Sleep‐Autonomic Interactions in Parkinson's Disease and Multiple System Atrophy: A Comparative Study Using Structural Equation Modeling

Abstract Background Parkinson's disease (PD) and multiple system atrophy (MSA) are α‐synucleinopathies with overlapping autonomic and sleep dysfunction, but distinct trajectories. Objectives This study compared sleep and autonomic profiles in PD and MSA and elucidated disease‐specific associations using structural equation modeling (SEM). Methods We retrospectively analyzed drug‐naïve patients with PD and MSA presenting with sleep complaints. All participants underwent polysomnography (PSG), autonomic function tests, and cardiac [I‐123] metaiodobenzylguanidine (MIBG) scintigraphy. Significant parameters with moderate correlations (Spearman's ρ ≥ 0.35) were included in SEM to examine domain relationships. Results A total of 136 PD and 67 MSA patients were included. Patients with PD were older, with comparable sex, disease duration, and diabetes mellitus frequency. In PSG, patients with MSA showed lower‐stage N3 sleep, higher apnea–hypopnea index (35.4 vs. 23.2 events/h), and lower minimum oxygen saturation. Autonomic testing revealed that the MSA group demonstrated greater orthostatic blood pressure drops and higher total composite autonomic severity scores. Cardiac MIBG uptake was significantly reduced in the PD group. A directional SEM model in MSA revealed a significant association between autonomic dysfunction and increased sleep disruption ( β = −0.68, P = 0.006), with substantially greater explanatory power than observed in PD ( R 2 = 0.54 vs. 0.29). Conclusions Both autonomic and sleep parameters were significantly more impaired in patients with MSA than in those with PD. SEM further indicated that these domains were closely linked in MSA, with greater autonomic dysfunction associated with poorer sleep quality. This highlights the need for integrated management of both domains.