It’s estimated that as many as 2 out of 3 people with Parkinson’s disease have sleep problems, according to the National Sleep Foundation. Some of the issues are related to the disease itself, but in some cases sleep disturbances or insomnia can be a side effect of Parkinson’s disease medications. “There are a lot of chemical changes in the brain in people with Parkinson’s disease, and we know some of those changes can impact sleep,” says Marri Horvat, MD, a neurologist who specializes in sleep disorders at Cleveland Clinic in Ohio. The loss of dopamine-producing cells and changes in the levels of other neurotransmitters can disrupt sleep or cause issues with sleep overall, she says. Although sleep issues are common, up to 30 percent of people with PD don’t talk with their doctor about it, according to a study published in April 2019 in Parkinsonism & Related Disorders. If you have having problems sleeping, you should definitely bring this up with your provider, says Dr. Horvat. “In many cases, there are medications or interventions that can improve sleep or help with other issues that are making sleep difficult,” she says. Here are some of the most common sleep problems in Parkinson’s disease and expert advice on how to deal with them:
1. Drugs Used to Treat Parkinson’s Disease
The common Parkinson’s disease medication of carbidopa and levodopa (Sinemet) can contribute to insomnia for some people, says Horvat. “That’s because it’s replacing the dopamine that you’ve lost in Parkinson’s disease,” she says. Research has shown that dopamine receptors play a role in wakefulness. Sometimes when people are first started on this medication, they will take a dose right before bed rather than closer to their dinner, says Horvat. “Then they’re not able to get to sleep because the dopamine affects the reward center in the brain and gives people a ‘high,’” she says. Besides timing the medication further from bedtime, your doctor may suggest taking an extended-release capsule of carbidopa and levodopa, says Horvat. “That has a lower peak dose effect, so the stimulation is milder, and it lasts a little longer. It can allow patients to have more of a baseline rather than a peak at night, which can cause the insomnia,” she says. If you suspect your medication is making sleep difficult, tell your doctor; don’t stop taking the medicine as prescribed, says Horvat. “Sometimes we can time the medication in a different way or in some cases we do change the medication — but this is not something to try to figure out on your own.”
2. Anxiety and Depression
People with Parkinson’s disease are more likely to have some mental health conditions, including depression and anxiety, says Horvat. “Depression is very common in people with Parkinson’s disease, either before or after the diagnosis, and it can impact sleep — either sleeping too much or too little, says Horvat. Insomnia, or difficulty going to sleep or staying asleep, is present in 30 to 80 percent of people with Parkinson’s disease and is often associated with depression, according to a paper published in October 2019 in Clinics in Geriatric Medicine. “It’s really common for some people with Parkinson’s disease to wake up really early in the morning — around 4 a.m., for example — and then not being able to go back to sleep. That can be linked with the fact that they are also dealing with depression,” Horvat says. There is also evidence to suggest that depression potentially may be an early symptom of Parkinson’s, says Horvat. A meta-analysis published in May 2022 in Neurogenerative Disease Management found a strong association between depression and a later diagnosis of PD. Their findings indicated “an increased risk in developing PD in formerly depressed patients.” Anxiety can also make it hard to fall asleep, and if you wake up in the middle of the night it can make it harder to go back to sleep. All of those things are linked with PD, says Horvat. Talking to your doctor about depression and anxiety and getting treatment is often the best way you can improve your sleep, both for people with Parkinson’s disease and for those in the general population, she says.
3. Circadian Rhythm Disorders
The dementia and cognitive decline that can occur in Parkinson’s disease may lead to circadian rhythm disorders, says Horvat. These are also known as sleep-wake cycle disorders, and they are sleeping problems that occur when the body’s internal clock, which signals us that it’s time to sleep or wake, is out of sync. “I have patients with Parkinson’s disease who come to me thinking that they have insomnia, but they actually have circadian rhythm disorder. They may be sleeping only four hours at night, maybe two hours in the middle of the day, and two hours later in the evening,” says Horvat. When you’re having these random spurts of sleeping throughout the day, that can be very difficult, she says. “Addressing this is not as easy as saying, ‘Don’t take naps during the day,’ because these are often patients with cognitive deficits; it can be hard to reorient a dementia patient a lot of times,” says Horvat. “There aren’t many treatments for this either, beyond light therapy and melatonin therapy. Seeking out a sleep specialist can sometimes help,” she says.
4. Parkinson’s Symptoms, Including Pain and Frequent Urination
Pain is a common cause of sleep disturbances in Parkinson’s, says Horvat. A study published in June 2019 in the Journal of Pain Research found that about one-third of people with Parkinson’s had clinically relevant sleep disturbances, and that central parkinsonian pain was the pain subtype that was most often associated with sleep issues. Central pain can vary widely from person to person. It can feel like a constant burning or tingling that affects the whole body or it can be an intermittent sharp episode of pain, according to the Parkinson’s Foundation. “You should definitely talk to your doctor if pain or Parkinson’s symptoms are waking you up or keeping you up at night, to see what your treatment options may be,” says Horvat. Frequent urination can be a sign of several different things, and so it’s important to pay attention to any other symptoms you may also be having, she says. “Autonomic instability is often present in Parkinson’s disease, which basically means the autonomic system is not firing regularly, as it should be,” says Horvat. The autonomic system controls functions that keep you alive, including your heartbeat, breathing, and digestion. This condition can lead to incontinence or urinary retention, she says. “This is something to talk with your doctor about; there are some medications that can be helpful.”
5. Sleep Apnea
Sleep apnea is a condition in which your breathing stops and restarts many times while you sleep, and it can keep your body from getting enough oxygen, according to the National Heart, Lung and Blood Institute. There are a few signs — including frequent urination — that may indicate that a person has sleep apnea. “In sleep medicine, we often test someone for sleep apnea if someone is going to the bathroom a lot at nighttime, especially if you snore a lot. If we find someone does have sleep apnea and we treat it, sleep will likely improve,” says Horvat. Researchers are also exploring whether sleep apnea and the intermittent hypoxia (low oxygen) can lead to changes in the brain that are seen in people with PD, she says. “That’s another reason getting a formal sleep evaluation is important,” says Horvat.
6. Restless Legs Syndrome
This main symptom of restless legs syndrome (RLS) is the urge to move the legs, especially when at rest. Restless legs syndrome is more common in the very early stage of Parkinson’s disease, according to the National Sleep Foundation. Symptoms of RLS typically start or worsen in the evening or night and can sometimes be an underlying cause of insomnia, according to research. If your doctor determines that you do have restless leg syndrome, there are lifestyle changes you can try, such as avoiding or decreasing alcohol and tobacco, moderate exercise, and leg massage, per the National Institute of Neurological Disorders and Stroke. There are also medications available to treat the condition.
7. REM Sleep Behavior Disorder
“REM sleep behavior disorder (RBD) is common in people with Parkinson’s disease,” says Horvat. REM stands for rapid eye movement, and REM sleep is a stage of sleep associated with dreaming. People with RBD can have very vivid dreams (often described as nightmares) in which they are defending themselves or a loved one from being attacked or are being chased by animals, insects, or people, said Joohi Jimenez-Shahed, MD, a neurologist at Mount Sinai Health System in New York City, in a caregiver presentation sponsored by the Houston Area Parkinson Society. During these episodes, people with RBD will start acting out their dreams, usually in the last half of the night, says Horvat. Shouting, swearing, grabbing, punching, jumping, and kicking while asleep are all symptoms of RBD. “I’ll have patients tell me, ‘I was fighting someone in my dream, I woke up punching, and I hit my significant other who was in bed next to me,’” she says. This can be very dangerous for both the person with PD and their partner, says Horvat. “It can cause someone to fall out of bed; I’ve had patients suffer brain bleeds because of this.” There are treatments that can help, such as melatonin or benzodiazepines [drugs commonly prescribed for anxiety], she says. “We also look for other sleep disorders because they can make RBD worse: I actually have a patient where we resolved these episodes by treating their sleep apnea,” says Horvat. If you’re experiencing these types of dreams, you need to discuss this with your doctor, she adds. These symptoms should also be investigated even if you haven’t been diagnosed with PD, says Horvat. “These types of dreams can be a precursor to Parkinson’s disease and so you want to get that checked out.”
