AcuteCare Telemedicine Blog


RLS in Four Easy Questions

Restless Leg Syndrome (RLS) is an often undiagnosed or misdiagnosed, yet relatively common, sensorimotor disorder, with a prevalence rate of 7.2% in the United States and Western Europe (a prevalence rate as high as 29% has also been reported). The effect of RLS on one’s quality of life can be significant. Furthermore, RLS can be a harbinger of other disease processes and therefore prompt and accurate diagnosis is essential.

Diagnosis of RLS is based on four clinical findings; an often indescribable sensation in the legs (or arms) causing an urge to move, an increase in symptoms with rest, symptom relief with movement, and symptom worsening at night. It is more prevalent in women than men (2:1) and although RLS can be genetic, the etiology in many cases is unknown. Research has suggested that the cause of RLS may be due to the brain’s inability to correctly utilize dopamine and or iron. Although causative effects are not clear, RLS is often seen in patients with chronic disorders such as diabetes mellitus, uremia, autoimmune disorders, thyroid disease and iron deficiency. Thorough laboratory evaluation in adult patients, especially with recent symptom onset should be pursued. In particular, ferritin levels should be checked in all men and post-menopausal women as iron deficiency is present in about 20% of those with RLS. Iron deficiency in this population can be the result of occult bleeding, which can be a sign of an underlying malignancy, such as colon cancer.

In 2005, the Restless Legs Syndrome Prevalence and Impact General Population study was published in the Archives of Internal Medicine. Of the 416 study participants found to have a clinical diagnosis consistent with RLS, 81% had discussed their symptoms with a primary care physician and 74% of these received a diagnosis. However, RLS was actually the second least common diagnosis comprising only 6.2% of all diagnoses. The most common diagnosis was “poor circulation” comprising 18.3% of the diagnoses. Other diagnoses in descending percentages included arthritis, back/spinal injury, varicose veins, depression/anxiety, and nerve entrapment. Although these may have been accurate, “secondary” diagnoses, in approximately 94% of patients, the diagnosis of RLS was not made. Unfortunately, the treatment of most of the above conditions would not effectively alleviate symptoms of RLS and in some cases may exacerbate them. (ie antidepressants).

Given reported prevalence rates, RLS it is not a rare disorder. The potential negative impact upon the lives of those with RLS has been found to be as high as in those with diabetes and clinical depression. Because the symptoms of RLS are more prevalent in the evenings, it can have a significant impact upon sleep onset and sleep maintenance. This in turn can lead to complaints of insomnia, daytime sleepiness and fatigue, cognitive dysfunction and poor daytime performance, all of which tend to lower quality of life. If not diagnosed and treated effectively, the cumulative impact of untreated RLS may lead to an increased economic burden due to work absenteeism and increased health care utilization.

Once RLS is diagnosed, there are several effective treatment options available, including behavior modification, discontinuation of offending agents, and medications such as dopamine agonists, gabapentin enacarbil, and iron supplementation.

To diagnose RLS is quick, easy, and done without the cost of diagnostic studies or procedures. Hopefully, increased healthcare provider and patient awareness will lead to fewer undiagnosed or misdiagnosed cases of RLS. It takes only four easy questions to diagnose a patient with RLS; a seemingly but not so benign disorder.



Insomnia: Limiting the Use of Sedatives and Hypnotics

Insomnia is the most commonly encountered sleep disorder or complaint, with a wide prevalence range reported to be between 10 and 40 percent  (the variance is due to differences in the definition of insomnia). Suffice it to say, millions of individuals are affected by insomnia at some point in their lives. Because of the significant increased rate of comorbidity associated with insomnia, the burden placed on society by way of increased utilization of health care resources, poor work performance, and missed work days, it is essential that insomnia is appropriately and efficiently managed.

Individuals who suffer from insomnia frequently seek help from medical professionals and this help is often provided in the form of a sedative/hypnotic medication. Significant risks are associated with the use of sedatives and hypnotics, such as dependency, falls (particularly in the elderly), and even an increase in cancer and death rates, as shown by a recent study. Prescription medications do have a role in the treatment of some individuals with insomnia, as well as those with conditions and situations that may call for temporary use, such as time zone changes and jet lag. However, these medications are often over prescribed and/or misused due to insufficient patient evaluation.

It is well understood that when evaluating a patient with complaints of insomnia, an underlying medical and or psychiatric disorder should be considered. Ruling out and treating underlying etiologies is requisite. With resolution or control of the causative medical or psychiatric condition, the insomnia will often times abate. When thorough evaluations are performed in the setting of insomnia, sedative use can be potentially limited, if not completely avoided.

Complaints of insomnia may also be indicative of another (primary) sleep disorder such as restless leg syndrome (RLS) and periodic limb movements (PLMs), delayed sleep phase disorder (DSPD), or obstructive sleep apnea (OSA). Sleep onset and maintenance difficulties may be the result of both PLMs and OSA. The inability to fall asleep at the desired sleep time will be seen in individuals with DSPD. Patients with the above conditions will frequently complain of daytime sleepiness, a complaint not usually expressed in individuals with primary insomnia. These sleep disorders can all be treated without the use of sedatives. Furthermore, the use of sedatives in these cases will only serve to mask and possibly exacerbate the primary sleep disorder, leading to increased morbidity and mortality rates.

In the July 2010 issue of SLEEP, a study was published showing that the prevalence of sedative use in the general Canadian population had more than doubled between 1994 and 2003. Interestingly, this increase had occurred moreso in men, non-elderly, and obese individuals. The study concluded that “the greater odds of sedative medication use found among morbidly obese men may reflect the presence of underlying obstructive sleep apnea, which may in turn serve to explain in part the known relationship between sedative medications and mortality.” When patients with untreated sleep apnea are prescribed sedative/hypnotic medications, apneic events typically worsen, setting up for poorer outcomes and placing them in danger of respiratory arrest.

When underlying etiologies of insomnia have been ruled out and sedatives are needed, they should be used sparingly and temporarily. When possible, alternative treatment modalities such as cognitive behavioral therapy should be employed to avoid or limit the use of sedative and hypnotic medications.

 

 

 

 



The Importance of Recognizing Sleep Disordered Breathing in Patients with Cognitive Dysfunction

Awareness of sleep disorders has increased over the past several years, leading more physicians to appreciate that Obstructive Sleep Apnea (OSA) is an independent risk factor for hypertension, cardiovascular disease and stroke. Although seemingly overlooked, studies as far back as 15 years have also suggested that OSA may be a risk factor for cognitive dysfunction.

When patients present to a neurologist with complaints of cognitive dysfunction, most are screened for potentially reversible causes such as vitamin B12 deficiency, hypothyroidism, undiagnosed/untreated syphilis, or normal pressure hydrocephalus. If all laboratory and imaging studies are normal, these patients are often started on acetylcholinesterase inhibitors, in hopes of slowing down the rate of cognitive decline.  Screening for sleep apnea, however, is often times not performed. As a result, the opportunity to treat an otherwise harmful disorder and potentially reverse cognitive impairment is forfeited.

In 2010, an article was published in the New York Times entitled “When Sleep Apnea Masquerades as Dementia.” A case study was reported: “The woman was only in her 60s but complained that she was having trouble concentrating.” She couldn’t follow a television program or stay focused during a conversation. As he evaluated the woman, the physician asked, as he usually does, how she was sleeping. The woman, who lived alone, hadn’t noticed any problems. Her son, however, had stayed with her the previous night to drive her to the appointment. “She was snoring like a freight train,” he reported.  Overnight sleep testing determined that the woman had obstructive sleep apnea – nightlong interruptions in breathing that reduce oxygen flow to the brain and prevent deep sleep. The interruptions are quite common in older adults, exacerbating – or sometimes mimicking – dementia symptoms. Treated with a CPAP (continuous positive airway pressure) machine her scores on neuropsychological tests eventually climbed back into normal range.

Another recent study published in JAMA, also showed that sleep disordered breathing may contribute to the development of dementia. 298 women 65 years or older and without dementia were enrolled in this study, undergoing overnight polysomnography testing. Those who were found to have sleep disordered breathing were more likely to have developed cognitive impairment or dementia on follow up testing. It is thought that hypoxemia resulting from sleep disordered breathing is responsible. Dr Michael J. Thorpy, director of the Sleep-Wake Disorders Center at the Montefiore Medical Center in the Bronx, NY stated “We used to think that impaired sleep caused cognitive impairment, but this shows that nocturnal hypoxemia plays an important role and this suggests that the cognitive impairment might be partially reversible in some cases.

Although further studies are needed, these findings do stress the importance of screening patients with complaints of cognitive dysfunction for sleep apnea.  Because the large majority of people who develop dementia do so after the age of 65, it would seem imperative to screen younger patients with cognitive complaints for sleep disordered breathing.