Treating Sleep Apnea in People With PD

Obstructive sleep apnea (OSA) is commonly found in patients with PD. It contributes to poor quality of life, including higher rates of cognitive dysfunction in people with both conditions, according to a report published in the Annals of Movement Disorders in late 2018.

The report reflects on the findings of two previous studies—Harmell et al (Sleep Medicine, 2016) and Mery et al (Neurology, 2017)—which showed higher cognitive dysfunction in people with PD who also have OSA, as opposed to those with PD without OSA.

But what is OSA?

What does OSA look like?

OSA is a sleep breathing disorder with several identifiable risk factors. Sleeping partners may have witnessed their loved ones choking or gasping for air in their sleep. Also, snoring—though not proof alone of OSA—is still suspect if it’s loud and frequent.

OSA is identified as pauses of breathing during sleep which last at least 10 seconds each and which occur five times or more (usually quite a bit more) per hour, on average, during a full night’s sleep. By comparison, healthy people without OSA experience less than three episodes of breathing pauses per hour per night.

When these pauses occur, a flurry of other processes within the body take flight: higher blood pressure and pulse, the release of stress hormones, and shifts in insulin-glucose ratios.

When experienced repeatedly over the long-term, but left untreated, OSA is a leading cause for many chronic health issues, including cardiovascular disease, hypertension, type 2 diabetes, major depression, and anxiety disorder. Untreated OSA is also a significant cause of motor vehicle accidents and dangerous mistakes and errors that occur during the day as a result of lingering daytime sleepiness.

Other classic symptoms include frequent nocturnal awakenings, and a variety of sensations upon awakening, such as shortness of breath, sore throat, dry mouth, and headache.

Identifying sleep apnea in someone with Parkinson's

We already know that PD is linked to the parasomnia known as REM sleep behavior disorder (RBD).

If a person with PD presents symptoms that resemble sleepwalking, they are urged to have an overnight test in a sleep lab. Not only is this important for treating RBD, but research suggests that, in severe OSA, its symptoms may mimic those in RBD (Zhang et al, Sleep Medicine 2016).

Nocturnal polysomnography (NPSG), more commonly referred to as an overnight sleep study, is the gold standard diagnostic assessment used to identify OSA.

If someone with PD is diagnosed with OSA, the go-to treatment is a form of noninvasive ventilation, usually along the line of therapies known as PAP, or positive airway pressure. Current research continues to support the long-term use of PAP therapy to treat OSA in people with PD. Kaminska et al (Journal of Clinical Sleep Medicine, 2018) found that PAP therapies improved the overall non-motor symptom burden of PD (anxiety and cognitive dysfunction, specifically).

Why treating OSA matters

Problems with cognition, anxiety, and daytime sleepiness are hallmarks for many disorders, including several different sleep disorders. It’s in the best interest of the person with PD to have any suspected sleep problems checked out as soon as possible.

The good news? Treating OSA should bring relief to someone with PD who routinely suffers from daytime sleepiness, brain fog, and mood problems.

What is PAP therapy for OSA?

PAP therapy involves the use of a nasal interface to mechanically deliver pressurized air to the upper airway while the user sleeps. This delivery system essentially “splints” the airway open, preventing its collapse and keeping the airway unobstructed. The different kinds of PAP include:

• CPAP = Continuous positive airway pressure (a single delivery of pressurized air)
• BiLevel PAP = BiLevel positive airway pressure (two deliveries of pressurized air: one for inhalation, the other for exhalation)
• AutoPAP = Autotitrating positive airway pressure (a “smart” delivery system which delivers a range of pressurized air based on the patient’s airway needs throughout the night)
• ASV = Adaptive servoventilation (a sophisticated delivery system for treating both obstructive sleep apnea and its neurological cousin, central sleep apnea)

On the horizon: drug therapies for treating OSA in PD?

Another option gaining favor is the use of sustained-release levodopa/carbidopa in people who have both PD and OSA.

This pharmacological approach (researched here by Gros et al, Sleep and Breathing, 2015) uses this drug combination to improve the rigidity (or patency) of the tissues of the upper airway, preventing their collapse while also improving their coordination with the muscles in the upper airways.

The recent FDA approval of the oral inhalation medication Inbrija, prescribed to treat OFF episodes in people with PD using a levodopa/carbidopa regimen, makes potential pharmaceutical relief an attractive option for those with both PD and OSA who don’t respond well to or tolerate PAP therapy.