Concurrent respiratory resistance training and changes in respiratory muscle strength and sleep in an individual with spinal cord injury: case report

Context

Quality sleep possesses numerous benefits to normal nighttime and daytime functioning. High-level spinal cord injury (SCI) often impacts the respiratory muscles that can lead to poor respiratory function during sleep and negatively affect sleep quality. The impact of respiratory muscle training (RMT) on sleep quality, as assessed by overnight polysomnography (PSG), is yet to be determined among the spinal cord-injured population. This case report describes the effects of 10 weeks of RMT on the sleep quality of a 38-year-old male with cervical SCI.

Methods

Case report.

Findings/results

The subject completed overnight PSG, respiratory muscle strength assessment, and subjective sleepiness assessment before and after 10 weeks of RMT. The post-test results indicated improvements in sleep quality (e.g. fewer electroencephalographic (EEG) arousals during sleep) and daytime sleepiness scores following RMT.

Conclusion/clinical relevance

Respiratory activity has been proven to impact EEG arousal activity during sleep. Arousals during sleep lead to a fragmented sleeping pattern and affect sleep quality and daytime function. Our subject presented with a typical sleep complaint of snoring and excessive sleepiness. The subject''s pre-test PSG demonstrated a large number of arousals during sleep. It is important for all individuals complaining of problems during sleep or daytime problems associated with sleep (i.e. excessive daytime sleepiness) to seek medical attention and proper evaluation.     

The multiple sleep latency test in the diagnosis of sleep disorders

The multiple sleep latency test provides an objective measure of a patient's daytime sleepiness. Sixteen tests were performed at Groote Schuur Hospital in 1987 and 1988 according to a fixed protocol. In 8 patients the test was definitely abnormal (mean sleep latency less than 5 minutes) with 3 subjects diagnosed as having narcolepsy, 1 sleep apnoea syndrome, 1 idiopathic central nervous system hypersomnolence, 2 environment-related hypersomnolence and 1 psychophysiological hypersomnolence. In 2 patients the test results fell in the equivocal range (mean sleep latency 5-10 minutes), while in 5 the test revealed no evidence for a disorder of excessive sleep (mean sleep latency greater than 10 minutes). The test was uninterpretable for technical reasons in only 1 patient. In conclusion, the test--when performed in a standardised manner--is extremely helpful in the elucidation of possible disorders of excessive sleep.     

Athletes after anterior cruciate ligament reconstruction demonstrate asymmetric intracortical facilitation early after surgery

Quadriceps dysfunction persists after anterior cruciate ligament reconstruction (ACLR), yet the etiology remains elusive. Inhibitory and facilitatory intracortical networks (ie, intracortical excitability) may be involved in quadriceps dysfunction, yet the investigation of these networks early after ACLR is sparse. The purposes of this study were to examine (a) changes in intracortical excitability in athletes after ACLR compared to uninjured athletes during the course of postoperative rehabilitation, (b) the association between intracortical excitability and quadriceps strength in athletes after ACLR. Eighteen level I/II athletes after ACLR between the ages of 18 to 30 years and eighteen healthy sex, age, and activity matched athletes were tested at three‐time points: (a) 2 weeks after surgery, (b) achievement of a “quiet knee” defined as full range of motion and minimal effusion, (c) return to running time point defined as achievement of a quadriceps index ≥80% and at least 12 weeks post‐ACLR. Short‐interval intracortical inhibition (SICI) and intracortical facilitation (ICF), measured via transcranial magnetic stimulation and isometric quadriceps strength were examined bilaterally at each time point. There was a significant group × limb interaction (P = .017) for ICF. The ACLR group demonstrated asymmetric ICF (greater in the nonsurgical limb) compared to controls and a significant relationship between SICI and quadriceps strength of the surgical limb at the quiet knee time point (P = .018). ACLR individuals demonstrate differential effects on ICF between limbs. Also, SICI is associated with isometric quadriceps strength after ACLR, suggesting increased inhibition of the motor cortex may contribute to impaired quadriceps strength following ACLR.     

Daytime sleepiness, cognitive performance and mood after continuous positive airway pressure for the sleep apnoea/hypopnoea syndrome.

BACKGROUND--Patients with the sleep apnoea/hypopnoea syndrome often receive continuous positive airway pressure to improve their symptoms and daytime performance, yet objective evidence of the effect of this treatment on cognitive performance is lacking. METHODS--A prospective parallel group study was performed comparing the change in objective daytime sleepiness as assessed by multiple sleep latency, cognitive function, and mood in 21 patients (mean (SE) number of apnoeas and hypopnoeas/hour 57 (6)) who received continuous positive airway pressure for three months and 16 patients (49(6) apnoeas and hypopnoeas/hour) who received conservative treatment for a similar period. RESULTS--Both groups showed significant within group changes in cognitive function between baseline and three months, but when comparisons were made between groups the only significant difference was a greater improvement in multiple sleep latency with continuous positive airway pressure. However, the improvement in sleep latency with continuous positive airway pressure was relatively small (3.5 (0.5) to 5.6 (0.7) min). The group treated with continuous positive airway pressure was divided into those who complied well with treatment (> 4.5 hours/night) and those who did not. Those who complied well (n = 14) showed significant improvement in mean sleep latency and also in depression score compared with the controls but no greater improvement in cognitive function. CONCLUSION--This study confirms significant improvements in objective sleepiness and mood with continuous positive airway pressure, but shows no evidence of major improvements in cognitive function.     

Relationships between nasal obstruction, observed apnea, and daytime sleepiness.

OBJECTIVE: We administered a questionnaire survey to a working population in an attempt to clarify the relationships between self-reported nasal obstruction, observed apnea during sleep, and daytime sleepiness. STUDY DESIGN: A total of 7980 daytime workers were asked to complete questionnaires about nasal obstruction, apnea during sleep, and daytime sleepiness. Of the 7702 responses, the data from 4818 subjects were analyzed. Nasal obstruction and observed apnea were graded into 3 categories. Daytime sleepiness was assessed by the Epworth Sleepiness Scale. RESULTS: Subjects with chronic nasal obstruction had 5.22 and 2.17 times higher odds for having habitual observed apnea and excessive daytime sleepiness (EDS), respectively, compared with those without nasal obstruction (P < 0.001). After adjusting for 3 potential confounding factors (age, sex, and body mass index) and the presence of habitual observed apnea, odds ratios for having EDS decreased, but still remained significant. CONCLUSION: Nasal obstruction is likely to cause daytime sleepiness, at least in part, by causing sleep-disordered breathing including apnea during sleep.     

慢性肾脏病对帕金森病患者白天过度嗜睡的影响

目的探讨帕金森病(PD)合并慢性肾脏病(CKD)患者出现白天过度嗜睡(EDS)的临床特征,并评估肾功能对PD患者EDS的影响。 方法将60例PD合并CKD患者作为研究对象。根据CKD分期,利用相关量表[爱波沃斯嗜睡量表(ESS)评分等]评估不同肾功能状态PD患者临床特征,探讨肾功能对PD患者EDS的影响。以多元线性回归分析影响PD患者EDS的相关因素,以确定影响EDS的预测因素。 结果PD合并CKD患者白天过度嗜睡各组的人口学资料间差异无统计学意义。合并CKD的PD患者发生EDS率为51.7%。随着患者肾功能下降,ESS评分(F＝4.578,P＝0.001)、匹茨堡睡眠质量指数(PSQI)评分(F＝3.399,P＝0.025)、统一PD评定量表Ⅲ(UPDRSⅢ)评分(F＝3.745,P＝0.015)、统一PD评定量表II(UPDRSII)评分(F＝3.244,P＝0.030)逐渐升高;多次睡眠潜伏期试验(MSLT)时间逐渐缩短(F＝5.672,P＝0.001)、每日服用左旋多巴等效剂量(LED)用量逐渐减少(F＝5.785,P＝0.001),患者的夜间睡眠质量、运动功能、日常生活能力、生活质量均变差。LED剂量与EDS呈正相关,肾功能与EDS呈负相关。 结论合并CKD的PD患者伴发EDS常见,其原因不仅与疾病本身的病理改变、睡眠中枢调节机制紊乱有关,也与夜间睡眠质量差和抗帕金森病药物的应用有关。CKD可能是PD患者发生EDS的危险因素。     

Sleep apnea and other sleepwake disorders in stroke

Opinion statement Sleep-disordered breathing (SDB) and sleep-wake disturbances (SWD) are frequent in stroke patients. They deserve attention, because they may significantly influence rehabilitation process and functional outcome. In addition, SDB may increase the risk of stroke recurrence. More than 50% of stroke patients have SDB, mostly obstructive sleep apnea (OSA). In some patients, stroke recovery is accompanied by an improvement of SDB. The treatment of choice for OSA is continuous positive airway pressure. Oxygen, theophylline, and other forms of ventilation may be helpful in patients with other forms of SDB (eg, Cheyne-Stokes breathing). In at least 20% to 40% of stroke patients, SWD are present, mainly in form of increased sleep needs (hypersomnia), excessive daytime sleepiness, or insomnia. Depression, anxiety, SDB, stroke complications (eg, nocturia, dysphagia, and urinary or respiratory infections), and drugs may contribute to SWD and should be addressed first. In patients with SWD of primary neurologic origin, treatment with stimulants or dopaminergic drugs and hypnotics or sedating antidepressants, respectively, can be attempted.     

Morbidity in nocturnal asthma: sleep quality and daytime cognitive performance.

Most patients with asthma waken with nocturnal asthma from time to time. To assess morbidity in patients with nocturnal asthma nocturnal sleep quality, daytime sleepiness, and daytime cognitive performance were measured prospectively in 12 patients with nocturnal asthma (median age 43 years) and 12 age and intellect matched normal subjects. The median (range) percentage overnight fall in peak expiratory flow rate (PEF) was 22 (15 to 50) in the patients with nocturnal asthma and 4 (-4 to 7) in the normal subjects. The patients with asthma had poorer average scores for subjective sleep quality than the normal subjects (median paired difference 1.1 (95% confidence limits 0.1, 2.3)). Objective overnight sleep quality was also worse in the asthmatic patients, who spent more time awake at night (median difference 51 (95% CL 8.1, 74) minutes), had a longer sleep onset latency (12 (10, 30) minutes), and tended to have less stage 4 (deep) sleep (-33 (-58, 4) minutes). Daytime cognitive performance was worse in the patients with nocturnal asthma, who took a longer time to complete the trail making tests (median difference 62 (22, 75) seconds) and achieved a lower score on the paced serial addition tests (-10 (-24, -3)). Mean daytime sleep latency did not differ significantly between the two groups (2 (-3, 7) minutes). It is concluded that hospital outpatients with stable nocturnal asthma have impaired sleep quality and daytime cognitive performance even when having their usual maintenance asthma treatment.     

Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis

BACKGROUND: Obstructive sleep apnoea syndrome (OSAS) affects an estimated 2-4% of the middle aged population. Meta-analyses of randomised controlled trials have shown that the severe presentation of the syndrome (apnoea hypopnoea index (AHI) >30/hour) is effectively treated with continuous positive airway pressure (CPAP). Until recently there have been insufficient data to determine whether CPAP improves sleepiness in the larger subgroup with mild to moderate OSAS (AHI 5-30/hour). METHODS: A systematic search of Medline and a hand search identified seven randomised controlled trials where CPAP was compared with either a placebo or with conservative management in the treatment of mild to moderate OSAS (AHI 5-30/hour). All trials used the Epworth Sleepiness Scale (ESS), four used the Multiple Sleep Latency Test (MSLT), and three used the Maintenance of Wakefulness Test (MWT) to measure sleepiness. RESULTS: Meta-analyses indicated that CPAP significantly reduced subjective daytime sleepiness (ESS) by 1.2 points (95% CI 0.5 to 1.9, p = 0.001), improved objective daytime wakefulness (MWT) by 2.1 minutes (95% CI 0.5 to 3.7, p = 0.011), but did not affect objective daytime sleepiness (MSLT, mean benefit -0.2 minutes, 95% CI -1.0 to 0.6, p = 0.6). The two significant effects were small (effect size <0.30). CONCLUSIONS: CPAP elicits small improvements in subjective sleepiness and objective wakefulness in people with mild to moderate OSAS. However, the effects on sleepiness are of limited clinical significance.     

Sleep disorders in chronic renal failure

Sleep disorders are common in patients with chronic renal failure (CRF), especially in those receiving hemodialysis. Sleep-related complaints in this patient population may include insomnia, daytime sleepiness or fatigue and depression. In addition to causing impairment of daytime function and quality of life, sleep apnea may also increase the cardiovascular morbidity and mortality, especially in dialysis patients. In CRF patients, an increased prevalence of sleep apnea, restless legs syndrome and periodic limb movement during sleep has been reported. Epidemiology, pathophysiology and treatment of sleep disorders in CRF and dialysis patients are still unclear and require further research.     

Prevalence of sleep apnea and excessive day time sleepiness in patients with end-stage renal disease on dialysis

Sleep apnea (SA) and excessive daytime sleepiness (EDS) are common sleep disorders among patients with end-stage renal disease (ESRD). This cross-sectional study, carried out in two dialysis centers in Saudi Arabia, assessed the prevalence of sleep apnea and sleepiness in Saudi patients with ESRD who are on maintenance dialysis with either peritoneal or hemodialysis. We used questionnaires to assess the prevalence of SA and EDS. The association between sleep apnea, EDS, and other sleep disorders, the underlying causes of renal failure, and other demographic data were also examined. Among 227 enrolled patients, the mean patient age was 55.7 years ± 17.2 years; 53.7% were male, and 46.3% were female. The overall prevalence of SA as defined by the Berlin questionnaire (BQ) was 37% in males and 34% in females, which was not a statistically significant difference (P = 0.459). Sleep apnea was significantly associated with age, neck size, afternoon and evening hemodialysis shift, obesity, diabetes, and hypertension (P-values, 0.001, 0.029, < 0.0001, < 0.0001, < 0.008, 0.002, and < 0.001, respectively). Sleep apnea was also significantly associated with other sleep disorders such as restless leg syndrome, insomnia, habitual snoring, and EDS (P-values, < 0.001, < 0.001, < 0.001, and < 0.001, respectively). The prevalence of EDS was 44%, and EDS was significantly more prevalent in patients undergoing peritoneal dialysis (P < 0.001); it was also associated with older age, diabetes mellitus, and other sleep disorders. SA and EDS are common in dialysis patients and are significantly associated with other sleep disorders.     

Epilepsy and sleep

Opinion statement A sleep history should be taken routinely in patients with epilepsy. Treatment of sleep disorders and improvement in sleep hygiene may improve seizure control, daytime cognitive functioning, and quality of life. Patients with recurrent sleepiness interfering with daily activities or an Epworth Sleepiness Scale score more than 10 should be considered for additional evaluation by a sleep specialist. Treatment options for insomnia include improvements in sleep hygiene, cognitive behavior therapies, and sedative or hypnotic drugs. Alterations in the timing or type of antiepileptic drugs (AEDs) may be helpful (for example, using sedating medications [eg, benzodiazepines, barbiturates] before bedtime and avoiding evening use of drugs that may exacerbate insomnia [eg, felbamate, lamotrigine]). Improvements in sleep hygiene alone are less effective than cognitive behavioral therapy or pharmacologic therapy. Cognitive behavioral therapy is more efficacious and its effects longer lasting than pharmacologic treatments. Sedative and hypnotic drugs may exacerbate AED cognitive adverse effects during the day and should be used only after other therapies have failed. Excessive daytime sleepiness (EDS) in patients with epilepsy may be secondary to AEDs, nocturnal seizures, or a concomitant sleep disorder such as sleep apnea or restless leg syndrome. Sedating AEDs should be minimized during the day, and activating AEDs should be used as appropriate. Video electroencephalogram polysomnography should be performed when EDS interferes with daily activities and the etiology of sleepiness is unclear. AEDs that are associated with weight gain should be avoided in patients with sleep apnea. AEDs that may promote weight loss should be considered for obese patients with sleep apnea. Continuous positive airway pressure is the treatment of choice for sleep apnea.     

维持性血液透析患者睡眠质量和日间嗜睡状况的研究

目的 本研究调查维持性血透患者的睡眠质量和日间嗜睡状况,探讨影响睡眠质量的相关因素。 方法 112例维持性高通量血透患者和53例健康人对照进行匹兹堡睡眠质量指数（PSQI）问卷评估睡眠质量和Epworth Sleep Scale（ESS）问卷评估日间嗜睡程度,并比较结果。比较睡眠好（PSQI总分≤5）和睡眠差（PSQI总分>5）的患者PSQI 7部分得分及各种睡眠障碍的原因;观察不同时间段血透患者的睡眠情况;多元线性回归和logistic回归分析年龄、透析龄等临床基本资料以及血钙、磷、血红蛋白等生化指标与睡眠质量的相关性。 结果 血透患者PSQI总分高于对照组（7.02±4.94比3.28±2.79,P < 0.05）,而ESS总分低于对照组[3（0～6）比8（4.25～11.75）,P < 0.05]。58%的血透患者睡眠差,入睡时间明显延长（30 min比15 min,P < 0.05）,失眠是主要原因。早、中、夜班血透睡眠质量无显著差异。年龄（OR = 1.75,P = 0.003）、透析龄（OR = 1.26,P = 0.008）、血红蛋白（OR = 0.64,P = 0.008）、钙磷乘积（OR = 1.60,P = 0.02）与睡眠质量评分显著相关。 结论 血透患者普遍存在睡眠不良,老年、透析龄长、贫血、钙磷乘积升高是危险因素。     

Circadian modulation of GABA-mediated cortical inhibition

Circadian rhythms exert powerful influence on various aspects of human physiology and behavior. Here, we tested changes of human cerebral cortex excitability over the course of the day with transcranial magnetic stimulation (TMS). At different times of the day, intracortical and corticospinal excitability of the primary motor cortex (M1) was evaluated in 15 healthy subjects by TMS of left M1. While motor thresholds, short-interval intracortical inhibition and facilitation and input/output curves remained unchanged, we found that a specific form of γ-aminobutyric acid (GABA)-mediated intracortical inhibition, revealed by long-interval intracortical inhibition and cortical silent periods, progressively decreased during the course of the day. Additional experiments demonstrated that morning inhibition persisted irrespective of previous sleep or sleep deprivation. Corticotropin-releasing hormone (CRH) infusions in the evening lead to morning cortisol levels but did not restore levels of morning inhibition, whereas suppression of endogenous CRH release by repeated oral dexamethasone intake over 24 h prevented morning inhibition. The findings suggest a specific modulation of GABAergic motor cortex inhibition within the circadian cycle, possibly linked to the CRH system, and may indicate a neurobiological basis for variable neuroplasticity over the course of the day.     

Randomised placebo controlled trial of daytime function after continuous positive airway pressure (CPAP) therapy for the sleep apnoea/hypopnoea syndrome

BACKGROUND—Patients with the sleepapnoea/hypopnoea syndrome (SAHS) report improved sleepiness, cognitivefunction, and psychological well being after continuous positive airwaypressure (CPAP) therapy, and it is for these daytime features that CPAPis usually given. However, few randomised or controlled studies existon the effects of CPAP on daytime function.
METHODS—A prospective, randomised, single blind,placebo controlled, crossover trial of daytime function after CPAP wasconducted in 23 patients with SAHS, all with 15apnoeas+hypopnoeas/hour and 2 symptoms of SAHS. All patients spentfour weeks on CPAP therapy and four weeks on oral placebo treatment,following randomisation to treatment order. With ethics committeeapproval, patients were told the placebo tablet might improve upperairway function. Average effective CPAP use was monitored using hiddentime clocks. Assessments of objective and subjective sleepiness,symptoms, cognitive performance, and psychological well being wereperformed on the last day of each treatment and compared.
RESULTS—Objective sleepiness measured by sleeponset latency on the multiple sleep latency test improved with CPAP(mean difference from placebo +2.4 min, 95% CI 0.8 to 4.0; p<0.001)as did subjective sleepiness on the Epworth scale (mean difference -6,95% CI -3 to -9; p = 0.001). Symptom total score also fell with CPAP(mean difference -1.6, 95% CI -2.2 to -1.0; p<0.001). Nodeterminants of these changes with active treatment were identified,and no significant enhancements to cognitive function or psychosocial well being were found in this small sample.
CONCLUSIONS—These findings provide furtherevidence for clinically significant benefits to daytime function from CPAP.

     

Better sleep quality and less daytime symptoms in patients on evening hemodialysis: a questionnaire-based study

The aims of this study were to investigate the prevalence of sleep disorders in patients with end-stage renal disease (ESRD), and to assess the effect of dialysis schedule on sleep quality and the presence of daytime symptoms. We prospectively selected 150 long-term hemodialysis (HD) patients in three groups (morning, afternoon, and evening dialysis) and gave them a sleep questionnaire, the Epworth sleepiness scale and the Pittsburgh sleep quality index. Snoring was the most common complaint (56%), followed by insomnia (38%) and restless legs syndrome (22.7%). The evening dialysis group experienced more sleep time in bed (P = 0.02), required less hypnotic medication (P = 0.049), had fewer daytime symptoms (P < 0.01), and experienced less daytime sleepiness (P = 0.034). Our study confirms the high prevalence of sleep disorders in ESRD patients, and indicates a beneficial effect of evening HD on sleep quality and reduction of daytime symptoms.     

Recent Advances in the Treatment of Narcolepsy

A diagnosis of narcolepsy requires pharmacologic treatment in more than 90% of patients. Wake-promoting compounds are used to treat excessive daytime sleepiness (EDS), and anticataplectics are used for cataplexy. The treatment of EDS includes the use of amphetamine-like CNS stimulants (such as dextroamphetamine and methylphenidate), modafinil, and its R-enantiomer, armodafinil. Because of its high safety and low side-effect profiles, modafinil has become the first-line treatment of choice for EDS associated with narcolepsy. However, wake-promoting compounds do not improve cataplexy and dissociated manifestation of REM sleep, and so antidepressants (monoamine uptake inhibitors) are additionally used for the treatment of cataplexy and REM sleep abnormalities. Tricyclic antidepressants potently reduce REM sleep and thus have been used for the treatment of cataplexy and REM sleep abnormalities, but these have recently been replaced by more selective serotonin and/or noradrenaline uptake inhibitors with better side-effect profiles. As sodium oxybate (the approved formula of γ-hydroxybutyrate in the United States), given at night, improves both EDS and cataplexy, the number of US patients treated with sodium oxybate is increasing, while much progress has been made in understanding the modes of action of amphetamine-like CNS stimulants.     

Sleep disorders in end-stage renal disease: 'Markers of inadequate dialysis'?

Excessive daytime sleepiness and sleep disorders, including sleep apnea syndrome, restless legs syndrome, and periodic limb movement disorder, occur with increased frequency in patients with end-stage renal disease (ESRD). The detection and management of sleep disorders in ESRD patients is often challenging but may have significant clinical benefits. Some of the poor quality of life in ESRD may be attributed to the presence of concomitant sleep disorders, yet the classical symptoms of sleep disorders (poor concentration, daytime sleepiness, and insomnia) are often ascribed to the uremic syndrome itself. Conventional risk factors and screening tools used in the diagnosis of sleep disorders seem to have limited applicability in dialysis patients implicating the unique pathophysiology of sleep disorders in ESRD. Emerging evidence suggests that sleep apnea may contribute to the augmented cardiovascular event rates and to the accelerated development of atherosclerosis in ESRD. Whether treatment of sleep disorders in ESRD patients can affect the high morbidity and mortality of ESRD patients has yet to be elucidated. To date, conventional renal replacement therapies do not appear to have a significant impact on the treatment of sleep disorders in ESRD. The promising therapeutic effects of optimal uremia control in the forms of nocturnal hemodialysis and renal transplantation on sleep disorders require further mechanistic and clinical studies.     

Sleep apnea and daytime sleepiness in end-stage renal disease

Sleep disorders are common in patients with end-stage renal disease (ESRD). The prevalence of sleep apnea is 10 times greater in patients with ESRD than in the general population. Although sleep apnea is not improved by conventional modes of dialysis, it is corrected by nocturnal hemodialysis, which provides a new and unique model to study its pathophysiology in this patient population. In addition to causing sleep disruption and impairment of daytime function, sleep apnea may also increase the cardiovascular morbidity and mortality that is commonly found in patients with ESRD. "Pathological" daytime sleepiness is found in 50% of patients with ESRD. Although its pathogenesis has been related both to sleep apnea and periodic limb movements, it has also been attributed to a variety of metabolic factors, including the severity of uremia. Further research is required to evaluate the impact of sleep disorders on the clinical outcome of patients with ESRD.     

Sleepiness and unintended sleep in Parkinson’s disease

Opinion statement Patients with Parkinson’s disease (PD) and parkinsonian syndromes (eg, dementia with Lewy bodies, multisystem atrophy, and Shy-Drager syndrome) suffer from daytime sleepiness. Sleepiness in PD is common (10% to 50% of patients) and very real, often approaching levels observed in the prototypical disorder of sudden-onset sleep, viz, and narcolepsy with cataplexy. Physicians need to be vigilant in assessing parkinsonian patients for sleepiness, because treatment can dramatically enhance quality of life and prevent the significant morbidity and mortality that attends daytime sleepiness. Men with advanced disease, cognitive impairment, drug-induced psychosis, and orthostatic hypotension are most at risk for developing pathologic sleepiness. Because primary sleep disorders can coexist with Parkinsonism (eg, sleep apnea, insufficient or interrupted sleep), these potential causes should be carefully assessed with polysomnography and treated appropriately. Dopaminomimetics may exacerbate sleepiness in a small subset of patients. The primary pathologies involved in Parkinsonism appear to be the greatest contributors to the development of daytime sleepiness. Sleepiness in Parkinsonism, especially a narcolepsy-like phenotype, may necessitate treatment with wake-promoting agents, such as bupropion, modafinil, or traditional psychostimulants.