±18.3). Overnight monitoring of turnover movements using a wearable three-axis accelerometer was performed in all patients. Nocturnal kinetic parameters including total time recumbent, total time supine, number of turnover movements, and mean interval between turnover movements were obtained. Daytime immobility was assessed using the Barthel index (B-I), UPDRS, and mH-Y stage. Patients were also assessed with the Epworth Sleepiness Scale (ESS), Parkinson’s Disease Sleep Scale-2 (PDSS-2), and Beck Depression Inventory (BDI).

Results

Number of turnover movements in bed correlated negatively with disease duration (r = -0.305; p<0.05), L-dopa-equivalent dose (r = -0.281; p<0.05), mH-Y staging (r = -0.336; p<0.01), total score of UPDRS (r = -0.386; p<0.01) and positively with B-I score (r = 0.365; p<0.01). Number of turnover movements in bed was generally inconsistent with awareness of turnover movement impairment as evaluated by PDSS-2 Item 9 scores, but patients who were never aware of impaired turnover movements showed ≥5 turnover movements overnight. Multivariate logistic regression analyses revealed no correlations between number of nocturnal turnover movements in bed and BDI, ESS, or PDSS-2. Use of anti-psychotic drugs was associated with ESS (p = 0.045). UPDRS was associated with PDSS-2 (p = 0.016).

Conclusion

Decreased number of turnover movements may not be a direct determinant of daytime sleepiness, sleep disorders, or depressive mood in PD patients. Use of anti-psychotic drugs and higher UPDRS score are factors significantly associated with daytime sleepiness and uncomfortable sleep, respectively.

Qigong Exercise May Reduce Serum TNF-α Levels and Improve Sleep in People with Parkinson's Disease: A Pilot Study

Background: Inflammatory cytokine levels are often elevated in people with Parkinson’s disease (PD). People with PD often experience sleep disturbances that significantly impact quality of life. Past studies suggest inflammatory cytokines may be associated with various symptoms of PD. Benefits of Qigong, a mind–body exercise, have been shown in different neurological conditions, but there is still a lack of clinical evidence in the PD population. Methods: Ten people with PD were recruited and randomly assigned into two groups receiving six weeks of Qigong (experimental group) or sham Qigong (control group) intervention. The levels of TNF-α, IL-1β, and IL-6 in subjects’ serum and sleep quality were measured before and after the intervention. Results: After the intervention, the serum level of TNF-α in the experimental group was significantly decreased in all subjects, while the level in the control group showed a trend to increase. Qigong exercise significantly improved sleep quality at night. There was a strong correlation between changes in the level of TNF-α and sleep quality. Conclusion: Qigong exercise decreased TNF-α level in people with PD and helped improve sleep quality. TNF-α may have a potential to influence the sleep quality in people with PD.

Clinically relevant cut-off values for the Parkinson's Disease Sleep Scale-2 (PDSS-2): a validation study

BACKGROUND

Sleep disturbances are a major problem encountered by neurologists attending Parkinson's disease (PD) patients. The Parkinson's Disease Sleep Scale-2 (PDSS-2) assesses a wide spectrum of disease-specific sleep problems and is easy to administer as a patient self-rating scale. The validation study showed that the scale is reliable, valid, and precise. Until now, however, only one Japanese study has assessed cut-off scores to define poor sleepers.

OBJECTIVES

In this context we aimed to determine the PDSS-2 cut-off values that define a sleep disturbance severe enough to require referral of the patient to a sleep center or the need for specific treatment.

METHODS

Inpatients with idiopathic PD consecutively admitted to our hospital were enrolled. Patients completed the PDSS-2. The attending physician, who was blinded to the PDSS-2 results, but familiar with the patients' history and current disease status, completed a questionnaire consisting of two general questions on the presence of PD-specific and non-PD related sleep problems. Statistical analysis was performed to determine cut-off values for the PDSS-2 and correlation with the physician's evaluation of sleep disturbance severity. A natural cohort of non-PD patients with sleep disorders represented the control group.

RESULTS

The sample consisted of 52 (56%) men and 41 (44%) women with an average age of 69.22 ± 8.74 years. PDSS-2 showed a sensitivity of 77.6% and a specificity of 74.3% in relation to physician's evaluation of PD-specific sleep problems. According to the physician's evaluation, PD-specific sleep disturbances occurred in 62% of the patients. 83% of patients with PDSS-2 scores ≥18 had clinically relevant sleep disturbances compared to only 33% of PD patients with scores <18. The severity of PD-specific sleep problems was well correlated with the PDSS-2 total score (r = 0.49).

CONCLUSIONS

To our knowledge, this is the first study to define PDSS-2 cut-off values for the severity of sleep disturbances in a European PD sample. Our study shows that scores ≥18 define clinically relevant PD-specific sleep disturbances.

Human behavioral assessments in current research of Parkinson's disease

Parkinson's disease (PD) is traditionally classified as a movement disorder because patients mainly complain about motor symptoms. Recently, non-motor symptoms of PD have been recognized by clinicians and scientists as early signs of PD, and they are detrimental factors in the quality of life in advanced PD patients. It is crucial to comprehensively understand the essence of behavioral assessments, from the simplest measurement of certain symptoms to complex neuropsychological tasks. We have recently reviewed behavioral assessments in PD research with animal models (Asakawa et al., 2016). As a companion volume, this article will systematically review the behavioral assessments of motor and non-motor PD symptoms of human patients in current research. The major aims of this article are: (1) promoting a comparative understanding of various behavioral assessments in terms of the principle and measuring indexes; (2) addressing the major strengths and weaknesses of these behavioral assessments for a better selection of tasks/tests in order to avoid biased conclusions due to inappropriate assessments; and (3) presenting new concepts regarding the development of wearable devices and mobile internet in future assessments. In conclusion we emphasize the importance of improving the assessments for non-motor symptoms because of their complex and unique mechanisms in human PD brains.

Sleep Disorders in Parkinsonian and Nonparkinsonian LRRK2 Mutation Carriers

Objective

In idiopathic Parkinson disease (IPD) sleep disorders are common and may antedate the onset of parkinsonism. Based on the clinical similarities between IPD and Parkinson disease associated with LRRK2 gene mutations (LRRK2-PD), we aimed to characterize sleep in parkinsonian and nonmanifesting LRRK2 mutation carriers (NMC).

Methods

A comprehensive interview conducted by sleep specialists, validated sleep scales and questionnaires, and video-polysomnography followed by multiple sleep latency test (MSLT) assessed sleep in 18 LRRK2-PD (17 carrying G2019S and one R1441G mutations), 17 NMC (11 G2019S, three R1441G, three R1441C), 14 non-manifesting non-carriers (NMNC) and 19 unrelated IPD.

Results

Sleep complaints were frequent in LRRK2-PD patients; 78% reported poor sleep quality, 33% sleep onset insomnia, 56% sleep fragmentation and 39% early awakening. Sleep onset insomnia correlated with depressive symptoms and poor sleep quality. In LRRK2-PD, excessive daytime sleepiness (EDS) was a complaint in 33% patients and short sleep latencies on the MSLT, which are indicative of objective EDS, were found in 71%. Sleep attacks occurred in three LRRK2-PD patients and a narcoleptic phenotype was not observed. REM sleep behavior disorder (RBD) was diagnosed in three LRRK2-PD. EDS and RBD were always reported to start after the onset of parkinsonism in LRRK2-PD. In NMC, EDS was rarely reported and RBD was absent. When compared to IPD, sleep onset insomnia was more significantly frequent, EDS was similar, and RBD was less significantly frequent and less severe in LRRK2-PD. In NMC, RBD was not detected and sleep complaints were much less frequent than in LRRK2-PD. No differences were observed in sleep between NMC and NMNC.

Conclusions

Sleep complaints are frequent in LRRK2-PDand show a pattern that when compared to IPD is characterized by more frequent sleep onset insomnia, similar EDS and less prominent RBD. Unlike in IPD, RBD and EDS seem to be not markers of the prodromal stage of LRRK2-PD.