帕金森病睡眠障碍主观与客观评价研究

The study of subjective and objective evaluation of sleep disturbances in Parkinson's disease

研究背景 睡眠障碍是帕金森病患者常见的非运动症状之一,其评价方法包括主观量表和客观检查。目前我国对帕金森病睡眠障碍的研究主要以单一主观量表观察或多导睡眠图监测的客观方法为主,不能全面反映患者病情。本研究采用匹兹堡睡眠质量指数(PSQI)与多导睡眠图监测相结合的方法评价帕金森病患者睡眠情况,以分析其临床特点,探讨主观量表评价方法与客观检查方法之间的差异性及一致性。方法 选择116例帕金森病患者,进行PSQI评分及多导睡眠图监测,于病情"开"期进行统一帕金森病评价量表(UPDRS)评分及HoehnYahr分级,以及抑郁症状[汉密尔顿抑郁量表(HAMD,24项)]、认知功能[蒙特利尔认知评价量表(MoCA,北京版)]和嗜睡症状[Epworth嗜睡量表(ESS)]评价。结果 根据PSQI评分,选择有睡眠障碍(PSQI≥7分)和无睡眠障碍(PSQI<7分)患者各58例(50%)。与无睡眠障碍组相比,睡眠障碍组患者MoCA评分降低(23.34±3.50对24.89±3.52;t=2.377,P=0.019),UPDRSⅠ[4.00(2.00,5.00)对3.00(2.00,5.00);U=2.306,P=0.021]和Ⅱ评分[12.00(9.00,16.00)对10.00(6.00,13.00);U=1.995,P=0.046]增加,左旋多巴日等效剂量增加[(508.14±335.85)对(394.06±236.42)mg/d;t=2.115,P=0.037)];虽然UPDRSⅢ评分及HoehnYahr分级亦有所增加,但差异无统计学意义(P>0.05)。多导睡眠图监测显示,睡眠障碍组患者总睡眠时间减少、睡眠效率降低、睡眠潜伏期延长、非快速眼动睡眠期Ⅱ期时间减少(均P<0.05);但两组患者快速眼动睡眠潜伏期、觉醒次数、非快速眼动睡眠期Ⅰ期时间和比例、慢波睡眠比例、快速眼动睡眠期时间和比例、睡眠中周期性肢体运动指数、快速眼动睡眠期行为障碍发生率、氧减指数、最低血氧饱和度及睡眠呼吸暂停低通气指数差异均无统计学意义(P>0.05)。PSQI评分分别与ESS(r=0.200,P=0.032)、HAMD(r=0.202,P=0.030)、UPDRSⅠ(rs=0.266,P=0.004)和Ⅱ评分(rs=0.254,P=0.007)、左旋多巴日等效剂量(r=0.213,P=0.022)及睡眠潜伏期(rs=0.211,P=0.023)等因素呈正相关;而与总睡眠时间(r=0.231,P=0.003)、睡眠效率(r=0.192,P=0.039)、MoCA评分(r=0.236,P=0.011)呈负相关。结论 当帕金森病患者出现睡眠障碍时,其认知损害加剧、思维和情绪障碍常见、左旋多巴日等效剂量增大,多项客观睡眠参数呈病理性改变,且睡眠障碍程度与这些因素均有关联性。无论是主观或客观评价方法评价帕金森病患者总体睡眠质量均具有较好的一致性,但了解睡眠结构紊乱程度及筛查其他睡眠障碍性疾病仍需进行多导睡眠图监测。

Background Sleep disorder is one of the most common non motor symptoms in Parkinson's disease (PD) patients. At present, there are subjective and objective tools to evaluate sleep disorders. Nevertheless, previous studies commonly used single subjective questionnaires or objective examinations. Therefore, we used the combinations of subjective and objective tools to analyze clinical characteristics of sleep disturbances in PD and investigated differences and consistence between subjective and objective tools. Methods One hundred and sixteen PD patients were eligible to participate into this study. All participants were evaluated by Pittsburgh Sleep Quality Index (PSQI), Unified Parkinson's Disease Rating Scale (UPDRS) in 'on' condition, Hoehn Yahr (H Y) stage, Hamilton Depression Rating Scale (HAMD 24 items), Montreal Cognitive Assessment (MoCA), Epworth Sleepiness Scale (ESS), and underwent a video polysomnography (Video PSG). Results According to PSQI score of 116 PD patients, the proportion of PD patients with sleep disturbances (PSQI ≥ 7) was 50% (N = 58). Compared to PD patients without sleep disturbances, PD patients with sleep disturbances had lower score of MoCA (23.34 ± 3.50 vs 24.89 ± 3.52; t = 2.377, P = 0.019), higher score of UPDRSⅠ[4.00 (2.00, 5.00) vs 3.00 (2.00, 5.00); U = 2.306, P = 0.021], UPDRSⅡ[12.00 (9.00, 16.00) vs 10.00 (6.00, 13.00); U = 1.995, P = 0.046], higher levodopa equivalent daily dose [LED, (508.14 ± 335.85) vs (394.06 ± 236.40) mg/d; t = 2.115, P = 0.037]. Although PD patients with sleep disturbances had more score of UPDSRⅢ and higher H Y stage, the differences were not significant (P > 0.05). On the other hand, decreased total sleep time (TST), reduced sleep efficiency (SE), increased sleep latency (SL), decreased non rapid eye movement (NREM) sleep stage Ⅱ time were found for PD patients with sleep disturbances (P < 0.05, for all). Other PSG parameters had no significant differences between PD patients with and without sleep disturbances (P > 0.05, for all). The score of PSQI was positively correlated with the score of ESS (r = 0.200, P = 0.032), HAMD (r = 0.202, P = 0.030), UPDRSⅠ(r s = 0.266, P = 0.004) and Ⅱ (r s = 0.254, P = 0.007), LED (r = 0.213, P = 0.022), SL (r s = 0.211, P = 0.023). Moreover, the score of PSQI was negatively correlated with TST (r = 0.231, P = 0.003), SE (r = 0.192, P = 0.039) and MoCA (r = 0.236, P = 0.011). Conclusion PD patients with sleep disturbances had worse cognition impairment, more mood disorders, decreased activity of daily life. Meanwhile, most of PSG parameters were altered in PD patients with sleep disturbances. Moreover, the severity of sleep disturbances in PD patients was correlated with these factors. Overall sleep quality of PD patients assessed with the objective tool could be predicted by the subjective scale. However, to evaluate sleep architecture and other sleep disorders for PD patients, the objective tools (such as Video PSG monitoring) are necessary to be used.