Movement Disorders Vol. 5 , No. 4, 1990, pp. 280-285 0 1990 Movement Disorder Society

Sleep Disorders and Sleep Effect in Parkinson’s Disease Stewart A. Factor, *Terence McAlarney, “Juan R. Sanchez-Ramos, and *William J. Weiner Albany Medical College Department of Neurology, Albany, New York, and *University of Miami Department of Neurology, Miami, Florida, U . S . A .

Summary: It has been suggested that sleep may have a positive effect on morning motor symptoms in Parkinson’s disease (PD). We examined this possibility and also looked at common sleep disorders in PD. Seventy-eight PD patients and 43 normal elderly subjects answered a questionnaire. Of the PD patients, 43.6% reported improved motor symptoms in the morning, 37.2% worse, and 19.2% unchanged compared to the rest of the day. No difference was found between morning-better and -worse groups with respect to age, duration or stage of PD; antiparkinsonian medications utilized, and predominant motor symptoms. However, the morning-same group had a shorter duration of PD and less severe disease and required fewer dopaminergic medications. Sleep disorders were seen with equal frequency in the morning-better and -worse groups. Our results suggest that sleep does not have a direct effect on morning motor function. Alterations in morning motor symptomatology probably represent a manifestation of motor fluctuations. Sleep fragmentation and spontaneous daytime dozing occurred much more frequently in PD patients than controls. In addition, nocturnal vocalizations and daytime hallucinations occurred only in the PD group. Key Words: Parkinson’s disease-Sleep disorders-Motor fluctuations-Sleep effect.

performance differ in any way from other PD patients. Sleep disorders are a common problem in PD (3). Difficulty with sleep maintenance (sleep fragmentation) is the earliest and most frequent sleep disorder in these patients (3,4). Other common sleepassociated complaints include excessive daytime sleepiness and parasomnias such as nocturnal vocalizations and altered dreaming. A typical pattern of sleep disruption has not been clearly delineated in PD (5,6), and the etiology of such problems is unknown. Whether these disorders are related to the disease process itself (5,7) or to complications of medical therapy (3) is unclear. Sleep disorders are also common in the normal elderly population (4), suggesting that normal aging may play a role in the etiology of sleep disorders in PD. This study also examines the frequency of various sleep disor-

The effect of sleep on motor performance in Parkinson’s disease (PD) is often commented on by patients. Some have observed that they function better in the morning compared to the rest of the day (1,2). It has been suggested that this is due to improved dopaminergic function because of an increase in the storage of dopamine in nigral neuronal terminals during sleep (2). This study evaluates whether or not there is any consistent effect of sleep on motor function in PD. It also addresses the question of whether or not those patients who report a beneficial effect of sleep on their morning motor Address correspondence and reprint requests to Dr. S. A. Factor, Albany Medical College, Department of Neurology (A-70), New Scotland Ave., Albany, NY 12208, U.S.A. This study was presented in part at the 40th annual meeting of the American Academy of Neurology, Cincinnati, Ohio, 1988.

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ders in PD and compares them to that of normal elderly subjects.

PATIENTS AND METHODS Seventy-eight consecutive PD patients (46 men and 32 women) and 43 healthy elderly control subjects (21 men and 22 women) participated in this study. Mean age of the PD patients was 67 (range, 41-86); mean duration of PD, 6.7 years (range, 1 month-20 years); and mean Hoehn and Yahr stage was 2.7 (range, 1-4). Only three of the patients had signs and symptoms of dementia. A questionnaire was completed during an outpatient visit. Patients were first questioned with regard to four categories of sleep disorders. These included sleep initiation (whether or not it was difficult to fall asleep and how many minutes were required: 0-20, 21-45, >45), sleep maintenance (number of awakenings that occurred each night: &l, 2-3, 4-5, >5), parasomnias (nocturnal vocalizations, alterations in dreaming content, and daytime hallucinations), and daytime somnolence (napping and spontaneous dozing). Questions were posed to family members when appropriate. The second part of the questionnaire evaluated the effect of sleep on the motor symptomatology of PD. Patients were asked if morning was their best or worst part of the day with regard to motor performance or whether there was any difference compared to the rest of the day. Additional information was obtained regarding predominant symptomatology of PD, antiparkinsonian medications, and sleep medication requirements. The healthy elderly subjects were independent and living in the community. These subjects were participating, as controls, in neuropsychologic research at the University of Miami. Mean age for this group was 63 (range, 48-87). They had no neurologic diseases. The questionnaire administered was the same except the questions related to PD were omitted. Patients with PD whose conditions were better, worse, or the same in the morning were compared with regard to age, duration of disease, Hoehn and Yahr stage, and predominant symptomatology . The percentage of patients in each group taking different antiparkinsonian medications was also compared, but the total doses and timing of doses were not, as the information gathered was difficult to analyze. In addition, morning better and worse groups were compared with regard to sleep initiation and maintenance to evaluate the effect on morning functioning. Aspects of sleep disorders in PD patients and

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elderly controls were also compared. RS1 statistics software was used to run chi-squared analysis of the information that is frequency (of symptoms) data. The contingency table is suited for answering the key question as to whether variables are statistically independent. RESULTS Our analysis of the effect of sleep on motor symptomatology revealed that 43.6% of PD patients felt that morning was the time of best motor performance. Mean age in this group was 67.6, mean Hoehn and Yahr stage was 2.8, and duration of disease was 7.3 years. There were 37.2% of PD patients who felt that morning was the time of worst motor performance. Their mean age was 63.8 years, mean Hoehn and Yahr stage was 2.6, and mean disease duration was 7.4 years. There were 19.2% of PD patients who noticed no difference between morning and the rest of the day with regard to severity of PD symptoms. Mean age and Hoehn and Yahr stage were similar to those of the other two groups (66.8 and 2.4). However, mean duration of disease was substantially shorter than that of the other two groups (4.8 years). No significant relationship was demonstrated between predominant PD symptomatology or antiparkinsonian medications utilized and whether patients were in the morning-better or morning-worse groups. However, x2 analysis demonstrated a dependence between major PD symptoms and whether the patients were in the morning-same group (p = 0.005), with the morning-same group having less postural instability, rigidity, and tremor. Analysis also demonstrated a dependence between use of antiparkinsonian medications and whether or not they were in the morning-same group (p < 0.03), with the morning-same group utilizing fewer medications (see Table 1 for data summary). A comparison of sleep initiation and maintenance between morningbetter and -worse groups was performed to see if either of these factors played a role in morning function (Table 2). Differences were not significant. Difficulty with sleep initiation was experienced by 66.6% of PD patients and 53.5% of elderly controls. The number of minutes required to initiate sleep overall was similar in both groups. The differences were not signifcant (Table 3). There were 88.5% of PD patients who complained of difficulty with maintaining sleep, and most awakened two to five times per night. Of control subjects, 74.4% complained of difficulty with sleep fragmentation,

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TABLE 1. Predominant symptomatology and antiparkinsonian medications in morning-better, morning-worse, and morning-same groups Predominant symptomatology

Parkinsonian medications

Group

Tremor

Rigidity

Bradykinesia

Postural instability

Sinemet

Anticholinergics

Amantadine

Dopamine agonists

Better Worse Same

47.0 41.4 20.0

32.4 44.8 13.3

50.0 48.3 40.0

38.2 37.9 6.7

97.0 96.6 46.7

35.3 24.1 6.7

23.5 20.7 6.6

35.3 51.7 13.3

All data given as percentages of the total number of patients in each group.

awakening one to three times per night. Chisquared analysis demonstrated a dependence between awakenings and the presence of PD (p < 0.05) (Table 3). Nocturnal vocalizations and daytime hallucinations occurred frequently in PD patients, while neither occurred in the control group. Spontaneous dozing was more common in PD patients than controls. Altered dream content and daytime napping were equal for both groups. x2 analysis demonstrated a dependence between these five features and PD (p = 0.0001) (see Table 4 for data summary). The PD patients more frequently utilized sleep medications than controls (Table 5); however, x2 analysis could not be performed because several values were too small. DISCUSSION This study evaluated subjective sleep data retrieved through a questionnaire survey of PD patients and elderly controls. Actual sleep studies were not performed. The results are an indication of how the subjects perceive their problems in sleep and the effect on motor symptoms. Limitations of this method are related to accuracy of reporting by subjects (and their families) and correlation (or lack thereof) of subjective complaints with objective findings that might be documented with electrophysiologic studies. However, our results were comparable in many ways to results of previously

performed sleep studies. Despite expected limitations, information gathered in this manner with regard to sleep and its relation to the motor aspects of disease is clearly of value in day-to-day patient care and can be useful when studying sleep patterns and fluctuations in disability in PD. Both sleep initiation and maintenance problems were common in PD patients and in healthy elderly subjects. No significant differences were seen with regard to sleep initiation; however, difficulties with sleep maintenance were more common in PD. Daytime napping was also a common feature in both groups, although PD patients experienced spontaneous dozing twice as often as the normal elderly. Daytime hallucinations and nocturnal vocalizations were characteristic of the PD group, with neither occurring in the control group. Altered dreaming content occurred with equal frequency in both groups. Finally, PD patients required more sleep medication than elderly controls. Previous questionnaire studies evaluating sleep disorders in PD patients (3,8,9) have not included a normal elderly control group. This may explain some of the discrepancies between these reports and ours. Sleep initiation problems were considered common in the general population but rare in PD by some investigators (3,4). When these difficulties arose in PD patients they were attributed to an early amphetamine-like effect of levodopa that disappears with time (3) or to severity of illness (10). This

TABLE 2. Sleep initiation and maintenance in morning-better and morning-worse groups Sleep initiation

Sleep maintenance No. of awakenings

Minutes Group

Total

0-20

20-45

>45

Total

1

2-3

6 5

>5

Better Worse

76.5 58.6

26.5 31.0

20.6 13.8

29.4 13.8

79.4 93.1

14.7 20.1

44.1 37.9

17.7 31.0

2.9 3.5

The total represents the percentage of patients in each group reporting difficulties with sleep initiation and maintenance. All other numbers are percentages of the total number of patients in each group who required a certain amount of time to fall asleep or reported a particular number of awakenings per night.

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TABLE 3. Sleep initiation and sleep maintenance difficulties in Parkinson’s disease (PO) patients and elderly controls Sleep initiation

Sleep maintenance No. of awakenings

Minutes

PD patients Elderly controls

Total

0-20

20-45

>45

Total

1

2-3

4-5

>5

66.6 53.5

29.5 27.9

16.7 11.6

20.5 14.0

88.5 74.4

16.6 27.9

43.6 27.9

24.4 18.6

3.9 0

The total represents the percentage of patients in each group reporting difficulties with sleep initiation and maintenance. All numbers are percentages of the total number of subjects in each group.

was not the case in our study. Sleep initiation difficulties are present in equal proportions in both control and PD subjects, suggesting that when difficulty with sleep initiation arises in patients with PD, age may be an important factor. Kales et al. (1 l), in an electrophysiologic study, also found sleep initiation problems to be prominent in PD patients; however, normal elderly subjects were not as severely affected. These findings suggest that disease-related factors may also play a role in the etiology of sleep initiation difficulties in PD. They also found that sleep initiation problems did not change with levodopa therapy. In this study, the most common sleep disorder in PD patients was difficulty with sleep maintenance (sleep fragmentation). This is in agreement with previous reports (3,4). Sleep fragmentation was also common in the control group; however, they awakened less frequently. Difficulties with sleep maintenance may also be related to age. However, its significantly higher prevalence in PD suggests that the disease itself may play a more important role. Nausieda et al. (3) found no correlation between sleep fragmentation and age in PD patients. Elderly controls were not evaluated in that study. Kales et al. (1 1) also showed that sleep fragmentation was a characteristic of PD patients but not elderly controls. Whether sleep fragmentation is a disease- or treatment-related phenomenon in PD is controver-

sial. Askenasy and Yahr (5) reported light fragmented sleep to be present in untreated PD patients and improved with dopaminergic therapy. Bergozoni et al. (7) also observed frequent awakenings in untreated PD patients with a tendency toward normalization with dopaminergic therapy. Kales et al. (1 1) observed problems with sleep maintenance in untreated patients as well that did not improve with levodopa therapy. All these studies suggest that sleep fragmentation is directly related to the disease process in PD. On the contrary, Nausieda et al. (3) found that sleep fragmentation increased with the length of therapy, suggesting a cause-and-effect relationship. Other factors that may play a particular role in sleep disruption in PD patients include pain and depression (12). It has also been suggested that sleep fragmentation is a nonspecific phenomenon since it occurs in other chronic debilitating disorders (Alzheimer’s disease and stroke) and psychiatric disorders (5). Difficulties with sleep initiation and sleep maintenance often result in excessive daytime sleepiness. Since more than half the elderly controls experienced these problems, it is not surprising that a large number of these subjects required daytime naps or experienced spontaneous dozing. An equal number of PD patients also napped, while twice as many experienced spontaneous dozing. The latter observation probably reflects the greater disruption of sleep patterns seen in PD patients. It has been

TABLE 4. Daytime sleepiness and parasomnias in Parkinson’s disease (PO) patients and elderly controls Daytime sleepiness

PD patients Elderly controls

Parasomnias

Napping

Spontaneous dozing

Altered dreaming

Nocturnal vocalization

Hallucination

66.6 65.1

48.7 25.6

9.0 9.3

30.8 0

21.8 0

All numbers are percentages of the total number of subjects in each group.

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TABLE 5 . Sleep medication requirements in Parkinson’s disease (PO) patients and elderly controls Sleep medications

PD patients Elderly controls

Total

Every night

34.6

20.5

14.0

2.3

4-6 nights/wk

1-3 nights/wk

Sleep disorders and sleep effect in Parkinson's disease.

It has been suggested that sleep may have a positive effect on morning motor symptoms in Parkinson's disease (PD). We examined this possibility and al...
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