Sleep Disturbance
Sleep disorders are a common problem in people with Parkinson's Disease. The most common issues are:
daytime hypersomnolence (extreme sleepiness);
nocturnal akinesia (turning over in bed);
restless leg syndrome (RLS);
dyskinesia (difficulty or distortion in making voluntary movements);
periodic leg movements of sleep;
REM sleep behaviour disorder (RBD) which is the movement of body or limbs associated with dreaming;
sudden onset of sleep;
vivid dreams and/or hallucinations;
nocturia (frequent passing of urine);
sleep fragmentation.
Any or all of these features may occur in people with Parkinson's. If sleep problems are reported then doctors are advised by the NICE guidance
to undertake a full sleep history including:
- about all three phases of sleep- initiation, maintenance and wakening;
- leg movements - periodic leg movements in sleep (RLS);
- hallucinations and vivid dreams;
- whether dreams are acted out, sometimes violently which is indicative of RBD.
RBD affects 15% of people with Parkinson's, NICE recommends low doses of clonazepam as the best pharmacological response.
People with sleep disturbance should be advised about good sleeep hygiene which includes:
- avoidance of stimulants (for example coffee, tea, caffeine) in the evening;
- establishment of a regular pattern of sleep;
- comfortable bedding and temperature;
- provision of assistive devices, such as a bed lever or rails to aid with moving and turning
allowing the person to get more comfortable;
- restriction of daytime siestas;
- advice about taking regular and appropriate exercise to induce better sleep;
- a review of all medication and avoidance of any drugs that may affect sleep or
alertness, or may interact with other medication (for example, selegiline,
antihistamines, H2 antagonists, antipsychotics and sedatives).
The guidance advises that people with sudden onset of sleep should be advised not to drive and to consider any hazards in the workpplace.
Doctors are also advised to consider reducing the patient's medication in an attempt to reduce occurrence.
With regard to daytime hypersomnolence, NICE recommends that modafinil may be considered even though there is little evidence as to its effectiveness.
Modified-release levodopa is recommended for use in people who experience nocturna akinesia- turning over in bed can be difficult for people with
Parkinson's because of the rigidity of the trunk. This can lead to disturbed sleep and thus to hypersomnolence during the day.
Falls
Falls are a common event for people with Parkinson's Disease with 65% falling at least once each year. Apart from the obvious physical injuries caused by falls,
consideration should also be given to the psychological cost (loss of confidence, anxiety and fear) all of which will have a negative impact on the
quality of life.
The NICE guidance lists the following as Parkinson-specific predictors of falling:
- longer disease duration;
- more advanced disease;
- dyskinesia;
- motor fluctuations;
- atypical parkinsonism;
- postural instability;
- small steps;
- freezing;
- stride-to-stride variability;
- altered step and stance width;
- loss of arm swing.
All people with Parkinson's should undergo a multidisciplinary and multifactorial assessment which may include:
- identfication of falls history
- assessment of gait, balance and mobility:
- assessment of osteoporsis risk:
- assessment of the person’s perceived functional ability and fear relating to falling
- assessment of visual impairment;
- assessment of cognitive impairment and neurological examination;
- assessment of urinary incontinence;
- assessment of home hazards;
- cardiovascular examination and medication review;
- multifactorial interventions.
In terms of treatment, the NICE guidance lists the following interventions as common components in a successful programme:
- strength and balance training;
- home hazard assessment and intervention;
- vision assessment and referral;
- medication review with modification/withdrawal.
Any intervention with regard to falls should be individualised, aim to promote independence and improve physical and psycholgical function.
Weight Loss
Unintended weight loss occurs in over 50% of individuals with Parkinson's Disease. Doctors are encouraged to consider the following:
- other medical causes for weight loss (eg malignancy, endocrine causes);
- investigation of swallow;
- review of anti-parkinsonian medications if dyskinesias are problematic;
- dietary supplements;
- referral to a dietitian.
A dietitian is best placed to help people attain and maintain an appropriate body weight, providing other factors have been ruled out.
