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*It is only for medical professionals to read and refer to the wonderful content, not to be missed! At the 15th Chinese Neurology Forum and the 2nd Annual Conference of Shanghai Stroke Society and the Pan-Yangtze River Delta Forum on Neurological Diseases to be held on October 29-30, 2021, serve as the forum host of the Parkinson and Dyskinesia Sub-forum Professor Liu Chunfeng from the Second Affiliated Hospital of Soochow University shared a wonderful lecture on "Parkinson's Disease Sleep Disorder Management", explaining in detail the disease characteristics, assessment and treatment methods of various Parkinson's disease (PD) sleep disorders
.
Due to the large content, it is divided into multiple issues, and there are 3 issues in total: the first issue focuses on insomnia and excessive daytime sleepiness
.
The second session will focus on rapid eye movement sleep behavior disorder (RBD)
.
The third session focuses on restless legs syndrome (RLS), sleep disordered breathing and other parasomnias
.
This article is the first issue.
Next, let's follow in the footsteps of Professor Liu Chunfeng and enter the learning mode
.
Sleep disorder is a common non-motor symptom of PD, with an incidence of about 46.
66%-89.
66%.
Insomnia (insufficient sleep, broken sleep, early awakening), excessive daytime sleepiness (EDS), rapid eye movement sleep behaviors are more common Disorders (RBD), periodic limb movements (PLMS), restless legs syndrome (RLS), central or obstructive sleep apnea (OSA)
.
▌ Common causes of PD sleep disorders ①Degenerative changes in central sleep regulation areas such as the brainstem; ②The destruction of sleep structure and the influence of biological rhythms by therapeutic drugs; ③The influence of motor symptoms such as tremor on sleep; ④Non-motor symptoms such as pain , Depression and other effects on sleep
.
▌ PD sleep disorder assessment ①Comprehensive medical history, physical examination, sleep questionnaire and/or polysomnography (PSG), etc.
; ②Clarify the type of sleep disorder; ③Assess the relationship between PD night motor symptom control and sleep disorder Relevance; ④Drugs used, especially anti-PD drugs and psychotropic drugs
.
▌ General principles of management ①First emphasize the standardized treatment of the clinical symptoms of PD, and effectively deal with sleep disorders based on the control of nocturnal motor symptoms; ②Pay attention to drug-related sleep disorders; ③To reduce the incidence of sleep disorders and improve The purpose of the patient’s quality of life
.
1.
Insomnia Insomnia is a common type of sleep disorder in PD, with an incidence of 30% to 86.
8%
.
Insomnia refers to a subjective experience that has suitable sleep opportunities and sleep environment, and still feels dissatisfied with sleep time and/or quality, and affects social functions during the day
.
▌ The main symptoms are ① difficulty falling asleep (the latency period of falling asleep exceeds 30 min); ② sleep maintenance disorder (wake up ≥ 2 times throughout the night); ③ early awakening, decreased sleep quality and reduced total sleep time (usually less than 6.
5h), At the same time, it is accompanied by daytime dysfunction; ④ PD patients in our country are mostly difficult to maintain sleep and sleep structure disorders
.
Professor Liu Chunfeng emphasized that the type of insomnia must be clarified
.
▌ Common causes of insomnia①Influencing factors include gender, course of disease, depression and anxiety, factors that cause sleep disruption (such as nocturnal motor symptoms, mental symptoms, nocturia, pain, dystonia), and endogenous circadian rhythm disorders; ②Drugs ( Such as amantadine, selegiline), especially when used at night, may increase the risk of insomnia; ③ Dopaminergic drugs can improve night motor dysfunction, but may also worsen sleep quality
.
Therefore, the time and dose of dopaminergic drugs must be considered; ④ Higher doses of dopamine receptor agonists are related to early awakening, frequent awakening at night, and subjective lack of sleep, and mainly affect sleep maintenance
.
▌ Evaluation ①Combined with medical history, questionnaires, and objective monitoring such as PSG and movement recorder; ②Scaling screening, such as Pittsburgh Sleep Quality Index (PSQI), Parkinson's Disease Sleep Scale (PDSS or PDSS2)
.
▌ non-drug treatment ① cognitive behavioral therapy (CBTi): No matter how insomnia causes of PD, should first take CBTi, such as sleep hygiene education, stimulus control therapy, sleep restriction, reverse the will, relaxed mood and so on
.
Music therapy can also be used as one of the treatment methods; ②Physical exercise: A recent meta-analysis included 10 randomized trials and 2 non-randomized controlled trials (690 patients), showing that physical exercise, especially moderate-intensity physical exercise, has an effect on PD Improvement of sleep quality
.
Objective polysomnography parameters also confirmed the effectiveness of high-intensity physical exercise for sleep; ③Others, such as Tai Chi and Qigong, may also be effective for PD patients with insomnia; ④Strong light therapy: daytime bright light therapy may be effective for PD patients with insomnia; ⑤Repetitive transcranial magnetic stimulation: Change cortical excitability by stimulating or inhibiting neural activity in different brain regions, which can improve subjective sleep quality and insomnia symptoms; ⑥Deep electrical stimulation: bilateral deep brain electrical stimulation of the subthalamic nucleus can improve The patient's night sleep quality is partly benefited from the improvement of motor symptoms and the relief of anxiety
.
▌ Drug treatment ①Insomnia is related to the aggravation of nocturnal PD motor symptoms or nocturnal end-of-dose phenomenon
.
Dopaminergic treatment drugs should be optimized first .
Add a sustained-release compound levodopa before going to bed or a long-acting dopamine receptor agonist, monoamine oxidase B inhibitors such as rasagiline and endicapone doubledopa tablets during the day
.
②For the drug treatment of PD primary insomnia, please refer to the "Guidelines for the Diagnosis and Treatment of Insomnia in Adults in China (2017 Edition)"
.
However, only dexzopiclone, melatonin, agomelatine, and doxepin have been involved in small-sample clinical studies in PD patients
.
③PD can be accompanied by symptoms of depression and anxiety, which can also induce and aggravate insomnia
.
If nocturnal motor symptoms improve, but the insomnia symptoms do not improve, you can consider using traditional antidepressant and anxiolytic drugs to improve Parkinson's disease depression and anxiety comorbid insomnia
.
④Traditional Chinese medicine and acupuncture: Yangxue Qingnao Granules, Compound Congrong Yizhi Capsules, Guipi Pills, Anshen Wendan Pills, Wuling Capsules, and acupuncture may be effective
.
2.
Excessive daytime sleepiness is mainly manifested as inappropriate or unintentional sleepiness during daytime awakening, which can occur in any scene, or sleep attacks, that is, sudden irresistible sleep during the daytime waking period, often without obvious aura; or The aura is very short, often too late to take protective measures, similar to the performance of narcolepsy
.
The incidence of PD with EDS is 21%~76%, and the report in China is about 13.
2%~46.
9%
.
EDS can appear before the motor symptoms of PD and increase as the course of the disease progresses
.
Follow-up for patients with early PD for 5 years, the incidence of EDS can rise from 11.
8% to 23.
4%
.
The motor and non-motor symptoms of EDS and PD are interrelated and affect each other
.
For example, patients with cognitive impairment may also have a higher rate of EDS
.
PD patients with EDS have higher disease severity; the efficacy of drugs is reduced; the risk of falls is increased; there are cognitive impairment, dementia, depression, fatigue, and even autonomic dysfunction such as cardiovascular and urinary dysfunction
.
Main reasons for EDS: ①Sleep-wake cycle changes; ②Side effects of dopamine agonists; ③Poor sleep quality at night; ④Genetic factors; ⑤Hypothalamus secretin levels; ⑥Benodiazepine drugs; ⑦Autonomic nerve dysfunction; ⑧ Depression
.
Figure 1: EDS caused by drug effects (Professor Tu Yuan PPT) ▌ Evaluation of EDS ①The diagnosis of PD combined with EDS is mainly based on medical history data.
Patients and family members should be asked in detail about sleep-related conditions, including daytime sleepiness and nighttime sleep, medication history, and combined Diseases and other possible influencing factors; ②Clinically, relevant scales can be selected for evaluation, such as Epworth Sleepiness Scale, Stanford Sleepiness Scale, PSQl and PDSS Scale
.
▌ EDS non-drug therapy treatment ①: As CBTI, light therapy, repetitive transcranial magnetic stimulation, deep brain stimulation
.
② If EDS is related to drug use, antihistamine hypnotics, benzodiazepines and other sedative antidepressants should be reduced or stopped
.
③Reducing the dose of dopaminergic drugs, changing the type of dopamine receptor agonists, choosing selegiline and levodopa in combination can all reduce daytime sleepiness to a certain extent
.
④ Modafinil, methylphenidate, adrenal receptor agonists (such as caffeine, itraphylline), and sodium oxybate all have case reports showing that they can improve EDS in PD patients, but large sample studies are needed for verification
.
⑤ Atomoxetine can be considered for the treatment of EDS in PD patients with depression
.
Summary: 1.
Clarify the type of PD sleep disorder 2.
Pay attention to PD nocturnal motor symptoms 3.
Adjust PD's own medication 4.
Reasonably choose sleep disorder drug treatment 5.
Pay attention to non-drug treatment of sleep disorder.
Diseases related to insomnia and excessive daytime sleepiness in PD patients The characteristics, evaluation and treatment methods are introduced here first.
If you have any questions, you can leave a message in the comment area to discuss.
Welcome everyone to pay attention to the content of the second and third issues, so that you can have a more comprehensive view of "Parkinson's Disease Sleep Disorder Management" Awareness
.
Expert Profile: Professor Liu Chunfeng, Chief Physician, Professor, Doctoral Supervisor, Director of the Neuroscience Institute of Soochow University, Director of the Department of Neurology, The Second Affiliated Hospital of Soochow University Chairman and former chairman of the Sleep Disorders Special Committee Chairman of the Neurology Branch of the Jiangsu Medical Association Chairman of the Sleep Professional Committee of the Jiangsu Medical Association Director of the 2019 Chinese Outstanding Neurologist Jiangsu Medical Leader presided over 1 national major research and development plan, the Ministry of Science and Technology and 7 National Natural Science Foundation of China, 5 provincial and ministerial projects, and 10 provincial and ministerial scientific and technological progress awards
.
Due to the large content, it is divided into multiple issues, and there are 3 issues in total: the first issue focuses on insomnia and excessive daytime sleepiness
.
The second session will focus on rapid eye movement sleep behavior disorder (RBD)
.
The third session focuses on restless legs syndrome (RLS), sleep disordered breathing and other parasomnias
.
This article is the first issue.
Next, let's follow in the footsteps of Professor Liu Chunfeng and enter the learning mode
.
Sleep disorder is a common non-motor symptom of PD, with an incidence of about 46.
66%-89.
66%.
Insomnia (insufficient sleep, broken sleep, early awakening), excessive daytime sleepiness (EDS), rapid eye movement sleep behaviors are more common Disorders (RBD), periodic limb movements (PLMS), restless legs syndrome (RLS), central or obstructive sleep apnea (OSA)
.
▌ Common causes of PD sleep disorders ①Degenerative changes in central sleep regulation areas such as the brainstem; ②The destruction of sleep structure and the influence of biological rhythms by therapeutic drugs; ③The influence of motor symptoms such as tremor on sleep; ④Non-motor symptoms such as pain , Depression and other effects on sleep
.
▌ PD sleep disorder assessment ①Comprehensive medical history, physical examination, sleep questionnaire and/or polysomnography (PSG), etc.
; ②Clarify the type of sleep disorder; ③Assess the relationship between PD night motor symptom control and sleep disorder Relevance; ④Drugs used, especially anti-PD drugs and psychotropic drugs
.
▌ General principles of management ①First emphasize the standardized treatment of the clinical symptoms of PD, and effectively deal with sleep disorders based on the control of nocturnal motor symptoms; ②Pay attention to drug-related sleep disorders; ③To reduce the incidence of sleep disorders and improve The purpose of the patient’s quality of life
.
1.
Insomnia Insomnia is a common type of sleep disorder in PD, with an incidence of 30% to 86.
8%
.
Insomnia refers to a subjective experience that has suitable sleep opportunities and sleep environment, and still feels dissatisfied with sleep time and/or quality, and affects social functions during the day
.
▌ The main symptoms are ① difficulty falling asleep (the latency period of falling asleep exceeds 30 min); ② sleep maintenance disorder (wake up ≥ 2 times throughout the night); ③ early awakening, decreased sleep quality and reduced total sleep time (usually less than 6.
5h), At the same time, it is accompanied by daytime dysfunction; ④ PD patients in our country are mostly difficult to maintain sleep and sleep structure disorders
.
Professor Liu Chunfeng emphasized that the type of insomnia must be clarified
.
▌ Common causes of insomnia①Influencing factors include gender, course of disease, depression and anxiety, factors that cause sleep disruption (such as nocturnal motor symptoms, mental symptoms, nocturia, pain, dystonia), and endogenous circadian rhythm disorders; ②Drugs ( Such as amantadine, selegiline), especially when used at night, may increase the risk of insomnia; ③ Dopaminergic drugs can improve night motor dysfunction, but may also worsen sleep quality
.
Therefore, the time and dose of dopaminergic drugs must be considered; ④ Higher doses of dopamine receptor agonists are related to early awakening, frequent awakening at night, and subjective lack of sleep, and mainly affect sleep maintenance
.
▌ Evaluation ①Combined with medical history, questionnaires, and objective monitoring such as PSG and movement recorder; ②Scaling screening, such as Pittsburgh Sleep Quality Index (PSQI), Parkinson's Disease Sleep Scale (PDSS or PDSS2)
.
▌ non-drug treatment ① cognitive behavioral therapy (CBTi): No matter how insomnia causes of PD, should first take CBTi, such as sleep hygiene education, stimulus control therapy, sleep restriction, reverse the will, relaxed mood and so on
.
Music therapy can also be used as one of the treatment methods; ②Physical exercise: A recent meta-analysis included 10 randomized trials and 2 non-randomized controlled trials (690 patients), showing that physical exercise, especially moderate-intensity physical exercise, has an effect on PD Improvement of sleep quality
.
Objective polysomnography parameters also confirmed the effectiveness of high-intensity physical exercise for sleep; ③Others, such as Tai Chi and Qigong, may also be effective for PD patients with insomnia; ④Strong light therapy: daytime bright light therapy may be effective for PD patients with insomnia; ⑤Repetitive transcranial magnetic stimulation: Change cortical excitability by stimulating or inhibiting neural activity in different brain regions, which can improve subjective sleep quality and insomnia symptoms; ⑥Deep electrical stimulation: bilateral deep brain electrical stimulation of the subthalamic nucleus can improve The patient's night sleep quality is partly benefited from the improvement of motor symptoms and the relief of anxiety
.
▌ Drug treatment ①Insomnia is related to the aggravation of nocturnal PD motor symptoms or nocturnal end-of-dose phenomenon
.
Dopaminergic treatment drugs should be optimized first .
Add a sustained-release compound levodopa before going to bed or a long-acting dopamine receptor agonist, monoamine oxidase B inhibitors such as rasagiline and endicapone doubledopa tablets during the day
.
②For the drug treatment of PD primary insomnia, please refer to the "Guidelines for the Diagnosis and Treatment of Insomnia in Adults in China (2017 Edition)"
.
However, only dexzopiclone, melatonin, agomelatine, and doxepin have been involved in small-sample clinical studies in PD patients
.
③PD can be accompanied by symptoms of depression and anxiety, which can also induce and aggravate insomnia
.
If nocturnal motor symptoms improve, but the insomnia symptoms do not improve, you can consider using traditional antidepressant and anxiolytic drugs to improve Parkinson's disease depression and anxiety comorbid insomnia
.
④Traditional Chinese medicine and acupuncture: Yangxue Qingnao Granules, Compound Congrong Yizhi Capsules, Guipi Pills, Anshen Wendan Pills, Wuling Capsules, and acupuncture may be effective
.
2.
Excessive daytime sleepiness is mainly manifested as inappropriate or unintentional sleepiness during daytime awakening, which can occur in any scene, or sleep attacks, that is, sudden irresistible sleep during the daytime waking period, often without obvious aura; or The aura is very short, often too late to take protective measures, similar to the performance of narcolepsy
.
The incidence of PD with EDS is 21%~76%, and the report in China is about 13.
2%~46.
9%
.
EDS can appear before the motor symptoms of PD and increase as the course of the disease progresses
.
Follow-up for patients with early PD for 5 years, the incidence of EDS can rise from 11.
8% to 23.
4%
.
The motor and non-motor symptoms of EDS and PD are interrelated and affect each other
.
For example, patients with cognitive impairment may also have a higher rate of EDS
.
PD patients with EDS have higher disease severity; the efficacy of drugs is reduced; the risk of falls is increased; there are cognitive impairment, dementia, depression, fatigue, and even autonomic dysfunction such as cardiovascular and urinary dysfunction
.
Main reasons for EDS: ①Sleep-wake cycle changes; ②Side effects of dopamine agonists; ③Poor sleep quality at night; ④Genetic factors; ⑤Hypothalamus secretin levels; ⑥Benodiazepine drugs; ⑦Autonomic nerve dysfunction; ⑧ Depression
.
Figure 1: EDS caused by drug effects (Professor Tu Yuan PPT) ▌ Evaluation of EDS ①The diagnosis of PD combined with EDS is mainly based on medical history data.
Patients and family members should be asked in detail about sleep-related conditions, including daytime sleepiness and nighttime sleep, medication history, and combined Diseases and other possible influencing factors; ②Clinically, relevant scales can be selected for evaluation, such as Epworth Sleepiness Scale, Stanford Sleepiness Scale, PSQl and PDSS Scale
.
▌ EDS non-drug therapy treatment ①: As CBTI, light therapy, repetitive transcranial magnetic stimulation, deep brain stimulation
.
② If EDS is related to drug use, antihistamine hypnotics, benzodiazepines and other sedative antidepressants should be reduced or stopped
.
③Reducing the dose of dopaminergic drugs, changing the type of dopamine receptor agonists, choosing selegiline and levodopa in combination can all reduce daytime sleepiness to a certain extent
.
④ Modafinil, methylphenidate, adrenal receptor agonists (such as caffeine, itraphylline), and sodium oxybate all have case reports showing that they can improve EDS in PD patients, but large sample studies are needed for verification
.
⑤ Atomoxetine can be considered for the treatment of EDS in PD patients with depression
.
Summary: 1.
Clarify the type of PD sleep disorder 2.
Pay attention to PD nocturnal motor symptoms 3.
Adjust PD's own medication 4.
Reasonably choose sleep disorder drug treatment 5.
Pay attention to non-drug treatment of sleep disorder.
Diseases related to insomnia and excessive daytime sleepiness in PD patients The characteristics, evaluation and treatment methods are introduced here first.
If you have any questions, you can leave a message in the comment area to discuss.
Welcome everyone to pay attention to the content of the second and third issues, so that you can have a more comprehensive view of "Parkinson's Disease Sleep Disorder Management" Awareness
.
Expert Profile: Professor Liu Chunfeng, Chief Physician, Professor, Doctoral Supervisor, Director of the Neuroscience Institute of Soochow University, Director of the Department of Neurology, The Second Affiliated Hospital of Soochow University Chairman and former chairman of the Sleep Disorders Special Committee Chairman of the Neurology Branch of the Jiangsu Medical Association Chairman of the Sleep Professional Committee of the Jiangsu Medical Association Director of the 2019 Chinese Outstanding Neurologist Jiangsu Medical Leader presided over 1 national major research and development plan, the Ministry of Science and Technology and 7 National Natural Science Foundation of China, 5 provincial and ministerial projects, and 10 provincial and ministerial scientific and technological progress awards
