Objective: Treatment by continuous diurnal intestinal infusion of levodopa is effective in improving sleep quality in Parkinson’s disease (PD), but its use exclusively at night for this purpose has not been reported. We herein report a case of a patient with GBA-associated PD with disrupting sleep behavior disorder successfully treated with nocturnal levodopa-carbidopa intestinal gel infusion.

Background: A 56-year-old patient with PD starting at 43, showing a mixed motor phenotype with cognitive impairment and motor fluctuations. From the beginning presented symptoms of REM sleep behaviour disorder to which 2 years later an anxiety disorder of increasing intensity and insomnia were added. Sleep became fragmented, with frequent confusional awakenings, motor activity, vocalizations, screaming, and nocturnal hyperphagia. Progressively the sleep behavior disorder became more disrupting and unresponsive to multiple therapies. Finally, the patient is admitted to a psychiatric institution on a bed night regime. We subsequently observed that three overnight doses of 250 mg each, every 4 hours, provided an intermittent sleep benefit. Based on this observation we tested a continuous nocturnal intestinal administration of levodopa infusion to provide continuous dopaminergic stimulation.

Method: The PSG study showed a marked alteration of the macro and microstructure of sleep, with an overall slowing of the recording, with an increase in the percentage of sleep stages classified as N3. Frequent interruptions were identified during NREM sleep due to intrasleep awakenings with vocalizations, complaints, and crying, sometimes accompanied by discrete non-finalist movements of the upper or lower extremities. A pattern of absence of atonia was identified during REM sleep.

Results: The response to treatment with nocturnal intestinal levodopa infusion was dramatic, with the patient achieving 10-12 hours of uninterrupted sleep each night and being discharged from the psychiatric institution.

Conclusion: Nocturnal intestinal infusion of levodopa may be a therapeutic option in cases of severe and refractory sleep disorder once a response to levodopa has been proved. We interpret the sleep behavior disorder in this patient as the result of motor and non-motor fluctuations during the night, which could be resolved by continuous nocturnal dopaminergic stimulation.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/the-benefit-of-exclusive-nocturnal-administration-of-a-levodopa-carbidopa-intestinal-infusion-for-severe-refractory-sleep-behavior-disorder-in-parkinsons-disease/