The Park Sleep subtype in Parkinson’s disease: from concept to clinic

Figures & data

Figure 1. A proposed algorithm for identifying causes and establishing pathway for personalized management of somnolence in people with Park Sleep.

^aDiaries can help to record clinical details in a standardized way. Formal screening tools may be useful, but note that few questionnaires for sleep disorders have been validated for use in people with PD.

^bClinical practice guidelines define the indications for diagnostic tests when sleep disorders are suspected; the same indications apply for patients with PD.

^cManage sleep disorder as per relevant guidelines for that sleep disorder.

^dManagement of the most complex cases should be transferred to specialized sleep centers.

ICSD-3 International Classification of Sleep Disorders version-3; MSLT multiple sleep-latency test; MWT multiple wakefulness test, OSA obstructive sleep apnea; OSLAR oxford sleep resistance test; PSG polysomnography; RBD rapid eye movement behavior disorder; RSL restless leg syndrome.

Figure 2. Algorithm of managing poor nighttime sleep in Park Sleep subtype.

Note: ^aSuch as sleep apnea, circadian rhythm sleep disorders, non-REM parasomnia, central hypersomnia, periodic limb movement disorder.

PSG polysomnography; SSRI selective serotonin reuptake inhibitors; REM rapid eye movement; RBD REM behavior disorder.

Table 1. Interventions, alongside pharmacological and non-pharmacological management strategies for the treatment of several sleep disorders in PD.

	Interventions	Pharmacological	Non-pharmacological
Insomnia	Management of contributing factors (irregular sleep patterns, ‘bad’ habits prior sleep, side effects of medication, undertreated motor symptoms, association of non-motor symptoms) Optimization of dopaminergic treatment (long-acting ropinirole, sustained-release pramipexole, or transdermal rotigotine)	Eszopiclone Doxepin (low doses) Benzodiazepines/Benzodiazepine receptor agonists* Mirabegron (nocturia)	Sleep hygiene CBT for insomnia If co-morbid with circadian rhythm disorder consider melatonin supplements, light therapy and/or chronotherapy. Physical exercise programs DBS Behavioral changes-nocturia (reduced fluid intake before night) Botulinum-toxin injections in detrusor muscle (nocturia)
Rapid eye movement (REM) sleep behavior disorder (RBD)	Reduction/discontinuation of drugs that exacerbate symptoms (selective serotonin and norepinephrine reuptake inhibitors, tricyclic antidepressants)	Clonazepam Melatonin Dopaminergic agonists (pramipexole, rotigotine) Melatonin receptor agonists (Agomelatine, ramelteon) Rivastigmine patch Calcium alpha-2-delta ligands (pregabalin)** Sodium oxybate***	Sleep hygiene (regular sleep routine, safe sleep environment) DBS
Excessive Daytime Sleepiness	Improvement of nocturnal sleep duration & quality (e.g. treatment of primary sleep disorders) Medication adjustments (hypnotics, antidepressants, PD drugs)	Wake-promoting agents: Modafinil Caffeine Memantine Istradefylline Methylphenidate Atomoxetine Pitolisant/Solriamfetol	Sleep hygiene Adequate exposure to daytime light If co-morbid with circadian rhythm disorder consider melatonin supplements, light therapy, and/or chronotherapy. Bright light therapy Physical activity (not recommended 3–4 h prior to sleep)
Sleep attacks (sudden onset of sleep)	Reduction/discontinuation of incriminated drugs (e.g. dopaminergic agents)

*Careful consideration: risk of cognitive decline and risk of pneumonia in elderly PD patients.

**Not widely used for this indication, careful consideration might aid sleep continuity and prevent sleep fragmentation.

***Careful consideration: risk of central nervous system & respiratory depression and risk of addiction.

CBT cognitive behavioral therapy; CPAP continuous positive airway pressure; DBS deep brain stimulation.

Figure 3. Algorithm for managing excessive daytime sleepiness in Park Sleep subtype.

Note: ^aSuch as sleep apnea, circadian rhythm sleep disorders, non-REM parasomnia, Restless Leg Syndrome, Periodic Limb Movement Disorders

EDS excessive daytime sleepiness; ESS Epworth Sleepiness Scale; PSG polysomnography; REM rapid eye movement; RBD REM behavior disorder.

Figure 4. A pictorial summary of potential mind-body approaches to address sleep dysfunction as observed in Park Sleep…

CBT cognitive-behavioral therapy.