Dr. Gilbert Answers Questions About Parkinson’s Disease and Sleep Issues

A recent episode of APDA’s Dr. Gilbert Hosts featured special guest Dr. Maria Ospina, a movement disorders specialist, who spoke to us about sleep issues and Parkinson’s disease (PD), a very common symptom for people with PD. We covered a lot of ground during the broadcast and answered many questions from the audience, but we ran out of time and couldn’t get to every question. In this blog, we are answering the questions we didn’t have time for.

Highlights from the Episode

In case you missed it, the August broadcast of Dr. Gilbert Hosts was a very informative conversation, and we encourage you to watch the full episode. For your convenience, we’ve listed the topics and questions from the episode below with timestamps, so you can skip to what may interest you most:

00:48 Introduction of Dr. Ospina

01:27 Dr. Ospina’s presentation about sleep issues

23:37 My husband sleeps fairly well at night but sleeps a lot during the day. How do we get him to not sleep so much during the day?

25:19 My father has had much improvement in his sleep by taking CBD. What is your opinion on this?

27:20 Discussion of OFF time

31:23 Will Prozac affect my sleep? Is it better to take it in the morning or at lunch rather than at night?

32:48 Does deep brain stimulation help insomnia and sleep issues?

35:13 I wake up frequently with leg and foot cramps/dystonia. How should I treat this?

36:51 Is it OK to take Nyquil for insomnia? Melatonin? If so, how much melatonin should I take?

38:05 Could numbness in the feet be associated with restless leg syndrome?

39:36 Can you get accustomed to sleep medications whereby the medication is no longer effective?

40:40 What should I do if I’m wide awake in the middle of the night? Should I try to be active and get something done, or should I try to stay in bed?

Additional Questions About Sleep Issues

Below we present some of the additional questions from the broadcast and their answers.

Ways to Manage Low Energy, Activities, and Sleep Issues with Parkinson’s

Sleep Issues and Fatigue During the Day

Q: ​I am very tired by lunchtime and fall asleep in the afternoon. Is this normal?

A: People with PD may have fatigue at particular times during the day, occurring after a dose of medication. This can be very common. Sometimes the best solution is to take a short nap to regain energy for the rest of the day.

Q: My driving has been impacted by PD, causing difficulty with focus and I find myself dozing off while driving. What should I do?

A: Please be aware that medications for PD can cause falling asleep without warning. Talk with your doctor about whether this side effect may be a factor in your dozing off at the wheel. It goes without saying that the most important thing for you and those around you is to stay safe. If your fatigue and falling asleep cannot be solved with a change in medication or another approach, then you may not be able to drive anymore. Driving alternatives such as taxis, ride share options (such as Uber, Lyft), municipal van services, and public transportation can help you maintain your independence. You can read more about the important topic of driving and PD.

Physical Activity Impacting Positive Sleep Schedules

Q: I notice that when I spend my day very active, it helps my sleep! Is this common?

A: Yes, this is the best way to improve your sleep – make your days more active! This can be through physical activity, social interactions, mental stimulation, or ideally a combination of all three. If you are looking for inspiration, we have a blog that details ways to improve physical activity.

Q: You suggest that to help keep a person awake during the day, his/her activities should be increased, but my husband’s PD is very advanced, and he needs constant supervision to do anything. What are some good activities to consider?

A: Listening to music, looking through family photos, looking through magazines, taking walks, going to the park, going grocery shopping, and participating in a seated exercise class are ways that someone with advanced PD can stay active.

Q:  My grandmother has moderate motor symptoms, but I want her to remain active. I would like to find safe ways for us to exercise together, but I am concerned about her falling.

A: Ask her neurologist for a referral to a physical therapist who can evaluate her walking/balance and determine safe exercises that she could do with you. There are exercise classes tailored for people with PD, including seated exercise classes, that may be appropriate for her. Participating in exercise could help her balance if done carefully and appropriately.

Accessories for Sleep: How can they help?

Sleep Apnea and Masks

Q: I have obstructive sleep apnea but can’t tolerate a mask. Sleeping on my side helps though. What else can I do?

A: Obstructive sleep apnea (OSA) is a sleep disorder in which breathing stops and starts through the night. This leads to periods of low oxygenation in the blood and frequent awakenings. It is a common condition in people with PD and is one of the reasons why a person may feel excessively tired during the day. OSA is treated with a machine called continuous positive airway pressure (CPAP) which pushes air through a mask into your lungs to keep your airways open. It is important to know that there are multiple different mask shapes and sizes – some that cover the nose only and others that cover both the mouth and nose. Mask manufacturers are very aware that some people find certain masks uncomfortable and are designing new masks with comfort in mind. Before giving up on CPAP, which can be very beneficial not only to help you sleep but to reduce risk of stroke and other chronic conditions, try different masks to find one that works for you. 

Monitoring Tools and Wearable Devices for Sleep

Q: Are wearable monitoring tools helpful to monitor sleep?

A: There are several wearable devices that can give you a sense of how long you spend sleeping and in what stages. Talk with your neurologist to find out if this information would be helpful in making treatment decisions for you.

Questions About Medications for Sleep Issues and Parkinson’s

Anti-Depressants

Q: Can you recommend an antidepressant that won’t make RBD worse?

A: Certain anti-depressants have been associated with REM behavior sleep disorder (RBD) including selective serotonin reuptake inhibitors (SSRIs) such as paroxetine, sertraline, and citalopram, and tricyclic antidepressants (TCAs) such as amitriptyline and nortriptyline. In clinical studies, about 5% of all people taking these antidepressants (with and without PD) report RBD, although rates vary from study to study. Other types of anti-depressants have not been studied as formally, although there are case reports that serotonin norepinephrine reuptake inhibitors (SNRIs) such as duloxetine can also be associated with RBD. It is therefore not clear which anti-depressant has absolutely no chance of worsening RBD, so it may be a case of trial and error to find the one that works for you without worsening RBD.

Levodopa and Other Parkinson’s Disease Medications

Q: ​Levodopa seems to give me a lot of energy during the day, so I avoid taking it within about three hours of bedtime. Does that make sense?

A: Yes, it does. Some people get very sleepy from levodopa, but if you find that it has the opposite effect, then avoiding it before bed makes sense. Be aware that this may mean that you have more OFF time (when your dopamine levels are low) through the night.

Q: ​Does levodopa doses help insomnia?

A: Some people find that they are sleepier after a dose of levodopa, although that is not the case for everyone. Levodopa is not typically used as a treatment for insomnia since it has many other effects besides causing sleepiness, such as improving tremor, slowness, and stiffness of PD. Its use is reserved for helping the motor symptoms of PD. 

If you are seeking addition information on levodopa, our blog post Five Myths about Levodopa details the medication and its misconceptions.

Q: Anxiety is a major problem for me and keeps me up at night. What do I do? How do I know if symptoms of anxiety are due to side effects of the medications or of the disease?

A: Anxiety in PD is a very common non-motor symptom. It is more likely that your anxiety is due to the disease than your medications, although everyone’s responses to medications can be different, so discuss the specifics of your situation with your doctor. Anxiety in PD can be treated with cognitive behavioral therapy or with a variety of medications.

Q: My husband has been hallucinating during the afternoon and evening and this interferes with his falling asleep. Can a change in medication help him?

A: Definitely bring this problem to the attention of your husband’s neurologist. Hallucinations are often precipitated by PD medications and lowering them or changing the timing may be helpful. If PD meds can’t be changed because of their positive effects (e.g. helping with movement, allowing for walking, improving balance, etc.) then another medication could be added to decrease hallucinations.

Melatonin

​Q: Is melatonin addictive? Does it cause memory problems?

A: Unlike other sleep medications, melatonin does not cause dependence, in which the body adjusts to the presence of the medication and requires more for the same effect. It does not cause withdrawal symptoms if you stop taking it. Taking one pill a night to help you sleep is a safe way to help insomnia. Of course, you should treat melatonin like any sleep medication and talk with your doctor about using it.

Research indicates that melatonin may have beneficial effects on memory, although this is not entirely established. Promoting sleep in and of itself can have beneficial effects on memory, so this is important to consider when addressing poor sleep in PD.

Q: What do you think about taking a small dose of melatonin (1-2 mg) about 2 hours before bedtime?

A: Many sleep specialists recommend using melatonin in this way.

Magnesium

Q: ​What are your thoughts on magnesium at night? I take a glycinate version which sometimes helps.

A: Magnesium is a natural way to try to improve insomnia. As always, talk with your doctor before starting it to make sure that it is a safe option for you.

Trazadone and Other Sleep Medications

Q: Is trazodone helpful for the sleep problems of PD? Remeron? Neurontin? Clonazepam?  Others?

Each of these medications (and others) can make a person sleepy and can be used for the sleep problems of PD. There are many choices, so the choice would need to be tailored to the individual. For example, each medication has other uses as well. Trazodone and Remeron are anti-depressants. Neurontin can help with pain. Clonazepam can help with REM behavior sleep disorder. Therefore, your doctor may consider the totality of your clinical situation before picking a medication that makes sense for you. There might be a period of trial and error to see which one works best for you. All of these medications, however, may make you feel groggy in the morning, so this would be something to assess as you are trying a medication.

Additional Disorders and Related Symptoms Impacting Sleep

Restless Leg Syndrome (RLS)

Q: ​My wife has restless leg syndrome (RLS) but not Parkinson’s. She is not getting enough relief. Are there doctors who specialize in RLS?

A: Both Sleep specialists and Movement disorders specialists see patients with RLS.

Age-Related Sleep Problems

Q: Could occasional sleep problems just be age related?

A: Not every symptom that someone with PD experiences is caused by PD. Many people in the general population experience sleep problems and many of the strategies that were discussed by Dr. Ospina can be relevant for a wider audience. Also keep in mind that if the problems are not persistent and only occasional, no treatment may be necessary at all.

Progressive Supranuclear Palsy (PSP)

Q: Do people with Progressive supranuclear palsy (PSP) also have problems with their sleep?

A: Yes, people with PSP can also have difficulties with their sleep, with much overlap with the problems seen by people with PD. Many of the same approaches would be used for people with PSP.

Deep Brain Stimulation (DBS)

Q:  Can deep brain stimulation (DBS) make sleep worse?

A: This is not a common complaint. In fact, several studies have shown that subthalamic nucleus DBS improves subjective and objective measures of sleep, including sleep efficiency, nocturnal mobility, and wake after sleep onset. However, every person is different, and your reaction to DBS might be different than others.

Tips & Takeaways

• Sleep disorders including insomnia, restless leg syndrome, obstructive sleep apnea, sleep fragmentation, and excessive daytime sleepiness are very common in PD
• Listen to a broadcast dedicated to answering questions about Sleep and PD
• APDA’s fact sheet about Fatigue & Parkinson’s Disease might also be helpful.
• You can track your PD symptoms (including fatigue/sleep disturbances and many others) using the APDA Symptom Tracker app, available for free through the Apple Store or Google Play.
• If you have a PD-related question, you can submit it to our Ask A Doctor portal