Sleep

Sleep hygiene education is the first step towards managing sleep disorders and Parkinson’s Disease. It is proven to create healthy sleeping habits and improve quality of sleep.
• Go to bed and wake up at the same time every day, even on weekends.
• Use your bed only for sleep and intimacy. Avoid using your bed for watching TV, using your phone, working, or eating.
• Do not overstimulate yourself close to bedtime. Try relaxing activities such as reading or listening to music.
• Keep your bedroom dark, quiet, and a comfortable temperature.
• Do not watch TV or use your phone in bed. Try to avoid screen time at least 1 hour before bedtime.
• Practice relaxation techniques like deep breathing, meditation, or mindfulness if he feels stressed or anxious at bedtime.
• Avoid caffeine, alcohol, tea, or nicotine within 4 hours of bedtime.
• Avoid self-medicating with alcohol to make yourself sleepy.
• Exercise regularly throughout the day, but avoid vigorous exercise close to bedtime.

Melatonin

You may consider starting Melatonin 5mg tablets 3 hours before bedtime as below:

• This medication resets your circadian rhythm (when your body knows it is time for sleep) and can help promote sustained sleep.
• While melatonin does not sedate you, it can make you more tired. If taking 3 hours before bedtime makes you too sleepy, take it closer to bedtime.
• The most common side effect is morning sleepiness.
• It may take 4 to 6 weeks for each dose to take maximum effect.
• Increase to the dosage that seems to help with the symptoms without causing side effects.

REM Behavioral Disorder (RBD)

RBD is characterized by sleep talking, acting out dreams, and/or falling out of bed during the rapid eye movement (REM) stage of sleep (when you normally dream). Your body is supposed to be paralyzed during REM sleep, but in people with RBD this is typically incomplete or absent. Because of this, this allows you to move or speak while you are dreaming. This can be severe and necessitate medications, particularly if you are harming your bed partner or at risk for falling out of bed.

Behavioral strategies:
• Using bed rails.
• Lowering the height of the bed.
• Positioning the bed against a wall or placing cushions/pillows on the floor beside the bed.
• Removing hazardous objects nearby (sharp desk corners).

Medications:
• Melatonin is a natural hormone that is proven to reduce RBD movements, reset sleep cycles, and promote sleep. Details above.
• In those with RBD, melatonin should reduce RBD symptoms (sleep talking, acting out dreams, and/or falling out of bed).
• If symptoms continue while on 20 mg nightly, we will need to consider a different agent called Klonopin (clonazepam) to suppress RBD.
• If needed, it may be necessary to use a stronger medications (eg, benzodiazepines) to suppress your movements while you are asleep.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

You may also look into Cognitive Behavioral Therapy for Insomnia (CBT-I). CBT-I is a structured, evidence-based treatment that helps people overcome chronic insomnia. It works by retraining the brain with techniques like sleep restriction, stimulus control, relaxation training, and cognitive restructuring to improve sleep quality and duration. It is considered the first-line treatment for insomnia and has been shown to be effective for both short-term and long-term sleep problems.

• Level 1: free resources and introductory tools that are likely effective in those with mild insomnia.
  – Download “insomnia coach” app.
  – Look at insomniacoach.com (different than the above app) and utilize the free emails and podcast.
• Level 2:
  – Read “Say Goodnight to Insomnia,” by Gregg Jacobs, PhD.
  – Online CBT-I courses:
  thesleepreset.com
  drlullaby.com
  insomniacoach.com
• Level 3: best evidence-based therapy for chronic insomnia.
  – Go to behavioralsleep.org and select a sleep therapist certified in CBT-I.
  – Complete a full course with them (usually one visit per week for 5-8 weeks).

Author Mick Reedy, MD, is a Movement Disorders Specialist with
Inova Parkinson’s and Movement Disorders Center (IPMDC)