Sleep disorder related to Parkinson’s disease

Sleep disorders occur in 74–98% of patients with idiopathic Parkinson’s disease (PD), adversely affecting their quality of life. Sleep disruption takes the form of sleep fragmentation with frequent and prolonged awakenings and daytime sleepiness. Nocturia, difficulty in turning over in bed, painful leg cramps, vivid dreams/nightmares, back pain, limb/facial dystonia and leg jerks are the main causes of nocturnal awakening in PD patients. Sleep disturbance gradually worsens with disease progression, suggesting that it is related to the severity of the disease. Sleep disturbances may be generally considered as part of the normal aging process, being more common in the elderly. However, no significant association between sleep disturbances and either age or disease duration was found in a survey of 100 PD patients. Disturbed sleep maintenance in PD patients was more severe than in age-matched controls, and nocturnal awakening was frequently caused by nocturia, pain, stiffness and difficulty in turning over in bed. Sleep disturbance is also a complication of chronic levodopa therapy. Recent data suggest that controlled-release levodopa is less likely to cause nocturnal symptoms than standard levodopa, particularly in mild-to-moderate disease. Depression, which is common in PD patients, contributes to sleep disturbance but has a lesser influence than the disease process itself. Hypnotic and sedative agents, as well as anti-depressants if required, are useful in ameliorating sleep disturbances in PD patients; intranasal desmopressin appears to be effective in reducing nocturia.

     

Correlation between eating disorders and sleep disturbances]

Anorectics and bulimics often complain sleep onset insomnia and disrupted sleep. During awakenings bulimics can have binges. Conversely, eating disorders can be a clinical expression of a concomitantly occurring sleep disorder. Two clinical entities have been recently described: the Night Eating Syndrome (NES) and the Sleep Related Eating Disorders. The main goal of this literature review was to better characterize the relationships between eating disorders and sleep disturbances. No specific EEG sleep pattern emerges in anorectic and bulimic patients. However, all studies include several methodological limitations: a few number of patients, heterogeneous patient groups, various diagnostic criteria. The results of studies evaluating the impact of depression on sleep EEG in eating disorder patients are also subject to controversy. The only study examining the relationship between sleep EEG and morphological alterations in anorectics and normal weight bulimics shows that patients with enlarged cerebrospinal fluid spaces spent more time in slow wave sleep and that the duration of rapid eye movement (REM) sleep was reduced. The ventricular brain ratio was negatively correlated with REM sleep. The Night Eating Syndrome consists in insomnia, binge eating and morning anorexia. Other criteria are proposed to characterize the NES: more than 50% of the daily energy intake is consumed after the last evening meal, awakenings at least once a night, repetition of the provisional criteria for more than 3 months, subjects do not meet criteria for bulimia nervosa or binge eating disorder. Patients have no amnesia nor alteration of alertness, and no other sleep disorder. There is no modification of sleep EEG except sleep maintenance. The prevalence of the NES is 1.5% in the general population. Some neuroendocrine disturbances have been found in the NES. The delimitation with eating disorders is not yet clearly established. If it shares the compulsive features with eating disorders, particularly the "Binge Eating Disorder", and occurs during full awakenings, the night eating syndrome may be recognized as a specific eating disorder. The sleep related eating syndrome is also characterized by compulsive binge eating during awakenings. But in this case, night eating is linked with a reduced consciousness and sleep disorders, mainly somnambulism. Patients never experience hunger, abdominal pain, nausea or hypoglycemia. Night-eating takes place invariant across weekdays, weekend and vacations. Patients consumed high caloric foods and fluids but never alcohol and purging does not occur. Diurnal bulimia is frequently associated with the sleep-related eating disorder. In conclusion, the sleep related eating disorder seems rather be a clinical subtype of sleep disorders whereas the NES could be considered as an eating disorder.     

Sleep disturbances in a case of Morvan's chorea (author's transl)]

Six nocturnal polygraphic recordings were carried out in a young man with fibrillary chorea of Morvan, during the acute period of the disease. Sleep was remarkably fragmented by numerous and brief awakenings but the total sleep time fluctuated between 157 and 312 mins.; the sleep structure was altered by the almost total absence of stages 3,4 and REM. During the day, the subject had one or two periods of sleep (1-2 hours) and complained of being tired. The nocturnal awakenings were correlated by the patient with pain and burning dysaesthesiae of distal distribution that were more severe than those occurring during the day. The patient improved gradually, and five month later both sleep disturbances and other signs of disease had disappeared.     

Evolution of sleep structure following brief intervals of wakefulness

Structural components of sleep following brief waking intervals were examined. Following an uninterrupted baseline night, 10 subjects were awakened on the next 5 nights for either 20, 40, 60, 90 or 120 min. All awakenings occurred at 02.30 h. During waking intervals subjects sat quietly in an illuminated room. Following each waking interval subjects returned to bed and slept uninterrupted until the next morning. Such awakenings had the effect of increasing the mean duration of the first SWS episode following return to sleep, and increasing the mean duration of first and second REM episodes following return to sleep. Sleep stage sequencing was also affected, with REM sleep preceding the first epoch of SWS in 38% of the sleep episodes following return to sleep. Eye movement density was essentially unaffected by controlled awakenings and timing of the REM/NREM cycle bridging awakenings appeared to be sleep dependent.     

Behavioral management of sleep disturbances secondary to chronic pain

The clinical efficacy of a behavioral management program for treating insomia secondary to chronic pain was evaluated within a multiple-baseline design a across subjects. Treatment consisted of a combination of stimulus control and sleep restriction procedures. Daily sleep diaries and all-night polysomnographic (PSG) measures were used to document changes in sleep/wake patterns. The results showed that treatment was effective in improving sleep patterns in all three patients. A substantial decrease of time awake at night was obtained and this was reflected by reductions of sleep onset latency, wake time after sleep onset, and early morning awakenings. Sleep improvements were well maintained at follow-ups and were also paralleled by improved mood states. The findings indicate that behavioral procedures are effective for treating sleep disturbances associated with chronic pain conditions.     

Sleep complaints and disorders in residential home patients taking hypnotic drugs

Objective: To analyze sleep of residential home patients taking hypnotic drugs. Patients and method: This prospective, observational and multicentric study was performed a given day in nursing homes. Residents over than?65, having MMSE ≥?15 and coherence?A or?B (for the AGGIR scale) were included. Aphasic residents or having acute pathology were excluded. Sleep complain was expressed by the resident himself and sleep disorder was observed by care givers. Sleep qualitative (complain versus disorder, difficulty to fall asleep and night awakenings) and quantitative (sleep duration) aspects were compared to residents who take or not hypnotic treatments. Results: 635?residents were included. 28.2% of the residents expressed sleep complains whereas care givers reported that only 11.4% of resident presented real sleep disorders (p<0.001). Compared to the residents who take hypnotic drugs (55.6%), residents without such treatment had shown less sleep complaints (31.2 versus 24.8%; p<0.05), less difficulties to fall asleep (38.6 versus 26.5%; p<0.001), and less night awakenings (69.5 versus 60.9%; p<0.05). No sleep duration difference was found according to hypnotic drugs. Discussion: Institutionalized geriatric patients who take hypnotic drugs seem to have a significant lower quality of sleep.     

Sleep disturbances in survivors of the Nazi Holocaust

OBJECTIVE AND METHOD: Sleep disturbances are commonly reported by victims of extraordinary stress and can persist for decades. This study was designed to test the hypothesis that survivors of the Nazi Holocaust would have significantly more and different sleep problems than depressed and healthy comparison subjects and that the severity of the survivors' problems would be correlated with length of time spent in a concentration camp. Forty-two survivors, 37 depressed patients, and 54 healthy subjects of about the same age, all living in the community, described their sleep patterns over the preceding month on the Pittsburgh Sleep Quality Index, a self-rating instrument that inquires about quality, latency, duration, efficiency, and disturbances of sleep, use of sleep medication, and daytime dysfunction. RESULTS: The survivors had significantly greater sleep impairment than the healthy comparison subjects, as measured by all subscales of the index, but had less impairment than the depressed patients except on the sleep disturbances and daytime dysfunction subscales. However, for specific items within these subscales, survivors had significantly more frequent awakenings due to bad dreams and had less loss of enthusiasm than the depressed subjects. Sleep disturbances and frequency of nightmares were significantly and positively correlated with the duration of the survivors' internment in concentration camps. CONCLUSIONS: These findings suggest that for some Holocaust survivors, impaired sleep and frequent nightmares are considerable problems even 45 years after liberation.     

Relationships Between Sleep Quality and Pain-Related Factors for People with Chronic Low Back Pain: Tests of Reciprocal and Time of Day Effects

Background

Poor sleep quality among people with chronic low back pain appears to be related to worse pain, affect, poor physical function, and pain catastrophizing. The causal direction between poor sleep and pain remains an open question, however, as does whether sleep quality exerts effects on low back pain differently across the course of the day.

Purpose

This daily diary study examined lagged temporal associations between prior night sleep quality and subsequent day pain, affect, physical function and pain catastrophizing, the reverse lagged temporal associations between prior day pain-related factors and subsequent night sleep quality, and whether the time of day during which an assessment was made moderated these temporal associations.

Methods

Chronic low back pain patients (n = 105) completed structured electronic diary assessments five times per day for 14 days. Items included patient ratings of their pain, affect, physical function, and pain catastrophizing.

Results

Collapsed across all observations, poorer sleep quality was significantly related to higher pain ratings, higher negative affect, lower positive affect, poorer physical function, and higher pain catastrophizing. Lagged analyses averaged across the day revealed that poorer prior night sleep quality significantly predicted greater next day patient ratings of pain, and poorer physical function and higher pain catastrophizing. Prior poorer night sleep quality significantly predicted greater reports of pain, and poorer physical function, and higher pain catastrophizing, especially during the early part of the day. Sleep quality × time of day interactions showed that poor sleepers reported high pain, and negative mood and low function uniformly across the day, whereas good sleepers reported relatively good mornings, but showed pain, affect and function levels comparable to poor sleepers by the end of the day. Analyses of the reverse causal pathway were mostly nonsignificant.

Conclusions

Sleep quality appears related not only to pain intensity but also to a wide range of patient mood and function factors. A good night’s sleep also appears to offer only temporary respite, suggesting that comprehensive interventions for chronic low back pain not only should include attention to sleep problems but also focus on problems with pain appraisals and coping.

     

A categorical approach to changes in latency, awakening, and sleep length in older subjects

Sleep latencies, within night awakenings, and lengths of sleep of 50- to 70-year-old males and females were analyzed using a categorical procedure. Subjects were assigned to qualitatively distinct categories. The data indicate that tendencies toward sleep disturbances along these dimensions are independent but increasing across this age range. There were disproportionately large numbers of females with long latencies and males with higher amounts of awakenings.     

Using difficulty resuming sleep to define nocturnal awakenings

ObjectiveNocturnal awakenings are one of the most prevalent sleep disturbances in the general population. Little is known, however, about the frequency of these episodes and how difficulty resuming sleep once awakened affects subjective sleep quality and quantity.MethodThis is a cross-sectional telephone study with a representative sample consisting of 8937 non-institutionalized individuals aged 18 or over living in Texas, New York and California. The interviews included questions on sleeping habits, health, sleep and mental disorders. Nocturnal awakenings were evaluated according to their frequency per week and per night, as well as their duration.ResultsA total of 35.5% of the sample reported awakening at least three nights per week. Of this 35.5%, 43% (15.2% of the total sample) reported difficulty resuming sleep once awakened. More than 80% of subjects with insomnia symptoms (difficulty initiating or maintaining sleep or non-restorative sleep) also had nocturnal awakenings. Difficulty resuming sleep was associated with subjective shorter sleep duration, poorer sleep quality, greater daytime impairment, greater consultations for sleep disturbances and greater likelihood of receiving a sleep medication.ConclusionsNocturnal awakenings disrupt the sleep of about one-third of the general population. Using difficulty resuming sleep identifies individuals with significant daytime impairment who are most likely to seek medical help for their sleep disturbances. In the absence of other insomnia symptoms, nocturnal awakenings alone are unlikely to be associated with daytime impairments.     

Effects of zopiclone on sleep, daytime somnolence and nocturnal and daytime performance in healthy volunteers

Ten healthy volunteers, aged 20 to 39, underwent 2 adaptation nights and 3 sessions of 2 consecutive experimental nights and days at 1 week intervals. In the 3 sessions, subjects received under double blind conditions either Zopiclone 3.75 mg or 7.5 mg or placebo, according to a latin-square design. On nights 1 and 2 of each session, subjects were continuously polygraphically monitored, except for a 45 min provoked wake episode 135 min after sleep onset on night 2. Sleep continuity and architecture were evaluated during night 1, degree of daytime somnolence during day 1 and residual effects during night 2 (0 h 00) and day 2 (8 h 00 and 12 h 00). Sleep continuity was not modified, except for a reduction of the number of night awakenings. NREM sleep stage 1 was reduced and stage 2 was increased (in duration but not in percentage) with Zopiclone 3.75 and 7.5 mg. NREM sleep stages 3 and 4 were increased with Zopiclone 3.75 mg only. REM sleep was reduced (in percentage only) with Zopiclone 3.75 and 7.5 mg. Daytime somnolence varied according to the time but not with the 3 different conditions. One performance test only (choice reaction time test) showed a significant impairment at 0 h 00 with Zopiclone 7.5 mg. From a subjective point of view, sleep quality was improved and night time awakening was reduced with Zopiclone 7.5 mg.     

EEG sleep studies in patients with generalized anxiety disorder

Sleep polygraphic recordings were performed during 3 consecutive nights in 12 inpatients with generalized anxiety disorder (GAD) in comparison with age- and sex-matched groups of patients with major depressive disorder (MDD) and normal subjects. GAD patients differed significantly from those with MDD. A lower number of awakenings and stage shifts in night 1 and the mean of the 3 nights and a shorter rapid eye movement (REM) duration in night 1 but longer REM latency in the mean of the 3 nights were observed in GAD in comparison to MDD. GAD patients also showed a significantly longer sleep onset latency and shorter duration of total sleep time and Stage 2 than control subjects. Electroencephalographic sleep recordings, as well as other laboratory tests, may help the clinician to differentiate anxiety from depressive disorders.     

Sleep alterations in juvenile neuronal ceroid-lipofuscinosis

In juvenile neuronal ceroid-lipofuscinosis (JNCL), sleep disorders are common. The purpose of this study was to investigate the sleep structure of 28 patients with JNCL compared with healthy controls subjects and to clarify the pathophysiology underlying the sleep disturbances in these patients. Each of 28 patients with JNCL (age range = 6-27 years), with or without sleep complaints, underwent one night of polysomnography. Electroencephalographic, electro-oculographic, electromyographic, and electrocardiographic findings were recorded. Sleep was scored and analyzed visually. The sleep parameters of the patients were compared with those of healthy control subjects. In most of the patients, the total sleep time, sleep efficiency, and percentages of rapid eye movement (REM) and non-REM (NREM) stage 2 sleep were significantly decreased, and the percentages of NREM stage 1 and slow-wave sleep and the number of nocturnal awakenings significantly increased. The percentage of NREM stage 1 and the number of awakenings increased with age and clinical stage. Paroxysmal epileptiform activity during light sleep (NREM stages 1-2) and high-amplitude delta-wave activity with intermingled sharp waves during slow-wave sleep were characteristic of the recordings. The present study revealed that in patients with JNCL, sleep is consistently altered.     

Ethical issues in early-intervention clinical trials involving minors at risk for schizophrenia

Twenty-four hour circadian activity rhythms and light-exposure levels of 28 older schizophrenia patients (mean age=58years) were examined using an Actillume recorder. Sleep and wake were scored using the algorithm of the ACTION3 software which revealed that the patients slept for 67% of the night and napped for 9% of the day. Patients with more disturbed sleep and less robust circadian rhythms performed more poorly on neuropsychological tests. Patients with higher cognitive functioning and fewer extrapyramidal symptoms were more alert during the day. Few patients were exposed to high levels of illumination during the day, and older age was associated with lower levels of light exposure. Duration of antipsychotic use and higher antipsychotic doses were associated with decreased daytime alertness and less robust circadian activity rhythms. Patients taking antipsychotics were more sleepy both during the day and night than patients not taking antipsychotics. The circadian rhythm disturbances found in these patients did not seem to be due solely to low levels of illumination exposure. Life-style factors, behavioral factors, psychiatric symptoms and medications were likely contributors to the disturbed rhythms. The effects of the sleep disturbances did not seem to be benign. There were strong relationships between sleep and circadian rhythms and functioning.     

Reliability of sleep log data versus actigraphy in veterans with sleep disturbance and PTSD

The goal of the study was to assess inter-rater reliability of the daily sleep log (a self-rating) with actigraphy (an objective measure of sleep based on activity) in veterans with Posttraumatic Stress Disorder (PTSD). This analysis focused on time asleep and number of awakenings during bedtime. Study participants consisted of 21 veterans with a lifetime diagnosis of Posttraumatic Stress Disorder and current sleep disturbance symptoms. Data collection included study participants' daily charting of sleep logs and actigraphy (utilizing study participants' activity level). Data analysis included the following: (1) interrater reliability for the tabulation of self-reported sleep logs by two trained raters using 99 nights of sleep from 10 cases; (2) comparison of sleep log data versus actigraphic findings for sleep time during 241 bedtimes; (3) comparison of sleep log data versus actigraphic findings for awakenings during 241 bedtimes. Findings showed that the two raters had intraclass correlation scores of .801 for time spent asleep and .602 for time spent in bed-acceptable scores for tabulation of the sleep logs. Comparison of patients' sleep logs versus actigraphy for 241 nights showed that 10 out of 21 study participants had acceptable intraclass correlations of 0.4 or above for duration of sleep. However, sleep logs and actigraphic data on number of sleep awakenings showed poor intraclass correlation, with only 1 subject having an intraclass correlation greater than .30. In conclusion, these data strongly suggest that sleep logs do not reproduce actigraphic records in patients with PTSD even though the sleep logs were reliably quantified. Sleep logs especially under-count awakenings in PTSD patients with sleep complaints.     

Sleep deprivation in chronic somatoform pain-effects on mood and pain regulation

Sleep deprivation was found to exert complex effects on affective dimensions and modalities of pain perception both in healthy volunteers and patients with major depression. Considering multifaceted links between mood and pain regulation in patients with chronic somatoform pain, it is intriguing to study sleep deprivation effects for the first time in this group of patients. Twenty patients with a somatoform pain disorder according to ICD-10 diagnostic criteria were sleep-deprived for one night, followed by one recovery night. Clinical pain complaints (visual analog scale), detection- and pain thresholds (temperature and pressure) as well as mood states (Profile of Mood States) were assessed on the day prior to the experiment, on the day after sleep deprivation and on the day after recovery sleep. We found a discrepancy between significantly increased clinical pain complaints and unaltered experimental pain perception after sleep deprivation. Only the clinical pain complaints, but not the experimental pain thresholds were correlated with tiredness-associated symptoms. Total mood disturbances decreased and feelings of depression and anger improved significantly after sleep deprivation. However, these changes were not correlated with a change in clinical pain perception. We conclude that sleep deprivation may generally change the reagibility of the limbic system, but mood processing and pain processing may be affected in an opposite way reflecting neurobiological differences between emotional regulation and interoceptive pain processing.     

Painful nocturnal erection

Sleep related painful erection is a parasomnia occurring during rapid eye movement (REM) sleep. It is rarely dealt with in the literature, and is very often poorly understood. Because of repeated awakenings, it is interpreted as insomnia, and is attributed to anxiety. EEG recordings associated with nocturnal penile tumescence monitoring indicate the existence of disturbed sleep organization, with awakenings during REM sleep and frequent nocturnal erections, often unrelated to REM sleep. Though the pathophysiological mechanisms involved are not yet understood, an interpretation of sleep-related painful erections is proposed, based on the current understanding and physiology of diurnal and nocturnal erections.     

Sleep disturbances and dementia

Sleep is a complex behavioural state, the ultimate functions of which remain poorly understood. It becomes more fragmented as we age, with more night‐time awakenings and greater tendency for daytime sleep. The magnitude of disordered sleep among individuals affected by dementia has been clearly demonstrated, and disturbed sleep is a major clinical problem in dementia. Comorbid insomnia and other sleep disturbances are common in patients with neurodegenerative disorders, such Alzheimer's disease and other dementing disorders. How and when sleep problems manifest themselves can depend on the type of dementia involved as well as the stage of the dementia. However, differences in sleep pattern presentation show more variation during the initial stages of dementias than they do during the later stages. Effective, pragmatic interventions are largely anecdotal and untested.     

Self-reported sleep disorder symptoms in epilepsy

Three groups of adult epileptic subjects with simple partial, complex partial, and generalized seizures and normal control subjects completed a brief self-report sleep questionnaire. The simple partial and complex partial groups indicated significantly more sleep disorder symptoms, especially frequent night awakenings. The generalized group was most similar to the controls. Irrespective of seizure type, the epileptic patients with the most frequent seizures also had the most sleep disturbances. Sleep disorder symptoms did not increase with age in the seizure groups. It would thus seem that epileptic patients with partial seizures and those with more frequent seizures are at risk for developing sleep disorders.     

Sleep-related disorders in carpal tunnel syndrome

Introduction – Patients with carpal tunnel syndrome (CTS) often wake up at night due to pain and numbness of affected fingers and hand. We studied the sleep disorder caused by CTS. Subjects and methods – 34 consecutive patients referred for operative treatment of CTS answered to a sleep questionnaire and the results were compared to a stratified random sample of 1600 Finns aged 36–50 year, whose response rate to the mailed questionnaires was 75.2% (n=1186). Six CTS patients underwent a polygraphic sleep study before and after operative treatment of CTS. Results – CTS patients reported suffering from poor sleep quality, fragmentary sleep and daytime sleepiness more often than controls. Before operative treatment of CTS there were more nocturnal body movements (p<0.01) and awakenings lasted longer (p<0.05) than after operation. During preoperative sleep studies no drop in median nerve conduction was detected during awakenings. Conclusions – Patients with CTS suffer from fragmentary sleep. Although patients reported waking up for the pain or numbness of hands no impairment in median and ulnar nerve conduction could be observed during these awakenings. Operative treatment of hand entrapment significantly reduced the number of nocturnal movements.