By Dr Jennifer Challberg, SpR in Geriatric Medicine, John Radcliffe Hospital, and D Stevenson
Parkinson’s Advanced MasterClass 36A, November 2019
Sleep disorders are common in Parkinson’s disease and Parkinson’s plus syndromes. Common sleep problems include, insomnia, restless leg syndrome, excessive daytime sleepiness and parasomnias, including REM sleep behavioural disorder (RBD). Diagnosis is usually based on clinical information, including history and collateral history from bed partners. The gold standard for diagnosis of sleep disorders, particularly RBD, is polysomnography, ideally with video. Management of sleep disorders in PD can be difficult and there is a relative lack of good evidence for best practice treatment. The current NICE guidelines for management of RBD suggest Melatonin or Clonazepam. Melatonin has a better side effect profile and can be used in people with cognitive impairment and obstructive sleep apnoea. However, GPs in Oxfordshire are currently prohibited from prescribing Melatonin to adults.
Current practice was evaluated in Oxford based Parkinson’s disease clinics to see how clinicians were identifying and managing sleep disorders. Notes were retrospectively reviewed from both Geratology-led and Neurology-led clinics to identify if sleep was discussed, if there were any problems, and if so, if these were investigated and treated.
One hundred sets of notes were reviewed, 50 from Geratology-led clinic and 50 from Neurology-led clinic. There were more male than female patients reviewed (Male=65, F=35). Most patients were seen by a consultant (83%). The average age in Geratology led clinic was 79 years old, and in Neurology led clinic was 71 years old. Sleep was discussed in 68% of patients. Of the patients in whom sleep was discussed, over half (56%) reported problems with their sleep. However, the specifics of the sleep problem was often not discussed. No patients were referred for investigation of sleep disorders. A small number of patients were already on treatment for sleep disorders (18%) and treatment was initiated in a further 31%.
Sleep disorders are common in Parkinson’s disease, and over half of the patients in this study reported problems with sleep. However, sleep was not discussed at all in a significant proportion of clinic patients and this could be improved. We are considering interventions that would facilitate this, including use of the Non Motor Symtoms Questionaire (NMS-Quest) in clinic. We have also not referred any patients for investigations of sleep disturbances. This likely relates to the waiting lists for sleep studies and polysomnography. Finally, although treatment was initiated in many patients for sleep disturbances, melatonin is currently not available as a treatment option for patients in Oxfordshire. Although the evidence is somewhat equvicol for use of Melatonin in RBD, as it has a relatively innocuous side effect profile and can be used in patients with cognitive impairment, it should be an option for clinicians. Work is underway to change the CCG prescribing guidelines in Oxfordshire to allow use of Melatonin in Parkinson’s disease.