Chapter 6-Physician's Guide To The Management of HD
Sleep disturbance is a common problem in Huntington's disease, and can be due to a variety of causes. A complaint of sleeplessness may be due to a mood disorder, either depression, or, less commonly, mania. In these cases, treatment of the mood disorder should lead to a normalization of sleep. The clinician should conduct a careful interview and speak to the patient's family to rule out this possibility.
Good sleep hygiene is also important. Patients who do not have enough to do, and whose days are insufficiently structured may develop a reversal of the sleep-wake cycle in which they nap most of the day, and are then awake at night. This pattern tends to reinforce itself and can be hard to interrupt. Helpful strategies include sleeping consistently in a room which is not used for wake-time activities, having a regular bedtime and waking time, and enrolling in a day program, which keeps the patient occupied and prevents daytime napping. In the later stages of illness, patients may have an increased need for rest and daytime napping may be entirely appropriate, as long as the patient is sleeping at night.
Some patients will require pharmacologic treatment of their insomnia. We would caution against long-term use of benzodiazepine or barbiturate hypnotics because of the potential for tolerance, dependence, and delirium and usually prefer to use a small dose of a sedating antidepressant such as trazodone (Desyrel), beginning at 25-50mg and increasing to about 200mg as necessary. Sedating tricyclics such as doxepin (Sinequan) or amitriptyline (Elavil) can also be employed, but are highly dangerous in overdose.
It is not entirely true that chorea ceases when patients are asleep. Sleep studies conducted in patients with refractory insomnia have suggested that some HD patients have restless sleep because of a large amount of involuntary movements at night. The patient himself will often be unaware of these nighttime movements, but they will often be reported by the spouse or caregiver. A small dose of fluphenazine, haloperidol (0.5-2mg) or clonazepam (0.5-lmg) at bedtime, may suppress the movements sufficiently to allow more restful sleep. Polysomnography or referral to a sleep disorder center may be helpful in these difficult cases.
Painful leg cramping caused by dystonia and spasticity can also disrupt sleep. Treatment with a muscle relaxant, such as baclofen may relieve the problem.
Type in Insomnia
Drugs that cause Insomnia
Selective Serotonin Reuptake Inhibitors (SSRI)
Medication Causes of Nightmares
http://www.fpnotebook.com/PSY174.htmNightmares due to Medications
Altered CNS Neurotransmitters
Monoamine Oxidase Inhibitors
Selective Serotonin Reuptake Inhibitors (SSRI)
Centrally acting Antihypertensive Medications
Alpha Adrenergic Agonists
Chemical Dependency: Drug Withdrawal
Alcohol Abuse with withdrawal
Barbiturate Abuse with withdrawal
Benzodiazepine Abuse with withdrawal
Although written for PD, helpful information
Difficulties with sleep are common in Parkinson's disease, and can be categorized into four types:
- difficulty staying asleep; early morning awakening
- involuntary movements and pain interrupting sleep
- frequent nighttime urination (addressed in Chapter 7)
- vivid dreams, nighttime agitation and hallucinations (addressed in Chapter 5)
Difficulty maintaining nighttime sleep is probably the most common sleep complaint in PD. Normal sleep is organized into stages, and an individual usually cycles through the various stages of sleep in a set order and time pattern. In Parkinson's disease the normal sleep cycles are frequently interrupted. Patients typically complain of difficulties staying asleep despite having little trouble falling asleep initially. In fact, many people complain that they fall asleep "too early" (7-8 p.m.) and then awaken at 3-4 a.m., unable to resume sleep. In addition, many people with PD will awaken several times throughout the night, although they may have no recollection of these events. Spouses may be more aware of the disrupted sleep than the patient. This disruption of normal sleep patterns may contribute to the daytime sleepiness often reported by Parkinson patients.
MEDICATIONS TO IMPROVE THE SLEEP CYCLE
While disrupted sleep seems to be an integral part of living with Parkinson's disease, the conventional antiparkinson drugs are not usually helpful. In fact, Parkinson drugs may be the cause of sleep disturbance in some patients. For example, selegiline can cause insomnia, particularly if taken in the afternoon or evening. By contrast, some patients sleep better on a trial of controlled-release Sinemet or one of the dopamine agonist preparations dosed late in the day, due to the long duration of action of these compounds. These drugs are probably most beneficial in those instances when the patient complains of severe immobility or tremor preventing resumption of sleep in the middle of the night. No single drug has proven to be uniformly effective in restoring nighttime sleep in Parkinson patients.
EXAMPLES OF DRUGS USED TO PROMOTE AND MAINTAIN SLEEP
- zolpidem (Ambien®)
- nefazodone (Serzone®)
- amitriptyline (Elavil®)
- nortriptyline (Pamelor®)
- trazodone (Desyrel®)
- temazepam (Restoril®)
- diphenhydramine (Benadryl®, Tylenol PM®)
- chloral hydrate
Some of the older antidepressant drugs can also be used to promote sleep because of their sedative properties; for example, amitriptyline or nortriptyline 10 - 25 mg. can be taken at bedtime. Some patients are able to achieve a more stable sleep pattern by using diphenhydramine 25 - 50 mg. at bedtime. Available as Benadryl® and many generic brands, this medication is available over-the-counter, and may also help reduce tremor and drooling in some patients. Patients should check with their physicians before using over-the-counter medications such as Benadryl®.
Benzodiazepines, discussed previously for treating anxiety, are also sometimes used as a sleep aid. These drugs can be helpful in falling asleep initially, but may wear off in 3-4 hours, thus providing no relief from early morning awakening. Also, tolerance to benzodiazepines develops with regular use over time, and dose increases have significant risks in the elderly, such as over-sedation, confusion, and balance impairment increasing the risk of falls.
Establishing good sleep hygiene habits can also help one get a good night's sleep. These include establishing a regular bedtime and getting up time, limiting daytime napping, and avoiding food, excessive fluid intake, and alcohol for several hours prior to bedtime.
Sleep Disorders - How is it treated?
Drug therapy, when combined with good sleep hygiene, may be helpful for the short-term management of insomnia.
Benzodiazepines are commonly used for the management of sleep disorders. Shorter-acting benzodiazepines are less likely than long-acting benzodiazepines to be associated with drowsiness or sluggishness the next morning.
Other drugs used in the short-term management of insomnia include a unique agent called Ambien(zolpidem), barbiturates, sedating antihistamines, and a new drug called Sonata.
Drug classes used to treat Sleep Disorders
Barbiturates slow down central nervous system function, heart rate, and respiration. People who use them continually may become tolerant to the effects of barbiturates, which also produce potentially serious side effects.
Drugs in the class
Butabarbital (Butalan Elixir, Butisol, Sarisol No.2)
Pentobarbital Oral (Nembutal)
Phenobarbital (Bellatol, Solfoton)
Pentobarbital Injection (Nembutal Injection)
Benzodiazepines are drugs that relieve anxiety by acting on the limbic system, an area deep inside the brain that appears to be involved in primitive emotional responses.
Benzodiazepines work at the level of the nerve cells in the brain. They enhance the effects of a chemical messenger called gamma aminobutyric acid (GABA) that slows down the activity of the nerve cell. When GABA binds to the nerve cell, a channel is widened allowing more chloride ions to move into the nerve cell. This makes the cell less active. When benzodiazepines bind to GABA receptors, the effects are enhanced.
Benzodiazepines enhance the sedating effect of GABA by allowing chloride ions (Cl-) into the nerve cells, slowing the activity of the neuron.
Drugs in the class
Chlordiazepoxide (Libritabs, Librium, Mitran, Reposans-10, Sereen)
Clorazepate (ClorazeCaps, ClorazeTabs, GenENE, Tranxene, Tranxene-SD)
Diazepam (Valium, Valrelease)
Lorazepam Injection (Ativan Injection)
Miscellaneous Sedatives and Hypnotics
Sonata is a newer drug, released in 1999 for the treatment of short-term insomnia. It is not a benzodiazepine or a barbiturate. This hypnotic's main advantage is that it is associated with less next morning drowsiness.
Ambien is not a benzodiazepine or a barbiturate, but it slows down the brain's normal function, in a way that is not harmful but that promotes sleep. It works relatively quickly and has fewer side effects than some of the other sleep-inducing medications.
Drugs in the class
Chloral Hydrate ()
Chloral Hydrate Rectal (Aquachloral Supprettes)