1. Restless Legs Syndrome Juan A. Albino, MD, FCCP Board Certified in Sleep Medicine Village Sleep Lab (VSL) 751-4955 Accredited by the AASM, 1/08 Accredited by the AASM, 1/08

2. Thank You !!! George Hess, Coordinator George Hess, Coordinator Central Florida RLS Support Group, Central Florida RLS Support Group, Heather Ellington, Office Manager, VSL Heather Ellington, Office Manager, VSL John Crawford, Technical Director, VSL John Crawford, Technical Director, VSL Thomas Chaput, Sleep Technologist, VSL Thomas Chaput, Sleep Technologist, VSL Miyoshi Scott, Nurse, VSL Miyoshi Scott, Nurse, VSL Dallas Douma, Receptionist, VSL Dallas Douma, Receptionist, VSL

3. Common Sleep Disorders Insomnia: wants to sleep but cannot Insomnia: wants to sleep but cannot Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep Deprivation: does not want to sleep but can; problem of sleep quantity Sleep Apnea: sleepy during day, snores (throat obstruction) problem of sleep quality Sleep Apnea: sleepy during day, snores (throat obstruction) problem of sleep quality RESTLESS LEGS SYNDROME: leg discomfort, relieved by movement, symptoms day and night RESTLESS LEGS SYNDROME: leg discomfort, relieved by movement, symptoms day and night Parasomnias (abnormal sleep behaviors) Parasomnias (abnormal sleep behaviors) Circadian Rhythm Disorders (Shift Work) Circadian Rhythm Disorders (Shift Work)

4. Insomnia: Acute or Chronic Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Insomnia: inability to get to sleep, stay asleep, wakes up early, with daytime impairment Acute Insomnia (<4 weeks): stress, illness Acute Insomnia (<4 weeks): stress, illness Sleep medicines work well in acute stage Sleep medicines work well in acute stage Chronic Insomnia: >4 weeks, often years Chronic Insomnia: >4 weeks, often years Treat basic problem: >60% psychological Treat basic problem: >60% psychological Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychotherapy and behavioral therapy better than medicines, not easy to treat Psychologists, Psychiatrists, PCP Psychologists, Psychiatrists, PCP

5. Sleep Deprivation Disasters: Exxon Valdez, Challenger Space Shuttle, Chernoble Nuclear Plant, Commuter plane crash in Kentucky Disasters: Exxon Valdez, Challenger Space Shuttle, Chernoble Nuclear Plant, Commuter plane crash in Kentucky 33% of fatal truck accidents 33% of fatal truck accidents 10% of fatal car accidents 10% of fatal car accidents Impairment the same whether: drunk, sleep deprived (<4-6hrs.), sleep apnea Impairment the same whether: drunk, sleep deprived (<4-6hrs.), sleep apnea Must be taken seriously: sleep 8 hours Must be taken seriously: sleep 8 hours Leads to obesity and diabetes Leads to obesity and diabetes

6. What is OSA? Cessation of airflow with ongoing respiratory effort NORMALSNORINGSLEEP APNEA Obstructive Sleep Apnea

7. Sleep Apnea: Consequences During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During night: snoring, snorting, gasping, difficult or stops breathing, wife worries During day: sleepy, tired, depressed, irritable, impotent, forgets, sometimes few complaints During day: sleepy, tired, depressed, irritable, impotent, forgets, sometimes few complaints More accidents: work, home, motor vehicle More accidents: work, home, motor vehicle Higher death rates with severe sleep apnea Higher death rates with severe sleep apnea Hypertension, Congestive Heart Failure Hypertension, Congestive Heart Failure Heart Attacks, Strokes, Atrial Fibrillation Heart Attacks, Strokes, Atrial Fibrillation Promotes Obesity and Diabetes Promotes Obesity and Diabetes Problems: at night, during day, risk factor Problems: at night, during day, risk factor

8. Treatment -CPAP treatment –Positive pressure keeps airway open –100% effective CPAP therapy Treatment Options: CPAP

9. Parasomnias Abnormal behaviors while asleep Abnormal behaviors while asleep Common in childhood: sleep walking, night terrors, nightmares, teeth grinding, talking or shouting Common in childhood: sleep walking, night terrors, nightmares, teeth grinding, talking or shouting Adults: REM Behavior Disorder in elderly Adults: REM Behavior Disorder in elderly Distinguish from seizures Distinguish from seizures Sleeping pills can worsen sleep walking Sleeping pills can worsen sleep walking

10. Circadian Rhythm Disorders The body’s natural clock is not in harmony with the light dark cycle or with sleep/wake social cycles The body’s natural clock is not in harmony with the light dark cycle or with sleep/wake social cycles External disorders: shift work, jet lag External disorders: shift work, jet lag Internal disorders: Delayed Sleep Phase Disorder, Advanced Sleep Phase Disorder, Irregular Sleep Phases (Alzheimer’s, Liver Cirrhosis) Internal disorders: Delayed Sleep Phase Disorder, Advanced Sleep Phase Disorder, Irregular Sleep Phases (Alzheimer’s, Liver Cirrhosis)

11. Restless Legs Syndrome (RLS) Urge to move legs, discomfort at rest, worse at night, relieved by movement Urge to move legs, discomfort at rest, worse at night, relieved by movement Severity: mild to incapacitating Severity: mild to incapacitating Affects 5-10% of population, women more Affects 5-10% of population, women more Familial, often begins in childhood Familial, often begins in childhood Still not well known by patients or doctors Still not well known by patients or doctors Common, easily diagnosed, and treatable Common, easily diagnosed, and treatable Restless Legs Syndrome Foundation Restless Legs Syndrome Foundation

12. Restless Legs Syndrome Neurological movement disorder of unknown cause, lead to severe insomnia Neurological movement disorder of unknown cause, lead to severe insomnia Primary or Familial Type, Secondary Type Primary or Familial Type, Secondary Type Common: 10% of population, 3% severe Common: 10% of population, 3% severe Disruptive of social activities and sleep Disruptive of social activities and sleep Can lead to social withdrawal and daytime fatigue and sleepiness Can lead to social withdrawal and daytime fatigue and sleepiness RLS occurs while awake, but can lead to waking at night, restlessness, nightwalker RLS occurs while awake, but can lead to waking at night, restlessness, nightwalker

13. Restless Legs Syndrome Do you have RLS: see questions from RLS Foundation brochure Do you have RLS: see questions from RLS Foundation brochure Irresistible urge to move legs Irresistible urge to move legs Leg discomfort occurs at rest or inactivity Leg discomfort occurs at rest or inactivity Leg discomfort gets better with movement Leg discomfort gets better with movement Worse in the evening, rare in the morning Worse in the evening, rare in the morning

14. Confused with RLS Leg Cramps, Fibromyalgia, Low potassium Leg Cramps, Fibromyalgia, Low potassium Anxiety, Stress, Akathisia (Drug effect) Anxiety, Stress, Akathisia (Drug effect) Arthritis, Vasculitis, Varicose Veins Arthritis, Vasculitis, Varicose Veins Pinched nerves, Neuropathy Pinched nerves, Neuropathy Blocked arteries (claudication) Blocked arteries (claudication) Positional discomfort, excess exercise Positional discomfort, excess exercise Leg pains from statins (cholesterol drugs) Leg pains from statins (cholesterol drugs)

15. RLS and PLMD Periodic Leg Movement Disorder, PLMD Periodic Leg Movement Disorder, PLMD Involuntary leg movements while asleep Involuntary leg movements while asleep RLS occurs while awake, but 80% PLMD RLS occurs while awake, but 80% PLMD Both PLMD and RLS can disrupt sleep Both PLMD and RLS can disrupt sleep Leg movements are common during sleep Leg movements are common during sleep Need sleep study to diagnose PLMD but not RLS Need sleep study to diagnose PLMD but not RLS Same treatment for PLMD and RLS Same treatment for PLMD and RLS

16. RLS / 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, Varicosities Chronic Renal Failure on Dialysis, Varicosities Rheumatoid Arthritis, Fibromyalgia Rheumatoid Arthritis, Fibromyalgia Diabetes, Peripheral Neuropathy, Spinal Stenosis Diabetes, Peripheral Neuropathy, Spinal Stenosis COPD, Chronic Lung Disease, Sleep Apnea COPD, Chronic Lung Disease, Sleep Apnea ADHD: Attention Deficit Hyperactivity Disorder, especially in children ADHD: Attention Deficit Hyperactivity Disorder, especially in children

17. RLS / PLMD: Drugs Many common drugs can worsen RLS/PLMD: caffeine, alcohol, smoking Many common drugs can worsen RLS/PLMD: caffeine, alcohol, smoking Medicines antihistamines, antidepressants, calcium channel blockers, anti-nausea, strong tranquilizers Medicines antihistamines, antidepressants, calcium channel blockers, anti-nausea, strong tranquilizers Antihistamines: Benadryl, sleep aid Antihistamines: Benadryl, sleep aid Big exception among antidepressants: Wellbutrin or bupropion does not worsen RLS Big exception among antidepressants: Wellbutrin or bupropion does not worsen RLS Problem with surgery: metoclopramide (Reglan), promethazine (Phenergan), restriction Problem with surgery: metoclopramide (Reglan), promethazine (Phenergan), restriction

18. Drugs That Worsen RLS Antihistamines: Benadryl, Antivert Antihistamines: Benadryl, Antivert Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac), Paxil, Zoloft, Celexa Antidepressants: amitriptyline (Elavil), fluoxetine (Prozac), Paxil, Zoloft, Celexa Major Tranquilizers: haldol, Zyprexa Major Tranquilizers: haldol, Zyprexa Anti-nausea: Reglan (metoclopramide) Anti-nausea: Reglan (metoclopramide) Calcium Channel Blockers: Procardia, Cardizem, Verapamil Calcium Channel Blockers: Procardia, Cardizem, Verapamil

19. RLS: General Treatment Mild, majority of patients, usually daily drugs not necessary, join support group Mild, majority of patients, usually daily drugs not necessary, join support group Intermittent therapy for stressful situations: surgery, long duration of travel or public events Intermittent therapy for stressful situations: surgery, long duration of travel or public events Always replace low iron (ferritin) in: pregnancy, blood loss, donations Always replace low iron (ferritin) in: pregnancy, blood loss, donations Good sleep hygiene, stretch, massage, exercise, cold/hot, move legs, stand Good sleep hygiene, stretch, massage, exercise, cold/hot, move legs, stand

20. Good Sleep Hygiene: Basics Regular times for sleeping and awakening Regular times for sleeping and awakening Maintain bedroom dark, quiet, cool Maintain bedroom dark, quiet, cool Use bed only for sleep and sex Use bed only for sleep and sex Avoid late daytime naps, bedtime routine Avoid late daytime naps, bedtime routine Avoid at night: alcohol, caffeine, nicotine Avoid at night: alcohol, caffeine, nicotine Sleep around 7 to 8 hours every night Sleep around 7 to 8 hours every night Prudent exercise and eating Prudent exercise and eating Avoid stressful situations at bed night Avoid stressful situations at bed night Test: spontaneous bedtime and rise time Test: spontaneous bedtime and rise time

21. RLS / PLMD: Worsening Symptoms Look for excess caffeine or alcohol Look for excess caffeine or alcohol New medications that aggravate condition New medications that aggravate condition Drug withdrawals: anticonvulsants, sedatives, narcotics Drug withdrawals: anticonvulsants, sedatives, narcotics Sleep Apnea, fatigue, other new diseases Sleep Apnea, fatigue, other new diseases Subtle low iron (ferritin): GI blood loss (cancer or ulcer), blood donation Subtle low iron (ferritin): GI blood loss (cancer or ulcer), blood donation

22. RLS / PLMD: Drug Treatment Moderate to Severe: frequent symptoms, disabling, interfere with sleep, social events Moderate to Severe: frequent symptoms, disabling, interfere with sleep, social events Drug Class: dopaminergic: new, modern, preferred, highly effective, Sinemet not used Drug Class: dopaminergic: new, modern, preferred, highly effective, Sinemet not used Include: Requip and Mirapex, expensive Include: Requip and Mirapex, expensive Side effects: nausea, dizziness, sleepiness, rarely: impulsive behavior, more with high doses Side effects: nausea, dizziness, sleepiness, rarely: impulsive behavior, more with high doses Begin low and titrate up slowly, take 1-2 hours before bedtime Begin low and titrate up slowly, take 1-2 hours before bedtime

23. RLS / PLMD: Other Medicines Sedatives / Hypnotics: especially useful at night: lorazepam (Ativan), temazepam (Restoril), zolpidem (Ambien), Lunesta Sedatives / Hypnotics: especially useful at night: lorazepam (Ativan), temazepam (Restoril), zolpidem (Ambien), Lunesta Klonopin and Valium often last too long Klonopin and Valium often last too long Ambien and Sonata often last too short Ambien and Sonata often last too short Anticonvulsants: effective especially if pain or neuropathy involved: gabapentin (Neurontin), Lyrica (Fibromyalgia) Anticonvulsants: effective especially if pain or neuropathy involved: gabapentin (Neurontin), Lyrica (Fibromyalgia) Narcotics: low potency: Darvon, Codeine, Ultram high potency: Percocet, Vicodin, Methadone Narcotics: low potency: Darvon, Codeine, Ultram high potency: Percocet, Vicodin, Methadone

24. Complications of Therapy Drug side effects: new (dopaminergic) such as Mirapex & Requip: Drug side effects: new (dopaminergic) such as Mirapex & 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 up Begin at low dose, slowly titrate up

25. Complications of Therapy: Side Effect of Medications Benzodiazepines: temazepam (Restoril), lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium) Benzodiazepines: temazepam (Restoril), lorazepam (Ativan), clonazepam (Klonopin), diazepam (Valium) Sedation, falls, dizziness, addiction Sedation, falls, dizziness, addiction Narcotics: codeine, propoxyphene (Darvon), tramadol (Ultracette), morphine, oxycodone, methadone Narcotics: codeine, propoxyphene (Darvon), tramadol (Ultracette), morphine, oxycodone, methadone Sedation, falls, dizziness, addiction, hypoxemia, sleep apnea (central, obstructive), constipation, urination difficulty, nausea Sedation, falls, dizziness, addiction, hypoxemia, sleep apnea (central, obstructive), constipation, urination difficulty, nausea

26. Complications of Therapy: Side Effect of Medications Anticonvulsants: gabapentin (Neurontin), pregabalin (Lyrica) Anticonvulsants: gabapentin (Neurontin), pregabalin (Lyrica) Dizziness, confusion, blurred vision, dry mouth, constipation, allergic reactions Dizziness, confusion, blurred vision, dry mouth, constipation, allergic reactions Lyrica only drug also indicated for fibromyalgia Lyrica only drug also indicated for fibromyalgia

27. Problems with Therapy Tolerance to drugs: symptoms gradually less well controlled: can increase or change drug or add a second med Tolerance to drugs: symptoms gradually less well controlled: can increase or change drug or add a second med Rebound: symptoms return when drug wears off, usually in morning: change or increase drug Rebound: symptoms return when drug wears off, usually in morning: change or increase drug Augmentation: daily Sinemet main culprit, symptoms increase in distribution, time, and intensity: change drug, add 2 nd drug Augmentation: daily Sinemet main culprit, symptoms increase in distribution, time, and intensity: change drug, add 2 nd drug

28. Classification of RLS Mild / Intermittent: Symptoms less than 3/week, little insomnia or social problem; treat as necessary: Sinemet, Sleeping Pill, Mirapex, Requip, Gabapentin Mild / Intermittent: Symptoms less than 3/week, little insomnia or social problem; treat as necessary: Sinemet, Sleeping Pill, Mirapex, Requip, Gabapentin Moderate: Symptoms 3/week to every night, insomnia or social concern, treat daily one drug: Mirapex, Requip, if cannot afford: generic sedative/hypnotic or narcotic Moderate: Symptoms 3/week to every night, insomnia or social concern, treat daily one drug: Mirapex, Requip, if cannot afford: generic sedative/hypnotic or narcotic

29. Classification of RLS Severe: Symptoms cause marked nightly insomnia, daily fatigue, not only legs but arms, back or stomach can be involved, symptoms occur in afternoon or morning; use one drug: one or 2 doses, use 2 drugs Severe: Symptoms cause marked nightly insomnia, daily fatigue, not only legs but arms, back or stomach can be involved, symptoms occur in afternoon or morning; use one drug: one or 2 doses, use 2 drugs Intractable: Not responsive to either Requip or Mirapex alone: need 2 higher dosages, add 2 nd drug: sedative/hypnotic, narcotic, anticonvulsant Intractable: Not responsive to either Requip or Mirapex alone: need 2 higher dosages, add 2 nd drug: sedative/hypnotic, narcotic, anticonvulsant Intractable & Augmentation: 2 drugs including long acting narcotic (pill, patch, sublingual, pump); always replace iron if low Intractable & Augmentation: 2 drugs including long acting narcotic (pill, patch, sublingual, pump); always replace iron if low

30. Primary vs Secondary RLS Primary or Familial begins before age 30 Primary or Familial begins before age 30 Secondary mainly associated with pregnancy, renal failure, iron deficiency and resolves with these conditions Secondary mainly associated with pregnancy, renal failure, iron deficiency and resolves with these conditions Iron replacement is a very slow process and relief may take months Iron replacement is a very slow process and relief may take months Secondary RLS may be associated with peripheral neuropathy and have more pain; gabapentin or Lyrica most useful Secondary RLS may be associated with peripheral neuropathy and have more pain; gabapentin or Lyrica most useful

31. Anxiety and Depression Anxiety: difficulty going to sleep, worries Anxiety: difficulty going to sleep, worries Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun, sad Depression: difficulty going or staying asleep, or waking up early; hopeless, helpless, no fun, sad Depression: before or after RLS; problem recognizing, admitting to illness Depression: before or after RLS; problem recognizing, admitting to illness Drugs are effective in treating both Drugs are effective in treating both Treat chronic insomnia: behavioral therapy Treat chronic insomnia: behavioral therapy Beware: anti-anxiety drugs & sleepiness; anti- depressants & insomnia Beware: anti-anxiety drugs & sleepiness; anti- depressants & insomnia

32. Sleep Study: Polysomngram Not usually required to diagnose RLS Not usually required to diagnose RLS Not usually required for many circadian rhythm disorders: advanced or delayed sleep phases Not usually required for many circadian rhythm disorders: advanced or delayed sleep phases Required to diagnose sleep apnea, PLMD, and many parasomnias Required to diagnose sleep apnea, PLMD, and many parasomnias Sleep studies require considerable skill and expertise Sleep studies require considerable skill and expertise Assurance if technicians registered by the AAST, physician who interprets study is board certified in sleep medicine, and overall the sleep center is accredited by the AASM Assurance if technicians registered by the AAST, physician who interprets study is board certified in sleep medicine, and overall the sleep center is accredited by the AASM

33. RLS / PLMD: Summary RLS / PLMD: Summary Restless Legs Syndrome is diagnosed by history: exclude leg cramps, normal exam Restless Legs Syndrome is diagnosed by history: exclude leg cramps, normal exam Periodic Leg Movement Disorder is diagnosed by a sleep study Periodic Leg Movement Disorder is diagnosed by a sleep study Common, easily diagnosed, and treatable Common, easily diagnosed, and treatable Symptoms: usually mild but can be incapacitating and very severe Symptoms: usually mild but can be incapacitating and very severe Once not known but news is spreading Once not known but news is spreading

34. Websites Restless Legs Syndrome Foundation: www.rls.org Restless Legs Syndrome Foundation: www.rls.org The Movement Disorder Society: www.wemove.org The Movement Disorder Society: www.wemove.org National Sleep Foundation: www.sleepfoundation.org National Sleep Foundation: www.sleepfoundation.org www.sleepfoundation.org American Academy of Sleep Medicine: sleepeducation.com American Academy of Sleep Medicine: sleepeducation.com Village Sleep Lab www.villagesleeplab.com (Dr. Albino, coming in late February, 2007) Village Sleep Lab www.villagesleeplab.com (Dr. Albino, coming in late February, 2007)

35. RLS: Books Restless Legs Syndrome Restless Legs Syndrome by Robert H. Yoakum (Founder RLS Foundation) Restless Legs Syndrome: Coping with Your Sleepless Nights (American Academy of Neurology) by Mark J. Buchfuhrer, et. al. Restless Legs Syndrome: Coping with Your Sleepless Nights (American Academy of Neurology) by Mark J. Buchfuhrer, et. al. Restless Legs Syndrome: The RLS Rebel’s Survival Guide by Jill Gunzel Restless Legs Syndrome: The RLS Rebel’s Survival Guide by Jill Gunzel Sleep Thief: Restless Legs Syndrome Sleep Thief: Restless Legs Syndrome by Virginia N. Wilson