Associations of sleep disturbance symptoms with health-related quality of life in Parkinson's disease

A mouse model of sleep disorders in Parkinson's disease showing distinct effects of dopamine D2-like receptor activation

Excessive daytime sleepiness (EDS) and sleep fragmentation are often observed in Parkinson's disease (PD) patients and are poorly understood despite their considerable impact on quality of life. We examined the ability of a neurotoxin-based mouse model of PD to reproduce these disorders and tested the potential counteracting effects of dopamine replacement therapy. Experiments were conducted in female mice with a unilateral 6-hydroxydopamine lesion of the medial forebrain bundle, leading to the loss of dopamine neurons projecting to the dorsal and ventral striatum. Sham-operated mice were used as control. Electroencephalographic and electromyographic recording was used to identify and quantify awaken, rapid eye movement (REM) and non-REM (NREM) sleep states. PD mice displayed enhanced NREM sleep and reduced wakefulness during the active period of the 24-hour circadian cycle, indicative of EDS. In addition, they also showed fragmentation of NREM sleep and increased slow-wave activity, a marker of sleep pressure. Electroencephalographic analysis of the PD model also revealed decreased density and increased length of burst-like thalamocortical oscillations (spindles). Treatment of PD mice with the dopamine receptor agonist, pramipexole, but not with L-DOPA, counteracted EDS by reducing the number, but not the length, of NREM sleep episodes during the first half of the active period. The present model recapitulates some prominent PD-related anomalies affecting sleep macro- and micro-structure. Based on the pharmacological profile of pramipexole these results also indicate the involvement of impaired dopamine D2/D3 receptor transmission in EDS.

Setting the clinical context to non-motor symptoms reflected by Park-pain, Park-sleep, and Park-autonomic subtypes of Parkinson's disease

Non-motor symptoms (NMS) of Parkinson's disease (PD) are well described in both clinical practice and the literature, enabling their management and enhancing our understanding of PD. NMS can dominate the clinical pictures and NMS subtypes have recently been proposed, initially based on clinical observations, and later confirmed in data driven analyses of large datasets and in biomarker-based studies. In this chapter, we provide an update on what is known about three common subtypes of NMS in PD. The pain (Park-pain), sleep dysfunction (Park-sleep), and autonomic dysfunction (Park-autonomic), providing an overview of their individual classification, clinical manifestation, pathophysiology, diagnosis, and potential treatments.

Effects of deep brain stimulation on quantitative sleep electroencephalogram during non-rapid eye movement in Parkinson's disease

Introduction

Sleep dysfunction is frequently experienced by people with Parkinson's disease (PD) and negatively influences quality of life. Although subthalamic nucleus (STN) deep brain stimulation (DBS) can improve sleep in PD, sleep microstructural features such as sleep spindles provide additional insights about healthy sleep. For example, sleep spindles are important for better cognitive performance and for sleep consolidation in healthy adults. We hypothesized that conventional STN DBS settings would yield a greater enhancement in spindle density compared to OFF and low frequency DBS.

Methods

In a previous within-subject, cross-sectional study, we evaluated effects of low (60 Hz) and conventional high (≥130 Hz) frequency STN DBS settings on sleep macroarchitectural features in individuals with PD. In this post hoc, exploratory analysis, we conducted polysomnography (PSG)-derived quantitative electroencephalography (qEEG) assessments in a cohort of 15 individuals with PD who had undergone STN DBS treatment a median 13.5 months prior to study participation. Fourteen participants had unilateral DBS and 1 had bilateral DBS. During three nonconsecutive nights of PSG, the participants were assessed under three different DBS conditions: DBS OFF, DBS LOW frequency (60 Hz), and DBS HIGH frequency (≥130 Hz). The primary objective of this study was to investigate the changes in sleep spindle density across the three DBS conditions using repeated-measures analysis of variance. Additionally, we examined various secondary outcomes related to sleep qEEG features. For all participants, PSG-derived EEG data underwent meticulous manual inspection, with the exclusion of any segments affected by movement artifact. Following artifact rejection, sleep qEEG analysis was conducted on frontal and central leads. The measures included slow wave (SW) and spindle density and morphological characteristics, SW-spindle phase-amplitude coupling, and spectral power analysis during non-rapid eye movement (NREM) sleep.

Results

The analysis revealed that spindle density was significantly higher in the DBS HIGH condition compared to the DBS LOW condition. Surprisingly, we found that SW amplitude during NREM was significantly higher in the DBS LOW condition compared to DBS OFF and DBS HIGH conditions. However, no significant differences were observed in the other sleep qEEG features during sleep at different DBS conditions.

Conclusion

This study presents preliminary evidence suggesting that conventional HIGH frequency DBS settings enhance sleep spindle density in PD. Conversely, LOW frequency settings may have beneficial effects on increasing slow wave amplitude during sleep. These findings may inform mechanisms underlying subjective improvements in sleep quality reported in association with DBS. Moreover, this work supports the need for additional research on the influence of surgical interventions on sleep disorders, which are prevalent and debilitating non-motor symptoms in PD.

The Genetic Basis of Probable REM Sleep Behavior Disorder in Parkinson's Disease

Patients with Parkinson's Disease (PD) experience REM sleep behavior disorder (RBD) more frequently than healthy controls. RBD is associated with torpid disease evolution. To test the hypothesis that differential genetic signatures might contribute to the torpid disease evolution in PD patients with RBD we compared the rate of genetic mutations in PD patients with or without probable RBD. Patients with a clinical diagnosis of PD in the Parkinson's Progression Markers Initiative (PPMI) database entered the study. We excluded those with missing data, dementia, psychiatric conditions, or a diagnosis change over the first five years from the initial PD diagnosis. Probable RBD (pRBD) was confirmed by a REM Sleep Behavior Disorder Screening Questionnaire score > 5 points. Logistic regression and Machine Learning (ML) algorithms were used to relate Single Nucleotide Polymorphism (SNPs) in PD-related genes with pRBD. We included 330 PD patients fulfilling all inclusion and exclusion criteria. The final logistic multivariate model revealed that the following SNPs increased the risk of pRBD: GBA_N370S_rs76763715 (OR, 95% CI: 3.38, 1.45-7.93), SNCA_A53T_rs104893877 (8.21, 2.26-36.34), ANK2. CAMK2D_rs78738012 (2.12, 1.08-4.10), and ZNF184_rs9468199 (1.89, 1.08-3.33). Conversely, SNP COQ7. SYT17_rs11343 reduced pRBD risk (0.36, 0.15-0.78). The ML algorithms led to similar results. The predictive models were highly specific (95-99%) but lacked sensitivity (9-39%). We found a distinctive genetic signature for pRBD in PD. The high specificity and low sensitivity of the predictive models suggest that genetic mutations are necessary but not sufficient to develop pRBD in PD. Additional investigations are needed.

Sleep Disturbances in Neurological Disease: A Target for Intervention

Sleep is a biological function required for neurological and general health, but a significant and under-recognized proportion of the population has disturbed sleep. Here, we briefly overview the biology of sleep, sleep requirements over the lifespan, and common sleep disorders. We then turn our attention to five neurological diseases that significantly contribute to global disease burden and neurology practice makeup: epilepsy, headache, ischemic stroke, Parkinson's disease, and Alzheimer's disease. For each disease, we review evidence that sleep disturbances contribute to disease risk and severity and discuss existing data that addressing sleep disturbances may have disease-modifying effects. We provide recommendations derived from the literature and existing clinical guidelines to facilitate the evaluation and management of sleep disturbances within the context of each neurological disease. Finally, we synthesize identified needs and commonalities into future directions for the field and practical sleep-related recommendations for physicians caring for patients at risk for or currently suffering from neurological disease.

Management of Sleep Disturbances in Parkinson's Disease

Parkinson's disease (PD) is defined by its motor symptoms rigidity, tremor, and akinesia. However, non-motor symptoms, particularly autonomic disorders and sleep disturbances, occur frequently in PD causing equivalent or even greater discomfort than motor symptoms effectively decreasing quality of life in patients and caregivers. Most common sleep disturbances in PD are insomnia, sleep disordered breathing, excessive daytime sleepiness, REM sleep behavior disorder, and sleep-related movement disorders such as restless legs syndrome. Despite their high prevalence, therapeutic options in the in- and outpatient setting are limited, partly due to lack of scientific evidence. The importance of sleep disturbances in neurodegenerative diseases has been further emphasized by recent evidence indicating a bidirectional relationship between neurodegeneration and sleep. A more profound insight into the underlying pathophysiological mechanisms intertwining sleep and neurodegeneration might lead to unique and individually tailored disease modifying or even neuroprotective therapeutic options in the long run. Therefore, current evidence concerning the management of sleep disturbances in PD will be discussed with the aim of providing a substantiated scaffolding for clinical decisions in long-term PD therapy.

WATSU therapy for individuals with Parkinson's disease to improve quality of sleep and quality of life: A randomized controlled study

BACKGROUND

and Purpose: Sleep disorders are one of the most frequent non-motor symptoms of Parkinson's disease (PD). This study aimed to verify whether adding WATSU to land-based therapy leads to additional beneficial therapeutic effects regarding quality of sleep and quality of life (QOL) in individuals with PD.

MATERIALS & METHODS

A randomized control trial design was used. Participants completed nine-week interventions. The control group (CG) received land-based therapy, while the intervention group (IG) received the same land-based therapy and additionally WATSU. Sleep quality and QOL were measured at baseline and post-interventions by Pittsburgh Sleep Quality Index and Nottingham Health Profile, respectively.

RESULTS

Twenty-eight participants completed the study. In contrast to CG, the IG presented with significant improvements in both, quality of sleep and QOL (p < 0.001).

CONCLUSION

WATSU has the potential to be an attractive adjunct therapy for producing positive health impacts regarding sleep quality, which may translate to an overall improvement in QOL of individuals with PD.

Basal Ganglia Local Field Potentials as a Potential Biomarker for Sleep Disturbance in Parkinson's Disease

Sleep disturbances, specifically decreases in total sleep time and sleep efficiency as well as increased sleep onset latency and wakefulness after sleep onset, are highly prevalent in patients with Parkinson's disease (PD). Impairment of sleep significantly and adversely impacts several comorbidities in this patient population, including cognition, mood, and quality of life. Sleep disturbances and other non-motor symptoms of PD have come to the fore as the effectiveness of advanced therapies such as deep brain stimulation (DBS) optimally manage the motor symptoms. Although some studies have suggested that DBS provides benefit for sleep disturbances in PD, the mechanisms by which this might occur, as well as the optimal stimulation parameters for treating sleep dysfunction, remain unknown. In patients treated with DBS, electrophysiologic recording from the stimulating electrode, in the form of local field potentials (LFPs), has led to the identification of several findings associated with both motor and non-motor symptoms including sleep. For example, beta frequency (13–30 Hz) oscillations are associated with worsened bradykinesia while awake and decrease during non-rapid eye movement sleep. LFP investigation of sleep has largely focused on the subthalamic nucleus (STN), though corresponding oscillatory activity has been found in the globus pallidus internus (GPi) and thalamus as well. LFPs are increasingly being recognized as a potential biomarker for sleep states in PD, which may allow for closed-loop optimization of DBS parameters to treat sleep disturbances in this population. In this review, we discuss the relationship between LFP oscillations in STN and the sleep architecture of PD patients, current trends in utilizing DBS to treat sleep disturbance, and future directions for research. In particular, we highlight the capability of novel technologies to capture and record LFP data in vivo, while patients continue therapeutic stimulation for motor symptoms. These technological advances may soon allow for real-time adaptive stimulation to treat sleep disturbances.

The SleepFit Tablet Application for Home-Based Clinical Data Collection in Parkinson Disease: User-Centric Development and Usability Study

BACKGROUND

Parkinson disease (PD) is a common, multifaceted neurodegenerative disorder profoundly impacting patients' autonomy and quality of life. Assessment in real-life conditions of subjective symptoms and objective metrics of mobility and nonmotor symptoms such as sleep disturbance is strongly advocated. This information would critically guide the adaptation of antiparkinsonian medications and nonpharmacological interventions. Moreover, since the spread of the COVID-19 pandemic, health care practices are being reshaped toward a more home-based care. New technologies could play a pivotal role in this new approach to clinical care. Nevertheless, devices and information technology tools might be unhandy for PD patients, thus dramatically limiting their widespread employment.

OBJECTIVE

The goals of the research were development and usability evaluation of an application, SleepFit, for ecological momentary assessment of objective and subjective clinical metrics at PD patients' homes, and as a remote tool for researchers to monitor patients and integrate and manage data.

METHODS

An iterative and user-centric strategy was employed for the development of SleepFit. The core structure of SleepFit consists of (1) an electronic finger-tapping test; (2) motor, sleepiness, and emotional subjective scales; and (3) a sleep diary. Applicable design, ergonomic, and navigation principles have been applied while tailoring the application to the specific patient population. Three progressively enhanced versions of the application (alpha, v1.0, v2.0) were tested by a total of 56 patients with PD who were asked to perform multiple home assessments 4 times per day for 2 weeks. Patient compliance was calculated as the proportion of completed tasks out of the total number of expected tasks. Satisfaction on the latest version (v2.0) was evaluated as potential willingness to use SleepFit again after the end of the study.

RESULTS

From alpha to v1.0, SleepFit was improved in graphics, ergonomics, and navigation, with automated flows guiding the patients in performing tasks throughout the 24 hours, and real-time data collection and consultation were made possible thanks to a remote web portal. In v2.0, the kiosk-mode feature restricts the use of the tablet to the SleepFit application only, thus preventing users from accidentally exiting the application. A total of 52 (4 dropouts) patients were included in the analyses. Overall compliance (all versions) was 88.89% (5707/6420). SleepFit was progressively enhanced and compliance increased from 87.86% (2070/2356) to 89.92% (2899/3224; P=.04). Among the patients who used v2.0, 96% (25/26) declared they would use SleepFit again.

CONCLUSIONS

SleepFit can be considered a state-of-the-art home-based system that increases compliance in PD patients, ensures high-quality data collection, and works as a handy tool for remote monitoring and data management in clinical research. Thanks to its user-friendliness and modular structure, it could be employed in other clinical studies with minimum adaptation efforts.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02723396; https://clinicaltrials.gov/ct2/show/NCT02723396.

Changes in efficiencies and interactions of attentional networks in Parkinson's disease with sleep disturbance

Attention is composed of three distinct attentional networks: alerting, orienting, and executive control. Previous studies have confirmed that Parkinson's disease (PD) is associated with executive control deficits; however, the interactions among the three attentional networks and the influence of sleep disturbance in PD patients have not been investigated. Herein, the efficiencies for the three attentional networks and their interactions were evaluated using the revised attention network test. The results showed a significantly slower response and lower accuracy in the PD group than in the normal control group and a significantly slower response and lower accuracy in PD patients with sleep disturbance (PDS) than in PD patients without sleep disturbance (PDnS), which indicates a response deficit in PD and worsening in PDS. Additionally, the executive control efficiency was reduced in both PDS and PDnS, and significantly higher alerting efficiency and lower orienting efficiency were found in PDS. Furthermore, largely changed interactions and correlation patterns of attentional networks were found in PDS but not in PDnS. These results suggested that attentional networks were impaired in PD patients, particularly in those affected by sleep disturbances, and that PDS might establish special connections between attentional networks to compensate for cognitive dysfunction.

Exploring Nonmotor Neuropsychiatric Manifestations of Parkinson Disease in a Comprehensive Care Setting

Parkinson disease (PD) is a debilitating neurological condition that includes both motor symptoms and nonmotor symptoms (NMS). Psychiatric complaints comprise NMS and are collectively referred to as neuropsychiatric manifestations. Common findings include atypical depressive symptoms, anxiety, psychosis, impulse control disorder, deterioration of cognition, and sleep disturbances. Quality of life (QoL) of patients suffering from NMS is greatly impacted and many times can be more debilitating than motor symptoms of PD. We expand on knowledge gained from treatment models within a comprehensive care model that incorporates multidisciplinary specialists working alongside psychiatrists to treat PD. Insight into background, clinical presentations, and treatment options for patients suffering from neuropsychiatric manifestations of PD are discussed. Identifying symptoms early can help improve QoL, provide early symptom relief, and can assist tailoring treatment plans that limit neuropsychiatric manifestations.

Melatonin as a Chronobiotic and Cytoprotective Agent in Parkinson's Disease

This article discusses the role that melatonin may have in the prevention and treatment of Parkinson’s disease (PD). In parkinsonian patients circulating melatonin levels are consistently disrupted and the potential therapeutic value of melatonin on sleep disorders in PD was examined in a limited number of clinical studies using 2–5 mg/day melatonin at bedtime. The low levels of melatonin MT1 and MT2 receptor density in substantia nigra and amygdala found in PD patients supported the hypothesis that the altered sleep/wake cycle seen in PD could be due to a disrupted melatonergic system. Motor symptomatology is seen in PD patients when about 75% of the dopaminergic cells in the substantia nigra pars compacta region degenerate. Nevertheless, symptoms like rapid eye movement (REM) sleep behavior disorder (RBD), hyposmia or depression may precede the onset of motor symptoms in PD for years and are index of worse prognosis. Indeed, RBD patients may evolve to an α-synucleinopathy within 10 years of RBD onset. Daily bedtime administration of 3–12 mg of melatonin has been demonstrated effective in RDB treatment and may halt neurodegeneration to PD. In studies on animal models of PD melatonin was effective to curtail symptomatology in doses that allometrically projected to humans were in the 40–100 mg/day range, rarely employed clinically. Therefore, double-blind, placebo-controlled clinical studies are urgently needed in this respect.

Management of Sleep Disturbances in Parkinson's Disease Patients, Carers and the Patient and Carer Dyadic Relationship: A Scoping Review

OBJECTIVES

Sleep disturbances are a debilitating non-motor symptom in Parkinson's disease (PD) and negatively impact patients, their carers and the patient-carer dyadic relationship. This review outlines the phenomenology, as well as factors associated with and treatment of sleep disturbances, in PD patients and their informal carers.

METHODS

The following terms were used in four databases: Parkinson*, sleep* disturbance*, carer*, dyad*, intervention* and treatment*.

RESULTS

Across the articles reviewed, the frequency of reported sleep disturbances in PD ranged between 60% and 98%. Common sleep problems in PD included insomnia, excessive day time sleepiness, REM sleep behavior disorder (RBD), sleep apnoea, periodic limb movements and sleep attacks. Within dyads, significant correlations were found with depression, anxiety and carer burden relating to night time care in particular. Despite the negative impact of sleep disturbance in PD, the evidence-base for treatment remains limited.

CONCLUSIONS

While addressing individual factors associated with sleep disturbances, it is also important to emphasize the needs arising from the patient-carer dyadic relationship. While a number of non-pharmacological interventions were suggested in the literature, further well-controlled trials are still required.

CLINICAL IMPLICATIONS

Multiple approaches are required to reduce sleep disturbances and associated burden in PD.

Factors related to sleep disturbances for individuals with Parkinson's disease: a regional perspective

OBJECTIVES

Sleep disturbances negatively impact the quality of life of patients with Parkinson's disease (PD). While persons living in regional areas are at higher risk of PD, PD is poorly managed in regional communities. This study examined factors associated with sleep problems in PD in a regional context.

DESIGN

A mixed-methods cross-sectional design was used.

PARTICIPANTS

Patients with PD were recruited from the Queensland Parkinson's Project database.

MEASUREMENTS

Those who agreed to participate were sent a questionnaire assessing aspects of sleep, depression, anxiety, quality of life, and PD severity. Qualitative information was also gathered. Correlations between variables were examined; thematic analyses were performed for qualitative data.

RESULTS

All participants (n = 49) reported sleep disturbances, with 73% (n = 36) reporting sleep disturbance to be problematic. Global sleep dysfunction positively correlated with daytime napping (r = .34, p = .01), watching the clock when unable to sleep (r = .38, p = <.01), staying in bed when unable to sleep (r = .43, p = <.01), and going to bed hungry (r = .31, p = .03) and negatively correlated with daytime exercise (r = -.32, p = .02). Positive correlations were observed between global sleep dysfunction and depression (r = .55, p = <.01), anxiety (r = .31, p = .04), and dysfunctional sleep beliefs (r = .39, p = <.01).

CONCLUSION

There is a clear need for identifying factors related to sleep disturbances in PD for effective management.

The Parkinson's Disease Sleep Scale-2 (PDSS-2): Validation of the Spanish Version and Its Relationship With a Roommate-Based Version

Background

Because of the prevalence and impact of sleep disorders in Parkinson's disease (PD), valid instruments for their evaluation and monitoring are necessary. However, some nocturnal sleep disorders may go unnoticed by patients themselves.

Objectives

To validate a pan-Spanish version of the Parkinson's Disease Sleep Scale Version 2 (PDSS-2) and to test the relationships between the PDSS-2 and a PDSS-2 roommate version.

Methods

PD patients (n = 399) from seven Spanish-speaking countries were included. In addition to the tested PDSS-2 scales, valid measures for sleep disorders and both motor and nonmotor manifestations were applied. Acceptability, dimensionality, reliability, precision, and construct validity were explored, as well as discrepancies and agreement between the PDSS-2 and the roommate version.

Results

PDSS-2 showed negligible floor and ceiling effects. Four factors (57% of the variance) were identified. Reliability parameters were satisfactory: alpha = 0.84; item homogeneity coefficient = 0.27; corrected item total correlation = 0.28 to 0.61; and test-retest reliability (average kappa = 0.70; intraclass correlation coefficient [ICC] = 0.83). The standard error of measurement was 5.84, and correlations with other scales assessing nocturnal sleep were high (r_S = 0.62-0.56). In comparison to the patient-based total score, the by proxy total score showed no significant difference, high correlation (r_S = 0.70), and acceptable agreement (ICC = 0.69), but there were discrepancies in two or more points in 18% of item scores.

Conclusions

The Spanish version of the PDSS-2 has shown satisfactory clinimetric attributes. Acceptability and precision data are presented for the first time. The PDSS-2 roommate version could be useful to complement the patient-based evaluation, but additional studies are needed.

Circadian Rhythm Abnormalities in Parkinson's Disease from Humans to Flies and Back

Clinical and research studies have suggested a link between Parkinson’s disease (PD) and alterations in the circadian clock. Drosophila melanogaster may represent a useful model to study the relationship between the circadian clock and PD. Apart from the conservation of many genes, cellular mechanisms, signaling pathways, and neuronal processes, Drosophila shows an organized central nervous system and well-characterized complex behavioral phenotypes. In fact, Drosophila has been successfully used in the dissection of the circadian system and as a model for neurodegenerative disorders, including PD. Here, we describe the fly circadian and dopaminergic systems and report recent studies which indicate the presence of circadian abnormalities in some fly PD genetic models. We discuss the use of Drosophila to investigate whether, in adults, the disruption of the circadian system might be causative of brain neurodegeneration. We also consider approaches using Drosophila, which might provide new information on the link between PD and the circadian clock. As a corollary, since PD develops its symptomatology over a large part of the organism’s lifespan and given the relatively short lifespan of fruit flies, we suggest that genetic models of PD could be used to perform lifelong screens for drug-modulators of general and/or circadian-related PD traits.

Health-related quality-of-life, work productivity, and economic burden among patients with Parkinson's disease in Japan

AIMS

This study aimed to characterize the burden of Parkinson's disease (PD) by examining health-related quality-of-life (HRQoL), impairments to work productivity and daily activities, healthcare resource use, and associated costs among Japanese patients with PD.

MATERIALS AND METHODS

This retrospective cross-sectional study used data from the 2009-2014 Japan National Health and Wellness Survey (NHWS) (n = 144,692). HRQoL (Short Form 36-Item Health Survey version 2), impairments to work productivity and daily activities (Work Productivity and Activity Impairment Questionnaire), healthcare resource utilization, and annual costs were compared between respondents with PD (n = 133) and controls without PD (n = 144,559). The effect of PD on outcomes was estimated using propensity score weighting and multivariable regression models.

RESULTS

HRQoL was lower in patients with PD compared to the control group, with reduced physical (41.3 vs 51.3) and mental (35.7 vs 45.4) component summary scores and health state utility scores (0.62 vs 0.77; p < .001 for all). Patients with PD also reported higher levels of absenteeism (19.3% vs 3.3%), presenteeism (45.2% vs 18.5%), overall work impairment (52.8% vs 20.3%), and activity impairment (49.6% vs 20.8%) than controls without PD (p < .001 for all). In addition, patients with PD had higher healthcare resource utilization, direct (¥3,856,921/$37,994 vs ¥715,289/$7,046), and indirect (¥2,573,938/$25,356 vs ¥902,534/$8,891) costs compared with controls without PD (p < .001 for both).

LIMITATIONS

Data were cross-sectional and did not allow for causal inferences. Although the NHWS demographically represents the Japanese adult population, it is unclear whether it adequately represents the adult population with PD in Japan.

CONCLUSIONS

PD was associated with poorer HRQoL, greater work productivity loss, and higher direct and indirect costs. The findings suggest that an unmet need exists among patients with PD in Japan. Improving PD treatment and management could benefit both patients and society.

Clinical Predictors of Excessive Daytime Sleepiness in Patients with Parkinson's Disease

Background and Purpose

Excessive daytime sleepiness (EDS) is a common complaint among patients with Parkinson's disease (PD). Several factors have been associated with EDS in PD, especially neuropsychiatric symptoms. This study aimed to determine the relationships between neuropsychiatric symptoms, sociodemographic and clinical parameters, and EDS in PD.

Methods

This cross-sectional study analyzed 85 patients with PD. All patients underwent socioeconomic and clinical data evaluations followed by a psychiatric interview and a neurological examination, including the assessment of sleep features. Patients were divided into two groups according to the presence or absence of EDS, which was defined as a score higher than 10 on the Epworth Sleepiness Scale. Binary logistic regression was performed in order to describe the predictors of EDS.

Results

We found that EDS affects 40% of PD patients and is associated with older age, restless legs syndrome, depressive and anxious symptoms, and worse sleep quality. In the multivariate analysis, older age, levodopa use, and worse sleep quality remained as significant predictors of EDS in PD.

Conclusions

Nighttime sleep problems, older age, and levodopa use are significantly associated with EDS in PD. A careful assessment and the management of sleep problems in PD patients might help to improve their quality of life.

Sleep disturbances and depression severity in patients with Parkinson's disease

OBJECTIVES

Parkinson's disease (PD) is a multisystem movement disorder associated with sleep disturbance and depression. Sleep disturbances and depression severity share a bidirectional association. This association may be greater in individuals who are more vulnerable to the deleterious consequences of sleep disturbance and depression severity. We investigated whether the association between sleep disturbances and depression severity is greater in patients with PD than in matched controls (MC).

MATERIALS AND METHODS

The study sample (N = 98) included 50 patients with idiopathic PD and 48 age-, race-, sex-, and education-matched controls. Sleep disturbances were assessed using self-reported total sleep time (TST) on the Pittsburgh Sleep Quality Index, the sleep item on the Beck Depression Inventory, 2nd ed. (BDI-II), and the Insomnia Severity Index total score. Depression severity was assessed using the BDI-II total score, excluding the sleep item. Spearman's correlations, chi-squared tests, and multiple regression were used to assess associations between sleep disturbances and depression severity in PD and MC. Fisher's Z transformation was used to test whether the association between sleep disturbances and depression severity was stronger in patients with PD.

RESULTS

Shorter TST, sleeping less than usual, and insomnia severity were associated with depression severity in the total sample, rs(94) = -0.35, p = .001; rs(71) = 0.51, p < .001; rs(78) = -0.47, p < .001; rs(98) = 0.46, p < .001, respectively. The association between shorter TST and depression severity was greater in patients with PD than it was in MC, p < .05.

CONCLUSION

Short TST may be an important marker, predictor, or consequence of depression severity in patients with Parkinson's disease.

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.

Cognitive behavioral therapy for insomnia in Parkinson's disease: a case series

Chronic insomnia is common in patients with Parkinson's disease. There are limited data to guide its treatment in this patient population, especially in regards to non-pharmacologic interventions, some of which are highly effective in the non-Parkinson's disease population. The aim of this study is to describe a series of Parkinson's disease patients who underwent cognitive behavioral therapy for insomnia (CBTi). Parkinson's disease patients who had undergone a baseline and at least one follow-up CBTi session were identified. Electronic medical records and pre-treatment and post-treatment patient sleep diaries were reviewed. Sleep measures of interest included wake time after sleep onset, sleep efficiency, sleep onset latency, and total sleep time. Pre-treatment and post-treatment values were compared within subjects using paired t-test. Five patients were included. Patients attended an average of eight sessions of CBTi (range 5-12). Significant increases in sleep efficiency (p = 0.02) and decreases in number of awakenings per night (p = 0.02) were found. Our data provide preliminary evidence that cognitive behavioral therapy is an effective treatment for insomnia in Parkinson's disease, and is well tolerated and well received by patients. Given the limited data supporting use of medications to treat chronic insomnia in Parkinson's disease, combined with their risks, randomized trials to demonstrate the efficacy of CBTi in Parkinson's disease are warranted.

Sleeping difficulties and health-related quality of life in Parkinson's disease

OBJECTIVE

Various sleep-related symptoms occur in Parkinson's disease (PD). Their occurrence with health-related quality of life (HRQL), comorbid sleep disorders, and other comorbidities was studied.

METHODS

Altogether, 1447 randomly selected patients with Parkinson's disease, aged 43-89 years, participated in a questionnaire study. A structured questionnaire with 207 items was based on the Basic Nordic Sleep Questionnaire. Questions on demographics, PD, sleep disorders, and comorbidities were included.

RESULTS

The response rate was 59.0%, and of these, 80% had answered to all questions that were used in the analyses (N=684). Occurrence of long sleep was found in 26.2% of the subjects, short sleep in 32.5%, poor sleep in 21.2%, sleep deprivation in 33.8%, disrupted sleep in 47.4%, and difficulties to fall asleep in 12.2%, respectively. Poor self-rated health and poor quality of life occurred in 44.4% and in 43.3% of all participants. In the logistic regression, age and gender differentially predicted long sleep and sleep deprivation, such that older age and being male were positively associated with long sleep but negatively associated with the report of sleep deprivation. Depression, subjective negative stress, and fatigue occurred with long sleep. On the other hand, poor sleep and excessive daytime sleepiness occurred with short sleep and sleep deprivation.

CONCLUSIONS

The sleep difficulties in PD are frequent. The long sleeping patients have depression, stress, and fatigue.

Impact of Mood and Behavioral Disorders on Quality of Life in Parkinson's disease

BACKGROUND

Mood symptoms negatively affect quality of life of Parkinson's disease (PD); however little is known about the impact of behavioral disorders such as impulse control disorders, and non-motor fluctuations on quality of life.

OBJECTIVE

To assess the impact of mood and behavioral disorders on quality of life in PD.

METHODS

136 (84% male) PD were included (mean age: 61 ± 8y; mean duration of disease: 8.8 ± 5.4y). Mood symptoms, behavioral disorders and non-motor fluctuations were detected and quantified using the recently validated "Ardouin Scale of Behavior in Parkinson's Disease". Motor symptoms were assessed using UPDRS and quality of life with the "39-item Parkinson's Disease Questionnaire".

RESULTS

Both motor and non-motor factors significantly affected the quality of life of PD patients. Multivariate regression of the relationship between items of the quality of life questionnaire and the Ardouin Scale showed that alteration of patients' quality of life was strongly correlated with the presence of mood symptoms (such as depression, anxiety ...) and with non-motor fluctuations (especially in the OFF period). A significant correlation was also found between the number of symptoms and their severity, and the quality of life deterioration. Some behavioral disorders (compulsive buying / eating behavior) also negatively affected patient's quality of life to a lesser extent. Alternatively, excess in motivation and hobbyism behaviors had a positive impact on mobility and emotional well-being dimensions respectively of quality of life.

CONCLUSIONS

This study shows the main impact of mood symptoms and non-motor fluctuations on worsening quality of life in PD.

Sleep Dysfunction in Parkinson's Disease

INTRODUCTION

Sleep disorders are common in Parkinson's Disease (PD). It can antedate the motor manifestations of PD. It is related primarily to the involvement of sleep regulating structures, secondary involvement through motor, depressive and dysautonomic symptoms and the tertiary involvement through anti-parkinsonian medications.

AIM

The aim of our study is to evaluate the frequency and nature of the sleep abnormalities in Idiopathic Parkinson's Disease, analysing the sleep architecture using polysomnography and to correlate the results with the disease parameters.

MATERIALS AND METHODS

A cross-sectional study was done in 50 patients who fulfill the "UK Parkinson's Disease Society Brain Bank Clinical Diagnostic Criteria". They were assessed using detailed history and clinical neurological examination. The severity of the disease was assessed based on Unified Parkinson's Disease Rating Scale (UPDRS part III) and the sleep is assessed using Parkinson's Disease Sleepiness Scale (PDSS) and Epworth Sleepiness Scale (ESS). Objective sleep study was done using polysomnography.

RESULTS

Disturbed sleep was reported by 70% of patients. Sixty percent of them had difficulty in falling asleep and 48% had difficulty in maintaining the sleep due to frequent awakenings. Day time somnolence was reported by 30% of patients. Polysomnographic analysis showed reduced total sleep time in 40 patients (80%). Correlation analysis of the total sleep time, sleep efficiency, deep sleep time, REM sleep time with the disease duration, staging, severity, PDSS Score, showed significant positive correlation (p<0.05). Sleep related movement disorders like Periodic Limb Movements (PLMS), Restless Leg Syndrome (RLS) also showed inverse correlation with disease duration and severity (p<0.05).

CONCLUSION

Sleep architecture is markedly disturbed in patients with Idiopathic Parkinson's disease. There is a reduction in the total sleep time, deep sleep time and REM Sleep duration. Periodic limb movements in sleep, restless leg syndrome, and obstructive sleep apnea contributes to the sleep fragmentation resulting in defective day time functioning.

Sleep, Cognition and Dementia

The older patient population is growing rapidly around the world and in the USA. Almost half of seniors over age 65 who live at home are dissatisfied with their sleep, and nearly two-thirds of those residing in nursing home facilities suffer from sleep disorders. Chronic and pervasive sleep complaints and disturbances are frequently associated with excessive daytime sleepiness and may result in impaired cognition, diminished intellect, poor memory, confusion, and psychomotor retardation all of which may be misinterpreted as dementia. The key sleep disorders impacting patients with dementia include insomnia, hypersomnolence, circadian rhythm misalignment, sleep disordered breathing, motor disturbances of sleep such as periodic leg movement disorder of sleep and restless leg syndrome, and parasomnias, mostly in the form of rapid eye movement (REM) sleep behavior disorder (RBD). RBD is a pre-clinical marker for a class of neurodegenerative diseases, the "synucleinopathies", and requires formal polysomnographic evaluation. Untreated sleep disorders may exacerbate cognitive and behavioral symptoms in patients with dementia and are a source of considerable stress for bed partners and family members. When left untreated, sleep disturbances may also increase the risk of injury at night, compromise health-related quality of life, and precipitate and accelerate social and economic burdens for caregivers.

Parkinson's disease and sleep/wake disturbances

Sleep disturbances are a common non-motor feature in patients with Parkinson's disease (PD). Early diagnosis and appropriate management are imperative for enhancing patient quality of life. Sleep disturbances can be caused by multiple factors in addition to age-related changes in sleep, such as nocturnal motor symptoms (rigidity, resting tremor, akinesia, tardive dyskinesia, and the "wearing off" phenomenon), non-motor symptoms (pain, hallucination, and psychosis), nocturia, and medication. Disease-related pathology involving the brainstem and changes in the neurotransmitter systems (norepinephrine, serotonin, and acetylcholine) responsible for regulating sleep structure and the sleep/wake cycle play a role in emerging excessive daytime sleepiness and sleep disturbances. Additionally, screening for sleep apnea syndrome, rapid eye movement sleep behavior disorder, and restless legs syndrome is clinically important. Questionnaire-based assessment utilizing the PD Sleep Scale-2 is useful for screening PD-related nocturnal symptoms. In this review, we focus on the current understanding and management of sleep disturbances in PD.