Fatigue & Sleep

Fatigue

One of Parkinson's more subtle symptoms is fatigue — not your garden variety bone-tired, but fatigue on a deeper level. Your body is working overtime to accomplish even simple tasks: taking a shower, answering the phone, pouring orange juice. People with Parkinson's disease (PD) who experience fatigue say they feel exhausted but they don't necessarily feel like sleeping. They're tired physically and sometimes mentally, too. Mental fatigue can make it difficult to start projects or concentrate. Fatigue also can interfere with work, home and social life.

Fatigue can be part of Parkinson's, but it also can come from the medications used to treat it. In some people, fatigue is a result of another Parkinson's symptom, such as depression or apathy.

There are steps you can take to ease fatigue:

• Exercise regularly: Working out may be the last thing you feel like doing. But regular exercise, especially in the morning, can be energizing.
• Keep a schedule: Get enough sleep at night and plan daytime activities, such as exercise classes or lunch with friends. (Social activities prevent isolation, which can worsen fatigue.)
• Take short naps: In the early afternoon, quick rests can be refreshing and boost energy.
• Review your medications: Talk to your doctor about which of your Parkinson's or other medications might be contributing to fatigue. No medications are approved to treat fatigue in PD, but when fatigue is severe, doctors may prescribe drugs for this symptom.

Sleep

A good night's sleep can help you feel and do your best. Unfortunately, many people with Parkinson's have trouble falling or staying asleep at night. Sleep problems can arise from Parkinson's motor or non-motor symptoms, medication side effects or other conditions that affect sleep.

Sleep Disorders and Parkinson’s

Sleep problems in Parkinson's can have many different causes. A few of the more common conditions are:
 

• Insomnia: Difficulty falling or staying sleep. Stiffness and slowness may make it difficult to get comfortable or turn over in bed. Depression or having to go to the bathroom often at night can interfere with sleep, too. Some Parkinson's drugs, such as amantadine immediate release, Osmolex ER (amantadine extended release) or Zelapar (selegiline), may cause insomnia if they're taken too close to bedtime. Sometimes insomnia happens on its own, which means there is no other cause for the change in sleep pattern.
  
  If you have trouble falling or staying asleep, review your symptoms and medications with your doctor. Also practice behaviors to maximize sleep, such as exercising regularly and avoiding caffeine and naps in the late afternoon. In some cases, doctors may recommend medications to help you fall asleep at night. Sleep medications can cause side effects or temporarily worsen some Parkinson's symptoms, so take them only on your doctor's advice.

• Excessive daytime sleepiness (EDS): Extreme tiredness during the day, which makes it difficult to stay awake. EDS may be caused by Parkinson's disease and the medications used to treat it, especially dopamine agonists. Some people have EDS because of problems sleeping at night. If you're extremely sleepy, your doctor may perform studies to evaluate your sleep and ability to stay awake during the day. The doctor might also adjust your medications. As with insomnia, good sleep habits often are the first steps in treatment. If these aren't enough, your doctor may prescribe medications to help keep you awake, such as Provigil (modafinil).
• REM sleep behavior disorder (RBD): Acting out your dreams. People with RBD often kick, punch or yell during sleep. Some even get out of bed without realizing it. When RBD is dangerous or disruptive to a person or their sleeping partner, doctors may prescribe treatment. Klonopin (clonazepam) or melatonin (over-the-counter hormonal supplement) are most commonly used. RBD is an active area of Parkinson's research.
• Restless legs syndrome (RLS): An uncomfortable feeling in the legs that is resolved only by moving them. Because symptoms of RLS most often develop in the evening, they may affect sleep. RLS can be from Parkinson's, the medications used to treat it or another condition, such as iron deficiency. Your doctor may want to adjust your Parkinson's medications or suggest another treatment, such as a drug (the anti-seizure drug Neurontin [gabapentin], for example) or a device to calm symptoms.
• Obstructive sleep apnea (OSA): Repeated episodes of shallow or paused breathing at night that interrupt sleep. People with OSA typically don't realize that their breathing stops for short periods throughout the night, but often snore loudly. They also may have fatigue, morning headaches and even memory or thinking problems. The most common treatment is a breathing mask or dental appliance at night, which keeps the airway open and prevents breathing pauses. Weight loss also is recommended for overweight individuals.

Parkinson's Symptoms and Sleep

The symptoms of Parkinson's also can impact sleep:
 

• Movement Problems: For some, tremor makes it difficult to fall asleep. For others, stiffness or slowness of movement makes it challenging to find a comfortable position or turn over in bed. Still others experience painful dystonia (muscle cramping) that interrupts sleep. When motor symptoms prevent restful sleep, your doctor may adjust your Parkinson's medications. This could include adding a longer-acting medication at bedtime or another dose if you awaken with symptoms. Some find using satin sheets or wearing silk pajamas improves movement in bed.
• Depression: A common symptom in Parkinson's, depression may make it hard to fall asleep, or cause you to wake up in the middle of the night or early in the morning. Medications, specifically those that act on the serotonin brain chemical pathway, may ease depression and help sleep. Some people also benefit from cognitive behavioral therapy or counseling.
• Urinary changes: Because of Parkinson's effects on the nerves that control urination, you may have to use the bathroom more often at night. Try to drink less fluid in the afternoon and evenings (but make sure you drink enough during the day, especially if you have low blood pressure or constipation). Sometimes doctors prescribe medication to decrease urination. But these drugs have many potential side effects, which are more common in older people, so are to be used cautiously. If slowness and stiffness make getting to the bathroom harder at night, you also may want to consider a bedside urinal or commode.

Tips for Good Sleep

No matter what trouble you may be having with sleep, you can build good sleep habits to make sure you're getting the best sleep possible:
 

• Keep a regular schedule: Go to sleep and get up at around the same time every day, even on the weekends.
• Create a bedtime routine: An hour before bed, start to wind down and get ready for sleep. Turn off the television, computer and other electronics, as the light they emit can keep you awake. Take a warm bath, drink a cup of decaffeinated tea or read something for fun.
• Limit naps: Sleeping too much during the day, especially in the late afternoon, can disrupt your bedtime routine. If you need a nap, snooze for 20 to 30 minutes in the early afternoon.
• Avoid caffeine, alcohol and exercise later in the day: Drinking caffeine (in coffee, soda or tea) in the afternoon or evening can keep you up. Alcohol might make you fall asleep more easily, but it can interrupt your sleep later in the night. Regular exercise is good for sleep, but too close to bedtime can make it hard to get to sleep.
• Don’t drink fluids before bed: This is especially important if going to the bathroom often at night disturbs your sleep.
• Use the bed only for sleep and intimacy: When your body is accustomed to only sleeping in bed, it automatically knows what to do when you get in bed. Don’t watch television, read or use your phone in bed.

As you work with your doctor to pinpoint the cause of your sleep problems so you can best treat them, you may find it useful to keep a diary of your sleep patterns. Note when you go to bed and get up, how often you wake up during the night and why (because you have to go to the bathroom or your foot is cramping, for example), and how many hours you sleep. Also include how much caffeine you drink and when, if you nap and when you exercise. This sleep diary can help you have a productive conversation with your doctor about your sleep.

Ongoing Research

For both fatigue and sleep problems in Parkinson's, researchers are looking for better understanding of symptoms and better treatments. Therapies in trials include medication, exercise and non-invasive brain stimulation. These include drugs with new ways of working, as well as those that are already available but have never been tested for safety and efficacy in people with Parkinson's. 

REM sleep behavior disorder (RBD) is an area of particular interest, because many people with Parkinson's experience RBD years before their motor symptoms and diagnosis. The Michael J. Fox Foundation's Parkinson's Progression Markers Initiative (PPMI) study is following people with RBD who don't have Parkinson's and gathering data on them over time. Information from studies such as PPMI could tell us how to diagnose Parkinson's earlier and possibly even predict and prevent it.

The medical information contained in this article is for general information purposes only. The Michael J. Fox Foundation for Parkinson's Research has a policy of refraining from advocating, endorsing or promoting any drug therapy, course of treatment, or specific company or institution. It is crucial that care and treatment decisions related to Parkinson's disease and any other medical condition be made in consultation with a physician or other qualified medical professional.