Sleep Dysfunction in Parkinson's Disease

Efficacy of non-pharmacological interventions for sleep quality in Parkinson's disease: a systematic review and network meta-analysis

Background

Sleep disorders are one of the most common non-motor symptoms in PD. It can cause a notable decrease in quality of life and functioning in PD patients, as well as place a huge burden on both patients and caregivers. Currently, there are numerous non-pharmacological interventions available to improve sleep quality in PD, with disagreement as to which intervention is most effective. This network meta-analysis was performed to compare and rank non-pharmacological interventions to explore their efficacy in improving sleep quality in PD and to select the best interventions, with a view to providing references and bases for the development of clinical treatments and care programs.

Methods

The PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, China National Knowledge Infrastructure (CNKI), and Wanfang databases were searched from inception to December 6, 2023. Two authors independently screened all studies, extracted the data, and evaluated risk of bias of included studies. STATA software version 17.0 was used to conduct the network meta-analysis.

Results

Our network meta-analysis included 29 studies involving 1,477 participants and 16 non-pharmacological interventions. Although most nonpharmacological interventions showed non-significant effects, the surface under the cumulative ranking curve (SUCRA) values indicated that the best non-pharmacological intervention for sleep disorders was massage therapy (97.3%), followed by music therapy (94.2%), and Treadmill training (85.7%).

Conclusion

Massage therapy can be considered as an effective therapy for improving sleep quality in patients with PD. Due to limited quantity and quality of the included studies, more high quality studies are required to verify the conclusions of this network meta-analysis.

Systematic review registration

identifier CRD42023429339, PROSPERO (york.ac.uk).

Setting the clinical context to non-motor symptoms reflected by Park-pain, Park-sleep, and Park-autonomic subtypes of Parkinson's disease

Non-motor symptoms (NMS) of Parkinson's disease (PD) are well described in both clinical practice and the literature, enabling their management and enhancing our understanding of PD. NMS can dominate the clinical pictures and NMS subtypes have recently been proposed, initially based on clinical observations, and later confirmed in data driven analyses of large datasets and in biomarker-based studies. In this chapter, we provide an update on what is known about three common subtypes of NMS in PD. The pain (Park-pain), sleep dysfunction (Park-sleep), and autonomic dysfunction (Park-autonomic), providing an overview of their individual classification, clinical manifestation, pathophysiology, diagnosis, and potential treatments.

Non-oral continuous drug delivery based therapies and sleep dysfunction in Parkinson's disease

Continuous drug delivery (CDD) has emerged as a feasible and pragmatic therapeutic option for dopamine replacement therapy in advanced Parkinson's disease (PD). CDD aims to mimic the physiological tonic dopamine release from striatal dopaminergic neurons and thus reduces the severity and duration of motor and non-motor fluctuations partly related to pulsatile levodopa stimulation. Non-motor symptoms and fluctuations are ubiquitous in PD and include sleep dysfunction, a problem that occurs in over 90% of PD patients across all stages, from prodromal to palliative. In this review, we discuss the currently available and in development non-oral dopaminergic CDD strategies with a focus on their efficacy in the treatment of the burdensome sleep dysfunction in PD.

Sarcopenia is associated with non-motor symptoms in Han Chinese patients with Parkinson's Disease: a cross-sectional study

BACKGROUND

Sarcopenia is commonly seen in the older adults and increases in incidence with age, also in Parkinson's disease (PD). Although research has indicated that the development of sarcopenia in patients with PD may be related to both motor symptoms and non-motor symptoms (NMS), the precise relationship between the two conditions remains unclear. Therefore, we aimed to investigate the incidence of sarcopenia in patients with PD and its association with NMS.

METHODS

The study included 123 patients with PD and 38 age- and sex-matched healthy controls (HC). All participants were evaluated for sarcopenia using the 2019 Asian Sarcopenia Diagnostic Criteria, and patients with PD underwent standard assessments of motor symptoms and NMS. Multiple logistic regression and receiver operating characteristic (ROC) curve analyses were used to examine the association between sarcopenia and NMS in patients with PD.

RESULTS

The incidence of sarcopenia was significantly higher in patients with PD than in HC (26.8% vs. 10.4%, p = 0.046). Multiple logistic regression analysis revealed that poorer sleep quality (odds ratio [OR]: 1.245; 95% confidence interval [CI]: 1.011-1.533; p = 0.040) and fatigue (OR: 1.085, 95% CI: 1.006-1.170, p = 0.034) were independently associated with sarcopenia. ROC analysis indicated that the optimal cut-off value for Pittsburgh Sleep Quality Index (PSQI) scores was 10, with 72.7% sensitivity and 74.4% specificity (area under the curve [AUC] = 0.776, 95% CI: 0.683-0.868, p < 0.001). The optimal cut-off value for Fatigue Severity Scale (FSS) scores was 39, with 87% sensitivity and 50% specificity (AUC = 0.725, 95% CI: 0.629 -0.820, p < 0.001). Joint use of FSS and PSQI scores increased the predictive value for sarcopenia(AUC = 0.804, 95% CI: 0.724-0.885, p < 0.001).

CONCLUSION

Patients with PD are more susceptible to sarcopenia than healthy older adults, and fatigue and poorer sleep are positively associated with sarcopenia. Further longitudinal studies are needed to clarify the causal relationships.

Nocturia and Sleep in Parkinson's Disease

BACKGROUND

Nocturia has a high prevalence in Parkinson's Disease (PD) and is known to be a bothersome symptom for people with Parkinson's disease (PwPD).

OBJECTIVE

to characterize nocturia in a sample of PwPD, in relation to sleep, fatigue and other non-motor symptoms (NMS).

METHODS

we assessed 130 PwPD using a comprehensive battery of scales, which includes the Non-Motor Symptoms Questionnaire (NMSQ), International Parkinson and Movement Disorder Society Non-Motor Rating Scale (MDS-NMS), Parkinson's Disease Sleep Scale version 2 (PDSS-2), Parkinson's Disease Questionnaire (PDQ-39), The Overactive Bladder Questionnaire-Short form (OABq-SF), and the Parkinson's Fatigue Scale (PFS-16).

RESULTS

according to the positive answers to the item of the NMSQ related to nocturia, patients were divided into PwPD + nocturia, and PwPD - nocturia. Nocturia was reported by 112 patients (86.15%). Quality of life in PwPD + nocturia was worse than in PwPD - nocturia, according to the PDQ-39 scores (13.32 ± 9.00 vs. 26.29 ± 14.55, p < 0.001). Sleep was significantly disturbed in PwPD + nocturia compared to PwPD - nocturia, according to the total scores of various scales, such as PDSS-2, PFS-16. PwPD who complained of nocturia presented higher scores of several NMS.

CONCLUSIONS

nocturia has a high prevalence in PwPD and it is associated with impaired sleep, fatigue, and reduced quality of life.

[Insomnia in neurological patients with disabilities]

Sleep is the most important factor reflecting the level of psychophysical well-being of a person and influencing him/her to the same extent. The greater susceptibility to sleep disturbances in patients with disabilities is associated with numerous factors. In the existing literature, there are few studies of insomnia in people with neurological disabilities. This article presents a current view on sleep disorders in disabled people and methods for their treatment.

Long-term effects of intrajejunal levodopa infusion on sleep in people with advanced Parkinson's disease

Background

Sleep disturbances are commonly encountered in people with advanced Parkinson's disease (PD). In these stages, levodopa-carbidopa intestinal gel (LCIG) is recommended for improving motor symptoms, some non-motor dysfunctions, and quality of life in these patients. This study aimed to assess the effects of LCIG on sleep in PD in a longitudinal study.

Study design

An open-label observational study in patients with advanced PD undergoing LCIG treatment was carried out.

Measures and outcomes

In total, 10 consecutive advanced people with PD were evaluated at the baseline and after 6 months and 1 year, respectively, of LCIG infusion. Sleep parameters were assessed with several validated scales. We assessed the evolution of sleep parameters under LCIG infusion over time and the effects on sleep quality.

Results

Significant improvement following LCIG was observed in PSQI total score (p = 0.007), SCOPA-SLEEP total score (p = 0.008), SCOPA-NS subscale (p = 0.007), and AIS total score (p = 0.001) at 6 months and 1 year, compared to the baseline. The PSQI total score at 6 months correlated significantly with the Parkinson's Disease Sleep Scale, version 2 (PDSS-2) "disturbed sleep" item at 6 months (p = 0.28; R = 0.688), while the PSQI total score at 12 months significantly correlated with the PDSS-2 total score at 1 year (p = 0.025, R = 0.697) and with the AIS total score at 1 year (p = 0.015, R = 0.739).

Conclusion

LCIG infusion demonstrated beneficial effects on sleep parameters and sleep quality, which were constant over time for up to 12 months.

Correction of the wake-sleep cycle by intranasal administration of dopamine in modeling of the preclinical stage of Parkinson's disease in rats

Sleep disorders, which are among the earliest and most sensitive non-motor manifestations of Parkinson's disease (PD), are not diagnosed in 40–50 % of patients and are not subject to the necessary correction. In this regard, the ineffectiveness of a late start of treatment, when more than 50 % of dopamine-producing neurons are already affected, dictates the need to search for and develop approaches to the prevention and slowdown of neurodegenerative pathology at the preclinical stages of its development using adequate experimental models. Taking into account the low bioavailability of dopamine (DA) and data on the advantages of the intranasal route of administration in comparison with oral and parenteral methods of drug delivery to the CNS, the aim of the work was to study the neurophysiological features of the wake-sleep cycle as early manifestations of nigrostriatal insufficiency and the effect of intranasal administration of DA on the quality of sleep during the formation of the preclinical stage of PD in rats. It was shown that under the conditions of modeling PD, the cyclic organization of sleep with a predominance of incomplete cycles against the background of hyperproduction of slow-wave sleep and REM phases are early manifestations of nigrostriatal insufficiency. Course administration of DA at a dose of 3 mg/kg is accompanied by the normalization of sleep quality in the form of reduction (by 76 %) in the number of incomplete cycles. The preventive orientation of the obtained effects may indicate a certain therapeutic potential of intranasal delivery of DA to the brain, aimed at slowing down the processes of neurodegeneration and possibly delaying its clinical manifestation

Poor sleep quality is associated with fatigue and depression in early Parkinson's disease: A longitudinal study in the PALS cohort

Background

Sleep disorders are common in Parkinson's disease (PD). However, the longitudinal relationship between sleep quality and the other non-motor symptoms of PD has not been well characterized, especially in early PD.

Objective

To explore the value of baseline sleep quality in predicting the progression of other non-motor symptoms in early PD.

Methods

109 early PD patients were recruited to the study. Patients were stratified into good and poor sleepers using the Pittsburgh Sleep Quality Index (PSQI). Assessments performed at baseline and 1 year follow-up included the Epworth Sleepiness Scale, Fatigue Severity Scale, Non-Motor Symptom Scale, Geriatric Depression Scale, Hospital Anxiety and Depression Scale, Apathy Scale, Montreal Cognitive Assessment and detailed neuropsychological assessments. Multivariable linear regression was performed at baseline to investigate differences in clinical scores between poor and good sleepers, while multivariable regression models were used to investigate associations between sleep quality and progression of test scores at 1 year follow-up.

Results

59 poor sleepers and 50 good sleepers were identified. At baseline, poor sleepers had greater HADS anxiety scores (p = 0.013) [2.99 (95% CI 2.26, 3.73)] than good sleepers [1.59 (95% CI 0.75, 2.42)]. After 1 year, poor sleepers had greater fatigue (FSS scores +3.60 as compared to −2.93 in good sleepers, p = 0.007) and depression (GDS scores +0.42 as compared to −0.70, p = 0.006).

Conclusion

This study shows a longitudinal association between sleep quality, fatigue, and depression in early PD patients, independent of medication effect and disease severity, this may support the hypothesis that a common serotonergic pathway is implicated in these non-motor symptoms.

Efficacy of Moxibustion in the Treatment of Parkinson's Disease Based on Meta-Analysis under Intelligent Medical Treatment

Dementia in Parkinson's disease (PD) has become a major factor affecting the quality of life of patients with Parkinson's disease. Early detection and timely prevention can delay the progression of dementia, improve the quality of life of patients, and reduce the burden on society. This article is aimed at studying how to analyze the efficacy of moxibustion in the treatment of Parkinson's disease through meta-analysis on the basis of smart medicine. This article puts forward the related conceptual knowledge of smart medicine and meta-analysis and moxibustion treatment and proposes a deep learning method based on smart medicine to analyze the effects of moxibustion treatment on patients. The experiment in this article can be seen from the data in one of the figures that the highest curative effect of using a single moxibustion to treat Parkinson's disease is about 46%, while the curative effect of using a combination of moxibustion and Western medicine has reached 90%. It can be seen that a single moxibustion is not as effective as a combination of the two for Parkinson's disease. From the data in one of the tables, it can be seen that the proportion of Parkinson's disease in 2016 was 15%, showing an increase of 5%. By 2020, the proportion of Parkinson's disease was as high as 38%, and the growth rate reached 9%. It can be seen that the prevalence of this disease is getting higher and higher. Parkinson's disease has caused many undesirable effects on patients, such as slow movement, mental disorders, and a decline in mental state. Therefore, it is urgent to study the treatment of Parkinson's disease. Moxibustion can improve the patient's blood circulation and help the patient's local limbs to recover more easily and can help improve the patient's motor function.

Personalized Assessment of Insomnia and Sleep Quality in Patients with Parkinson's Disease

Sleep disturbances are more common in patients with Parkinson’s disease (PD) than in the general population and are considered one of the most troublesome symptoms by these patients. Insomnia represents one of the most common sleep disturbances in PD, and it correlates significantly with poor quality of life. There are several known causes of insomnia in the general population, but the complex manifestations that might be associated with PD may also induce insomnia and impact the quality of sleep. The treatment of insomnia and the strategies needed to improve sleep quality may therefore represent a challenge for the neurologist. A personalized approach to the PD patient with insomnia may help the clinician to identify the factors and comorbidities that should also be considered in order to establish a better individualized therapeutic plan. This review will focus on the main characteristics and correlations of insomnia, the most common risk factors, and the main subjective and objective methods indicated for the assessment of insomnia and sleep quality in order to offer a concise guide containing the main steps needed to approach the PD patient with chronic insomnia in a personalized manner.

Management of Sleep Disturbances in Parkinson's Disease

Parkinson's disease (PD) is defined by its motor symptoms rigidity, tremor, and akinesia. However, non-motor symptoms, particularly autonomic disorders and sleep disturbances, occur frequently in PD causing equivalent or even greater discomfort than motor symptoms effectively decreasing quality of life in patients and caregivers. Most common sleep disturbances in PD are insomnia, sleep disordered breathing, excessive daytime sleepiness, REM sleep behavior disorder, and sleep-related movement disorders such as restless legs syndrome. Despite their high prevalence, therapeutic options in the in- and outpatient setting are limited, partly due to lack of scientific evidence. The importance of sleep disturbances in neurodegenerative diseases has been further emphasized by recent evidence indicating a bidirectional relationship between neurodegeneration and sleep. A more profound insight into the underlying pathophysiological mechanisms intertwining sleep and neurodegeneration might lead to unique and individually tailored disease modifying or even neuroprotective therapeutic options in the long run. Therefore, current evidence concerning the management of sleep disturbances in PD will be discussed with the aim of providing a substantiated scaffolding for clinical decisions in long-term PD therapy.

Cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and Morita therapy (MT); comparison of three established psychotherapies and possible common neural mechanisms of psychotherapies

Psychotherapies aim to relieve patients from mental distress by guiding them toward healthier attitudes and behaviors. Psychotherapies can differ substantially in concepts and approaches. In this review article, we compare the methods and science of three established psychotherapies: Morita Therapy (MT), which is a 100-year-old method established in Japan; Cognitive Behavioral Therapy (CBT), which-worldwide-has become the major psychotherapy; and Acceptance and Commitment Therapy (ACT), which is a relatively young psychotherapy that shares some characteristics with MT. The neuroscience of psychotherapy as a system is only beginning to be understood, but relatively solid scientific information is available about some of its important aspects such as learning, physical health, and social interactions. On average, psychotherapies work best if combined with pharmacotherapies. This synergy may rely on the drugs helping to "kickstart" the use of neural pathways (behaviors) to which a patient otherwise has poor access. Improved behavior, guided by psychotherapy, can then consolidate these pathways by their continued usage throughout a patient's life.

The Correlation Between Parkinson's Disease and Rapid Eye Movement Sleep Behavior Disorder: A Systematic Review

Parkinson's disease (PD) is a neurodegenerative disease caused due to the destruction of dopaminergic neurons and the deposition of α-synuclein proteins, known as Lewy bodies. Generally, the diagnosis of PD is centered around motor symptoms. However, the early recognition of non-motor symptoms such as autonomic dysfunction, sleep disturbances, and cognitive and psychiatric disturbances are gaining increased attention for the early diagnosis of PD. Rapid eye movement (REM) sleep behavior disorder or REM sleep behavior disorder (RBD) is described as parasomnia, which is a condition of loss of normal muscle atonia causing the person to act out vivid dreams and it has been seen to be associated with the misprocessing of intercellular α-synuclein leading to neurodegenerative diseases such as PD. This review's objective is to highlight the significance of RBD as a prodromal premotor marker for the early detection of PD. We used PubMed as our primary database to search for articles on May 2, 2021, and a total of 1849 articles were found in our initial search using keywords and medical subject heading (MeSH) keywords. Thereafter, we removed the duplicates, applied the inclusion/exclusion criteria, and did a quality appraisal to include 10 articles in this study. We concluded that the recognition and diagnosis of RBD are of paramount importance to detect early PD, and further longitudinal studies and clinical trials are of utmost importance to understand their correlation; also, treatment trials are needed to prevent the phenoconversion of RBD into PD.

REM sleep behaviour disorder in Parkinson's disease (Review)

Rapid eye movement (REM) sleep behavior disorder (RBD) is a parasomnia defined by simple or complex abnormal movements occurring in REM state, instead of the physiological muscular atonia. RBD may be idiopathic, or secondary as in the case of Parkinson's disease (PD). Several studies have confirmed that idiopathic RBD may precede with several years the onset of the specific motor characteristics of PD. The high prevalence of RBD in PD (19-70%) may be explained by several common pathophysiological pathways, mainly related to the dopaminergic cell loss. RBD is also associated with several comorbidities, including cognitive impairment, hallucinations, dysautonomia, or daytime sleepiness. The gold standard investigation for the diagnosis and assessment of RBD is video polysomnography, but in clinical practice, the use of clinical scales and questionnaires is reasonable for the screening of this complex parasomnia. Management options include ensuring a safe environment for the patient and pharmacological treatment, incuding clonazepam, melatonin or certain antiparkinsonian drugs.

Effects of home-based exercise on motor, non-motor symptoms and health-related quality of life in Parkinson's disease patients: A randomized controlled trial

AIM

To explore the effect of home-based exercise on motor symptoms (MS), non-motor symptoms (NMS), and health-related quality of life (HRQOL) in Parkinson's disease (PD) patients.

METHODS

This study was a randomized control trial with a convenience sample of 98 PD patients. Data were collected at baseline and interventions after 4 and 8 weeks. The exercise group was instructed to perform 150 min/week of exercise at home; the control group maintained their regular lifestyle. Questionnaires measured MS, NMS, and HRQOL. We also compare compliance and non-compliance subgroups of the exercise group. The generalized estimating equation (GEE) was used to determine the exercise effect of 120 and 150 min per week after testing for exercise times was at six time points (90-140 min).

RESULTS

The exercise (n = 49) and control groups (n = 49) were homogeneous except for disease stage at baseline. Significant differences were found for depression, HRQOL, motor ability, activity of daily living, and fatigue (p < .000) between the exercise and control groups, and also between the compliance and non-compliance subgroups (p < .05). The GEE revealed that exercising 150 min/week significantly improved HRQOL, depression, motor ability, ADL, fatigue, and sleep quality (p < .05), though not anxiety, and exercising 120 min/week was also effective.

CONCLUSIONS

This home-based exercise was effective in improving MS, NMS, and HRQOL. We recommend PD patients to exercise 30-50 min at least three times a week, or 10-15 min per session daily, to accumulate 120-150 min per week.

Spectrum of Non-Motor Symptoms in Parkinson's Disease

Parkinson's disease is predominantly classified as a movement disorder. Beyond the textbook definition of rigidity, tremors, and bradykinesia, Parkinson's disease encompasses an entire entity of non-motor symptom complexes that can precede the motor features by many years. Despite their significant clinical importance, the awareness of non-motor symptoms is quite negligible. Sleep disorders, gastrointestinal dysfunction, olfactory disturbances, anxiety, and depressive episodes are some of the most common non-motor presentations. The wide-spread occurrence of olfactory symptoms and the low cost of the assessment, is favoring olfactory dysfunction as a potential biomarker in Parkinson's. Sleep disorders may manifest before the motor and autonomic symptoms and might be linked to concomitant sleeping disorders like insomnia, REM sleep disorders, restless leg syndrome, narcolepsy, or obstructive sleep apnea. Non-motor symptoms can deteriorate the quality of life in Parkinson's patients. Early detection of non-motor symptoms can help in the diagnosis of Parkinson's disease and can fairly improve the survival and prognosis of these patients.

Impact of home confinement during COVID-19 pandemic on sleep parameters in Parkinson's disease

Background

Literature shows that home confinement during coronavirus disease 2019 (COVID-19) pandemic has significantly affected sleep. However, such information regarding subjects having Parkinson's disease (PD) is unavailable.

Methods

This cross-sectional study was conducted using a questionnaire, developed and validated by experts. PD subjects from nine centers across India were included. Questionnaire assessed presence as well as change in sleep-related parameters and PD symptoms during home confinement. Restless legs syndrome (RLS) and REM sleep behavior disorder (REMBD) was diagnosed using validated questionnaire. Additionally, changes in physical activity, adoption of new hobbies during home confinement and perceived quality of life were assessed.

Results

Of 832 subjects, 35.4% reported sleep disturbances. New-onset/worsening of sleep disturbances (NOWS) was reported by 23.9% subjects. Among those with sleep disturbances (n = 295), insomnia symptoms worsened in half (51.5%) and nearly one-fourth reported worsening of RLS (24.7%) and REMBD (22.7%) each. NOWS was common in subjects lacking adequate family support during home confinement (P = 0.03); home confinement > 60 days (P = 0.05) and duration of PD > 7 years (P = 0.008). Contrarily, physical activity >1 h/day and engagement in new hobbies during home confinement were associated with better sleep. NOWS was associated with worsening of motor as well as non-motor symptoms of PD (P < 0.001) and poorer life quality (P < 0.001).

Conclusion

Home confinement during COVID-19 pandemic was significantly associated with NOWS among PD subjects. NOWS was associated with global worsening of PD symptoms and poorer life quality. Physical activity >1 h/day and adoption of new hobbies during home confinement were associated with better sleep.

Clinical Features and Correlates of Poor Nighttime Sleepiness in Patients with Parkinson's Disease

Objective

The present study investigated the clinical features and correlates of poor nighttime sleepiness (PNS) in patients with Parkinson's disease (PD).

Methods

One hundred ten patients with PD (divided into PD-PNS group and PD-nPNS group) and forty-seven controls (nPD-PNS group) were enrolled in this study. Demographic information was collected. Patients were assessed according to the unified Parkinson's disease rating scale (UPDRS) and Hoehn–Yahr (H&Y) stage scale. Patients were also evaluated according to the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), rapid eye movement sleep behavior disorder screening questionnaire (RBD-SQ), restless leg syndrome (RLS) diagnosis, Hamilton's depression scale (HAMD), and Hamilton's anxiety scale (HAMA).

Results

The prevalence of PNS was 55.45% (61/110) in patients with PD. The PD-PNS group tended to have a longer duration of disease, higher UPDRS-I and UPDRS-III scores, a higher percentage of RLS patients, and higher HAMA and HAMD scores than those of the PD-nPNS group. The PD-PNS group tended to have a higher percentage of RBD and RLS patients and higher HAMA and HAMD scores than those of the nPD-PNS group. Analysis of the PSQI components and PSQI impact factors showed that the PD-PNS group had worse subjective sleep quality (χ² = −2.267, P = 0.023), shorter sleep latency (χ² = −2.262, P = 0.024), fewer sleep medications (χ² = −4.170, P ≤ 0.001), worse daytime functioning (χ² = −2.347, P = 0.019), and an even higher prevalence of increased nocturia (χ² = 4.447, P = 0.035), nightmares (χ² = 7.887, P = 0.005), and pain (χ² = 9.604, P = 0.002) than those of the nPD-PNS group. Analysis also indicated that the PSQI global score positively correlated with BMI (r = 0.216, P < 0.05), H&Y stage (r = 0.223, P < 0.05), UPDRS-I (r = 0.501, P < 0.01), UPDRS-III (r = 0.425, P < 0.01), ESS (r = −0.296, P < 0.01), RBD (r = 0.227, P < 0.05), RLS (r = 0.254, P < 0.01), HAMA (r = 0.329, P < 0.01), and HAMD (r = 0.466, P < 0.01). In the final model, H&Y stage, RLS, UPDRS-III, and HAMD remained associated with the PQSI score (P ≤ 0.001, P ≤ 0.001, P = 0.049, P ≤ 0.001, respectively).

Conclusions

Our data showed that PNS was common in patients with PD. H&Y stage, UPDRS-III, HAMD, and RLS were positively associated with PNS. Attention to the management of motor symptoms, RLS, and depression may be beneficial to nighttime sleep quality in patients with PD.

A Non-invasive Digital Biomarker for the Detection of Rest Disturbances in the SOD1G93A Mouse Model of ALS

Amyotrophic Lateral Sclerosis (ALS) is a devastating neurodegenerative disease that affects both central and peripheral nervous system, leading to the degeneration of motor neurons, which eventually results in muscle atrophy, paralysis, and death. Sleep disturbances are common in patients with ALS, leading to even further deteriorated quality of life. Investigating methods to potentially assess sleep and rest disturbances in animal models of ALS is thus of crucial interest. We used an automated home cage monitoring system (DVC®) to capture irregular activity patterns that can potentially be associated with sleep and rest disturbances and thus to the progression of ALS in the SOD1G93A mouse model. DVC® enables non-intrusive 24/7 long term animal activity monitoring, which we assessed together with body weight decline and neuromuscular function deterioration measured by grid hanging and grip strength tests in male and female mice from 7 until 24 weeks of age. We show that as the ALS progresses over time in SOD1G93A mice, activity patterns start becoming irregular, especially during day time, with frequent activity bouts that are neither observed in control mice nor in SOD1G93A at a younger age. The increasing irregularities of activity pattern are quantitatively captured by designing a novel digital biomarker, referred to as Regularity Disruption Index (RDI). We show that RDI is a robust measure capable of detecting home cage activity patterns that could be related to rest/sleep-related disturbances during the disease progression. Moreover, the RDI rise during the early symptomatic stage parallels grid hanging and body weight decline. The non-intrusive long-term continuous monitoring of animal activity enabled by DVC® has been instrumental in discovering novel activity patterns potentially correlated, once validated, with sleep and rest disturbances in the SOD1G93A mouse model of the ALS disease.

Practical Evaluation and Management of Insomnia in Parkinson's Disease: A Review

Background

Insomnia is one of the most common nonmotor features of Parkinson's disease (PD). However, there are few practical guidelines for providers on how to best evaluate and treat this problem.

Methods and Findings

This review was developed to provide clinicians with a pragmatic approach to assessing and managing insomnia in PD. Recommendations were based on literature review and expert opinion. We addressed the following topics in this review: prevalence of insomnia in PD, sleep-wake mechanisms, theoretical models of insomnia, risk factors, assessment, pharmacologic and nonpharmacologic treatments. Insomnia treatment choices may be guided by PD severity, comorbidities, and patient preference. However, there is limited evidence supporting pharmacotherapy and nonpharmacologic treatments of insomnia in PD.

Conclusions

We provide a pragmatic algorithm for evaluating and treating insomnia in PD based on the literature and our clinical experience. We propose personalized insomnia treatment approaches based on age and other issues. Gaps in the existing literature and future directions in the treatment of insomnia in PD are also highlighted.

Sleep fragmentation as an important clinical characteristic of sleep disorders in Parkinson's disease: a preliminary study

BACKGROUND

Sleep disorders are one of the earliest non-motor symptoms of Parkinson's disease (PD). Sleep disorders could, therefore, have value for recognition and diagnosis in PD. However, no unified classification and diagnostic criteria exist to evaluate sleep disorders by polysomnography (PSG). Utilizing PSG to monitor sleep processes of patients with PD and analyze sleep disorder characteristics and their relationship with demographic parameters could aid in bridging this gap. This preliminary study aimed to evaluate the clinical characteristic of sleep disorders in PD using PSG.

METHODS

PSG was used to evaluate sleep disorders in 27 patients with PD and 20 healthy volunteers between August 2015 and July 2018 in Fujian Medical University Union Hospital. Total sleep time (TST), sleep efficiency (SE), total wake time, and other parameters were compared between the two groups. Finally, the correlation between sleep disorders and age, disease duration, Unified Parkinson's Disease Rating Scale-III scores, Hoehn-Yahr stage, and levodopa dose were analyzed. The main statistical methods included Chi-square test, two independent samples t test, Fisher exact test, and Pearson correlation.

RESULTS

Sleep fragmentation in the PD group was significantly increased (74.1%) while difficulty falling asleep and early awakening were not, as compared to healthy controls. No significant differences were found in time in bed, sleep latency (SL), non-rapid eye movement (NREM) stage 1 (N1), N1%, N2, N2%, N3%, and NREM% between PD and control groups; but TST (327.96 ± 105.26 min vs. 414.67 ± 78.31 min, P = 0.003), SE (63.26% ± 14.83% vs. 76.8% ± 11.57%, P = 0.001), R N3 (20.00 [39.00] min vs. 61.50 [48.87] min, P = 0.001), NREM (262.59 ± 91.20 min vs. 337.17 ± 63.47 min, P = 0.003), rapid-eye-movement (REM) (32.50 [33.00] min vs. 85.25 [32.12] min, P < 0.001), REM% (9.56 ± 6.01 vs. 15.50 ± 4.81, P = 0.001), REM sleep latency (157.89 ± 99.04 min vs. 103.47 ± 71.70 min, P = 0.034) were significantly reduced in PD group.

CONCLUSION

This preliminary study supported that sleep fragmentation was an important clinical characteristic of sleep disorders in PD. Whether sleep fragmentation is a potential quantifiable marker in PD needs to be further investigated in the future study.

Effect of simplified Tai Chi exercise on relieving symptoms of patients with mild to moderate Parkinson's disease

BACKGROUND

Tai Chi, a kind of physical exercise, may act as a non-pharmacologic approach to reducing the symptoms of Parkinson's disease. This study was conducted to investigate the effect of simplified Tai Chi training plus routine exercise on motor and non-motor symptoms in patients with mild to moderate Parkinson's disease in comparison with routine exercise regimen alone.

METHODS

Forty-one outpatients and inpatients with Parkinson's disease (PD) were randomized into Tai Chi group (N.=19) and routine exercise group as control group (N.=22) for 12 weeks. The Tai Chi group included both Tai Chi traning and routine exercise. Motor and non-motor functions were assessed. Motor function was evaluated by Unified Parkinson's Disease Rating Scale part III (UPDRS-III) and Berg Balance Scale (BBS). The non-motor symptoms like quality of life, sleep quality, depression and anxiety state, cognitive function were assessed by Parkinson's Disease Questionnaire-39 (PDQ-39), Parkinson's Disease Sleep Scale (PDSS), Hamilton Depression Scale (HAMD), Hamilton Anxiety Scale (HAMA), Montreal Cognitive Assessment (MOCA) respectively.

RESULTS

After 12 weeks of intervention, participants in both Tai Chi and routine exercise groups gained effects in UPDRS-III, BBS, PDQ-39, PDSS and HAMD compared to the baseline. However, significant improvements between Tai Chi group and routine exercise group were only found in PDSS (P=0.029) and MoCA (P=0.024).

CONCLUSIONS

Tai Chi training plus routine exercise might therefore be an ideal alternative non-pharmacological approach for the motor and non-motor symptoms of PD patients, and especially be more useful for the improvement of sleep quality and cognitive function in Parkinson's disease compared with routine exercise regimen alone.

Blue Light Therapy Glasses in Parkinson's Disease: Patients' Experience

Background

Blue light glasses have been introduced as a possible new treatment option to treat sleep disturbances in patients with Parkinson disease (PD). Assessing patient attitudes represents a key step in the road towards formal testing and introduction into clinical practice. Specifically, we aimed to assess how patients experience the use of blue light glasses, aiming to optimise compliance in upcoming clinical trials where these glasses will be tested for efficacy.

Methods

We invited 58 PD patients who had used the blue light glasses for at least one week on a daily basis to complete an online survey about their experiences and self-reported impact. For this purpose, the System Usability Scale was used, supplemented with additional questions about (side)effects. A total of 31 patients (53%) replied.

Results

74% of respondents reported subjective improvements in night-time sleep, daytime sleepiness, depressive symptoms, motor functioning, or a combination thereof. The median score for the System Usability Scale (SUS; 0–100 range, higher scores indicating better performance) was 70.0. A total of 26 patients (84%) had an overall positive attitude towards the technique, with patients rating the glasses with an average score of 6.9 ± 2.0 (SD) out of 10. Except for one patient, all responders would like to continue using the glasses, mostly because they considered it a useful aid.

Conclusion

Blue light therapy appears to have a positive effect on sleep, mood, and motor symptoms in PD. PD patients had an overall positive attitude towards blue light glasses as treatment for sleep disorders.

Role of pedunculopontine nucleus in sleep-wake cycle and cognition in humans: A systematic review of DBS studies

BACKGROUND

Animal studies have demonstrated that the pedunculopontine nucleus (PPN) is involved in the control of posture and gait, and that it is also a key structure in controlling basic non-motor functions such as sleep, attention and arousal. In this systematic review we aimed to evaluate all available studies assessing the role of PPN on cognition, nocturnal sleep and alertness in humans. Finally, we attempted to define a model in which PPN acts as an interface structure between motor control and behavior.

METHODS

A systematic search of the computerized databases MEDLINE and PubMed was conducted to identify papers on PPN and cognitive functions, sleep and alertness. Key search terms included: 'PPN', 'arousal', 'sleep', 'cognition', 'memory', 'language', 'attention', 'alertness', 'PPN-DBS', 'Parkinson's and PPN', 'Parkinson's and PPN-DBS'.

RESULTS

Twelve studies met our inclusion criteria and were included. All of them involved PD patients implanted with unilateral or bilateral PPN-DBS, most patients had concomitant DBS of another anatomical structure (subthalamic nucleus or Zona incerta). There is a lack of consistent evidences confirming the effect of PPN-DBS on specific cognitive functions, alertness or sleep in PD. There is heterogeneity between and within surgical centres of study protocols especially regarding DBS targeting, parameters of stimulation and experimental methods. Moreover, the available studies are limited by the small sample size and the short follow-up time. It has been suggested that low frequency stimulation (25 Hz) has a better effect compared to the high frequency one (60-80 Hz) on alertness, however this needs to be confirmed in further studies.

CONCLUSIONS

PPN-DBS is a promising but yet an experimental procedure. PD represents an encouraging pathological model for future studies aiming to shade light on the role of PPN in cognition, attention and alertness in humans.

Relationship of Nocturnal Sleep Dysfunction and Pain Subtypes in Parkinson's Disease

Background

Little research has been conducted regarding the relationship between sleep disorders and different pain types in Parkinson's disease (PD).

Objective

To explore the influence of the various pain subtypes experienced by PD patients on sleep.

Methods

Three hundred consecutive PD patients were assessed with the PD Sleep Scale-Version 2 (PDSS-2), King's PD Pain Scale (KPPS), King's PD Pain Questionnaire (KPPQ), Visual Analog Scales for Pain (VAS-Pain), and Hospital Anxiety and Depression Scale.

Results

According to the PDSS-2, 99.3% of our sample suffered from at least one sleep issue. Those who reported experiencing any modality of pain suffered significantly more from sleep disorders than those who did not (all, P < 0.003). The PDSS-2 showed moderate-to-high correlations with the KPPS (r_S = 0.57), KPPQ (0.57), and VAS-Pain (0.35). When PDSS-2 items 10 to 12 (pain-related) were excluded, the correlation values decreased to 0.50, 0.51, and 0.28, respectively, while these items showed moderate-to-high correlations with KPPS (0.56), KPPQ (0.54), and VAS-Pain (0.42). Among the variables analyzed, multiple linear regression models suggested that KPPS and KPPQ were the most relevant predictors of sleep disorders (as per the PDSS-2), although following exclusion of PDSS-2 pain items, depression was the relevant predictor. Depression and anxiety were the most relevant predictors in the analysis involving the VAS-Pain. Regression analysis, considering only the KPPS domains, showed that nocturnal and musculoskeletal pains were the best predictors of overall nocturnal sleep disorder.

Conclusions

Pain showed a moderate association with nocturnal sleep dysfunction in PD. Some pain subtypes had a greater effect on sleep than others.

Excessive Daytime Sleepiness in Parkinson's Disease: Clinical Implications and Management

Objective

Excessive daytime sleepiness (EDS) is one of the most common sleep abnormalities in patients with Parkinson's disease (PD), yet its multifactorial etiology complicates its treatment. This review summarized recent studies on the epidemiology, etiology, clinical implications, associated features, and evaluation of EDS in PD. The efficacy of pharmacologic and non-pharmacologic treatments for EDS in PD was also reviewed.

Data Sources

English language articles indexed in PubMed and Cochrane databases and Chinese-language papers indexed in Wanfang and National Knowledge Infrastructure databases that were published between January 1987 and November 2017 were located using the following search terms: "sleepiness", "sleep and Parkinson's disease", and "Parkinson's disease and treatment".

Study Selection

Original research articles and critical reviews related to EDS in PD were selected.

Results

EDS is a major health hazard and is associated with many motor and nonmotor symptoms of PD. Its causes are multifactorial. There are few specific guidelines for the treatment of EDS in PD. It is first necessary to identify and treat any possible factors causing EDS. Recent studies showed that some nonpharmacologic (i.e., cognitive behavioral therapy, light therapy, and repetitive transcranial magnetic stimulation) and pharmacologic (i.e., modafinil, methylphenidate, caffeine, istradefylline, sodium oxybate, and atomoxetine) treatments may be effective in treating EDS in PD.

Conclusions

EDS is common in the PD population and can have an immensely negative impact on quality of life. Its causes are multifactorial, which complicates its treatment. Further investigations are required to determine the safety and efficacy of potential therapies and to develop novel treatment approaches for EDS in PD.