We all know good sleep is important. And it becomes even more important when living with disease. How unfair then, that Parkinson’s disease (PD) makes sleep more difficult. Many people say they have trouble falling asleep, wake up throughout the night or get only a few hours of shut eye. And these sleep problems — as well as others, like acting out dreams — can disturb bed and care partners’ sleep, too. Let’s talk about why sleep changes happen in Parkinson’s.

Sleep seems simple, but is a complex activity

But first, let’s talk about sleep itself. Our brain has a central clock that directs the 24-hour sleep-wake cycle, or circadian rhythm. This brain center takes cues from how and how often we move; what and when we eat and drink; what type of light we’re exposed to when; and more. These signals determine whether we feel awake and alert or ready for sleep.

Sleep is divided into four stages, which repeat throughout the night:

• Stage 1: This “light” sleep marks the transition between wakefulness and sleep. Muscles relax and heart rate, breathing, eye movement, and brain wave activity slow down. This stage lasts several minutes.
• Stage 2: Sleep begins to deepen. Muscles relax more. Heart rate and breathing slow further. Eye movements stop. Body temperature decreases. This is the longest of the four sleep stages.
• Stage 3: This “deep” or “slow wave” sleep plays an important role in helping you feel refreshed and alert the next day. Heart rate, breathing and brain wave activity reach their lowest levels. Muscles are as relaxed as they will be. This stage is longer at first but decreases throughout the night.
• Rapid Eye Movement (REM) sleep: During this stage, as the name suggests, eyes move back and forth quickly under the eyelids. Breathing, heart rate, and blood pressure increase. Dreaming occurs, even in those who don’t recall dreams. Muscles are temporarily paralyzed so that you can’t physically act out your dreams. Research links REM sleep to memory consolidation, which is when recently learned information turns into longer-term memories. The first REM stage happens about 90 minutes after you fall asleep. REM duration increases as the night progresses.

Parkinson’s can disturb sleep in many ways
Sleep problems are common in PD because the disease — and medications used to treat it — can impact both brain circuits that play a role in sleep as well as the stages of sleep themselves. That can mean feeling too sleepy during the day, having trouble falling or staying asleep, or experiencing changes in the amount or quality of sleep. (That’s because PD decreases slow wave and REM sleep.) Simply put, Parkinson’s can cause more disrupted and less restorative sleep.

But PD can also cause other symptoms and conditions that affect sleep. Non-motor symptoms, such as anxiety or depression, can disturb sleep. Other sleep conditions can, too. Some people act out their dreams while sleeping. This is called REM sleep behavior disorder, or RBD. Acting out dreams happens when the brain circuits that temporarily paralyze muscles during REM sleep don’t work. People have vivid, sometimes frightening dreams involving fighting, chasing or other high-intensity activities. They could yell, kick, punch or run out of bed — making big, quick movements that contrast with their typically smaller, slower movements. RBD increases risk of injury and decreases sleep quality for both the person acting out dreams and their bed partner.

In some people, RBD is one of the earliest signs of Parkinson’s disease. People with RBD can help researchers learn how PD comes on and why, in some people, it doesn’t. Learn more at michaeljfox.org/ppmi.

Others experience Restless Legs Syndrome (RLS), which is just what it sounds like — a feeling of restlessness in the legs that decreases with movement and, because it happens at night, delays falling asleep. Many people with RLS also have Periodic Limb Movements of Sleep — frequent arm, leg or foot twitching or jerking during sleep, which interrupts their and their bed partner’s sleep. For more on these and other sleep symptoms, check out MJFF’s guide on sleep and Parkinson’s.

The challenge, as many of you know, is that significant sleep changes can temporarily worsen motor symptoms. They also may contribute, over the long run, to memory and thinking (cognitive) changes. And research suggests there may be a link between poor sleep and progression of disease.

Research on sleep and Parkinson’s is moving forward

Scientists are working to better understand how sleep brain circuits are affected by PD, who experiences sleep changes and when, and who with RBD goes on to develop Parkinson’s. In tandem, they’re working toward better treatments for these bothersome symptoms as, unfortunately, limited options currently exist. New treatments might include light therapy, novel drugs, or even novel deep brain stimulation (DBS) systems. To be clear, there are treatments to help with RBD, insomnia and some other sleep symptoms. But too often, they don’t fully treat symptoms and they don’t work in everyone. And the benefits and risks of most haven’t been widely researched in people with PD. To learn more about trials on sleep and Parkinson’s, visit foxtrialfinder.org.

Good sleep starts when you wake in the morning

So, what can you do now? Start by talking with your doctor. And, if you haven’t yet, build healthy habits that may invite better sleep:

• Move more: We often talk about how exercise can help sleep, and that’s true. But regular movement throughout the day is helpful, too. Try to stand or walk a few minutes each hour. (Set an alarm to remind you.) If you have trouble moving, a rocking or rotating chair can mimic movement.  
• Watch light exposure: Keep in sync with the sun. Get as much natural light as you can. Sit near a window and get outdoors for exercise, socializing and other activities, when possible. Use soft white bulbs in lamps and red nightlights, which are less likely to keep you up, if nightlights are needed. Dim lights an hour or more before bed and turn off screens — TV, computer, phone — at the same time. (Keep these out of the bedroom, too.) If you have trouble sleeping, ask your doctor if a light box or lamp might help and how to use it. Small trials have shown some benefit of light for easing sleep symptoms, but questions remain on the intensity, amount and timing of this treatment.  
• Note what and when you eat: Keep mealtimes consistent — whether that’s three bigger meals or six smaller ones throughout the day — and don’t graze between. Don’t eat a big dinner, especially within three hours of bedtime. Watch your evening intake of high-sodium (processed foods or frozen meals), high-carb (white rice or bread), and spicy or fatty foods, which could interfere with sleep. Skip the nighttime snack and stay hydrated throughout the day. Limit caffeine and alcohol.
• Keep stress out of the bedroom: An hour before bed, begin to wind down. Set an alarm to remind you. If you can’t devote an hour, any amount of time is better than none. Practice relaxing activities to calm your body and mind. You might meditate, pray or breathe deeply; read (or listen to) a fun book or bedtime story; knit; journal concerns, to-dos or things for which you’re grateful; take a warm bath or shower; stretch or do light yoga; cuddle with your pet; chat with your spouse or kids (keep the conversation light); call a friend; or listen to relaxing music.

These tips only scratch the surface of daily routines and nighttime habits that can help or hinder sleep. Talk with your doctor and others in the community for more information and tips. And remember, as much as we’d like to, we can’t control sleep. We can only do our best to prepare for and welcome sleep and then wait for it to arrive.

Thanks to Smita Patel, DO, integrative neurologist and sleep specialist for lending her expertise to this article.