In Parkinson’s disease, the individual, symptomatic therapy is crucial for the quality of life. This should be initiated as early as possible. This is because it can delay or even prevent the transition from the clinical prodromal phase to manifest PD. Sleep behavior is of particular importance in this context. Sleep disorders are not only a burden, but often occur even before the clinically manifest Parkinson’s syndrome.
Parkinson’s syndrome and sleep disorders often go hand in hand – and not only when the disease has manifested itself clinically. Even in very early stages, when no symptoms are detectable yet, sleep is often disturbed. Sleep disorders are very stressful and significantly reduce the quality of life. In later stages of the disease, they may also contribute to worsening physical symptoms. This must be avoided.
The neurodegenerative processes begin many years before the Parkinson’s syndrome with the cardinal symptoms of bradykinesia, rigor and tremor clinically manifests itself. First signs can usually be observed in the prodomal phase. As soon as one speaks of classical Parkinson’s, about 60% of the dopaminergic neurons have already degenerated. Therefore, in order to apply progression-modifying therapies, the prodomal phase is crucial. But identifying those who are affected comes with some hurdles. Attention should be paid if, for example, erectile dysfunction, constipation, micturition disorders or orthostatic hypotension are present. Neurologic deficits or depression and anxiety may also indicate a prodomal stage. However, by far the most important marker is REM sleep behavior disorder.
Counter sleep disorders early
REM sleep behavior disorder is defined as loss of atonic phase of musculature in REM sleep with acting out of dreams, a memory of dreams that are often very vivid, including violent or aggressive dreams, and in adults, a high level of vigilance during periods of awakening. The risk of injury to patients, but also to their partners, is very high. Therefore, sufferers should adjust sleeping arrangements accordingly. Be it sleeping alone in a big bed, padding the floor – in case they fall out of bed – or sleeping on the floor right away.
First-line clonazepam and melatonin are available as drug therapy. Furthermore, gabapentin may also be used in the second-line, followed by other agents such as pramipexole, rivastigmine, or donepezil, among others. Individuals should be informed that serotonergic medications, antipsychotics, barbiturates, alcohol, and caffeine could potentially worsen symptoms.
Treat effectively even in the late phase
In the late phase of Parkinson’s disease, the spectrum of motor and non-motor symptoms expands manifold. But sleep disorders often remain a serious problem. This is then no longer necessarily due to REM sleep behavior disorder alone, but other possible causes are added. So, for example, also a diminishing effect of medication. Fluctuations in the effect of levodopa during the course of the disease are known to result in nocturnal akinesia, among other symptoms. Painful muscle tension and cramps interrupt night sleep. In these cases, optimization of PD therapy is indicated. This can be done, for example, with L-dopa retard preparations, soluble L-dopa, and combination with dopamine agonists, COMT inhibitors, or MAO-B inhibitors. COMT inhibitors (e.g., opicapone, entacapone, tolcapone) inhibit the degradation of levodopa to 3-O-methyldopa, thereby increasing its bioavailability in plasma. MAO-B inhibitors increase striatal dopamine levels by blocking cerebral degradation of dopamine via monoamine oxidase B. The choice of the right combination should always be made individually and adapted to the particular situation of the person concerned.
Congress: Neuroweek 2022
Source: Movement disorders: Rare but relevant to everyday life. Diagnosis and symptomatic therapy of Parkinson’s disease: in the prodromal stage. Diagnosis and symptomatic therapy of Parkinson’s disease: late stage. 04.11.2022.
InFo NEUROLOGY & PSYCHIATRY 2022; 20(6): 30 (published 4.12.22, ahead of print).
