These sleep disorders in parkinson’s are mainly excessive daytime sleepiness, insomnia, rapid eye movement behavior disorder of sleep, and restless legs syndrome. Sleep can also be affected by nocturia, difficulty turning over in bed, hallucinations, dyskinesias, pain, dystonia.

How can we treat these symptoms? The best evidence is for using modafinil for excessive daytime sleepiness. Caffeine may be effective but with less robust evidence. The antidepressant doxepin may help insomnia. Rivastigmine may be effective for RDB of sleep, along with clonazepam, generally used first-line. Other studies show that stopping sedative medications and reducing dopamine agonists during the daytime help. Amoxetine, a “stimulating” antidepressant, could also help daytime sleepiness and would simultaneously be helpful for depression. Quetiapine and memantine do not help daytime sleepiness.

For insomnia, studies support use of doxepin, melatonin, eszopiclone. Nortriptyline but not paroxetine may also improve sleep quality, especially in patients with depression. Dopamine agonists have been long used to treat RLS and are FDA-approved to do so.

The most surprising new finding is that rivastigmine may help RBD, when it is refractory to clonazepam and melatonin. Less surprising is that modafinil helps daytime sleepiness.

See Parkinsonism & Related Disorders, 2016, page 25-34. Lead author is T.M. Rodrigues, MD.

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