- Dans une auto immobilisée quelques minutes dans un encombrement
4. Le traitement antiparkinsonien :
Les effets des médicaments dopaminergiques sur le sommeil sont connus être dose dépendant, avec des doses plus faibles favorisant le sommeil paradoxal et profond et des doses plus élevées ayant l’effet contraire, cela peut-être due à une activation différentielle des récepteurs D1 et D2 [148].
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La Levodopa ou les agonistes dopaminergiques sont souvent suggérés pour permettre l’amélioration du sommeil chez les patients atteints de MP en soulageant les symptômes moteurs nocturnes tels que l’akinésie, mais il n'est pas établi s’ils améliorent la durée totale du sommeil.
Stocchi et al rapportent qu’avec la lévodopa/Carbidopa à libération prolongée, il y’a une augmentation de la durée du sommeil [149] ; tandis que Wailke et al. (2011) n’ont pas trouvé une augmentation de la durée totale du sommeil avec la levodopa/carbidopa [145]. Il n'est pas certain si pour chaque patient l'optimisation individuelle de la posologie de la lévodopa permettrait dans de telles études d'améliorer la durée totale du sommeil.
Rye et al.(2000) aussi n’ont pas trouvés de corrélations entre le temps de sommeil total et la dose quotidienne de levodopa [141].
Arnulf et al.(2002) ont trouvé uniquement une faible corrélation entre la latence du sommeil et la dose quotidienne de Levodopa, et aucune corrélation avec la dose quotidienne des agonistes dopaminergiques avec la somnolence diurne [142]
L’optimisation de la qualité subjective du sommeil comprend aussi la gestion des symptômes dépressifs chez les patients souffrant de MP, et la prise des antidépresseurs sédatifs le soir pourrait aider à améliorer le sommeil nocturne chez les malades parkinsoniens insomniaques [150].
Le traitement par lévodopa peut engendrer des hallucinations nocturnes. Mais il est souvent difficile de dire si les troubles du sommeil sont dus au syndrome parkinsonien ou au traitement de celui-ci. Selon Van Hilten et al, le traitement par
lévodopa ainsi que par agonistes dopaminergiques serait à la base du sommeil perturbé du patient souffrant d'une maladie de Parkinson d'une sévérité faible à modérée à cause de leur influence sur la régulation du sommeil [151].
Si subjectivement, on incrimine l’effet du traitement dopaminergique dans les perturbations du sommeil, du point de vue polysomnographique, l’étude la plus intéressante qui a cherché l’effet de la dopathérapie sur les paramètres du sommeil, reste celle de Jakub M. Antczak (2013) et qui a inclus 27 parkinsoniens consommant d’une façon chronique des doses élevés et anciennes de dopamine comparés à 24 patients contrôles, et elle n’a pas montré de grand changements dans les paramètres du sommeil (surtout les stades du sommeil) en PSG (tableau 17) [152].
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Tableau 17 : données de PSG, chez des malades parkinsoniens sous dopathérapie comparés à un groupe contrôle [150].
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Notre étude a permis de discuter à partir d’une cohorte de 10 patients ayant une maladie de parkinson idiopathique, l'importance des troubles du sommeil existant dans cette maladie. Les troubles du sommeil sont ainsi fréquents, multifacettaires et persistent malgré un traitement antiparkinsonien bien adapté.
Notre étude a montré la présence de différents types de troubles du sommeil : insomnie, SJSR, TCSP, SAOS, MPJ, à proportion variable. Elle a aussi trouvé un retentissement sur la vigilance diurne chez ce groupe de malades.
L’étude polysomnographique était un moyen de confirmation de ces troubles et d’évaluation objective de leur sévérité. Elle a aussi montré qu’il y’a une réduction du temps du sommeil total, de son efficacité, ainsi que sa fragmentation, mais sans réduction des proportions des stades du sommeil. Ces résultats sont généralement comparables aux ceux décrits dans la littérature..
Néanmoins, une étude prospective avec un échantillon plus large comparé à un groupe témoin s’avère nécessaire pour confirmer ou infirmer nos résultats.
La prise en charge du trouble du sommeil, doit tenir compte de plusieurs facteurs: âge, comorbidités, sévérité du trouble, traitement dopaminergique..
Le traitement des symptômes dépressifs et l’ajustement judicieux des médicaments dopaminergiques peuvent être utiles dans la gestion des complications subjectives liées au sommeil chez les patients atteints de MP.
En fait, Les altérations des rythmes circadiens restent en général un domaine non suffisamment exploré, qui semblerait prometteur pour la compréhension des interactions entre les troubles du sommeil et la MP. On peut dire donc que
« La maladie de Parkinson ne comporte pas uniquement des troubles moteurs, mais aussi c’est une maladie du sommeil ».
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