Treatments for Insomnia in Patients With Parkinson's Disease

McGill University

Status and phase: Completed; Early Phase 1

Conditions: Insomnia; Parkinson's Disease

Treatments: Behavioral: CBT and sleep hygiene; Device: Light box ( Litebook company); Drug: Doxepin and Zopiclone; Device: Light box (Litebook company)

Study type: Interventional

Funder types: Other

Identifiers

NCT01489982

INS-09-10

Details and patient eligibility

About

More than half of patients with Parkinson's have troubles with insomnia. There are several treatment options for insomnia that have been studied in the general population - however, the investigators don't know if these treatments work for patients with Parkinson's. It is possible that people with Parkinson's may have different treatment responses.

The goal of this project is to test in a pilot study the tolerability and effectiveness of pharmacologic and non-pharmacologic treatments to improve insomnia in patients with Parkinson's disease. Each participant in this study will be wearing a wrist actigrapch and fill out the sleep diary. Three main treatment strategies will be tested: Placebo Light therapy, Cognitive behavioural therapy and active light therapy, and insomnia medications. The treatment that each person will receive first will be chosen randomly. If the first therapy has not been effective, participant may choose to re-enrol in the trial with one of the remaining two therapies.

Full description

There are now a variety of treatments that can help to manage insomnia, including non-pharmacological and pharmacologic measures. Although many of these strategies have been proven to be effective in the general population very few studies have been conducted with Parkinson's Disease (PD) patients. Insomnia in PD has unique characteristics and pathophysiology; therefore, measures to treat insomnia in the general population may be ineffective in PD.

The goal of this project is to test in a pilot study the tolerability and effectiveness of pharmacologic and non-pharmacologic treatments to improve insomnia in patients with Parkinson's disease.

Participants will come for four visits: for screening, then in 1 week, 3 weeks and 7 weeks. Study visits should take approximately 1.5 to 2 hours. During the entire period of the study, the participant will be wearing a wrist actigraph - this is a motion sensing device the size of a wristwatch. Specific instructions how to use this device and how to use the sleep diary will explained at the first visit. Participant will also be filling out sleep diaries every day, to keep track of how many hours you sleep, etc. During each of the study visits there will be an in-depth interview, and researcher will review with the participants their sleep diaries and troubleshoot any problems.

In this trial the investigators will be testing three main treatment strategies. The treatment that the patient will receive first will be chosen randomly - this is essential to properly test our strategies. Participant will know which group he/she has been assigned to. If the first therapy has not been effective for the patient, he/she may choose to re-enroll in the trial, in which case participant will receive one of the remaining two therapies. The therapies are:

1. Light therapy, which patient will use for 30 minutes, starting at two hours (+/- 1 hour) before your usual bedtime. Light boxes will be provided by our team. Patient will be instructed how to use this light.
2. Cognitive behavioural therapy and sleep hygiene training - This will involve education about sleep in general, giving techniques related to sleep and relaxation, tips on stress management, etc.. This will take place at the Lady Davis Institute of the Jewish General Hospital. There will be 6 weekly sessions totaling 90 minutes - most of the time this will be in a group setting, with a maximum of 6 patients per group. Light therapy will also be part of this treatment strategy.
3. Insomnia medications - In this portion patient will receive medications to help them sleep. Depending on the type of patient's sleep problem, this will either be a medication called desipramine (also called Doxepin), or zopiclone (also called Imovane). Both of these medications are currently used for insomnia in people without Parkinson's. These medications will be prescribed exactly as any other medical prescription, and participant will take them as any other medical prescription.

Enrollment: 20 patients

Sex: All

Ages: 18+ years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• All patients will be recruited from the Movement Disorder Clinics at the McGill University Health Center.
• Patients will be eligible for inclusion if they have a diagnosis of idiopathic PD and suffer from insomnia, defined as an SCOPA-sleep nocturnal subscore of >7.
• The insomnia must have been persistent for at least 6 months (by patient self-report).
• The subjects must speak either English or French sufficiently to fill out questionnaires.

Exclusion criteria

1. Use of sedative medications at night (including sedating antidepressants). Patients may be taking non-sedating antidepressants if dose is stable for 1 month.
2. Untreated restless legs syndrome, night shift work, occupational causes of abnormal sleep pattern, or other reversible causes of insomnia detected upon baseline clinical interview. If treatment of a potentially-reversible cause is unsuccessful and insomnia is persistent >3 months following treatment initiation, patients can be enrolled.
3. Insomnia is not secondary to suboptimal dopaminergic therapy. If changes to dopaminergic therapy are required after clinical interview, patients can still be eligible for inclusion if insomnia is persistent >3 months.
4. Pre-menopausal women who are not using effective methods of birth control (note that only a small minority of women with PD are pre-menopausal, so the effects of this exclusion criterion in creating gender imbalance should be minimal).
5. Dementia, defined according to PD dementia criteria as MMSE <26/30 and ADL impairment secondary to cognitive loss, or inability to understand consent process.
6. Change to dopaminergic therapy over the preceding three months.
7. Patients with very severe PD, defined as Hoehn and Yahr of 5 (i.e. nonambulatory). Provision of sleep hygiene measures, etiology of insomnia, and potential confounds in interpretation of actigraphy in immobile patients is problematic in very advanced stages of PD.
8. Insomnia is related to untreated moderate-severe depression or anxiety. Beck depression score > 20i.e, moderate depression).

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Parallel Assignment

Masking: Single Blind

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20 participants in 4 patient groups, including a placebo group

Light therapy

Experimental group

Description:

For patients who have sleep maintenance insomnia light therapy will be administered daily. If patients suffer only from sleep onset insomnia, this light therapy will be given upon awakening in the morning. Light boxes will be provided by Litebook company. In the active therapy group, the intensity of the light will be set at 10,000 lux with a head-to-light distance of 20cm. Patients will be instructed to let the light shine indirectly on their eyes (i.e. they do not look directly at the light). Patients can be reading, eating, watching TV, etc., during the time of light therapy.

Treatment:

Device: Light box (Litebook company)

CBT and sleep hygiene training

Experimental group

Description:

This will involve education about sleep in general, giving techniques related to sleep and relaxation, tips on stress management, etc.. This will take place at the Lady Davis Institute of the Jewish General Hospital. There will be 6 weekly sessions totalling 90 minutes - most of the time this will be in a group setting, with a maximum of 6 patients per group. Light therapy will also be part of this treatment strategy. There will be separate gropus for English and French-speaking patients

Treatment:

Behavioral: CBT and sleep hygiene

Insomnia medications

Experimental group

Description:

Pharmacologic treatment will be individualized depending on patient characteristics and initial response. It will consist of two potential treatments - Doxepin or Zopiclone. Both of these agents are currently used commonly in the general population and also in PD patients. The agents will be prescribed exactly as any other medical prescription (i.e. patients will fill their own prescriptions at their own pharmacy).The decision for which agent to use will be as follows: a)If patients suffer from sleep onset insomnia (with or without sleep maintenance insomnia), or if doxepin is contraindicated, Zopiclone will be prescribedb) or b)If patients suffer from sleep maintenance insomnia only (or if Zopiclone is contraindicated), Doxepin will be the first choice agent.

Treatment:

Drug: Doxepin and Zopiclone

Placebo intervention of light therapy

Placebo Comparator group

Description:

The inactive/placebo intervention will be 30 minutes of light therapy, using red light below the threshold required to entrain light cycles. This therefore functions as a placebo condition for the active light therapy protocol. Patients be informed that some forms of light therapy will be expected to be less active, but we will not disclose what type of condition is inactive.

Treatment:

Device: Light box ( Litebook company)