Daytime sleepiness in elderly Parkinson's disease patients and treatment with the psychostimulant modafinil: A preliminary study

Parkinson's disease: a review of non-motor symptoms

Parkinson's disease (PD) is a neurodegenerative disorder resulting from degeneration of the substantia nigra and the dopaminergic nigrostriatal pathway. Most treatments are geared toward the management and relief of motor symptoms in Parkinson's patients; however, as the disease progresses, various complications can be observed. Non-motor symptoms (NMS) may arise simply from the disease itself and are highly destructive to quality of life. These symptoms include mood disorders, cognitive dysfunction, pain, sensory dysfunction, and dysautonomia. Though it is undisputed that many NMS may appear years or even decades prior to the clinical diagnosis of PD, the focus of this review will be the overt motor phase of the condition. As such, the focus of this paper is to review the major NMS found in PD patients status post-diagnosis, their etiology, as well as treatment options available for the individual NMS.

Modafinil: Parkinson disease-related somnolence

This Hospital Pharmacy feature is extracted from Off-Label Drug Facts, a publication available from Wolters Kluwer Health. Off-Label Drug Facts is a practitioner-oriented resource for information about specific drug uses that are unapproved by the US Food and Drug Administration. This new guide to the literature enables the health care professional or clinician to quickly identify published studies on off-label uses and determine if a specific use is rational in a patient care scenario. References direct the reader to the full literature for more comprehensive information before patient care decisions are made. Direct questions or comments regarding Off-Label Drug Uses to jgeneral@ku.edu.

Efficacy of modafinil on fatigue and excessive daytime sleepiness associated with neurological disorders: a systematic review and meta-analysis

Background

Modafinil is a novel wake-promoting agent approved by the FDA ameliorating excessive daytime sleepiness (EDS) in three disorders: narcolepsy, shift work sleep disorder and obstructive sleep apnea. Existing trials of modafinil for fatigue and EDS associated with neurological disorders provided inconsistent results. This meta-analysis was aimed to assess drug safety and effects of modafinil on fatigue and EDS associated with neurological disorders.

Methods

A comprehensive literature review was conducted in order to identify published studies assessing the effects of modafinil on fatigue and EDS associated with neurological disorders. Primary outcomes included fatigue and EDS. Secondary outcomes included depression and adverse effects.

Findings

Ten randomized controlled trials were identified including 4 studies of Parkinson’s disease (PD), 3 of multiple sclerosis (MS), 2 of traumatic brain injury (TBI) and 1 of post-polio syndrome (PPS). A total of 535 patients were enrolled. Our results suggested a therapeutic effect of modafinil on fatigue in TBI (MD -0.82 95% CI -1.54 - -0.11 p=0.02, I²=0%), while a beneficial effect of modafinil on fatigue was not confirmed in the pooled studies of PD or MS. Treatment results demonstrated a clear beneficial effect of modafinil on EDS in patients with PD (MD -2.45 95% CI -4.00 - -0.91 p=0.002 I²=14%), but not with MS and TBI. No difference was seen between modafinil and placebo treatments in patients with PPS. Modafinil seemed to have no therapeutic effect on depression. Adverse events were similar between modafinil and placebo groups except that more patients were found with insomnia and nausea in modafinil group.

Conclusions

Existing trials of modafinil for fatigue and EDS associated with PD, MS, TBI and PPS provided inconsistent results. The majority of the studies had small sample sizes. Modafinil is not yet sufficient to be recommended for these medical conditions until solid data are available.

Agitation and psychosis associated with dementia with lewy bodies exacerbated by modafinil use

Dementia with Lewy bodies (DLB) is commonly associated with excessive daytime somnolence (EDS). Modafinil is a wakefulness-promoting agent that is considered to have limited interaction with the dopaminergic system. As individuals with DLB are predisposed to psychotic symptoms that might be exacerbated by dopaminergic stimulation, modafinil is considered to be an attractive option for the treatment of EDS in DLB. We describe 2 cases in which administration of modafinil exacerbated agitation and hallucinations in DLB, and we also review data that may explain the mechanisms underlying this effect. In both cases, psychotic symptoms emerged concomitantly with modafinil administration and remitted following its discontinuation. Although definitive data regarding the benefits and adverse effects of modafinil for the treatment of EDS in DLB await controlled prospective randomized studies, our observations warrant caution regarding its use in this context.

Treatment options for sleep dysfunction in Parkinson's disease

OPINION STATEMENT

Sleep disturbance is an important feature of Parkinson's disease (PD) that deserves clinical attention. Various disorders need to be considered and treatment should be customized to the patient's specific symptoms and lifestyle. Evaluation of a PD patient complaining of difficulty sleeping begins with a detailed history from the patient and bed partner about the specific problem the patient is experiencing. It is important to inquire about difficulties with sleep onset, frequent awakenings, increased movements during sleep, acting out dreams, uncomfortable motor symptoms, disordered breathing, and nocturia. Current medications should be reviewed to determine whether the recent addition of a drug or a change in dose may be contributing to sleep difficulties, and one should ask about daytime sleepiness, frequent daytime naps, and sleep hygiene in the evening that can contribute to problems sleeping at night. The goal of therapy is to restore quality nighttime sleep without excessive daytime sedation and to improve the patient's daily mental and physical function and overall quality of life.

Sleep-wake changes and cognition in neurodegenerative disease

With the increasing aging population, neurodegenerative disorders will become more common in clinical practice. These disorders involve multiple pathophysiological mechanisms that differentially affect cognition, mood, and physical functions. Possibly due to the involvement of common underlying neurobiological circuits, sleep and/or circadian (sleep-wake) changes are also common in this disease group. Of significance, sleep-wake changes are often a prodromal feature and are predictive of cognitive decline, psychiatric symptoms, quality of life, need for institutional care, and caregiver burden. Unfortunately, in neurodegenerative disease, few studies have included detailed polysomnography or neuropsychological assessments although some data indicate that sleep and neurocognitive features are related. Further studies are also required to address the effects of pharmacological and nonpharmacological treatments on cognitive functioning. Such research will hopefully lead to targeted early intervention approaches for cognitive decline in older people.