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Parkinson patients; Sleep disorders; Insomnia; REM sleep disorders; Restless leg syndrome

Introduction

Parkinson’s disease is a chronic, progressive, and disabling disorder characterized by both motor and non-motor symptoms. Millions of people worldwide are affected by this disease, the second most prevalent neurodegenerative condition next to Alzheimer’s disease [1].

The English physician James Parkinson first defined Parkinson’s disease in his 1817 monograph “An Essay on the Shaking Palsy.” Parkinson described several people who displayed resting tremors, shuffling gait, stooped posture, sleep problems, and constipation [2].

The four cardinal motor symptoms of Parkinson’s disease are tremor, rigidity, bradykinesia, and postural instability; the secondary motor symptoms include diminished arm swing, decreased blink rate, masked faces (hypomimia), decreased voice volume (hypophonia), and difficulty turning over in bed. The nonmotor symptoms of Parkinson’s disease are:-Neuropsychiatric, Cognitive, Dysautonomia, and Sleep disorders which include insomnia, somnolence, excessive daytime sleepiness, restless legs syndrome, sleep attacks, periodic limb movements of sleep, and rapid eye movement (REM) sleep behavior disorder [3]. Sleep disturbances occur in up to 96% of patients with Parkinson’s disease and appear to arise from a combination of neurochemical and neurodegenerative changes in central sleep regulatory centres such as the forebrain, thalamus, and midbrain dopamine neurons [4]. In addition many drugs used in the treatment of PD can affect sleep. For example, selegiline—metabolized to methamphetamine and amphetamine—may cause insomnia [5].

The range of sleep disturbances in PD comprises the full spectrum of sleep disorder categories outlined in the International classification of sleep disorders 3rd edition (ICSD-3). The categories of sleep disturbances apparent in patients with PD thus comprise insomnia, disorders of daytime somnolence, sleep-related breathing disorders, circadian disorders, and sleep-related movement disorders, namely restless legs syndrome (RLS), and parasomnias [6].

Materials and Methods

The study was an observational, cross sectional; hospital-based study. It was conducted from January to October 2022 at Outpatient’s clinic in three specialized neurology centers in the National Center for Neurosciences (NCNS), Bashayir teaching Hospital and Medani Teaching Hospital. Ethical Approval was obtained from the Ethical Committee at the Research Unit-Educational Development Centre (EDC), Sudan Medical Specialization Board (SMSB), and Acceptance from the Council of MD Clinical Neurology-SMSB and verbal informed consent from the patients. A total of 70 patients were enrolled in the study. The inclusion criteria were, patients with idiopathic Parkinson disease and age more than 18. Patients documented to have atypical Parkinsonism, severely ill or have poor communication were excluded. Data was collected using pre-designed Questionnaires were filled by the investigator (with history points taken from the patient through a personal interview and thorough neurological examination performed) including, evaluation of demographic and clinical characteristics, duration of the disease , medication history, motor status assessment using Hoehn and Yahr stage and nocturnal sleep impairment using PDSS-2 (Arabic version). Data was analyzed by computer using descriptive statistics mean and SD for age, frequency table’s and charts using (SPSS) software version 25. With reference of P-value of less than.05 and CL 95%to be consider as significant.

The quantitative variables described using the mean ± stander deviation, while qualitative ones described by frequency and percent. To test the relation between variables, chi-square or fisher exact is used for qualitative data, while spearman used for quantitative variables.

Result

Among 71 patients with Parkinson disease (PD) males represented (50, 70.4%) and females (21, 29.6%). The age of the patients ranged between 37-90 years with mean of (64.66 ± 9.6) years. 56.7% (38) had PD for less than 5 years, while 40.3% (27) had the disease between 5 to 10 years and only 3%more than 10 years. The severity of motor status patients in H&Y stage were 1, 2, 3, 4 and 5 were 22.5%,38%, 25.4%, 11.3%, and 2.8%, respectively. Most patients were in early stages 60.6%, and late stages represent 39.0%. The severity of sleep disturbance in patients with PD was classified based on the cutoff value of 18 for the PDSS-2, with the good sleeper (0–17) and poor sleeper (18–60). Majority of our patients 58.8% self-reporting not sleeping well, however (27, 38%) were classified as poor sleepers (PDSS-2 = 18–60) with the mean score of PDSS-2 of 13.76. The most commonly occurrence sleep disorders are nocturia 51 (72%) followed by sleep maintenance insomnia 33 (46%) and sleep refreshment 33 (46%), pain in arms and legs 45%, sleep onset insomnia 42% and difficulty in turning in bed 41%. The least occurrence is nocturnal hallucination 15 (21%). Correlation analysis demonstrated that poor sleepers exhibited longer disease durations, the P-value (.013). Also a positive correlation with age, P-value of (.044) was noted. But failed to prove association with sex the P-value (.994), or higher PD severity, the P-value (.239).

Table 1 shows correlation between PD duration and PDSS-2 outcome in 71 patients with Parkinson’s disease, Sudan 2022. Table 2 shows cross table of severity of the disease (Hoehn and Yahr staging) and PDSS-2 outcome.

Table 1:PD duration and PDSS-2 outcome in 71 patients with Parkinson’s disease,Sudan 2022

Table 2: Cross table of severity of the disease (Hoehn and Yahr staging) and PDSS-2 outcome

Discussion

Seventy-one patients with PD were evaluated to identify the frequency and pattern of sleep disturbances among Sudanese patients with Parkinson’s disease. More than one-third (38%) had significant sleep disturbance (PDSS-2) with a cut-off point of 18. This finding goes with previous studies done in DO-Porto [7] for assessing the association of sleep and central parkinsonian pain, which reported that (33%) of patients with PD have significant ND using PDSS-2 with cutoff 18. They stated that these patients with sleep disturbances have more severe motor symptoms, motor fluctuation, more frequent pain, and lower functional independence. On the other hand, the Ethiopian study [8] in 2019 showed that 43.9% of PD patients had significant nocturnal disturbances using the same cut-off point. In contrast, the Taiwanese study in 2019 (15) revealed that 47.8%were poor sleepers (PDSS-2 = 15-60). This result is higher than our study, which can be explained by usage of the lower cut off value. In contrast, the Desai, I., Gupta, R., study [9] done during the Covid epidemic showed that 72% had poor sleep quality (PDSS‑2 ≥15). They attributed the high prevalence to the effect of the Covid 19 epidemic.

The most reported sleep disorder in our study was nocturia (72%); sleep maintenance insomnia (46%), sleep refreshment (46%), pain in arms and legs (45%), sleep onset insomnia (42%) and difficulty in turning in bed (41%). Less than one fifth had nocturnal hallucination (21%). While an Ethiopian study [8] reported that the most frequent sleep problems were nocturia (73.5%), difficulty with mobility in bed (37.4%), distressing dreams (36.1%) and sleep maintenance insomnia (34.8%).

There was no significant correlation of sleep disturbances with the severity of motor status (P 0.239). A significant correlation of severity of sleep disturbance with the duration of the disease was found (P 0.013).

This goes with a study done in Norway. While a Chinese study [10] showed; higher PDSS-2 scores were associated with longer disease duration and higher H&Y stage.

The Taiwanese study [11] showed poor sleepers to have longer disease durations, higher levodopa equivalent daily doses (LEDs), higher PD severity, more depression and anxiety symptoms, poorer QoL, and more frequent unemployed status. In a similar context, Zhang, Y. et al. study [12] supported the previous two studies stating that sleep disorders were associated with longer disease duration and higher modified H&Y stage.

Conclusion

One-third of Parkinson’s patients had significant sleep disturbances and a significant correlation of higher PDSS-2 with age and disease duration. However, it found no association with the severity of the motor symptoms.

Recommendations

More studies are needed to assess nocturnal sleep disturbances and daytime sleepiness among PD patients.

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