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Sleep disorder (sleep disorder) is one of the common non-motor symptoms of Parkinson's disease (PD).
It can also appear in the prodromal stage of PD during the entire course of the disease
.
In order to better guide the diagnosis and treatment of PD sleep disorders, the Chronic Nervous System Disease Professional Committee of Shanghai Association of Integrated Traditional Chinese and Western Medicine organized domestic Chinese and Western medicine experts in the field of PD, based on evidence-based medicine in recent years, combined with traditional Chinese medicine theories and expert experience, to form PD sleep disorders Expert consensus on management of integrated traditional Chinese and Western medicine
.
This article mainly sorts out the Western medical management of Parkinson's disease sleep disorders for reference
.
Classification of PD sleep disorders PD sleep disorders mainly include insomnia (insomnia), rapid eye movement sleep behavior disorder (RBD), restless legs syndrome (restless legs syndrome, RLS), excessive daytime sleepiness (Excessive daytime sleepiness, EDS) and sleep-disordered breathing (SDB)
.
The same patient can have multiple sleep disorders in the same period or different sleep disorders in different periods
.
PD insomnia is mainly manifested as difficulty falling asleep, frequent awakening or early awakening, the incidence is between 25% and 80%, and changes with the progression of the disease, so regular evaluation is required
.
The diagnosis of insomnia is mainly based on the patient’s subjective perception of sleep quality.
The Parkinson’s disease sleep scale (PDSS) is commonly used clinically to assess the impact of nocturnal symptoms on sleep in PD patients, and the Pittsburgh sleep quality index (Pittsburgh sleep quality index) index, PSQI) self-rating scale assesses the patient's overall sleep problems
.
For objective monitoring, a body motion recorder can be used to record indicators such as overall sleep time and sleep efficiency, or polysomnography (PSG) monitoring can be used to determine whether it is accompanied by RBD, SDB, etc.
at the same time
.
PD-RBD refers to abnormal behaviors (simple body twisting, but also complex movements such as kicking and punching), posture, and vocalization (speaking or shouting) in dreams.
The patient dreams that he is being attacked and is fighting or arguing with others
.
The incidence of PD-RBD is 19% to 70%, which is one of the symptoms of PD prodromal phase
.
The diagnosis of RBD refers to the definition of the third edition of the International Classification of Sleep Disorders revised by the American Academy of Sleep Medicine in 2014
.
PSG monitoring is the "gold standard" for the objective diagnosis of RBD
.
The rapid eye movement sleep behavior disorder questionnaire Hong Kong (RBDQ-HK) can be used for screening to assess the frequency and severity of RBD
.
PD-RLS means that the patient often feels discomfort in the lower limbs/upper limbs or ant-like pain and tightening, and therefore has the urge to swing the lower limbs/upper limbs.
It usually occurs during night sleep and affects falling asleep.
Fragmented sleep interferes with the quality of sleep and seriously affects the quality of sleep.
Physical and mental health
.
Approximately 15% of PD patients have RLS
.
Detailed medical history (including the time when the limb discomfort occurred, the state at that time, the severity, and the method of remission, etc.
) are of great value for diagnosis
.
The diagnosis of RLS refers to the RLS diagnostic criteria proposed by the International Restless Leg Syndrome Research Group in 2014, and PSG can confirm the diagnosis
.
The Johns Hopkins restless legs severity scale (Johns Hopkins restless legs severity scale) is commonly used to assess the severity of RLS
.
PD-EDS refers to the inability to maintain wakefulness and alertness during daytime awakening, resulting in uncontrollable or unconscious sleep at inappropriate times
.
The incidence of PD-EDS is 21% to 76% .
There is currently no diagnostic criteria for PD-EDS
.
The Epworth sleepiness scale (Epworth sleepiness scale, ESS) is commonly used in clinical practice for EDS screening; the multiple sleep latency test (MSLT) and wake maintenance test monitored by PSG are used for standardized evaluation of EDS, and long-range motion recorder It can also be used for the evaluation of EDS
.
PD-SDB mainly refers to obstructive sleep apnea syndrome (obstructive sleep apnea, OSA).
The typical symptoms are frequent snoring, repeated apneas and hypopneas during sleep
.
The incidence of PD-SDB is 60% .
The apnea/hypopnea index (≥5 times/h) recorded by PSG monitoring is the gold standard for diagnosing OSA
.
The diagnosis can also be assisted by the spouse or caregiver providing the patient's relevant medical history of snoring, irregular breathing, nocturnal breathing, wheezing and other symptoms during sleep
.
Treatment of PD sleep disorder Treatment of PD insomnia ➤ Identify the causes of insomnia, and deal with it in layers
.
①If insomnia is related to the worsening of nocturnal PD motor symptoms or nocturnal end-of-dose phenomenon, the dopaminergic therapy should be optimized first: add levodopa controlled release agent before going to bed or add long-acting dopamine receptor agonist during the day (such as Roti Gortin transdermal patch); ②If insomnia is related to the adverse reaction of anti-PD drugs, the time of taking the medication should be adjusted (such as selegiline taken in the morning and noon, and amantadine taken before 4 pm), or gradually reduce the dose Or stop anti-PD drugs that affect sleep; ③If there are also non-motor symptoms such as depression or anxiety, antidepressant or anxiety drugs can be added
.
➤For those who still cannot improve insomnia, sedative hypnotics (Zopiclone), melatonin, etc.
can be added
.
➤For those with OSA, continuous positive airway pressure (CPAP) can be used to improve symptoms
.
PD-RBD treatment ➤ A safe sleeping environment must be established to avoid injury
.
➤Clarify and remove the triggers that may cause or aggravate symptoms, such as the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors, and ethanol , Benzodiazepine or barbiturate withdrawal may aggravate RBD
.
➤You can use melatonin, clonazepam, or a combination of both
.
Note that clonazepam may increase the risk of falls
.
Treatment of PD-RLS ➤First, stop drugs that may induce or aggravate RLS (such as dopamine receptor antagonists, antihistamines, SSRIs), and exclude other secondary factors, such as iron deficiency, metabolic disorders, and end-stage renal function insufficiency, diabetes, pregnancy and so on
.
➤It is recommended to use low-dose dopaminergic drugs or long-acting dopamine receptor agonists (such as pramipexole, rotigotine transdermal patch)
.
Treatment of PD-EDS ➤ First, clarify the possible causes of EDS.
If the patient develops drowsiness after each medication, adjust dopamine drugs (such as dopamine receptor agonists can cause EDS to occur, and reduce the dose or switch to levodopsin).
Bar instead); reduce or stop antihistamines, benzodiazepines and other sedative antidepressants; if it is caused by night insomnia, or accompanied by OSA, or accompanied by depression, treat the cause
.
➤Modafinil can be used to promote awakening
.
➤Can try light therapy, cognitive behavioral therapy (cognitive behavioral therapy, CBT)
.
PD-SDB treatment ➤General treatment includes weight loss, diet control, proper exercise, quitting smoking and alcohol, cautious use of sedative and hypnotic drugs and other drugs that induce or aggravate SDB (such as clonazepam), lying on your side, and raising the head of the bed And avoid overwork during the day
.
➤CPAP is currently the first choice for PD-SDB treatment
.
Health guidance PD sleep disorders, in addition to insomnia, has various clinical manifestations, and education should be strengthened to enable patients to fully understand
.
First of all, pay attention to sleep hygiene habits: regular work and rest, regular sleep and daily life, and at the same time conform to the four o'clock
.
Patients with insomnia and EDS should exercise properly during the day, especially increasing the time of sun exposure
.
Second, pay attention to a healthy diet: patients with insomnia and RBD should have a light diet and balanced nutrition
.
Try to avoid stimulating beverages such as coffee and tea, and yang-generating foods such as lamb and leeks
.
For EDS, this type of diet can be given appropriately
.
In addition, attention should be paid to the effect of drugs on PD sleep disorders
.
Because patients may have different types of sleep disorders, their medications interact with each other and also affect PD symptoms.
Therefore, specialist doctors are required to make medication adjustments
.
Yimaitong compiled from: Li Wentao, Gan Jing, Liu Zhenguo.
Expert consensus on the management of sleep disorders in Parkinson’s disease with integrated traditional Chinese and Western medicine (2021)[J].
Journal of Shanghai University of Traditional Chinese Medicine,2021,35(03):1-6.
It can also appear in the prodromal stage of PD during the entire course of the disease
.
In order to better guide the diagnosis and treatment of PD sleep disorders, the Chronic Nervous System Disease Professional Committee of Shanghai Association of Integrated Traditional Chinese and Western Medicine organized domestic Chinese and Western medicine experts in the field of PD, based on evidence-based medicine in recent years, combined with traditional Chinese medicine theories and expert experience, to form PD sleep disorders Expert consensus on management of integrated traditional Chinese and Western medicine
.
This article mainly sorts out the Western medical management of Parkinson's disease sleep disorders for reference
.
Classification of PD sleep disorders PD sleep disorders mainly include insomnia (insomnia), rapid eye movement sleep behavior disorder (RBD), restless legs syndrome (restless legs syndrome, RLS), excessive daytime sleepiness (Excessive daytime sleepiness, EDS) and sleep-disordered breathing (SDB)
.
The same patient can have multiple sleep disorders in the same period or different sleep disorders in different periods
.
PD insomnia is mainly manifested as difficulty falling asleep, frequent awakening or early awakening, the incidence is between 25% and 80%, and changes with the progression of the disease, so regular evaluation is required
.
The diagnosis of insomnia is mainly based on the patient’s subjective perception of sleep quality.
The Parkinson’s disease sleep scale (PDSS) is commonly used clinically to assess the impact of nocturnal symptoms on sleep in PD patients, and the Pittsburgh sleep quality index (Pittsburgh sleep quality index) index, PSQI) self-rating scale assesses the patient's overall sleep problems
.
For objective monitoring, a body motion recorder can be used to record indicators such as overall sleep time and sleep efficiency, or polysomnography (PSG) monitoring can be used to determine whether it is accompanied by RBD, SDB, etc.
at the same time
.
PD-RBD refers to abnormal behaviors (simple body twisting, but also complex movements such as kicking and punching), posture, and vocalization (speaking or shouting) in dreams.
The patient dreams that he is being attacked and is fighting or arguing with others
.
The incidence of PD-RBD is 19% to 70%, which is one of the symptoms of PD prodromal phase
.
The diagnosis of RBD refers to the definition of the third edition of the International Classification of Sleep Disorders revised by the American Academy of Sleep Medicine in 2014
.
PSG monitoring is the "gold standard" for the objective diagnosis of RBD
.
The rapid eye movement sleep behavior disorder questionnaire Hong Kong (RBDQ-HK) can be used for screening to assess the frequency and severity of RBD
.
PD-RLS means that the patient often feels discomfort in the lower limbs/upper limbs or ant-like pain and tightening, and therefore has the urge to swing the lower limbs/upper limbs.
It usually occurs during night sleep and affects falling asleep.
Fragmented sleep interferes with the quality of sleep and seriously affects the quality of sleep.
Physical and mental health
.
Approximately 15% of PD patients have RLS
.
Detailed medical history (including the time when the limb discomfort occurred, the state at that time, the severity, and the method of remission, etc.
) are of great value for diagnosis
.
The diagnosis of RLS refers to the RLS diagnostic criteria proposed by the International Restless Leg Syndrome Research Group in 2014, and PSG can confirm the diagnosis
.
The Johns Hopkins restless legs severity scale (Johns Hopkins restless legs severity scale) is commonly used to assess the severity of RLS
.
PD-EDS refers to the inability to maintain wakefulness and alertness during daytime awakening, resulting in uncontrollable or unconscious sleep at inappropriate times
.
The incidence of PD-EDS is 21% to 76% .
There is currently no diagnostic criteria for PD-EDS
.
The Epworth sleepiness scale (Epworth sleepiness scale, ESS) is commonly used in clinical practice for EDS screening; the multiple sleep latency test (MSLT) and wake maintenance test monitored by PSG are used for standardized evaluation of EDS, and long-range motion recorder It can also be used for the evaluation of EDS
.
PD-SDB mainly refers to obstructive sleep apnea syndrome (obstructive sleep apnea, OSA).
The typical symptoms are frequent snoring, repeated apneas and hypopneas during sleep
.
The incidence of PD-SDB is 60% .
The apnea/hypopnea index (≥5 times/h) recorded by PSG monitoring is the gold standard for diagnosing OSA
.
The diagnosis can also be assisted by the spouse or caregiver providing the patient's relevant medical history of snoring, irregular breathing, nocturnal breathing, wheezing and other symptoms during sleep
.
Treatment of PD sleep disorder Treatment of PD insomnia ➤ Identify the causes of insomnia, and deal with it in layers
.
①If insomnia is related to the worsening of nocturnal PD motor symptoms or nocturnal end-of-dose phenomenon, the dopaminergic therapy should be optimized first: add levodopa controlled release agent before going to bed or add long-acting dopamine receptor agonist during the day (such as Roti Gortin transdermal patch); ②If insomnia is related to the adverse reaction of anti-PD drugs, the time of taking the medication should be adjusted (such as selegiline taken in the morning and noon, and amantadine taken before 4 pm), or gradually reduce the dose Or stop anti-PD drugs that affect sleep; ③If there are also non-motor symptoms such as depression or anxiety, antidepressant or anxiety drugs can be added
.
➤For those who still cannot improve insomnia, sedative hypnotics (Zopiclone), melatonin, etc.
can be added
.
➤For those with OSA, continuous positive airway pressure (CPAP) can be used to improve symptoms
.
PD-RBD treatment ➤ A safe sleeping environment must be established to avoid injury
.
➤Clarify and remove the triggers that may cause or aggravate symptoms, such as the use of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs), monoamine oxidase inhibitors, and ethanol , Benzodiazepine or barbiturate withdrawal may aggravate RBD
.
➤You can use melatonin, clonazepam, or a combination of both
.
Note that clonazepam may increase the risk of falls
.
Treatment of PD-RLS ➤First, stop drugs that may induce or aggravate RLS (such as dopamine receptor antagonists, antihistamines, SSRIs), and exclude other secondary factors, such as iron deficiency, metabolic disorders, and end-stage renal function insufficiency, diabetes, pregnancy and so on
.
➤It is recommended to use low-dose dopaminergic drugs or long-acting dopamine receptor agonists (such as pramipexole, rotigotine transdermal patch)
.
Treatment of PD-EDS ➤ First, clarify the possible causes of EDS.
If the patient develops drowsiness after each medication, adjust dopamine drugs (such as dopamine receptor agonists can cause EDS to occur, and reduce the dose or switch to levodopsin).
Bar instead); reduce or stop antihistamines, benzodiazepines and other sedative antidepressants; if it is caused by night insomnia, or accompanied by OSA, or accompanied by depression, treat the cause
.
➤Modafinil can be used to promote awakening
.
➤Can try light therapy, cognitive behavioral therapy (cognitive behavioral therapy, CBT)
.
PD-SDB treatment ➤General treatment includes weight loss, diet control, proper exercise, quitting smoking and alcohol, cautious use of sedative and hypnotic drugs and other drugs that induce or aggravate SDB (such as clonazepam), lying on your side, and raising the head of the bed And avoid overwork during the day
.
➤CPAP is currently the first choice for PD-SDB treatment
.
Health guidance PD sleep disorders, in addition to insomnia, has various clinical manifestations, and education should be strengthened to enable patients to fully understand
.
First of all, pay attention to sleep hygiene habits: regular work and rest, regular sleep and daily life, and at the same time conform to the four o'clock
.
Patients with insomnia and EDS should exercise properly during the day, especially increasing the time of sun exposure
.
Second, pay attention to a healthy diet: patients with insomnia and RBD should have a light diet and balanced nutrition
.
Try to avoid stimulating beverages such as coffee and tea, and yang-generating foods such as lamb and leeks
.
For EDS, this type of diet can be given appropriately
.
In addition, attention should be paid to the effect of drugs on PD sleep disorders
.
Because patients may have different types of sleep disorders, their medications interact with each other and also affect PD symptoms.
Therefore, specialist doctors are required to make medication adjustments
.
Yimaitong compiled from: Li Wentao, Gan Jing, Liu Zhenguo.
Expert consensus on the management of sleep disorders in Parkinson’s disease with integrated traditional Chinese and Western medicine (2021)[J].
Journal of Shanghai University of Traditional Chinese Medicine,2021,35(03):1-6.
