Is ReM Behavior Ruining Your Sleep? Here are some tips to improve life at night: By Dr. De Leon

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This happened to my poor husband and me, as it does to nearly  1/2 of the bed partners of PD patients  around the world since REM Behavior is reported to occur in about 47% of Parkinson’s patients….

I have been having vivid dreams and talking in my sleep for years, I would not be a good secret agent as per my husband. My sleep talking (about 70% of individuals have somniloquence-talk in sleep in some point in their lives without being aware) drives my husband crazy because I usually speak in my native tongue.  As my Parkinson’s disease has advanced, my dreams have become more vivid more frequent thought the night and my sleep talking has increased. However, over the last few months I noticed that my sleep talking had become louder to the point of awakening me. Then one morning I awoke to find my husband had built a wall of pillows between us for “protection,” he said. sleep talking

“Against whom?”  I asked.

“You, of course! I always knew that you were lethal. But, now I have confirmation!” He stated in a jokingly matter. ( I guess I picked up a thing or two watching all the boxing matches with my dad who was an avid boxer and boxer aficionado!)

A few days later in the middle of the night, I again awoke flinging my arms in the air and talking. Later the same night, I awoke because I felt hit something hard.  Apparently, I had punched my husband and was pulling his t-shirt. He was desperately pushing me away without trying to hurting me. “Sorry,” I muttered and fell asleep rather quickly.

Next day, at bed time he was building a bigger barrier.

“It’s amazing how you can’t throw a punch to save your life when awake,” he said “but people better what out if they try to mess with you when you are asleep. You throw a big punch that leaves a sting like ALi.”

After laughing, I apologized feeling really guilty. I told him that I was now having REM behavior ( RDB) due to my PD which was not only  causing me to ‘act out’ my wild dreams but was awaking me from sleep frequently since I was beginning to hear myself talk, punch and flail my arms in the air repeatedly.

“You are dangerous,” he commented. “If this keeps up, I may have to start sleeping in another room for my own safety.”

I knew it was time to adjust my meds recalling several patients who had gained weight suddenly not knowing the reason why only to find out they were sleep walking and raiding their refrigerators.sleepwalking-1

Others had broken bones from suddenly jumping out of bed and tripping on objects near bed. While other patients of mine had injured themselves on open chest drawers nearby. these scenarios were causing many partners to seek separate beds at night for fear of being assaulted by Manny Pacquiao’s and Floyd Mayweather’s and other famous boxer’s impersonators everywhere.  Even frail and weak appearing PD individuals can develop the strength of 100 men when in violent rage awake or asleep. I know I have seen it first hand as a doctor, a caregiver and a patient.

Thus, not wanting to continue 1) injuring my husband; 2) risking hurting myself; 3) continuing experiencing restless nights and chronic fatigue from lack of sleep; I increased my dopamine dose and started melatonin at night. I am sleeping better once more. My husband’s barricade has decreased and he no longer sleeps on the edge of the bed but still keeps a pillow nearby for protection just in case.

Few days ago, I asked him if I was still spilling state secrets. He answered in the affirmative, I surely would make a horrible spy I thought to just myself; but at the moment it appears that my boxing days and extreme fighting in bed at least for now appear to be behind me. I feel well rested and my dreaming although vivid has quieted down.

Things to know about REM behavior:

Sleep disorders is one of the most common non motor Parkinson’s symptoms that can precede motor symptoms of Parkinson’s many years before tremors and stiffness become noticeable. They can also occur in various forms ranging from insomnia, RLS, REM behavior (RDB) as the disease progresses. REM behavior is also known as “dream enacting behavior.”

Typically in REM sleep, which is part of deep sleep, our brains are very active and we experience a lot of dreaming while our bodies remain paralyzed. We usually go through this stage many times during the course of the night. About 20% of our sleep is spent in this stage which usually occurs more commonly in the second part of the night. REM behavior is more common in men over age 50 but more women are experiencing this phenomena (perhaps this goes along with the new trend of young women developing PD).  This sleep disorder is very common  in neurodegenerative diseases like Parkinson’s, MSA and dementia of Lewy body (LBD); it is also seen in narcolepsy. It can be the initial symptom of PD and MSA as well as that of  dementia of Lewy Body.

Dream enactment differs from night terrors by way that people if awoken from an episode of REM Behavior they are fully awake not confused and remember details of the dream unlike those with night terrors who have no recollection and are not fully awake.

Symptoms of REM Behavior include :

  • kicking,
  • talking,
  • punching,
  • arm flailing,
  • jumping
  • walking,
  • laughing,
  • shouting,
  • shouting profanity
  • at times emotional out cries.

Treatment:

  • increasing dopamine dosage,
  •  intake of small doses of klonopin is highly effective in most patients up to 90% with doses of .25 mg; it has complete effect in 79% of patients and the great thing about it is that it appears to do so without building tolerance or abuse.
  • The other extremely effective medication is over the counter melatonin in doses 3-12 mg taken at dinner around 5-6 pm.
  • tegretol ( carbamazepine) has also been shown to help
  • Mattress should be placed on floor
  • Put alarms in beds
  • remove potentially hazardous objects from around bed. One patient broke his lamp because he picked it up as sword, fortunately his  spouse awoke him before he struck her with it!

Habit-of-talking-in-sleep

Sources:

http://emedicine.medscape.com/article/1188651-treatment

http://www.mayoclinic.org/diseases-conditions/rem-sleep-behavior-disorder/basics/definition/con-20036654

What If the Cure to Pain and Other Non-Motor PDSymptom was Sleep?: By Dr. De Leon

Those of us who have chronic illnesses like PD often experience chronic pain as well. This in turn leads to increased problems with sleep- falling asleep, staying asleep as I am experiencing radicular pain at this moment keeping me up! (fortunately, I have taken my medication and waiting for it to kick in so I can have a good night’s rest)

The lack of sleep causes those of us most in need of pain relief to have more pain by depriving our bodies of the healing effects produced by a good night’s rest. If we don’t allow ourselves to rest and have deep sleep, this can then lead to a vicious cycle of pain and sleep deprivation.

According to the director of Behavioral Sleep Medicine at John Hopkins, Buenaver says that “people often make their situation worst by dwelling on the problem, and worrying about their pain.” So, I often recommend taking a strong pain medication even if it is an occasional narcotic to break the cycle and prevent the brain from becoming sensitized to pain. Because once pain becomes chronic it is much more difficult to treat because our brains have accustomed  themselves to thinking there is nothing to be done to make the symptoms better. You are defeated even before you have begun. This thinking is akin to an elephant who falsely believes it can be held captive or in place by a small chain not realizing its own potential because since they are small elephants in captivity are tied to trees which can hold them while young but not as they get stronger. The negative feelings that surge with dealing with chronic pain, the behavioral sleep director states, make those of us with chronic pain more sensitive to its effect.

His suggestion is to replace the negative thoughts, once they are identified, with a more balance positive train of thought which in turn is more likely to elicit greater sleep; since positive emotions not only cause relaxation but can actually ease pain by releasing chemicals like serotonin.

Next time you are bombarded with a negative thought or feeling, you have the power to STOP IT and replace it with a positive one…try it!  We begin by adjusting our mind sets, resetting our nocturnal habits- turn off all electronics, lights and commence meditation (prayer) adding positive thoughts to your daily life; otherwise we are not just sleep deprived but we are also hurting ourselves in more ways than one by potentially exacerbating all of our other non-motor PD symptoms.

Sleep impacts our entire being from our brains to how our body performs. Michael Smith, director of John Hopkins Center for Behavioral Health states that” during sleep the space between the cells in our brains expand and allow fluid to  flow through the entire brain and wipe away all the toxins of the day -that our brains put out.” We essentially clean house at night making for a more efficient and effective brain free of pollution. We all know what happens if we stopped cleaning our house? Soon it will be filled with garbage and uninhabitable.

Well, the same is true for our brain! We all know that when we are sleep deprived our minds operate less effectively and less efficiently. This is because it has to work extra hard to get over the trashed produced during the day’s activities. At night is when we sift through the waste and store what’s important. If not allowed to do this properly we become slower to recall and our reaction times increase…in a disease where we are already limited and experience slow recall and reaction time we do not need to increase this deficit by depriving our selves of sleep. Furthermore, sleep deprivation affects our prefrontal area – which is our decision making centers, also the area known for dealing with complex emotions and impulse control.

If we are hurting and sleepy we are at a total disadvantage to deal with primitive emotions like base needs and desires thus much more likely to succumb to impulse control effects of the PD medications. Lack of sleep can cause us to be anxious and emotionally become a train wreck which can even lead to severe depression if we allow ourselves to become chronically sleep deprived.

Remember, as I mentioned before, sleep helps with pain and healing. Sleep deprivation causes increase in inflammation which puts the neurons that fire up the pain signals on high alert ready to shoot at a moment’s notice. The neurons responsible for pain become extremely active -no wonder we are more pain sensitive when tired! From personal experience, I know that when I hurt the best remedy for me is to rest and sleep. Even my husband has become attuned to this- if I get enough sleep, I don’t hurt. The worst part is that researchers have discovered that disrupted sleep is even worse than sleeping for shorts amount of time…continuous arousals or interruptions in our nightly sleep cause greater inflammation and greater pain sensitivity…perhaps this is a reason why women and people with PD who have significant bladder issues or are wearing off at night tend to have greater pain? Even those of us who have REM behavior or severe RLS can be more likely to develop chronic pain if sleep continues to become disrupted.

As if being fuzzy minded, emotionally a wreck and sensitive to pain was not enough, sleep deprivation also increases our waistlines by making us eat more caloric foods, and increasing our food urges. Of course with all this topsy- turvy our bodies experiences when we don’t get enough sleep, we naturally become more fatigued. Perhaps, all of our Parkinson’s non motor symptoms would be much better off if we all took a concerted effort in making sure we not only got enough sleep (at least 6 hours a night) but, also a deep restful uninterrupted sleep.

Since, lack of sleep can lead to poor thinking, mood disorders, inhibit our abilities to deal with pain and actually increase our pain sensitivity while making it harder for us to metabolize food increasing our waistline- which by itself can put us at risk for other health issues. Therefore, it is imperative that if you are experiencing problems in any one of these areas, you speak with your  doctor  ASAP about adjusting medications for bladder, for “off “symptoms at night, RLS, and ReM behavior, pain and yes, perhaps asking them for a sleep medication to ensure a good night sleep.

However, things we can do to improve our lives and sleep are as follow:

1) Exercise in day time not night-preferably early in the morning @ least 3 times a week for at least 30minutes.

2) Limit caffeine intake- especially in the evening. No night caps-wine actually leads to rebound insomnia.

3) Control lights- turn off all electronics- do not read or watch TV in bed. Bed is only for sleep and sexual intimacy. Maintain your sleeping area cool and dark.

4) Relax. – have a ritual and a set time to go to bed and get up. Begin winding down and shutting off electronics at least an hour before bedtime.

I guarantee we will all be feeling much less pain, fatigue, forgetfulness, depression, and less likely to succumb to ICD’s (impulse control disorders).

Sources:

Richards, Sarah. (Fall 2014): “Cheating Sleep.” Johns Hopkins Health Review. Vol. 1(1):70-77.

“Hurt less, Sleep more.” (Psychology): (Fall 2014): Johns Hopkins Health Review. Vol. 1(1): 19.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

Excessive Sweating In Parkinson’s Patients: by Dr. De Leon

While I was still in practice, patients often would complain of having increase sweating particularly at night. Patients would often say to me; “I have a very hard time sleeping at night because of the sweats… and even Harder time staying dry!” I often concentrated more on the ‘lack of sleep’ and did not fully grasp the significance or discomfort, for that matter, of the “sweating” which was the real culprit. The issue of “sweating” somehow did not seem to be such a big problem in the grand scheme of ALL the other Parkinson’s symptoms.

But in reality, “excessive sweating” can be a real problem and if significant enough it can truly put a big damper on someone’s lifestyle; this in light of the fact that PD is already an extremely public disease for most of us. Unfortunately, sometimes in society we are judged whether we like it or not, primarily on first impressions which usually are as superficial as an appearance. Now, imagine the pressure, us PD patients’ feel, at times, when we go about in public being stiff, unable to smile with tremors and involuntary movements (dyskenisias) which only serve to fuel our inner anxiety causing a rise in our temperatures making us perspire even more adding to the embarrassment of being seen in public. Worst, although sweat typically does not smell…sweat caused by stress or anxiety does!

This overall scenario would make anyone of us want to hide under a rock or never leave our homes. However, there are a few steps we can take so that at least we can minimize our perspiration and reduce any chance for any offensive odor which might make us more self aware.
First of all, normal sweating helps to keep the body temperature in check like in hot weather or during high temperatures such as fever, or during exercise. Excessive sweating (hyperhidrosis)  means that you sweat more than normal even when you are not particularly hot, anxious or exercising. People with Parkinson’s suffer a number of changes in the skin one of which is increased perspiration. These changes can either result in under secretion (hypohidrosis) or over secretion presenting usually in the form of night sweats after starting on dopamine medications especially levodopa is very common.  But, because sweat is a way for our bodies to regulate our internal temperature any changes can be potentially harmful plus can cause severe emotional distress to an individual homeostasis and their lifestyle. For now, we are concentrating in the increase of sweat production.

So, why does this happen and what can we do to decrease the excessive sweating that may be contributing to  our  reluctance to go out in public or interfere with our  intimacy and sex life?

It is important to remember that all Parkinson’s people experience changes to their skin…skin is full of dopamine!

Over time Parkinson’s individuals lose sweating capabilities in the extremities like the hands and feet therefore increasing over the entire body as a compensatory mechanism! This process only worsens as the disease progresses. Plus, Parkinson’s medications also can cause generalized sweating or hyperhidrosis. Other causes of increased sweating are thyroid disease, anxiety disorder, cancers, and other hormonal problems to name a few as well as medications.

Anticholinergic medications can block sweat causing a dangerous rise in body temperatures especially in hot weather; hence it may be important to reconsider their use if you are an elderly patient or cut down on dose during the summer /hot months. This is because older people have a harder time regulating temperature especially during summer months if they live in very hot climates. Levodopa usually causes severe drenching especially during “off” states; but can also increase sweating at other times like night time. Therefore it is important to talk to your physician to adjust medication because if you are experiencing such severe sweating during the “off” state which usually means other motor and non-motor symptoms are uncontrolled during this time as well.

         What can you do?

  • Have medicines adjusted by tour physician /especially levodopa
  • Take lukewarm showers/baths
  • Drink extra fluids particularly water, even Gatorade and pedia-lyte (which comes in popsicles- best for hot weather)-stay hydrated
  • Wear light cotton clothes
  • If sweating is severe talk to doctor about medications like propranolol

 In order to avoid body odor due to excessive sweating:

1. Make sure you use antibacterial soap when bathing

2. Towel off completely

3. Use “industrial strength” antiperspirants/ deodorants – work best if you apply at night before bed time not after showering or will wash off; it takes 6 to 8 hours for antiperspirants to enter sweat ducts and properly clog pores plus body is cooler at night. But do reapply at least once during the day.

4.  Keep clothes clean and use garments which do not lock in sweat or bacteria, like cotton. Cut out or decrease offensive foods and drinks-like onion, garlic, alcohol, and spicy foods which tend to increase temperature of the body and wear breathable shoes and clothes.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at deleonenterprises3@yahoo.com contributor http://www.assisted-living-directory.com Contributor http://www.lavozbrazoriacounty.com

Tips for Dealing with Sleep Disorders in Parkinson’s : by Dr. De Leon

As many of you know sleep problems can wreak havoc with our lives if f we don’t get enough rest we are liable to turn from a mild manner soft spoken individual to an irritable cranky creature!

Not only does poor sleep affect our mood but also causes poor concentration leading to memory loss, fatigue, increase weight, and poor judgment. All of these can mimic actual Parkinson’s symptoms either from disease or as side effect of medications.

Therefore, when we don’t get enough sleep we are doing ourselves a disservice and making our symptoms seem worse while making our doctors jobs more difficult as they try to sort out the source. One way to avoid this confusion is to tell your doctor immediately if you are having trouble with sleep and be specific. The more details you tell them the better they are able to help you get back on your feet.

Keep a record of your problem :

1) Is the problem staying asleep

2) Falling asleep

3) Pain at night

4) Restless legs

5) Trouble turning- getting stuck in one place or in the sheets

6) Going to bathroom to often (as you are falling as sleep or does it awake you from sleep)

7) Trouble breathing and snoring

8)  Acting out dreams at night and or talking during sleep

9) Vivid dreaming and or hallucinations

10) Disturbance in sleep wake cycle-sleepy during day and awake at night

Sleep is a way we humans encode all the information we have learned during the day and store for long term. If sleep becomes interrupted enough this will lead to short term memory loss making it seem like you might have cognitive problems when I fact may just be sleep deprived. However, for those that do have early cognitive problems can through them into full blown psychosis and hallucinations and for those that have advance dementia or memory loss it will make things much worst. Not only this but also increase high blood pressure and risk of having a stroke and early death particularly in the presence of sleep apnea. As we age, our bodies do often require less sleep and there is a slight shift in cycle going to bed earlier and awaking earlier. But most people according to studies still need a good 7-8 hours to function optimally.

Some of the sleep problems can be treated more easily than others. For instance, for shift in awake cycle …two ways to treat one is to treat with medications like Provigil to maintain alert during daytime and prevent falling asleep so can then fall asleep at night and / or maintain a routine sleep hygiene where no naps are allowed during the daytime.  You MUST also arise at same time and go to bed at same time daily. Plus only use bedroom to sleep or  for sexual activities. Keep bedroom dark at a comfortable temperature. Do not try to force sleep. If you cannot sleep get out of bed and move to a separate room to read or watch TV or listen to soothing music. Go back to bed, if still unable to sleep repeat cycle. Do not exercise at least 3 hours before bedtime. If you have to go to bathroom a lot at night avoid drinking fluids 3 hours prior to bed time. Ask physician for medications to help with falling asleep or staying  asleep if none of these things work…there are many options.

If you are snoring and having sleep apnea your doctor will recommend a sleep study test-called a sonogram. I believe every Parkinson’s patient should have this done at some point in their disease process. This will also help evaluate for restless leg and periodic leg movements as well as REM behavior ( acting out in sleep your dreams when your body is supposed to be paralyzed!) so that adequate treatments can then be given. One sign that you might have sleep apnea is early morning headache or awaking from sleep with headache. Tegretol or Klonopin are some of the medications used for REM sleep disorders.

Do not drink alcohol particularly after dinner since this tends to interfere with sleep pattern may help to fall asleep quickly but will often arouse you because it causes shallow sleep patterns plus it can severely worsen sleep apnea. If trouble falling asleep- Do Not drink caffeinated beverages after noon and limit amount to one a day as well as try taking decaf products. These still contain caffeine only 50% less so you won’t feel totally deprived. If you smoke consider cessation since this is a stimulant. Increase physical activity– being active helps to deepen sleep.

If pain is a factor- your doctor will have to evaluate the source and treat accordingly. As he or she will also have to adjust dosages of medications if experiencing wearing off or freezing in bed and getting stuck. Likewise if having hallucinations. Therefore, if you are having any sleep disturbances make sure you speak with your physician as soon as possible since there is usually a good and effective treatment for most of the problems of sleep. Make sure you do not make any changes to your medication regimen without first consulting your doctor.

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Dr. M. De Leon is a movement disorder specialist on sabbatical, PPAC member and research advocate for PDF (Parkinson’s Disease Foundation); Texas State Assistant Director for PAN (Parkinson’s Action Network). You can learn more about her work at http://www.facebook.com/defeatparkinsons101 you can also learn more about Parkinson’s disease at www.pdf.org or at www.wemove.org; http://www.aan.org, http://www.defeatparkinsons.blogspot.com All materials here forth are property of Defeatparkinsons. without express written consent, these materials only may be used for viewers personal & non-commercial uses which do not harm the reputation of Defeatparkinsons organization or Dr. M. De Leon provided you do not remove any copyrights. To request permission to reproduce release of any part or whole of content, please contact me at defeatparkinsons101@yahoo.com contributor http://www.assisted-living-directory.com