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Mutti C, Sarnataro RB, Beretta J, Enzo P, Negrotti A, Rausa F, Pizzarotti S, Parrino L. Rasagiline, sleep quality and well-being in Parkinson’s disease: a pilot study. Neurol Sci 2022; 43:4791-4796. [PMID: 35334012 PMCID: PMC8948046 DOI: 10.1007/s10072-022-06008-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/11/2022] [Indexed: 10/29/2022]
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2
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Tsuboi T, Satake Y, Hiraga K, Yokoi K, Hattori M, Suzuki M, Hara K, Ramirez-Zamora A, Okun MS, Katsuno M. Effects of MAO-B inhibitors on non-motor symptoms and quality of life in Parkinson's disease: A systematic review. NPJ Parkinsons Dis 2022; 8:75. [PMID: 35697709 PMCID: PMC9192747 DOI: 10.1038/s41531-022-00339-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 05/24/2022] [Indexed: 11/09/2022] Open
Abstract
Non-motor symptoms (NMS) are common among patients with Parkinson's disease and reduce patients' quality of life (QOL). However, there remain considerable unmet needs for NMS management. Three monoamine oxidase B inhibitors (MAO-BIs), selegiline, rasagiline, and safinamide, have become commercially available in many countries. Although an increasing number of studies have reported potential beneficial effects of MAO-BIs on QOL and NMS, there has been no consensus. Thus, the primary objective of this study was to provide an up-to-date systematic review of the QOL and NMS outcomes from the available clinical studies of MAO-BIs. We conducted a literature search using the PubMed, Scopus, and Cochrane Library databases in November 2021. We identified 60 publications relevant to this topic. Overall, rasagiline and safinamide had more published evidence on QOL and NMS changes compared with selegiline. This was likely impacted by selegiline being introduced many years prior to the field embarking on the study of NMS. The impact of MAO-BIs on QOL was inconsistent across studies, and this was unlikely to be clinically meaningful. MAO-BIs may potentially improve depression, sleep disturbances, and pain. In contrast, cognitive and olfactory dysfunctions are likely unresponsive to MAO-BIs. Given the paucity of evidence and controlled, long-term studies, the effects of MAO-BIs on fatigue, autonomic dysfunctions, apathy, and ICD remain unclear. The effects of MAO-BIs on static and fluctuating NMS have never been investigated systematically. More high-quality studies will be needed and should enable clinicians to provide personalized medicine based on a non-motor symptom profile.
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Affiliation(s)
- Takashi Tsuboi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Yuki Satake
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Keita Hiraga
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Katsunori Yokoi
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Neurology, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Makoto Hattori
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Masashi Suzuki
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.,Department of Clinical laboratory, Nagoya University Hospital, Nagoya, Japan
| | - Kazuhiro Hara
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Adolfo Ramirez-Zamora
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Michael S Okun
- Department of Neurology, Norman Fixel Institute for Neurological Diseases, University of Florida, Gainesville, FL, USA
| | - Masahisa Katsuno
- Department of Neurology, Nagoya University Graduate School of Medicine, Nagoya, Japan.
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3
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Tan YY, Jenner P, Chen SD. Monoamine Oxidase-B Inhibitors for the Treatment of Parkinson's Disease: Past, Present, and Future. JOURNAL OF PARKINSON'S DISEASE 2022; 12:477-493. [PMID: 34957948 PMCID: PMC8925102 DOI: 10.3233/jpd-212976] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/13/2022]
Abstract
Monoamine oxidase-B (MAO-B) inhibitors are commonly used for the symptomatic treatment of Parkinson's disease (PD). MAO-B inhibitor monotherapy has been shown to be effective and safe for the treatment of early-stage PD, while MAO-B inhibitors as adjuvant drugs have been widely applied for the treatment of the advanced stages of the illness. MAO-B inhibitors can effectively improve patients' motor and non-motor symptoms, reduce "OFF" time, and may potentially prevent/delay disease progression. In this review, we discuss the effects of MAO-B inhibitors on motor and non-motor symptoms in PD patients, their mechanism of action, and the future development of MAO-B inhibitor therapy.
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Affiliation(s)
- Yu-Yan Tan
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Peter Jenner
- Neurodegenerative Diseases Research Group, Institute of Pharmaceutical Sciences, Faculty of Health Sciences and Medicine, King’s College, London, UK
| | - Sheng-Di Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Lab for Translational Research of Neurodegenerative Diseases, Institute of Immunochemistry, Shanghai Tech University, Shanghai, China
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4
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Riccardi C, Napolitano F, Montesarchio D, Sampaolo S, Melone MAB. Nanoparticle-Guided Brain Drug Delivery: Expanding the Therapeutic Approach to Neurodegenerative Diseases. Pharmaceutics 2021; 13:1897. [PMID: 34834311 PMCID: PMC8623286 DOI: 10.3390/pharmaceutics13111897] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 10/31/2021] [Accepted: 11/04/2021] [Indexed: 02/07/2023] Open
Abstract
Neurodegenerative diseases (NDs) represent a heterogeneous group of aging-related disorders featured by progressive impairment of motor and/or cognitive functions, often accompanied by psychiatric disorders. NDs are denoted as 'protein misfolding' diseases or proteinopathies, and are classified according to their known genetic mechanisms and/or the main protein involved in disease onset and progression. Alzheimer's disease (AD), Parkinson's disease (PD) and Huntington's disease (HD) are included under this nosographic umbrella, sharing histopathologically salient features, including deposition of insoluble proteins, activation of glial cells, loss of neuronal cells and synaptic connectivity. To date, there are no effective cures or disease-modifying therapies for these NDs. Several compounds have not shown efficacy in clinical trials, since they generally fail to cross the blood-brain barrier (BBB), a tightly packed layer of endothelial cells that greatly limits the brain internalization of endogenous substances. By engineering materials of a size usually within 1-100 nm, nanotechnology offers an alternative approach for promising and innovative therapeutic solutions in NDs. Nanoparticles can cross the BBB and release active molecules at target sites in the brain, minimizing side effects. This review focuses on the state-of-the-art of nanoengineered delivery systems for brain targeting in the treatment of AD, PD and HD.
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Affiliation(s)
- Claudia Riccardi
- Department of Chemical Sciences, University of Naples Federico II, Via Cintia 21, I-80126 Naples, Italy; (C.R.); (D.M.)
| | - Filomena Napolitano
- Department of Advanced Medical and Surgical Sciences, 2nd Division of Neurology, Center for Rare Diseases and InterUniversity Center for Research in Neurosciences, University of Campania Luigi Vanvitelli, Via Sergio Pansini, 5, I-80131 Naples, Italy; (F.N.); (S.S.)
| | - Daniela Montesarchio
- Department of Chemical Sciences, University of Naples Federico II, Via Cintia 21, I-80126 Naples, Italy; (C.R.); (D.M.)
| | - Simone Sampaolo
- Department of Advanced Medical and Surgical Sciences, 2nd Division of Neurology, Center for Rare Diseases and InterUniversity Center for Research in Neurosciences, University of Campania Luigi Vanvitelli, Via Sergio Pansini, 5, I-80131 Naples, Italy; (F.N.); (S.S.)
| | - Mariarosa Anna Beatrice Melone
- Department of Advanced Medical and Surgical Sciences, 2nd Division of Neurology, Center for Rare Diseases and InterUniversity Center for Research in Neurosciences, University of Campania Luigi Vanvitelli, Via Sergio Pansini, 5, I-80131 Naples, Italy; (F.N.); (S.S.)
- Sbarro Institute for Cancer Research and Molecular Medicine, Center for Biotechnology, Temple University, Philadelphia, PA 19122-6078, USA
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5
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Mc Carthy CE. Sleep Disturbance, Sleep Disorders and Co-Morbidities in the Care of the Older Person. Med Sci (Basel) 2021; 9:medsci9020031. [PMID: 34063838 PMCID: PMC8162526 DOI: 10.3390/medsci9020031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/17/2021] [Accepted: 05/18/2021] [Indexed: 01/14/2023] Open
Abstract
Sleep complaints can be both common and complex in the older patient. Their consideration is an important aspect of holistic care, and may have an impact on quality of life, mortality, falls and disease risk. Sleep assessment should form part of the comprehensive geriatric assessment. If sleep disturbance is brought to light, consideration of sleep disorders, co-morbidity and medication management should form part of a multifaceted approach. Appreciation of the bi-directional relationship and complex interplay between co-morbidity and sleep in older patients is an important element of patient care. This article provides a brief overview of sleep disturbance and sleep disorders in older patients, in addition to their association with specific co-morbidities including depression, heart failure, respiratory disorders, gastro-oesophageal reflux disease, nocturia, pain, Parkinson's disease, dementia, polypharmacy and falls. A potential systematic multidomain approach to assessment and management is outlined, with an emphasis on non-pharmacological treatment where possible.
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Affiliation(s)
- Christine E. Mc Carthy
- Department of Geriatric Medicine, University Hospital Galway, Galway, Ireland;
- HRB-Clinical Research Facility, National University of Ireland, Galway, Co., Galway, Ireland
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Zuzuárregui JRP, During EH. Sleep Issues in Parkinson's Disease and Their Management. Neurotherapeutics 2020; 17:1480-1494. [PMID: 33029723 PMCID: PMC7851262 DOI: 10.1007/s13311-020-00938-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 12/13/2022] Open
Abstract
Parkinson's disease (PD) is an alpha-synucleinopathy that leads to prominent motor symptoms including tremor, bradykinesia, and postural instability. Nonmotor symptoms including autonomic, neurocognitive, psychiatric symptoms, and sleep disturbances are also seen frequently in PD. The impact of PD on sleep is related to motor and nonmotor symptoms, in addition to the disruption of the pathways regulating sleep by central nervous system pathology. Rapid eye movement sleep behavior disorder is a parasomnia that can lead to self-injury and/or injury to partners at night. Restless legs syndrome is a subjective sensation of discomfort and urge to move the legs prior to falling asleep and can lead to insomnia and reduced sleep quality. Excessive daytime sleepiness is common in PD and exerts a negative impact on quality of life in addition to increasing the risk of falls. Obstructive sleep apnea is a breathing disorder during sleep that can cause frequent awakenings and excessive daytime sleepiness. Circadian rhythm dysfunction can lead to an advanced or delayed onset of sleep in patients and create disruption of normal sleep and wake times. All of these disorders are common in PD and can significantly reduce sleep quantity, sleep quality, or quality of life for patients and caretakers. Treatment approaches for each of these disorders are distinct and should be individualized to the patient. We review the literature regarding these common sleep issues encountered in PD and their treatment options.
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Affiliation(s)
| | - Emmanuel H During
- Stanford Center for Sleep Sciences and Medicine, Department of Psychiatry and Behavioral Sciences, Stanford University Medical Center, Palo Alto, CA, USA
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Lebrun C, Gély‐Nargeot M, Rossignol A, Geny C, Bayard S. Efficacy of cognitive behavioral therapy for insomnia comorbid to Parkinson's disease: A focus on psychological and daytime functioning with a single‐case design with multiple baselines. J Clin Psychol 2019; 76:356-376. [DOI: 10.1002/jclp.22883] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
| | | | - Alexia Rossignol
- Neurology DepartmentParkinson's Disease Expert Centre, Gui de Chauliac HospitalMontpellier France
| | - Christian Geny
- Neurology DepartmentParkinson's Disease Expert Centre, Gui de Chauliac HospitalMontpellier France
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Liu CF, Wang T, Zhan SQ, Geng DQ, Wang J, Liu J, Shang HF, Wang LJ, Chan P, Chen HB, Chen SD, Wang YP, Zhao ZX, Chaudhuri KR. Management Recommendations on Sleep Disturbance of Patients with Parkinson's Disease. Chin Med J (Engl) 2018; 131:2976-2985. [PMID: 30539911 PMCID: PMC6302643 DOI: 10.4103/0366-6999.247210] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Indexed: 02/05/2023] Open
Affiliation(s)
- Chun-Feng Liu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215004, China
- Institute of Neuroscience, Soochow University, Suzhou, Jiangsu 215004, China
| | - Tao Wang
- Department of Neurology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430022, China
| | - Shu-Qin Zhan
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China
| | - De-Qin Geng
- Department of Neurology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu 221006, China
| | - Jian Wang
- Department of Neurology and National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai 200040, China
| | - Jun Liu
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200025, China
| | - Hui-Fang Shang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Li-Juan Wang
- Department of Neurology, Guangdong Neuroscience Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong 510080, China
| | - Piu Chan
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China
| | - Hai-Bo Chen
- Department of Neurology, Beijing Hospital, National Center of Gerontology, Beijing 100730, China
| | - Sheng-Di Chen
- Department of Neurology and Institute of Neurology, Ruijin Hospital Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai 200025, China
| | - Yu-Ping Wang
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing 100053, China
| | - Zhong-Xin Zhao
- Department of Neurology, Changzheng Hospital, Second Military Medical University, Shanghai 200003, China
| | - K Ray Chaudhuri
- National Parkinson Foundation Centre of Excellence and The Maurice Wohl Clinical Neuroscience Institute, King's College London and King's College Hospital, London WC2R 2LS, UK
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Schrempf W, Fauser M, Wienecke M, Brown S, Maaß A, Ossig C, Otto K, Brandt MD, Löhle M, Schwanebeck U, Graehlert X, Reichmann H, Storch A. Rasagiline improves polysomnographic sleep parameters in patients with Parkinson's disease: a double-blind, baseline-controlled trial. Eur J Neurol 2018; 25:672-679. [PMID: 29322594 DOI: 10.1111/ene.13567] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 01/08/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The aim was to study the effects of rasagiline on sleep quality in patients with Parkinson's disease (PD) with sleep disturbances. Sleep disorders are common in PD. Rasagiline is widely used in patients with PD, but double-blind polysomnographic trials on its effects on sleep disturbances are missing. METHODS This was a single-center, double-blind, baseline-controlled investigator-initiated clinical trial of rasagiline (1 mg/day) over 8 weeks in patients with PD with sleep disturbances. Blinding was achieved by running a strategic matched placebo parallel group. Co-primary outcome measures were the changes between baseline and end of the treatment period in sleep maintenance/efficiency as assessed by polysomnography and the Parkinson's Disease Sleep Scale Version 2 (PDSS-2) score. RESULTS A total of 20 of 30 patients were randomized to rasagiline (mean ± SD age, 69.9 ± 6.9 years; 10 male; Hoehn-Yahr stage, 1.9 ± 0.8). Compared with baseline, sleep maintenance was significantly increased at the end of the treatment period (relative change normalized to baseline, +16.3 ± 27.9%; P = 0.024, paired two-sided t-test) and a positive trend for sleep efficiency was detected (+12.1 ± 28.6%; P = 0.097). Treatment with rasagiline led to significantly decreased wake time after sleep onset, number of arousals, percentage of light sleep and improved daytime sleepiness as measured by the Epworth Sleepiness Scale. We did not observe changes in the co-primary endpoint PDSS-2 score, and no correlations of polysomnographic sleep parameters or PDSS-2 score with motor function (Unified Parkinson's Disease Rating Scale motor score). Rasagiline was well tolerated with no unexpected adverse events. CONCLUSIONS In patients with PD with sleep disturbances, rasagiline showed beneficial effects on sleep quality as measured by polysomnography. These effects were probably not related to motor improvement or translated into improved overall sleep quality perception by patients.
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Affiliation(s)
- W Schrempf
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Interdisciplinary Sleep Laboratory, Technische Universität Dresden, Dresden, Germany
| | - M Fauser
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, University of Rostock, Rostock, Germany
| | - M Wienecke
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Interdisciplinary Sleep Laboratory, Technische Universität Dresden, Dresden, Germany
| | - S Brown
- Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - A Maaß
- Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - C Ossig
- Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - K Otto
- Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - M D Brandt
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Interdisciplinary Sleep Laboratory, Technische Universität Dresden, Dresden, Germany
| | - M Löhle
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, University of Rostock, Rostock, Germany.,German Center for Neurodegenerative Diseases (DZNE) Rostock, Rostock, Germany
| | - U Schwanebeck
- Koordinierungszentrum für Klinische Studien (Coordination Center for Clinical Trials), Technische Universität Dresden, Dresden, Germany
| | - X Graehlert
- Koordinierungszentrum für Klinische Studien (Coordination Center for Clinical Trials), Technische Universität Dresden, Dresden, Germany
| | - H Reichmann
- Department of Neurology, Technische Universität Dresden, Dresden, Germany
| | - A Storch
- Department of Neurology, Technische Universität Dresden, Dresden, Germany.,Interdisciplinary Sleep Laboratory, Technische Universität Dresden, Dresden, Germany.,Department of Neurology, University of Rostock, Rostock, Germany.,German Center for Neurodegenerative Diseases (DZNE) Rostock, Rostock, Germany
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Loddo G, Calandra-Buonaura G, Sambati L, Giannini G, Cecere A, Cortelli P, Provini F. The Treatment of Sleep Disorders in Parkinson's Disease: From Research to Clinical Practice. Front Neurol 2017; 8:42. [PMID: 28261151 PMCID: PMC5311042 DOI: 10.3389/fneur.2017.00042] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Accepted: 01/30/2017] [Indexed: 12/29/2022] Open
Abstract
Sleep disorders (SDs) are one of the most frequent non-motor symptoms of Parkinson’s disease (PD), usually increasing in frequency over the course of the disease and disability progression. SDs include nocturnal and diurnal manifestations such as insomnia, REM sleep behavior disorder, and excessive daytime sleepiness. The causes of SDs in PD are numerous, including the neurodegeneration process itself, which can disrupt the networks regulating the sleep–wake cycle and deplete a large number of cerebral amines possibly playing a role in the initiation and maintenance of sleep. Despite the significant prevalence of SDs in PD patients, few clinical trials on SDs treatment have been conducted. Our aim is to critically review the principal therapeutic options for the most common SDs in PD. The appropriate diagnosis and treatment of SDs in PD can lead to the consolidation of nocturnal sleep, the enhancement of daytime alertness, and the amelioration of the quality of life of the patients.
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Affiliation(s)
- Giuseppe Loddo
- Department of Biomedical and Neuromotor Sciences, University of Bologna , Bologna , Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Luisa Sambati
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Giulia Giannini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Annagrazia Cecere
- Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna , Bologna , Italy
| | - Pietro Cortelli
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Federica Provini
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy; Bellaria Hospital, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
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