[Re: Restless legs syndrome and periodic limb movements during sleep in a patient with obstructive sleep apnea].
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Diagnosis, Differential↗
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Restless legs syndrome in end-stage renal disease.
BACKGROUND AND PURPOSE: Patients undergoing dialysis therapy due to end-stage renal disease (ESRD) present a high prevalence of sleep disorders, including restless legs syndrome (RLS). However, the known data generally have been obtained from relatively small patient samples, coming from single or very few dialysis units. Moreover, some data were collected prior to the recent improvements in dialysis techniques, pharmacological therapies and to the establishment of internationally recognised diagnostic criteria for RLS. PATIENTS AND METHODS: In order to study the incidence of the different sleep disorders, and of RLS in particular, in a large population of dialysis patients, a questionnaire was administered to all the patients in dialysis units of the 'Triveneto' area (Italy) who agreed to participate. The first part of the questionnaire included questions about demographic data, general medical history, history of renal disease, dialytic treatment and pharmacological therapy. The second part, which was self-administered, explored the patient's complaints about sleep, the presence of the minimal International Restless Legs Syndrome Study Group (IRLSSG) criteria for the diagnosis of RLS, the Epworth Sleepiness Scale and questions particularly related to somnolence. Patients whose responses indicated a diagnosis of RLS according to the IRLSSG criteria were requested to answer the 10 questions of the IRLSSG Severity Scale. The same group of patients was compared to those who did not fulfil any of the four minimal criteria for RLS. Statistical analysis was performed by using ANOVA and non-parametric tests. Whenever possible, data were compared with the database of the Veneto Dialysis Register. The first 601 consecutive questionnaires that we were able to analyse are presented in this paper. RESULTS: Applying the IRLSSG criteria for the diagnosis, the percentage of RLS patients in our sample was 21.5%, with a score of 20.5+/-8.7 on the IRLSSG Severity Scale. Comparing patients who are definitely affected by RLS (n=127) with unaffected patients (n=280), we found that the two groups did not differ as to age, sex, weight, body mass index (BMI), and intake of nicotine, alcohol and caffeine. Similarly, the two groups did not differ as to the etiology of ESRD, type of dialysis or percentage of previous transplantations; however, the period of dialysis dependence was significantly lower in the group negative for RLS. The use of drugs did not differ in the two groups, except for lower intake of phosphorus binders and antihypertensive drugs among RLS patients. No patient was receiving specific treatment for RLS. RLS patients reported more fragmented, less restful nightly sleep and more daytime somnolence, more often presented symptoms of other sleep disorders and were more affected by anxiety or depression. CONCLUSIONS: The high prevalence of RLS and other sleep disorders among uremics requires careful investigation of nocturnal sleep; although often underdiagnosed, correct identification of these disorders can lead to better therapy and improvement of clinical conditions and quality of life. Sleep fragmentation and sleep deprivation caused by RLS may contribute to the cardiovascular complications and infections, often with bad prognosis in dialysis patients.
Aged↗
Propriospinal myoclonus: a motor phenomenon found in restless legs syndrome different from periodic limb movements during sleep.
Three patients presented with a 25-, 15-, and 5-year history of restless legs syndrome (RLS) and periodic limb movements during sleep (PLMS). For 1, 4, and 5 years, they reported additional involuntary trunk and limbs jerks preceding falling asleep and occasionally during intrasleep wakefulness. Videopolysomnography revealed jerks during relaxed wakefulness arising in axial muscles with a caudal and rostral propagation at a slow conduction velocity, characteristic of propriospinal myoclonus (PSM). Jerk-related EEG-EMG back-averaging did not disclose any preceding cortical potential. During relaxed wakefulness preceding falling asleep and during intrasleep wakefulness, PSM coexisted with motor restlessness and sensory discomfort in the limbs. PSM disappeared when spindles and K-complexes appeared on the EEG. At this time, typical PLMS appeared every 20 to 40 seconds, especially during light sleep stages. PLMS EMG activity was limited to leg, especially tibialis anterior muscles, and did not show propriospinal propagation. In one patient, alternating leg muscle activation was also present. Jerks with a PSM pattern represent another motor phenomenon associated with RLS and different from the more usual PLMS.
Adult↗
[Restless legs syndrome and periodic limb movements in sleep: pathophysiology and treatment].
The paper presents current views on the pathophysiology and treatment options in the restless legs syndrome (RLS) and periodic limb movements in sleep (PLMS). Moreover, concepts are outlined concerning possible involvement of various cerebral structures as well as neurotransmitter and metabolic systems in the RLS pathophysiology, with the focus on the role of dopamine and iron deficiency. Dopaminergic agents (i.e. L-dopa and dopamine agonists), currently regarded as the best therapeutic option in the treatment of RLS, are discussed in detail. Favorable outcomes attained in the treatment of RLS with the opioid receptor agonists, anticonvulsants, benzodiazepines, and adrenolytic agents are also reported.
Anemia, Iron-Deficiency↗
Pergolide and carbidopa/levodopa treatment of the restless legs syndrome and periodic leg movements in sleep in a consecutive series of patients.
Carbidopa/levodopa has become accepted as a primary treatment for both the restless legs (RL) syndrome and periodic leg movements in sleep (PLMS). It, however, usually significantly augments the RL symptoms in the day as well as night, requiring medication change for about 70% of the patients. The dopaminergic agonist pergolide provides a potentially useful treatment; doses given at dinner and before bed could suffice to treat the symptoms for most of the 24-hour day. A series of consecutive patients with RL syndrome or PLMS was studied using a standard medication protocol starting with carbidopa/levodopa, switching if needed to pergolide and, finally, to an opiate or other treatment. For 51 patients entered into the study, 21 (39%) continued on carbidopa/levodopa and 26 (50%) switched to pergolide. For those tried on pergolide, 19 (73%) responded well. Restless legs augmentation occurred for only four (15%) and was severe enough to require medication change for only one (4%) of these patients. The patients with PLMS responded best to carbidopa/levodopa, whereas severe RL patients responded best to pergolide. Pergolide provided a good treatment for the RL syndrome, particularly for the more severe RL cases without significant problems with RL augmentation.
Antiparkinson Agents↗
Restless legs syndrome and periodic leg movements in sleep: the primary role of dopaminergic mechanism.
We report here the possible effect of opiates on a patient exhibiting particularly severe restless legs syndrome (RLS) and periodic leg movements in sleep (PLMS). This patient was investigated in the sleep laboratory under three conditions, namely, unmedicated (baseline), medicated with codeine sulfate, and medicated with both codeine sulfate and pimozide. Codeine sulfate dramatically improved abnormal motor behavior in this patient. The addition of pimozide reversed the beneficial effect of codeine during the Forced Immobilization Test but not in spontaneous RLS or PLMS at night. These results are discussed in view of the possible involvement of the dopaminergic mechanism in RLS/PLMS syndrome.
Codeine↗
Sleep disturbances in dialysis patients.
Sleep disturbances are extremely common in dialysis patients. Subjective sleep complaints are reported in up to 80% of those surveyed and sleep apnoea syndrome, restless legs syndrome, and periodic limb movement disorder are much more prevalent than in the general population. Excessive daytime sleepiness is also an important problem. These sleep abnormalities appear to have significant negative effects on quality of life and functional health status. Although long-term studies regarding other effects on health outcomes remain to be conducted, available data also suggest that sleep disturbances may have an important impact on morbidity and mortality. Achieving a more complete understanding of the sleep problems experienced by this group is absolutely imperative if improving health outcomes is the goal. Clinicians and researchers alike face numerous challenges in this regard, especially when considering the complex clinical presentation and treatment needs typical of these patients. Therefore, the purpose of this article is to present an up-to-date review of the literature regarding sleep disturbances in dialysis patients with special emphasis on the numerous factors potentially contributing to these problems and associated clinical and research implications.
Disorders of Excessive Somnolence↗
Sleep disorders during pregnancy.
This paper reviews the topic of sleep disorders in pregnant women. We describe changes in sleep architecture and sleep pattern during pregnancy, discuss the impact of the physical and biochemical changes of pregnancy on sleep in pregnant women and examine whether maternal-fetal outcomes may be adversely affected in women with disordered sleep. The literature on common sleep disorders affecting pregnant women, including insomnia, sleep-disordered breathing and restless legs syndrome, is reviewed and recommendations are made for the management of these disorders during pregnancy.
Cerebral Cortex↗
Acute placebo-controlled sleep laboratory studies and clinical follow-up with pramipexole in restless legs syndrome.
In a single-blind, placebo-controlled crossover trial, the acute efficacy of the dopamine agonist pramipexole was investigated in 11 restless legs syndrome (RLS) patients by sleep laboratory methods, with a clinical follow-up for 4 weeks. In 3 nights (pre-treatment, placebo and drug night), objective sleep quality was determined by polysomnography (PSG), subjective sleep and awakening quality by rating scales, objective awakening quality by psychometry. Clinical follow-up consisted of completion of the International RLS Study Group (IRLSSG) Scale, Zung Depression (SDS) and Anxiety (SAS) Scale, Quality of Life Index, Pittsburgh Sleep Quality Index and Epworth Sleepiness Scale. Concerning acute effects, an omnibus significance test for PSG variables demonstrated a global difference between placebo and pramipexole, but none between pre-treatment and placebo. Pramipexole 0.27 mg significantly decreased the target variable periodic leg movements (PLM)/h of sleep as well as all other RLS/PLM variables and improved objective sleep efficiency and subjective sleep quality as compared with placebo. In sleep architecture, sleep stages S1 and S2 and stage shifts increased, while slow-wave sleep and SREM decreased. After 4 weeks of therapy, the total scores of the IRLSSG questionnaire, sleep quality and daytime sleepiness, depression and quality of life also improved. Thus, acute pramipexole markedly reduced PLM measures and slightly improved objective and subjective sleep quality. Follow-up ratings showed a moderate improvement of RLS and sleep quality, and to a lesser extent of daytime sleepiness, depression and quality of life. The psychopathological findings as well as acute sleep architecture changes are reminiscent of those seen after activating antidepressants.
Adult↗
Cardiovascular variability during periodic leg movements: a spectral analysis approach.
OBJECTIVE: Changes in cardiovascular measures have been advocated as sensitive markers of phasic events arising from sleep. The current study was aimed to analyse the effects of periodic leg movements (PLMS) on heart rate variability (HRV) during NREM sleep in patients having restless legs syndrome and periodic leg movements during sleep. METHODS: The absolute and normalized high- and low-frequency peaks from spectral analysis (FFT) of R-R intervals, the HRV changes using wavelet transform, the geometric and time domain HRV were measured in 14 patients with restless legs syndrome and PLMS. The analysis was done comparing one hundred, 10 min periods with PLMS (PLMS+) and 60 periods without PLMS (PLMS-) in stage 2 of NREM sleep. In 8 patients analysis was also done in slow wave sleep (SWS). RESULTS: Occurrence of PLMS induced changes in geometrical indices of HRV, with a rise of the triangular index and the triangular interpolation of R-R intervals in PLMS+ periods (P < 0.0001). Small changes in time domain indices were found during PLMS+ periods, while the SD of the R-R intervals (SDNN), reflecting global HRV, was significantly higher (P = 0.001). While the low frequency (LF) power significantly increased in PLMS+ periods (P < 0.0001), high frequency (HF) power showed a weak and not significant reduction. The rise in sympathetic activity as detected by frequency domain HRV analysis was related to density and interval of PLMS. Comparison between sleep stages of NREM sleep demonstrated lower values of HRV measures when PLMS+ periods occur in SWS. CONCLUSIONS: Overall, PLMS occurrence was associated with a shift to increased sympathetic activity without significant changes in cardiac parasympathetic activity. The frequency domain analysis of HRV appears to be an easy tool to estimate the autonomic changes related to PLMS and PLMS- arousals and to differentiate their occurrence during stage 2 and deep sleep. SIGNIFICANCE: Spectral HRV measures may offer a simple approach to estimate the degree of autonomic changes occurring in relation to periodic leg movements in restless legs patients.
Adult↗
Why do patients sleep on dialysis?
Sleep-associated symptoms and excessive daytime sleepiness are felt to be more common in dialysis patients. Several surveys conducted in this patient population have identified a prevalence of sleep disturbances in up to 80% of patients. This review article summarizes common disorders associated with sleep disturbances in dialysis patients, including sleep-disordered breathing, restless legs syndrome, and major depression. Special attention is given to pathophysiological processes and effective approaches for the prevention and timely treatment of these conditions, which in turn reduces the substantial morbidity associated with sleep disturbances.
Cardiovascular Diseases↗
Influence of repeated passive body heating on subsequent night sleep in humans.
Experiments were carried out on four healthy male subjects in two separate sessions: (a) A baseline period of two consecutive nights, one spent at thermoneutrality [operative temperature (To) = 30 degrees C, dew-point temperature (Tdp) = 7 degrees C, air velocity (Va) = 0.2 m.s-1] and the other in hot condition (To = 35 degrees C, Tdp = 7 degrees C, Va = 0.2 m.s-1). During the day, the subjects lived in their normal housing and were engaged in their usual activities. (b) An acclimation period of seven consecutive daily heat exposures from 1400 to 1700 hours (To = 44 degrees C, Tdp = 29 degrees C, Va = 0.3 m.s-1). During each night, the subjects slept in thermoneutral or in hot conditions. The sleep measurements were: EEG from two sites, EOG from both eyes, EMG and EKG. Esophageal and ten skin temperatures were recorded continuously during the night. In the nocturnal hot conditions, a sweat collection capsule recorded the sweat gland activity in the different sleep stages. Results showed that passive body heating had no significant effect on the sleep structure of subsequent nights at thermoneutrality. In contrast, during nights at To = 35 degrees C an effect of daily heat exposure was observed on sleep. During the 2nd night of the heat acclimation period, sleep was more restless and less efficient than during the baseline night. The rapid eye movement sleep duration was reduced, while the rate of transient activation phases observed in sleep stage 2 increased significantly. On the 7th night, stage 4 sleep increased (+68%) over values observed during the baseline night.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
[Sleep disorders in temporal lobe epilepsy].
The objective of this study was to evaluate sleep macrostructure and sleep disturbance in a group of 39 patients with temporal lobe epilepsy (TLE). Patients completed questionnaires to evaluate their sleep and subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]) and undergone Polysomnography and Multiple Sleep Latency Test (MSLT). Daytime sleepiness was the most frequent complaint (85%), followed by wakefulness during sleep, history of seizures during sleep (75%) and initial insomnia (26%). Parasomnias (67%), obstructive sleep apneas (13%), restless legs syndrome (15%) and periodic limb movements (5%) were the most frequent sleep disorders. The most frequent changes of sleep patterns were: sleep architecture fragmentation (100%), decreased amount of REM sleep (92%) and increase in time awake after sleep onset (77%). There were significative correlations between the ESS and the MSLT (p<0,05). In conclusion, TLE patients have fragmented sleep with increased sleep stages shifts, increased number of awakenings and in time awake after sleep onset. REM sleep was decreased. Daytime sleepiness was the most frequent complaint in TLE patients.
Adolescent↗
Neurocognitive consequences of sleep deprivation.
Deficits in daytime performance due to sleep loss are experienced universally and associated with a significant social, financial, and human cost. Microsleeps, sleep attacks, and lapses in cognition increase with sleep loss as a function of state instability. Sleep deprivation studies repeatedly show a variable (negative) impact on mood, cognitive performance, and motor function due to an increasing sleep propensity and destabilization of the wake state. Specific neurocognitive domains including executive attention, working memory, and divergent higher cognitive functions are particularly vulnerable to sleep loss. In humans, functional metabolic and neurophysiological studies demonstrate that neural systems involved in executive function (i.e., prefrontal cortex) are more susceptible to sleep deprivation in some individuals than others. Recent chronic partial sleep deprivation experiments, which more closely replicate sleep loss in society, demonstrate that profound neurocognitive deficits accumulate over time in the face of subjective adaptation to the sensation of sleepiness. Sleep deprivation associated with disease-related sleep fragmentation (i.e., sleep apnea and restless legs syndrome) also results in neurocognitive performance decrements similar to those seen in sleep restriction studies. Performance deficits associated with sleep disorders are often viewed as a simple function of disease severity; however, recent experiments suggest that individual vulnerability to sleep loss may play a more critical role than previously thought.
Cognition Disorders↗
[Studies on the occurrence of systemic manifestations during first eruption of teeth in children].
The aim of the study was establishing whether systemic symptoms and signs appearing in children during first eruption of teeth are connected with this process, and what is the correlation between the studied features and eruption of individual milk teeth. The study involved 55 generally healthy infants aged 3-4 months, and the observation was continued up to the age of 36 months. The study on the development of teeth was carried out in two Regional Paediatric Dental Clinics in Warsaw, at 6-week intervals in the first year of life, and at 10-week intervals in the 2nd and 3rd years. The systemic symptoms and signs were recorded by mothers, and the obtained data were stored on computer cards. The results were subjected to statistical analysis considering finally these systemic manifestations which were present in at least 25% of children. The manifestations connected with teeth eruption included: profuse salivation, biting of hard, things, restlessness, appetite loss and sleep disturbances. These symptoms were most pronounced at the time of milk incisors eruption, less evident during eruption of first molars, and were absent during eruption of second molars. Canine teeth eruption was connected particularly with restlessness and sleep disturbances. Such signs as raised body temperature, skin changes, gastrointestinal disturbances were only weakly connected with teeth eruption.
Child, Preschool↗
Sleep disorders in end-stage renal disease: 'Markers of inadequate dialysis'?
Excessive daytime sleepiness and sleep disorders, including sleep apnea syndrome, restless legs syndrome, and periodic limb movement disorder, occur with increased frequency in patients with end-stage renal disease (ESRD). The detection and management of sleep disorders in ESRD patients is often challenging but may have significant clinical benefits. Some of the poor quality of life in ESRD may be attributed to the presence of concomitant sleep disorders, yet the classical symptoms of sleep disorders (poor concentration, daytime sleepiness, and insomnia) are often ascribed to the uremic syndrome itself. Conventional risk factors and screening tools used in the diagnosis of sleep disorders seem to have limited applicability in dialysis patients implicating the unique pathophysiology of sleep disorders in ESRD. Emerging evidence suggests that sleep apnea may contribute to the augmented cardiovascular event rates and to the accelerated development of atherosclerosis in ESRD. Whether treatment of sleep disorders in ESRD patients can affect the high morbidity and mortality of ESRD patients has yet to be elucidated. To date, conventional renal replacement therapies do not appear to have a significant impact on the treatment of sleep disorders in ESRD. The promising therapeutic effects of optimal uremia control in the forms of nocturnal hemodialysis and renal transplantation on sleep disorders require further mechanistic and clinical studies.
Atherosclerosis↗
Computer-assisted detection of nocturnal leg motor activity in patients with restless legs syndrome and periodic leg movements during sleep.
STUDY OBJECTIVES: To assess the performance of a new method for automatic detection of periodic leg movements during sleep. METHODS: Leg movements during sleep were visually detected in the tibialis anterior muscles recordings of 15 patients with restless legs syndrome and 15 normal controls. Leg movements were detected automatically by means of a new computer method with which electromyogram signals are first digitally band-pass filtered and then rectified; subsequently, the detection of leg movements is performed by using 2 thresholds: one for the starting point and another to detect the end point of each leg movement. Sensitivity and false-positive rate were obtained; the American Sleep Disorders Association parameters were also computed, and the results analyzed by means of the Kendall W coefficient, the linear correlation coefficient and the Bland-Altman plots. SETTING: N/A. PARTICIPANTS: Fifteen patients with restless legs syndrome and periodic leg movements and 15 controls. MEASUREMENTS AND RESULTS: High values of the Kendall W coefficient of concordance between automatic and visual analysis were found with values close to 1 and the linear correlation coefficient for leg movements index and total leg movements index was > 0.950 (p < .000001). The Bland-Altman plots provided the limits of agreement between visual and computer detection, which were -9.01 and +9.89 for the periodic leg movement index. None of the normal controls was found to have periodic leg movement indexes >5 after automatic analysis. CONCLUSIONS: Our method can be applied to the clinical evaluation of periodic leg movements during sleep, with some caution in patients with a low periodic leg movement indexes. Large-scale research application is possible and can be considered as reliable.
Adult↗
EFNS guidelines on management of restless legs syndrome and periodic limb movement disorder in sleep.
In 2003, the EFNS Task Force was set up for putting forth guidelines for the management of the Restless Legs Syndrome (RLS) and the Periodic Limb Movement Disorder (PLMD). After determining the objectives for management and the search strategy for primary and secondary RLS and for PLMD, a review of the scientific literature up to 2004 was performed for the drug classes and interventions employed in treatment (drugs acting on the adrenoreceptor, antiepileptic drugs, benzodiazepines/hypnotics, dopaminergic agents, opioids, other treatments). Previous guidelines were consulted. All trials were analysed according to class of evidence, and recommendations formed according to the 2004 EFNS criteria for rating. Dopaminergic agents came out as having the best evidence for efficacy in primary RLS. Reported adverse events were usually mild and reversible; augmentation was a feature with dopaminergic agents. No controlled trials were available for RLS in children and for RLS during pregnancy. The following level A recommendations can be offered: for primary RLS, cabergoline, gabapentin, pergolide, ropinirole, levodopa and rotigotine by transdermal delivery (the latter two for short-term use) are effective in relieving the symptoms. Transdermal oestradiol is ineffective for PLMD.
Advisory Committees↗