Insomnia and Parkinson’s Disease

Insomnia and Parkinson’s Disease

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According to a research review published in 2020 (“Practical Evaluation and Management of Insomnia in Parkinson’s Disease:  A Review”), “there is little evidence supporting pharmacotherapy and nonpharmacologic treatments of insomnia in PD.”  How sad that there is no surefire fix for one of the most exasperating PD symptoms, affecting up to 80% of Parkies.  Instead, the authors propose “personalized insomnia treatment approaches based on age and other issues.”

The article identifies three kinds of insomnia:  (1) difficulty falling asleep when you first climb in bed; (2) waking up in the middle of the night, unable to fall back asleep; and (3) waking up too early in the morning.  Furthermore,

“These nocturnal symptoms must be accompanied by daytime impairment related to sleeping difficulties.  Diagnosis of chronic insomnia disorder requires that the complaints be present at least 3 times per week for at least 3 months.”

In other words, it’s a long haul of relentless exasperation to be officially diagnosed with chronic insomnia.

The authors note that “as PD severity worsens, the frequency of insomnia complaints increases.” The main culprit is waking up in the middle of the night, unable to fall back asleep.

What brings this inability to get a full night’s sleep?  Ordinary people have two competing systems working internally to drive the sleep/wake cycle:  homeostatic sleep drive (“homeostasis is the state of steady internal, physical, and chemical conditions maintained by living systems” – thanks, Wikipedia!) and circadian influence (“a natural, internal process that regulates the sleep-wake cycle and repeats roughly every 24 hours” – thanks again, Wikipedia!).

Here’s how the two processes work:

 “In the morning, homeostatic sleep drive is low but increases with prolonged wakefulness.  Acting as a counterbalance to homeostatic sleep drive, circadian drive for wakefulness increases during the morning, peaks during midday, and decreases in the evening.  At night, sleep drive peaks and circadian arousal is withdrawn, leading to sleep onset.  During sleep, homeostatic sleep drive diminishes, and the circadian arousal rhythm begins to increase, which facilitates morning awakening.”

That’s the normal process.  Unfortunately, with Parkinson’s disease you have lots of neuronal loss in your noggin, which, combined with some of the medications Parkies take, may interfere with the normal functioning of the brain when you go to bed.  Furthermore, especially for people with advanced Parkinson’s, lack of physical activity and limited exposure to sunlight may weaken the body’s natural circadian functions.

What else does the article have to say?  Let’s bullet the items in a list:

• Women with PD report a greater prevalence of insomnia symptoms than men with PD.
• As PD progresses, nocturnal bradykinesia and rigidity may cause difficulty turning or repositioning in bed, thus presenting challenges to sound sleep.
• Nocturia (getting out of bed to urinate) is another factor that causes people to lose sleep. Note: it’s also a frequent cause of falls for elderly Parkies.
• Depression often comes hand-in-hand with insomnia, as do other psychological issues, such as anxiety and ruminating about your life.
• Some Parkinson’s medications induce insomnia as a side effect.

What can you do about this?  Here are some options:

• Extended-release carbidopa/levodopa does not fix the problem of waking up at night, although prolonged-release ropinirole does help, as does the rotigotine patch.
• Low doses of melatonin worked to improve sleep in a number of controlled trials.
• Cognitive behavioral therapy is “the first line of therapy as endorsed by the American College of Physicians.”
• Exercise!
• Bright light therapy! (It’s the same technique that people use for Seasonal Affective Disorder.)

And what’s my personal interest in this?  Nocturia.  For all my years as an adult, I never needed to wake up in the middle of the night to pee.  This was true no matter what I ate or drank in the evenings.  But now I must urinate every night, sometimes twice.  I drink no liquids in the late afternoon or evening, and I’m careful at dinner not to eat a lot of foods that are primarily liquid, such as cherry tomatoes and cucumbers.  But still, I find myself waking up once or twice and stumbling my way to the bathroom.

I’m not upset about this, though.  I keep my iPhone by my bed, and if I touch the screen it lights up for a moment to tell me the time.  No matter what the time is, I feel good because I realize that I have many more hours to sleep before the day begins.

In this way, I’m a happy camper.