Restless Legs Restless Legs SyndromeSyndrome

Juan A. Albino, MD, FCCPJuan A. Albino, MD, FCCPBoard Certified in Sleep MedicineBoard Certified in Sleep MedicineVillage Sleep Lab (VSL) 751-4955Village Sleep Lab (VSL) 751-4955

Accredited by the AASM, 1/08Accredited by the AASM, 1/08

Thank You !!!Thank You !!!George Hess, CoordinatorGeorge Hess, CoordinatorCentral Florida RLS Support Group,Central Florida RLS Support Group,Heather Ellington, Office Manager, VSL Heather Ellington, Office Manager, VSL John Crawford, Technical Director, VSLJohn Crawford, Technical Director, VSLThomas Chaput, Sleep Technologist, VSLThomas Chaput, Sleep Technologist, VSLMiyoshi Scott, Nurse, VSLMiyoshi Scott, Nurse, VSLDallas Douma, Receptionist, VSLDallas Douma, Receptionist, VSL

Common Sleep DisordersCommon Sleep Disorders

Insomnia: wants to sleep but cannot Insomnia: wants to sleep but cannot Sleep Deprivation: does Sleep Deprivation: does notnot want to sleep but want to sleep but

can; problem of sleep quantitycan; problem of sleep quantity Sleep Apnea: sleepy during day, snores Sleep Apnea: sleepy during day, snores

(throat obstruction) problem of sleep quality (throat obstruction) problem of sleep quality RESTLESS LEGS SYNDROMERESTLESS LEGS SYNDROME: leg : leg

discomfort, relieved by movement, discomfort, relieved by movement, symptoms day and night symptoms day and night

Parasomnias (abnormal sleep behaviors)Parasomnias (abnormal sleep behaviors) Circadian Rhythm Disorders (Shift Work)Circadian Rhythm Disorders (Shift Work)

Insomnia: Acute or ChronicInsomnia: Acute or Chronic

Insomnia: inability to get to sleep, stay Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime asleep, wakes up early, with daytime impairmentimpairment

Acute Insomnia (<4 weeks): stress, illnessAcute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stageSleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often yearsChronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychologicalTreat basic problem: >60% psychological Psychotherapy and behavioral therapy Psychotherapy and behavioral therapy

better than medicines, not easy to treat better than medicines, not easy to treat Psychologists, Psychiatrists, PCPPsychologists, Psychiatrists, PCP

Sleep DeprivationSleep Deprivation

Disasters: Exxon Valdez, Challenger Disasters: Exxon Valdez, Challenger Space Shuttle, Chernoble Nuclear Plant, Space Shuttle, Chernoble Nuclear Plant, Commuter plane crash in KentuckyCommuter plane crash in Kentucky

33% of fatal truck accidents 33% of fatal truck accidents 10% of fatal car accidents10% of fatal car accidents Impairment the same whether: drunk, Impairment the same whether: drunk,

sleep deprived (<4-6hrs.), sleep apneasleep deprived (<4-6hrs.), sleep apneaMust be taken seriously: sleep 8 hoursMust be taken seriously: sleep 8 hoursLeads to obesity and diabetesLeads to obesity and diabetes

What is OSA?•Cessation of airflow with ongoing respiratory effort•NORMAL SNORING SLEEP APNEA

Obstructive Sleep Apnea

Sleep Apnea: ConsequencesSleep Apnea: Consequences During During nightnight: snoring, snorting, gasping, : snoring, snorting, gasping,

difficult or stops breathing, wife worriesdifficult or stops breathing, wife worries During During dayday: sleepy, tired, depressed, : sleepy, tired, depressed,

irritable, impotent, forgets, sometimes few irritable, impotent, forgets, sometimes few complaintscomplaints

More More accidentsaccidents: work, home, motor vehicle: work, home, motor vehicle Higher death rates with severe sleep apneaHigher death rates with severe sleep apnea Hypertension, Congestive Heart FailureHypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial FibrillationHeart Attacks, Strokes, Atrial Fibrillation Promotes Promotes ObesityObesity and and DiabetesDiabetes Problems: at night, during day, risk factorProblems: at night, during day, risk factor

Treatment -CPAP treatment–Positive pressure keeps airway open–100% effective

CPAP therapy

Treatment Options: CPAP

ParasomniasParasomnias

Abnormal behaviors while asleepAbnormal behaviors while asleepCommon in childhood: sleep walking, Common in childhood: sleep walking,

night terrors, nightmares, teeth night terrors, nightmares, teeth grinding, talking or shoutinggrinding, talking or shouting

Adults: REM Behavior Disorder in Adults: REM Behavior Disorder in elderlyelderly

Distinguish from seizuresDistinguish from seizuresSleeping pills can worsen sleep Sleeping pills can worsen sleep

walkingwalking

Circadian Rhythm DisordersCircadian Rhythm Disorders

The body’s natural clock is not in The body’s natural clock is not in harmony with the light dark cycle or harmony with the light dark cycle or with sleep/wake social cycleswith sleep/wake social cycles

External disorders: shift work, jet lagExternal disorders: shift work, jet lag Internal disorders: Delayed Sleep Internal disorders: Delayed Sleep

Phase Disorder, Advanced Sleep Phase Disorder, Advanced Sleep Phase Disorder, Irregular Sleep Phase Disorder, Irregular Sleep Phases (Alzheimer’s, Liver Cirrhosis)Phases (Alzheimer’s, Liver Cirrhosis)

Restless Legs Syndrome Restless Legs Syndrome (RLS)(RLS)

Urge to move legs, discomfort at rest, Urge to move legs, discomfort at rest, worse at night, relieved by movementworse at night, relieved by movement

Severity: mild to incapacitating Severity: mild to incapacitating Affects 5-10% of population, women moreAffects 5-10% of population, women moreFamilial, often begins in childhoodFamilial, often begins in childhoodStill not well known by patients or doctorsStill not well known by patients or doctorsCommon, easily diagnosed, and treatableCommon, easily diagnosed, and treatableRestless Legs Syndrome Foundation Restless Legs Syndrome Foundation

Restless Legs SyndromeRestless Legs Syndrome

Neurological Neurological movement disordermovement disorder of of unknown cause, lead to severe unknown cause, lead to severe insomniainsomnia

Primary or Familial Type, Secondary TypePrimary or Familial Type, Secondary TypeCommon: 10% of population, 3% severeCommon: 10% of population, 3% severeDisruptive of social activities and sleepDisruptive of social activities and sleepCan lead to social withdrawal and Can lead to social withdrawal and

daytime fatigue and sleepinessdaytime fatigue and sleepinessRLS occurs while awake, but can lead to RLS occurs while awake, but can lead to

waking at night, restlessness, waking at night, restlessness, nightwalkernightwalker

Restless Legs SyndromeRestless Legs Syndrome

Do you have RLS: see questions from Do you have RLS: see questions from RLS Foundation brochureRLS Foundation brochure

Irresistible urge to move legsIrresistible urge to move legsLeg discomfort occurs at rest or Leg discomfort occurs at rest or

inactivityinactivityLeg discomfort gets better with Leg discomfort gets better with

movementmovementWorse in the evening, rare in the Worse in the evening, rare in the

morningmorning

Confused with RLSConfused with RLS

Leg Cramps, Fibromyalgia, Low potassiumLeg Cramps, Fibromyalgia, Low potassiumAnxiety, Stress, Akathisia (Drug effect)Anxiety, Stress, Akathisia (Drug effect)Arthritis, Vasculitis, Varicose VeinsArthritis, Vasculitis, Varicose VeinsPinched nerves, NeuropathyPinched nerves, NeuropathyBlocked arteries (claudication)Blocked arteries (claudication)Positional discomfort, excess exercisePositional discomfort, excess exerciseLeg pains from statins (cholesterol drugs)Leg pains from statins (cholesterol drugs)

RLS and PLMDRLS and PLMD

Periodic Leg Movement Disorder, PLMDPeriodic Leg Movement Disorder, PLMD Involuntary leg movements while Involuntary leg movements while asleepasleepRLS occurs while RLS occurs while awakeawake, but 80% PLMD, but 80% PLMDBoth PLMD and RLS can disrupt sleepBoth PLMD and RLS can disrupt sleepLeg movements are common during sleepLeg movements are common during sleepNeed sleep study to diagnose PLMD but Need sleep study to diagnose PLMD but

not RLSnot RLSSame treatment for PLMD and RLSSame treatment for PLMD and RLS

RLS / PLMD : AssociationsRLS / PLMD : Associations

Iron deficiency, Pregnancy: 25%Iron deficiency, Pregnancy: 25% ? Other deficiency: B12, Folate, Magnesium? Other deficiency: B12, Folate, Magnesium Chronic Renal Failure on Dialysis, Chronic Renal Failure on Dialysis,

VaricositiesVaricosities Rheumatoid Arthritis, FibromyalgiaRheumatoid Arthritis, Fibromyalgia Diabetes, Peripheral Neuropathy, Spinal Diabetes, Peripheral Neuropathy, Spinal

StenosisStenosis COPD, Chronic Lung Disease, Sleep ApneaCOPD, Chronic Lung Disease, Sleep Apnea ADHD: Attention Deficit Hyperactivity ADHD: Attention Deficit Hyperactivity

Disorder, especially in childrenDisorder, especially in children

RLS / PLMD: DrugsRLS / PLMD: Drugs

Many common drugs can worsen RLS/PLMD: Many common drugs can worsen RLS/PLMD: caffeine, alcohol, smokingcaffeine, alcohol, smoking

Medicines antihistamines, antidepressants, Medicines antihistamines, antidepressants, calcium channel blockers, anti-nausea, calcium channel blockers, anti-nausea, strong tranquilizersstrong tranquilizers

Antihistamines: Benadryl, sleep aidAntihistamines: Benadryl, sleep aid Big exception among antidepressants: Big exception among antidepressants:

Wellbutrin or bupropion does not worsen RLSWellbutrin or bupropion does not worsen RLS Problem with surgery: metoclopramide Problem with surgery: metoclopramide

(Reglan), promethazine (Phenergan), (Reglan), promethazine (Phenergan), restrictionrestriction

Drugs That Worsen RLSDrugs That Worsen RLS

Antihistamines: Benadryl, AntivertAntihistamines: Benadryl, AntivertAntidepressants: amitriptyline (Elavil), Antidepressants: amitriptyline (Elavil),

fluoxetine (Prozac), Paxil, Zoloft, fluoxetine (Prozac), Paxil, Zoloft, CelexaCelexa

Major Tranquilizers: haldol, ZyprexaMajor Tranquilizers: haldol, ZyprexaAnti-nausea: Reglan (metoclopramide)Anti-nausea: Reglan (metoclopramide)Calcium Channel Blockers: Procardia, Calcium Channel Blockers: Procardia,

Cardizem, VerapamilCardizem, Verapamil

RLS: General TreatmentRLS: General Treatment

Mild, majority of patients, usually daily Mild, majority of patients, usually daily drugs not necessary, join support groupdrugs not necessary, join support group

Intermittent therapy for stressful Intermittent therapy for stressful situations: surgery, long duration of situations: surgery, long duration of travel or public eventstravel or public events

Always replace low iron (ferritin) in: Always replace low iron (ferritin) in: pregnancy, blood loss, donationspregnancy, blood loss, donations

Good sleep hygiene, stretch, massage, Good sleep hygiene, stretch, massage, exercise, cold/hot, move legs, standexercise, cold/hot, move legs, stand

Good Sleep Hygiene: BasicsGood Sleep Hygiene: Basics

Regular times for sleeping and awakeningRegular times for sleeping and awakening Maintain bedroom dark, quiet, coolMaintain bedroom dark, quiet, cool Use bed only for sleep and sexUse bed only for sleep and sex Avoid late daytime naps, bedtime routineAvoid late daytime naps, bedtime routine Avoid at night: alcohol, caffeine, nicotineAvoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every nightSleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bed nightAvoid stressful situations at bed night Test: spontaneous bedtime and rise timeTest: spontaneous bedtime and rise time

RLS / PLMD: Worsening RLS / PLMD: Worsening SymptomsSymptoms

Look for excess caffeine or alcoholLook for excess caffeine or alcoholNew medications that aggravate New medications that aggravate

conditionconditionDrug withdrawals: anticonvulsants, Drug withdrawals: anticonvulsants,

sedatives, narcotics sedatives, narcotics Sleep Apnea, fatigue, other new Sleep Apnea, fatigue, other new

diseasesdiseasesSubtle low iron (ferritin): GI blood loss Subtle low iron (ferritin): GI blood loss

(cancer or ulcer), blood donation(cancer or ulcer), blood donation

RLS / PLMD: Drug TreatmentRLS / PLMD: Drug Treatment

Moderate to Severe: frequent symptoms, Moderate to Severe: frequent symptoms, disabling, interfere with sleep, social eventsdisabling, interfere with sleep, social events

Drug Class: dopaminergic: new, modern, Drug Class: dopaminergic: new, modern, preferred, highly effective, Sinemet not usedpreferred, highly effective, Sinemet not used

Include: Requip and Mirapex, expensiveInclude: Requip and Mirapex, expensive Side effects: nausea, dizziness, sleepiness, Side effects: nausea, dizziness, sleepiness,

rarely: impulsive behavior, more with high rarely: impulsive behavior, more with high dosesdoses

Begin low and titrate up slowly, take 1-2 Begin low and titrate up slowly, take 1-2 hours before bedtimehours before bedtime

RLS / PLMD: Other MedicinesRLS / PLMD: Other Medicines

Sedatives / Hypnotics: especially useful at Sedatives / Hypnotics: especially useful at night: lorazepam (Ativan), temazepam night: lorazepam (Ativan), temazepam (Restoril), zolpidem (Ambien), Lunesta(Restoril), zolpidem (Ambien), Lunesta

Klonopin and Valium often last too longKlonopin and Valium often last too long Ambien and Sonata often last too shortAmbien and Sonata often last too short Anticonvulsants: effective especially if pain Anticonvulsants: effective especially if pain

or neuropathy involved: gabapentin or neuropathy involved: gabapentin (Neurontin), Lyrica (Fibromyalgia)(Neurontin), Lyrica (Fibromyalgia)

Narcotics: low potency: Darvon, Codeine, Narcotics: low potency: Darvon, Codeine, Ultram high potency: Percocet, Vicodin, Ultram high potency: Percocet, Vicodin, MethadoneMethadone

Complications of TherapyComplications of Therapy

Drug side effects: new Drug side effects: new (dopaminergic) such as Mirapex & (dopaminergic) such as Mirapex & Requip: Requip:

Nausea and vomiting Nausea and vomiting Dizziness, sleepiness Dizziness, sleepiness Sleep walking Sleep walking Impulsive behavior (gambling, sex)Impulsive behavior (gambling, sex)Begin at low dose, slowly titrate upBegin at low dose, slowly titrate up

Complications of Therapy:Complications of Therapy:Side Effect of MedicationsSide Effect of Medications

Benzodiazepines: temazepam (Restoril), Benzodiazepines: temazepam (Restoril), lorazepam (Ativan), clonazepam lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium)(Klonopin), diazepam (Valium)

Sedation, falls, dizziness, addictionSedation, falls, dizziness, addiction Narcotics: codeine, propoxyphene Narcotics: codeine, propoxyphene

(Darvon), tramadol (Ultracette), morphine, (Darvon), tramadol (Ultracette), morphine, oxycodone, methadoneoxycodone, methadone

Sedation, falls, dizziness, addiction, Sedation, falls, dizziness, addiction, hypoxemia, sleep apnea (central, hypoxemia, sleep apnea (central, obstructive), constipation, urination obstructive), constipation, urination difficulty, nauseadifficulty, nausea

Complications of Therapy:Complications of Therapy:Side Effect of MedicationsSide Effect of Medications

Anticonvulsants: gabapentin Anticonvulsants: gabapentin (Neurontin), pregabalin (Lyrica)(Neurontin), pregabalin (Lyrica)

Dizziness, confusion, blurred vision, Dizziness, confusion, blurred vision, dry mouth, constipation, allergic dry mouth, constipation, allergic reactionsreactions

Lyrica only drug also indicated for Lyrica only drug also indicated for fibromyalgiafibromyalgia

Problems with TherapyProblems with Therapy

ToleranceTolerance to drugs: symptoms gradually to drugs: symptoms gradually less well controlled: can increase or less well controlled: can increase or change drug or add a second medchange drug or add a second med

ReboundRebound: symptoms return when drug : symptoms return when drug wears off, usually in morning: change or wears off, usually in morning: change or increase drugincrease drug

AugmentationAugmentation: daily Sinemet main : daily Sinemet main culprit, symptoms increase in distribution, culprit, symptoms increase in distribution, time, and intensity: change drug, add 2time, and intensity: change drug, add 2ndnd drugdrug

Classification of RLSClassification of RLS

Mild / Intermittent:Mild / Intermittent: Symptoms less Symptoms less than 3/week, little insomnia or social than 3/week, little insomnia or social problem; treat as necessary: problem; treat as necessary: Sinemet, Sleeping Pill, Mirapex, Sinemet, Sleeping Pill, Mirapex, Requip, GabapentinRequip, Gabapentin

Moderate:Moderate: Symptoms 3/week to Symptoms 3/week to every night, insomnia or social every night, insomnia or social concern, treat daily one drug: concern, treat daily one drug: Mirapex, Requip, if cannot afford: Mirapex, Requip, if cannot afford: generic sedative/hypnotic or narcoticgeneric sedative/hypnotic or narcotic

Classification of RLSClassification of RLS

Severe:Severe: Symptoms cause marked nightly Symptoms cause marked nightly insomnia, daily fatigue, not only legs but insomnia, daily fatigue, not only legs but arms, back or stomach can be involved, arms, back or stomach can be involved, symptoms occur in afternoon or morning; use symptoms occur in afternoon or morning; use one drug: one or 2 doses, use 2 drugsone drug: one or 2 doses, use 2 drugs

Intractable: Intractable: Not responsive to either Requip Not responsive to either Requip or Mirapex alone: need 2 higher dosages, add or Mirapex alone: need 2 higher dosages, add 22ndnd drug: sedative/hypnotic, narcotic, drug: sedative/hypnotic, narcotic, anticonvulsantanticonvulsant

Intractable & Augmentation: Intractable & Augmentation: 2 drugs 2 drugs including long acting narcotic (pill, patch, including long acting narcotic (pill, patch, sublingual, pump); always replace iron if lowsublingual, pump); always replace iron if low

Primary vs Secondary RLSPrimary vs Secondary RLS

Primary or Familial begins before age 30Primary or Familial begins before age 30Secondary mainly associated with Secondary mainly associated with

pregnancy, renal failure, iron deficiency pregnancy, renal failure, iron deficiency and resolves with these conditionsand resolves with these conditions

Iron replacement is a very slow process Iron replacement is a very slow process and relief may take monthsand relief may take months

Secondary RLS may be associated with Secondary RLS may be associated with peripheral neuropathy and have more peripheral neuropathy and have more pain; gabapentin or Lyrica most usefulpain; gabapentin or Lyrica most useful

Anxiety and DepressionAnxiety and Depression

Anxiety: difficulty going to sleep, worriesAnxiety: difficulty going to sleep, worries Depression: difficulty going or staying Depression: difficulty going or staying

asleep, or waking up early; hopeless, asleep, or waking up early; hopeless, helpless, no fun, sad helpless, no fun, sad

Depression: before or after RLS; problem Depression: before or after RLS; problem recognizing, admitting to illnessrecognizing, admitting to illness

Drugs are effective in treating bothDrugs are effective in treating both Treat chronic insomnia: behavioral therapyTreat chronic insomnia: behavioral therapy Beware: anti-anxiety drugs & sleepiness; Beware: anti-anxiety drugs & sleepiness;

anti-depressants & insomniaanti-depressants & insomnia

Sleep Study: PolysomngramSleep Study: Polysomngram Not usually required to diagnose RLS Not usually required to diagnose RLS Not usually required for many circadian Not usually required for many circadian

rhythm disorders: advanced or delayed rhythm disorders: advanced or delayed sleep phasessleep phases

Required to diagnose sleep apnea, PLMD, Required to diagnose sleep apnea, PLMD, and many parasomniasand many parasomnias

Sleep studies require considerable skill and Sleep studies require considerable skill and expertise expertise

Assurance if technicians registered by the Assurance if technicians registered by the AAST, physician who interprets study is AAST, physician who interprets study is board certified in sleep medicine, and board certified in sleep medicine, and overall the sleep center is accredited by the overall the sleep center is accredited by the AASMAASM

RLS / PLMD: SummaryRLS / PLMD: Summary

Restless Legs Syndrome is diagnosed by Restless Legs Syndrome is diagnosed by historyhistory: exclude leg cramps, normal : exclude leg cramps, normal examexam

Periodic Leg Movement Disorder is Periodic Leg Movement Disorder is diagnosed by a diagnosed by a sleep studysleep study

Common, easily diagnosed, and Common, easily diagnosed, and treatabletreatable

Symptoms: usually mild but can be Symptoms: usually mild but can be incapacitating and very severeincapacitating and very severe

Once not known but news is spreadingOnce not known but news is spreading

WebsitesWebsites

Restless Legs Syndrome Foundation: Restless Legs Syndrome Foundation: www.rls.orgwww.rls.org

The Movement Disorder Society: The Movement Disorder Society: www.wemove.orgwww.wemove.org

National Sleep Foundation: National Sleep Foundation: www.sleepfoundation.orgwww.sleepfoundation.org

American Academy of Sleep Medicine: American Academy of Sleep Medicine: sleepeducation.comsleepeducation.com

Village Sleep Lab www.villagesleeplab.com Village Sleep Lab www.villagesleeplab.com (Dr. Albino, coming in late February, 2007)(Dr. Albino, coming in late February, 2007)

RLS: BooksRLS: Books

Restless LegsRestless Legs SyndromeSyndrome by Robert H. Yoakum (Founder RLS by Robert H. Yoakum (Founder RLS Foundation)Foundation)

Restless Legs Syndrome: Coping with Your Restless Legs Syndrome: Coping with Your Sleepless Nights (American Academy of Sleepless Nights (American Academy of Neurology) Neurology) by Mark J. Buchfuhrer, et. al.by Mark J. Buchfuhrer, et. al.

Restless Legs Syndrome: The RLS Rebel’s Restless Legs Syndrome: The RLS Rebel’s Survival Guide Survival Guide by Jill Gunzelby Jill Gunzel

Sleep Thief: Restless Legs Syndrome Sleep Thief: Restless Legs Syndrome

by Virginia N. Wilsonby Virginia N. Wilson