Americans are sleeping less: on average, 6.9 hours per night — less than we used to and less than what most sleep experts feel is optimal. For some, the problem is insomnia; others suffer from sleep apnea, where obstructed breathing leads to fitful sleep. For others, restless legs syndrome (RLS) prevents sleep onset, wakes them up and ruins an enjoyable evening. There is effective treatment for RLS that produces comfort, as well as a good night’s sleep.
Restless legs syndrome is a confusing condition; it is caused by the nervous system but, because it robs people of sleep, it is considered to be a sleep disorder. The condition, which was referred to as “fidgets in the legs” during the 19th century, is estimated to affect about 10 percent of Americans.
According to Gary Stanton, MD, an Emerson neurologist and sleep medicine specialist, people don’t always tell their physicians about the predictable itchy, uncomfortable sensation in their legs, despite years of suffering. “It’s amazing how many patients say to me ‘that’s just the way I am,’” he says.
But whether they seek treatment or decide to live with their RLS symptoms, they have one thing in common: something is wrong with how their body uses dopamine, a neurotransmitter required for muscle activity and movement. “RLS sometimes begins during childhood, but it is often misdiagnosed as hyperactivity,” Dr. Stanton notes.
RLS often runs in families; approximately 50 percent of those with RLS have a family member with the condition. About 80 percent of those with RLS also have periodic limb movement, a different condition that causes them to kick during their sleep. This can wake up the individual, as well as their startled sleeping companion.
“If someone is having a sleep test at Emerson, and we see them kicking, it’s clear they have periodic limb movement,” says Dr. Stanton.
Since there is no diagnostic test for RLS, Emerson sleep specialists take a careful medical history. “First we check to see if the patient has an iron deficiency,” says Dr. Stanton. “A low or low-normal iron level can cause or aggravate RLS; iron replacement therapy may improve or even cure it. Certain medical conditions, including kidney disease, Parkinson’s disease and diabetes, can produce RLS, and certain medications, especially antidepressants, can cause or aggravate RLS.”
The right medications do the trick
There is effective treatment, as Cindy Legault (pictured at right) found out. The Littleton resident suffered with RLS for years, but things turned around when she was referred to Dr. Stanton. “He was very thorough,” she recalls. “Dr. Stanton checked everything — every medication I take, my daily activities and what my sleep was like.”
The medication regimen he prescribed required some adjusting, but the combination of gabapentin, also known as Neurontin, taken in the early evening, and low-dose Mirapex, which regulates dopamine, a few hours later, does the trick. The timing is critical, notes Ms. Legault, a financial planner and investment advisor. “I set an alarm on my phone because I don’t want to take my medication late. If I miss that alarm, I’m going to have a really bad night.”
Successful treatment may require a bit of experimentation, says Dr. Stanton. “I find that different regimens work for different people. I encourage patients to vary the time they take their medication. We can increase the dosage or add another medication.”
Ms. Legault appeared to have more than one sleep problem, so Dr. Stanton suggested she have an overnight sleep study performed at Emerson. It revealed that she also has obstructive sleep apnea (OSA), typically characterized by snoring and gasping for breath, as well as periodic limb movement. “I wear a dental device, which corrects my sleep apnea,” she says. “I get a good night’s sleep now.”
She travels regularly to meet with clients. “The two things I won’t travel without are my dental device and my RLS medications.”
Ms. Legault, who is 55, has several family members with RLS. “My first recollection that it was a family problem was when I was in my twenties. I realized my grandmother was up at night, walking around in her bedroom,” she says. “I was up walking, too. My grandmother said ‘I think you got this from me.’ RLS became a family conversation, even though we didn’t know what to call it. My grandmother never got the treatment she needed.”
Ms. Legault did, and it has made a world of difference. “RLS used to keep me up at night, but not anymore.”
Overlapping syndromes make sleep a challenge
There are a number of conditions that result in tossing and turning — and make a good night’s sleep almost impossible. Sometimes these conditions travel together.
Obstructive sleep apnea (OSA) is all too common, says Anthony Bohnert, MD, an Emerson pulmonologist and sleep medicine specialist. “Up to 7 percent of adults have OSA, and the majority are undiagnosed; untreated sleep apnea is associated with heart disease, high blood pressure, stroke and increased blood sugar.” A sleep study, either at home or at the Emerson sleep lab, can diagnose the condition, for which there are several treatment options.
Dr. Bohnert gets concerned when OSA overlaps with chronic obstructive pulmonary disease (COPD). “Patients with obstructive disease, such as emphysema, or restrictive disease, such as pulmonary fibrosis, may become dependent on the use of accessory muscles to aid in normal breathing,” he explains. “During sleep, these muscles may not work as efficiently or even become nonfunctional, resulting in decreased oxygenation, increased carbon dioxide and subsequent sleep arousal.”
“People with depression or anxiety often are made worse if they have disturbed sleep,” notes Eliot Gelwan, MD, an Emerson psychiatrist. “We see a lot of OSA among our patients with depression. We don’t have much success in treating their depression if their sleep problem isn’t addressed.”
Insomnia can present challenges to patients and physicians. “If someone needs help with transient insomnia — caused by a personal or financial problem, for example — we might prescribe a sleep medication such as Ambien, but only for two or three weeks,” Dr. Gelwan explains. “These medications suppress non- REM sleep, which is the natural, restful sleep we require for good health. Also, patients require an increased dose in order to sleep.”
Chronic insomnia can lead to depression, says Dr. Gelwan. “It is often true that people worry about their sleep, which prevents them from sleeping. When someone becomes demoralized and feels the physiological effects of not sleeping, they are vulnerable for depression.”
Although an antidepressant medication should be effective in treating someone’s sleep disturbance, as well as the symptoms of low energy and despair, that is not always the case. “It’s a challenge to treat depression or anxiety in individuals who have disturbed sleep,” says Dr. Gelwan. “We sometimes suggest that a patient come to Emerson for a sleep study so that we can better understand the nature of their sleep deficit.”
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