SCOPA‐sleep and PDSS: Two scales for assessment of sleep disorder in Parkinson's disease

This study evaluated the comparative validity and usefulness of the Parkinson's Disease Sleep Scale (PDSS) and the Scales for Outcomes in PD‐Sleep Scale (SCOPA‐S), two disease‐specific rating scales for assessing sleep disorders in Parkinson's disease (PD). Hoehn and Yahr staging (HY), SCOPA‐Motor, Mini‐Mental State Examination, Clinical Impression of Severity Index for PD, Hospital Anxiety and Depression Scale, EuroQoL, and SCOPA‐Psychosocial, in addition to PDSS and SCOPA‐S (night‐time sleep (NS) and daytime sleepiness (DS) subscales), were applied to 187 consecutive PD patients. PDSS and SCOPA‐S proved similar in acceptability, scaling assumptions, precision, and internal consistency (Cronbach's α = 0.82–0.84). Factor analysis revealed five separate factors for PDSS (67% of the variance) and one factor for each SCOPA‐S subscale (60% of the variance for NS and 57% for DS). Correlation coefficient between PDSS and SCOPA‐S NS was ?0.60. Sleep scales correlated moderately with mood, low‐to‐moderate with HRQoL, and low with the rest of measures. PDSS and SCOPA‐S DS discriminated between patients grouped by HY severity levels and disease duration. Cutoff points of 82/83 for PDSS and 6/7 for SCOPA‐S NS were drawn to identify PD patients with sleep problems. Depression/anxiety scores explained 26% for PDSS and 22% for SCOPA‐S NS scores. Both scales provide valid, reliable, and useful means to evaluate sleep disorders in PD. PDSS may be used to obtain a profile about potential causes of “bad sleep,” but is barely useful to assess DS, whereas SCOPA‐S assesses nocturnal sleep disorders and daytime somnolence at a similar extent, without exploring the potential causes. © 2008 Movement Disorder Society     

Two polysomnographic features of REM sleep behavior disorder: Clinical variations insight for Parkinson's disease

IntroductionLoss of REM sleep muscle atonia (RWA) and dream-enactment behavior (DEB) are two associated features of REM sleep behavior disorder (RBD), which is frequently associated with Parkinson's disease (PD). Few studies have examined both DEB and RWA simultaneously in patients with PD. This study aimed to evaluate relationships between RWA, DEB and clinical characteristics of PD.MethodsWe conducted overnight polysomnography in 145 patients with PD. DEB (motor behaviors and/or vocalizations during REM) and increased RWA (IRWA; tonic and phasic chin EMG density ≥ 30% and ≥15%, respectively) were identified. Patients were categorized as clinical RBD (DEB and IRWA), sub-DEB positive (DEB only), subclinical RBD (IRWA only), or normal REM sleep.ResultsPatients with DEB had higher Hoehn and Yahr (H&Y) stage, Unified Parkinson's Disease Rating Scale (UPDRS) III score, levodopa equivalent dose(LEDs), and worse cognition. RWA was associated with H&Y stage, LEDs, cognition, and sleep structure in all patients. PD duration was associated with RWA, but not DEB. The PD patients who exhibited clinical or subclinical RBD, compared to sub-DEB positive, had higher H&Y stage, UPDRS III score and LEDs, lower cognitive score, worse sleep structure than the PD + cREM group.ConclusionBoth DEB and RWA were associated with severity of PD illness. Subclinical RBD might have different disease progression from sub-DEB positive. DEB symptoms may fluctuate or disappear whereas RWA may continue to develop as PD progresses. Differences in the course of DEB and RWA may reflect the difference in the degeneration process of neurodegenerative disorders.     

Fatigue in Japanese patients with Parkinson's disease: A study using Parkinson fatigue scale

The objective of this multicenter cross‐sectional study was to determine the prevalence of fatigue and factors contributing to it in a large sample of Japanese patients with Parkinson's disease (PD). We used the 16‐item Parkinson Fatigue Scale (PFS‐16), which was designed to assess fatigue exclusively associated with PD. We carried out this study using PFS‐16, the Unified Parkinson's Disease Rating Scale, Zung's Self‐Rating Depression Scale, Parkinson's Disease Sleep Scale (PDSS), and the PD quality of life (QOL) scale (PDQ‐39) by interview using questionnaires and physical examination by neurologists in 361 nondemented PD patients. Fatigue (an average PFS score of 3.3 or greater) was revealed in 151 patients (41.8%). Multiple logistic regression analysis indicated that the significant independent variables related to the presence of fatigue were the scores of PDSS and PDQ‐39. Depression score was not a significant contributing factor. Our study revealed that the prevalence of fatigue in Japanese PD patients is as high as that in Western countries, and that fatigue is a relatively independent symptom, although sleep disturbance may be associated with fatigue. Since fatigue is significantly related to QOL reduction, therapeutic interventions including treatment of sleep disturbance are important. © 2009 Movement Disorder Society     

A hypnotic drug for sleep disturbances in patients with Parkinson's disease]

Patients with Parkinson's disease have been known to have sleep disturbances of various types. Zolpidem tartrate, an imidazopyrimidine short-acting hypnotic drug used treat insominia and several patients with PD have described a significant improvement of parkinsonian symptoms after administration of zolpidem tartrate. We tried to evaluate effect of zolpidem tartrate for sleep disturbances in patients with PD by a Japanese version of Chaudhuri's Parkinson's disease Sleep Scale (PDSS) and Unified Parkinson's disease rating Scale (UPDRS) motor scale. Twelve patients with PD (mean age 67.4 years old, range 40-77 years old) were evaluated by PDSS and UPDRS before and two weeks after prescribed zolpidem tartrate 5 mg per day. Patients showed improvement in items relating overall sleep disturbances, sleep refreshment and morning stiffness. Disabilities remained unchanged before and two weeks after prescribing zolipdem tartrate. Zolpidem tartrate may be useful for sleep disturbances in patients with PD and for improving their quality of daily livings.     

Sleep disorders in Chinese patients with Parkinson's disease: validation study of a Chinese version of Parkinson's disease sleep scale

To evaluate the Chinese version of the Parkinson's disease sleep scale (PDSS) as an instrument for measuring sleep disorders in Chinese patients with Parkinson's disease (PD). The objective of the present study was to carry out a metric analysis of a Chinese version of PDSS using a cross-sectional study of 126 patients with PD who participated in the study. Usual measures for PD patients including the Pittsburgh sleep quality index (PSQI), the Epworth sleepiness scale (ESS), the Geriatric Depression Scale (GDS), and the Hamilton Anxiety Scale (HAMA) were applied by neurologists. The intra-class correlation coefficient was 0.880, and test-retest reliability for total PDSS score was 0.914. The Mean total PDSS score was 118.38+/-26.07. There was a significant correlation between the PDSS and PSQI, between the PDSS and ESS, between the PDSS and GDS, between the PDSS and HAMA, between the PDSS and the disease durations, and between the PDSS and the LDE, respectively. The Chinese version of PDSS met some basic standards required for sleep disorders measures. It could lead to better understanding the sleep disorders of PD of China in future studies.     

Sleep problems affect quality of life in Parkinson's disease along disease progression

ObjectivesNon-motor symptoms (NMS) frequently impact health-related quality of life (HRQoL) in patients with Parkinson's Disease (PD). Sleep problems represent one of the main NMS complained by PD patients. In this observation study, sleep problems measured by Parkinson's Disease Sleep Scale - 2nd version (PDSS-2), and HRQoL measured by Parkinson's Disease Questionnaire-39 (PDQ39) were quantified in patients with PD ranging from mild to moderate-advanced disease stages, and correlated to motor impairment and anti-PD therapy.MethodsWe included idiopathic PD patients who underwent PDSS-2 and PDQ39. Moreover, we assessed patients' motor symptoms by rating the Unified Parkinson's Disease Rating Scale (UPDRS) - III section (motor examination), patients' PD status following H&Y stage, and levodopa equivalent daily dose (LEDD).ResultsOne-hundred and fifty-four patients with PD were included and distributed for H&Y stage. PDSS-2 and PDQ39 total and sub-items scores significantly increased with the H&Y stage. PDSS-2 total score significantly correlated with PDQ39 total score (γ = 0.63, P < 0.01). Finally, distributing PD patients according to the PDSS-2 cut-off for detecting sleep disturbances, we found in poor sleepers (n = 58) higher PDQ39 scores than good sleepers (n = 89).ConclusionsSleep problems are very common in patients with PD and severely impact on HRQoL. Sleep impairment and low HRQoL occur from the early stages of the disease and deteriorate along disease progression. Further studies investigating sleep and quality of life should be planned for targeting sleep improvement to increase HRQoL and possibly reduce motor impairment.     

Sleep disturbances in Malaysian patients with Parkinson's disease using polysomnography and PDSS

BackgroundSleep disturbances such as sleep fragmentation, sleep disordered breathing (SDB), periodic limb movements (PLM), excessive daytime somnolence (EDS) and insomnia are prevalent in Parkinson's disease (PD). However, studies in the Asian population are limited.MethodsThis was a cross-sectional study involving 46 Malaysians with PD using polysomnography (PSG) and standardized translated Parkinson's disease sleep scale (PDSS). Overnight PSG recordings, UPDRS and PDSS scores, and baseline demographic data were obtained.ResultsData from 44 patients were analysed. Thirty-six patients (81.8%) had PSG-quantified sleep disorders. Twenty-three (52.3%) had sleep fragmentation, 24 (54.6%) had SDB and 14 (32%) had PLM. EDS was present in 9.1%. Insomnia was reported by 31.8%. Patients with sleep fragmentation had significantly higher UPDRS scores and lower PDSS insomnia sub-scores. The UPDRS scores correlated negatively with the TST and sleep efficiency. All patients with EDS had SDB (p = 0.056). The PDSS insomnia sub-items correlated with sleep fragmentation on PSG.Conclusion: The prevalence of sleep disorders based on PSG and PDSS in our PD patients was high, the commonest being sleep fragmentation and SDB, while EDS was the least prevalent. Problem specific sub-items of the PDSS were more accurate in predicting the relevant PSG-related changes compared to the PDSS as a whole.     

Rotigotine effects on early morning motor function and sleep in Parkinson's disease: A double‐blind,randomized, placebo‐controlled study (RECOVER)

In a multinational, double‐blind, placebo‐controlled trial (NCT00474058), 287 subjects with Parkinson's disease (PD) and unsatisfactory early‐morning motor symptom control were randomized 2:1 to receive rotigotine (2–16 mg/24 hr [n = 190]) or placebo (n = 97). Treatment was titrated to optimal dose over 1–8 weeks with subsequent dose maintenance for 4 weeks. Early‐morning motor function and nocturnal sleep disturbance were assessed as coprimary efficacy endpoints using the Unified Parkinson's Disease Rating Scale (UPDRS) Part III (Motor Examination) measured in the early morning prior to any medication intake and the modified Parkinson's Disease Sleep Scale (PDSS‐2) (mean change from baseline to end of maintenance [EOM], last observation carried forward). At EOM, mean UPDRS Part III score had decreased by ?7.0 points with rotigotine (from a baseline of 29.6 [standard deviation (SD) 12.3] and by ?3.9 points with placebo (baseline 32.0 [13.3]). Mean PDSS‐2 total score had decreased by ?5.9 points with rotigotine (from a baseline of 19.3 [SD 9.3]) and by ?1.9 points with placebo (baseline 20.5 [10.4]). This represented a significantly greater improvement with rotigotine compared with placebo on both the UPDRS Part III (treatment difference: ?3.55 [95% confidence interval (CI) ?5.37, ?1.73]; P = 0.0002) and PDSS‐2 (treatment difference: ?4.26 [95% CI ?6.08, ?2.45]; P < 0.0001). The most frequently reported adverse events were nausea (placebo, 9%; rotigotine, 21%), application site reactions (placebo, 4%; rotigotine, 15%), and dizziness (placebo, 6%; rotigotine 10%). Twenty‐four‐hour transdermal delivery of rotigotine to PD patients with early‐morning motor dysfunction resulted in significant benefits in control of both motor function and nocturnal sleep disturbances. © 2010 Movement Disorder Society     

Clinical usefulness of the Parkinson's disease sleep scale

OBJECTIVE: To test the usefulness of the Parkinson's disease sleep scale (PDSS) in identifying sleep disorders in the clinical practice setting. METHODS: Sixty-two PD patients were evaluated with the PDSS and the Epworth sleepiness scale (ESS). A cut-off of less than five for each PDSS item as an indicator of substantial sleep disturbance was chosen. If the ESS was equal to or greater than eight, patients were referred to a sleep disorder specialist and possible polysomnography. RESULTS: The mean total PDSS score was 104.7+/-21.5,which correlated with the mean Hoehn and Yahr score (1.9+/-0.9) as well as the mean ESS score (9.7+/-4.7). A significant correlation was also found between the ESS score and several items of the PDSS. CONCLUSIONS: The PDSS was useful in identifying sleep disturbances which were not previously diagnosed, such as sleep maintenance insomnia and excessive daytime sleepiness. Problems with the PDSS include ambiguities of some questions, lack of quantification and an inability to identify specific sleep disturbances such as sleep apnea.     

Multifactorial sleep disturbance in Parkinson's disease

Parkinson's disease (PD) is the second most common neurodegenerative disorder, ranking only behind Alzheimer's disease and affecting 2% of the population over the age of 65. Pathophysiologically, PD is characterized by selective degeneration of the dopaminergic neurons of the substantia nigra pars compacta (SNpc) and striatal dopamine depletion. Patients may also exhibit mild-to-severe degeneration of other central and peripheral nervous tissues. The most dramatic symptoms of the disease are profound dopamine-responsive motor disturbances, including bradykinesia, akinesia, rigidity, resting tremor, and postural instability. PD patients commonly present with debilitating non-motor symptoms, including cognitive impairment, autonomic nervous system dysfunction, and sleep disturbance. Of these, sleep disturbance is the most consistently reported, and likely represents a disorder integrative of PD-related motor impairment, autonomic nervous system dysfunction, iatrogenic insult, and central neurodegeneration. The pathophysiology of PD may also indirectly disrupt sleep by increasing susceptibility to sleep disorders, including sleep disordered breathing, periodic limb movements, and REM behavior disorder. In this review, we will discuss these systems representing a multifactorial etiology in PD sleep disturbance.     

Observational study of sleep-related disorders in Italian patients with Parkinson’s disease: usefulness of the Italian version of Parkinson’s disease sleep scale

Sleep disturbances are common in patients with Parkinson's disease (PD). We aimed to evaluate prevalence and severity of nighttime sleep disturbances in Italian PD patients and to validate the Italian version of the Parkinson's disease sleep scale. A total of 221 PD patients and 57 healthy controls participated in a cross-sectional study with retest. PDSS, Epworth Sleepiness Scale (ESS), Hamilton Depression Rating Scale, Unified Parkinson's Disease Rating Scale (UPDRS), and Hoehn and Yahr staging were applied. PDSS total and individual items scores from patients were significantly lower than those in controls. Internal consistency of PDSS scale was satisfactory and intraclass correlation coefficient for test-retest reliability was 0.96 for total PDSS score. A significant negative correlation was found between total PDSS and ESS scores, and between total PDSS and HDRS scores. PDSS scores were also related to UPDRS sections II, III and IV, and H&Y stage. PDSS and ESS scores were not related to levodopa equivalent dose. Daytime sleepiness, depressive symptoms and disease severity correlate with sleep disturbances in Italian PD patients. The PDSS is a valid and reliable tool to evaluate sleep disturbances in Italian patients.     

Validation of the sleep related items of the Non-motor Symptoms Questionnaire for Parkinson's disease (NMSQuest)

BackgroundThe Non-motor Symptoms Questionnaire (NMSQuest) is a recently developed questionnaire for the evaluation of non-motor symptoms in Parkinson's disease (PD) patients, which includes sleep disorders evaluation. The clinical validity of the questionnaire has not been explored.ObjectiveTo assess the performance of the sleep/fatigue domain of the NMSQuest against other sleep measures.MethodsSeventy PD patients were instructed to wear an actigraph and to fill in a sleep log over seven consecutive days in addition to the Parkinson's Disease Sleep Scale (PDSS) and the NMSQuest.ResultsPD patients who reported daytime sleepiness on NMSQuest obtained a significantly worse score on the PDSS sleepiness domain than PD patients who did not (12.0 ± 4.7 vs. 14.7 ± 3.4, p < 0.009). Patients reporting difficulty getting to sleep or staying asleep at night, showed lower scores on PDSS sleep quality domain than those without difficulties (15.8 ± 5.4 vs. 22.3 ± 4.6, p < 0.001). The presence of vivid dreams, acting out dreams and restlessness on NMSQuest correlated with PDSS and sleep log scores. Increased nocturnal activity was noted in subjects reporting acting out dreams. Furthermore, the number of positive answers to the sleep-fatigue questions of the NMSQuest correlated significantly with PDSS total score, sleep log total score and nocturnal activity measured by actigraphy.ConclusionNMSQuest sleep-fatigue domain identified appropriately sleep disturbances indicating its usefulness as a screening tool for sleep disorders in PD patients.     

The effects of bright light therapy on depression and sleep disturbances in patients with Parkinson's disease: a systematic review and meta-analysis of randomized controlled trials

BackgroundDepression and sleep disturbance are well-recognized non-motor features in patients with Parkinson's disease (PD). This meta-analysis aimed to explore the potential role of bright light therapy (BLT) in depression and sleep disturbances in Parkinson's Disease (PD).MethodsFour databases were independently searched by two reviewers: PubMed, Cochrane, Web of Science and Embase until February 2021. We evaluated the following depression related scales: Beck's Depression Inventory (BDI); the Geriatric Depression Rating Scale, 30-item (GDS-30); the Hamilton Depression Rating Scale (HDRS); the Hospital Anxiety and Depression Scale (HADS); the Epworth sleepiness scale (ESS); the Fatigue Severity Scale (FSS); the Pittsburgh sleep quality index (PSQI); the Parkinson's disease sleep scale (PDSS); Scales for Outcomes in Parkinson's disease Sleep Scale (SCOPA) and the Insomnia severity index (ISI) to access the effects of bright light therapy on depression and sleep disturbances in patients with PD. Effect size (standardized mean deviation [SMD] and 95% confidence interval [CI]) were used to analyze the continuous results data of intervention group and control light group. Data from five randomized, controlled trials totaling 173 patients with PD was included.ResultsBLT significantly improved depression symptoms (BDI, GDS-30, HDRS and HADS) of PD patients (0.34, 95% CI = 0.06–0.61). Insomnia symptoms (SCOPA and ISI) for patients with PD were significantly improved by BLT as well (1.15, 95% CI = 0.71–1.60). Whereas, no difference was observed in the control light group in improving the depression or insomnia symptoms of PD patients.ConclusionBLT is an effective intervention for improving depressive symptoms and sleep disturbances in patients with PD.     

REM sleep behavior disorder: Association with motor complications and impulse control disorders in Parkinson's disease

ObjectiveClinical phenotypes such as old age, longer disease duration, motor disability, akineto-rigid type, dementia and hallucinations are known to be associated with REM sleep behavior disorder (RBD) in Parkinson's disease (PD). However, the relationship between motor fluctuations/impulse control and related behaviors (ICRB) and RBD is not clear. We designed this study to elucidate the clinical manifestations associated with RBD to determine the implications of RBD in PD.DesignIn a cross-sectional study, a total of 994 patients with PD were interviewed to determine the presence of RBD and their associated clinical features including motor complications and ICRB.ResultsOf the 944 patients, 578 (61.2%) had clinical RBD. When comparing the clinical features between patients with RBD (RBD group) and without RBD (non-RBD group), older age, longer disease duration, higher Hoehn and Yahr stage (H&Y stage), higher levodopa equivalent daily dose (LEDD), and the existence of wearing off, dyskinesia, freezing, and ICRB, especially punding, were associated with the RBD group compared to the non-RBD group (P < .05 in all). Multivariate analysis showed that motor complications including wearing off, peak dose dyskinesia, and diphasic dyskinesia were the only relevant factors for RBD after adjusting for age and disease duration.ConclusionMotor complications and ICRB are more frequent in patients with RBD than in patients without RBD. In addition, motor complications are related to RBD even after adjusting for age and disease duration.     

广州地区帕金森病患者睡眠障碍情况调查

目的 调查广州地区帕金森病(Parkinson's disease,PD)患者睡眠质量,分析睡眠障碍特点及影响因素.方法 由中国医学科学院北京协和医院张振馨教授设计,采用PD非运动症状调查问卷中PD睡眠量表(PDSS)及Epworth嗜睡评分量表(ESS)对2007年4-6月在广州6家医院门诊或住院部的PD患者共107例进行睡眠情况调查,用统一PD评分量表(UPDRS)及Hoehn-Yahr(HY)分级进行运动功能的评定,了解睡眠与运动功能之间的关系.结果 107例PD患者中20.6%(22/107)的患者存在睡眠障碍,18.7%(20/107)的患者可能存在睡眠障碍.PD患者睡眠障碍的特点主要为夜尿增多、白天睡眠增多、睡眠浅.PD患者睡眠障碍与病程、H-Y分级、UPDRS及ESS评分相关(rs=-0.322、-0.259、-0.231、-0.198,均P＜0.05).UPDRS得分越高、H-Y分级越大以及病程越长则睡眠情况越差.左旋多巴类药物用量在有或无睡眠障碍患者中差异无统计学意义.结论 睡眠障碍在广州地区PD患者中较常见,主要表现为夜尿增多、睡眠浅及白天睡眠增多,PD的严重程度可能影响患者睡眠质量.     

Scales to assess sleep impairment in Parkinson's disease: Critique and recommendations

There is a broad spectrum of sleep disturbances observed in Parkinson's disease (PD). A variety of scales have been applied to the evaluation of PD sleep and wakefulness, but only a small number have been assessed specifically for clinimetric properties in the PD population. The movement disorder society has commissioned this task force to examine these scales and to assess their use in PD. A systematic literature review was conducted to explore the use of sleep scales in PD and to determine which scales qualified for a detailed critique. The task force members, all of whom have extensive experience in assessing sleep in PD reviewed each of the scales using a structured proforma. Scales were categorized into recommended, suggested and listed according to predefined criteria. A total of 48 potential scales were identified from the search and reviewed. Twenty‐nine were excluded because they did not meet review criteria or were variations of scales already included, leaving 19 scales that were critiqued and rated by the task force based on the rating criteria. Only six were found to meet criteria for recommendation or suggestion by the task force: the PD sleep scale (PDSS) and the Pittsburgh sleep quality index (PSQI) are recommended for rating overall sleep problems to screen and to measure severity, the SCOPA‐sleep (SCOPA) is recommended for rating overall sleep problems both to screen and to measure severity, and for rating daytime sleepiness; the Epworth sleepiness scale (ESS) is recommended for rating daytime sleepiness to screen and to measure severity; the inappropriate sleep composite score (ISCS) is suggested for rating severe daytime sleepiness or sleep attacks to screen and to measure severity; and the Stanford sleepiness scale (SSS) is suggested for rating sleepiness and to measure severity at a specific moment. The task force does not recommend the development of new scales, but emphasizes the need for educational efforts to train physicians in sleep interview techniques and polysomnography. © 2010 Movement Disorder Society     

The range and nature of sleep dysfunction in untreated Parkinson's disease (PD). A comparative controlled clinical study using the Parkinson's disease sleep scale and selective polysomnography

In this study we have explored the nature and range of sleep dysfunction that occurs in untreated Parkinson's disease (PD) comparing data obtained from the use of the Parkinson's disease sleep scale (PDSS) in an untreated PD patient group compared to advanced PD and healthy controls. 25 untreated (drug-naive, DNPD) PD patients (mean age 66.9 years, range 53-80, 18 males) completed the validated Parkinson's disease sleep scale (PDSS), mean duration of PD was 2.1 years (1-10, up to 4 years in all except one patient with tremulous PD reporting tremor duration of 10 years) and mean Hoehn and Yahr score 1.9 (1-3). Data were compared to 34 advanced PD (mean age 70.2 years, range 51-88, 23 male), mean duration of PD 11 years (range 4-22), mean Hoehn and Yahr score 3.4 (3-5) and PDSS data obtained from 131 healthy controls (mean age 66.6 years, range 50-93, 56 males). Total PDSS scores and PDSS sub-items, except PDSS item 2, were highly significantly different (p<0.001) between DNPD, advanced PD and controls. Controls reported higher mean PDSS scores than both groups of patients, and advanced cases reported lower (mean+/-S.D.) PDSS scores (86.95+/-20.78) than drug-naive (105.72+/-21.5) (p<0.001). Logistic regression analysis showed that items PDSS8 (nocturia), PDSS11 (cramps), PDSS12 (dystonia), PDSS13 (tremor), and PDSS15 (daytime somnolence) were significantly impaired in DNPD compared to controls while PDSS7 (nighttime hallucinations) additionally separated advanced PD from DNPD. In a subgroup of 11 advanced PD cases (mean age 62 years, range=49-84 years, mean Hoehn and Yahr score 2.5, range=1-3) with high Epworth Sleepiness Scale (ESS) scores (mean 14.5), low item 15 PDSS score (mean 4.7) and complaints of severe daytime sleepiness, underwent detailed overnight polysomnography (PSG) studies, all showing abnormal sleep patterns. We conclude that nocturia, nighttime cramps, dystonia, tremor and daytime somnolence seem to be the important nocturnal disabilities in DNPD and some of these symptoms may be reminiscent of "off" period related symptoms even though patients are untreated. Furthermore, polysomnography in "sleepy" PD patients may help diagnose unrecognised conditions such as periodic limb movement of sleep (PLMS), obstructive sleep apnoea (OSA) and REM Sleep Behaviour Disorder.     

Periodic leg movements and REM sleep without atonia in Parkinson's disease with camptocormia

Camptocormia (a flexion of the trunk that only appears when standing or walking) affects a minority of patients with Parkinson's disease (PD). As it responds poorly to levodopa and is associated with reduced midbrain and pons volume, it may result from non‐dopaminergic, brainstem lesions. As several sleep abnormalities in PD also result from non‐dopaminergic brainstem lesions, we monitored sleep in 24 non‐demented PD patients with (n = 12) and without (n = 12) camptocormia and in 12 controls. Nearly half (42%) patients with camptocormia had abnormal periodic leg movement indices (>15/h), versus 17% patients without camptocormia and 8% of controls (p = 0.02). In addition, the percentage of enhanced muscle activity during REM sleep (measured on the chin and on the limb muscles) tended to be higher in patients with than without camptocormia (51 ± 39% vs. 20 ± 25%, p = 0.06). The other sleep and REM sleep characteristics (sleep and REM sleep onset latencies, sleep time and sleep stage percentages, REMs density, arousal, and apnea‐hypopnea indices) were not different between these two PD groups. Lesions causing this axial dystonia may spare the sleep systems but affect the control of movements during sleep. © 2009 Movement Disorder Society     

High rates of fatigue and sleep disturbances in dystonia

Background: Nonmotor symptoms in dystonia are increasingly recognized to impair the quality of life. The primary objective of this study was to determine the prevalence of fatigue and sleep disturbances in dystonia and to ascertain their impact on quality of life using standardized questionnaires. Methods: Dystonia patients presenting to a Botulinum toxin clinic were prospectively administered Fatigue Severity Scale (FSS), Multidimensional Fatigue Inventory (MFI), Epworth Sleepiness Scale (ESS) and Parkinson's Disease Sleep Scale (PDSS) for assessment of fatigue and sleep disturbances. Health-related Quality of life (HRQOL) was determined using MOS SF-36 scale and depressive symptoms were assessed using the Beck Depression Inventory II. Results: Ninety-one patients with dystonia participated (66 women, 25 men, mean age 60 ± 17 years). Nine subjects had generalized dystonia, 18 segmental dystonia and 64 had focal dystonia. Moderate to severe fatigue was present in 43% of the cohort (FSS), excessive daytime somnolence in 27% (ESS) and other sleep disturbances in 26% (PDSS). FSS and MFI scores correlated significantly with HRQOL even when controlled for depression and sleep disturbances. Excessive daytime somnolence and nocturnal sleep disturbances correlated significantly with the HRQOL; however, these effects were not seen for daytime somnolence when controlled for depression. Psychometric testing found adequate reliabilities and convergent validities for both fatigue and sleep scales. Conclusion: Fatigue and sleep disturbances revealed high prevalence rates in this large, first of its dystonia study. They negatively impacted the quality of life even when controlled for comorbid depression.     

Daytime REM sleep in Parkinson's disease

BackgroundPrevious studies have demonstrated both clinical and neurochemical similarities between Parkinson's disease (PD) and narcolepsy. The intrusion of REM sleep into the daytime remains a cardinal feature of narcolepsy, but the importance of these intrusions in PD remains unclear. In this study we examined REM sleep during daytime Maintenance of Wakefulness Testing (MWT) in PD patients.MethodsPatients spent 2 consecutive nights and days in the sleep laboratory. During the daytime, we employed a modified MWT procedure in which each daytime nap opportunity (4 per day) was extended to 40 min, regardless of whether the patient was able to sleep or how much the patient slept. We examined each nap opportunity for the presence of REM sleep and time to fall asleep.ResultsEleven of 63 PD patients studied showed 2 or more REM episodes and 10 showed 1 REM episode on their daytime MWTs. Nocturnal sleep characteristics and sleep disorders were unrelated to the presence of daytime REM sleep, however, patients with daytime REM were significantly sleepier during the daytime than those patients without REM. Demographic and clinical variables, including Unified Parkinson's Disease Rating Scale motor scores and levodopa dose equivalents, were unrelated to the presence of REM sleep.ConclusionsA sizeable proportion of PD patients demonstrated REM sleep and daytime sleep tendency during daytime nap testing. These data confirm similarities in REM intrusions between narcolepsy and PD, perhaps suggesting parallel neurodegenerative conditions of hypocretin deficiency.