40 Clinical Rounds FAMILY P RACTICE N EWS • January 1, 2008 Restless Legs Syndrome Undetected, Mismanaged BY BRUCE K. DIXON answers “yes” to the rest of the questions, eases RLS symptoms,” she advised. en an anticonvulsant or opioid, she noted. Chicago Bureau and there’s no other apparent reason for RLS pathophysiology relates to dopa- “[Dopaminergic] agonist therapy can be the symptoms, then he or she has RLS. minergic dysfunction and iron use and stor- started in those whose symptoms occur C HICAGO — Restless legs syndrome af- Primary RLS likely is influenced by ge- age, and decreases in iron concentration in more than twice a week. Dosages are low- fects between 5% and 15% of the popula- netics, especially where onset occurs before the substantia nigra and the putamen cor- er than those used in Parkinson’s disease. If tion and is often manageable, yet it contin- the age of 45 years, she noted. relate with RLS severity. “After the URGE symptoms occur less often and sleep is a ues to be misdiagnosed and underreported. Iron deficiency, pregnancy, end-stage re- questions, check the patient for ferritin sat- problem, consider using an opioid or Dr. Penny Tenzer told the American nal disease, peripheral neuropathy, medica- uration. A ferritin [reading] under 40 mcg/L gabapentin as a third line, though usually Academy of Family Physicians annual sci- tions, and excessive caffeine consumption may be indicative and below 20 mcg/L def- two successive dopamine agonists are used.” entific conference that a simple mnemon- may worsen symptoms, said Dr. Tenzer, di- initely indicative that treatment is needed.” Dopaminergic agents require titration, ic, URGE (from the words uncomfortable rector of the residency program in the de- Before beginning pharmacotherapy, one and decisions to use these agents for RLS and urge, rest, getting up, and evening), partment of family medicine and commu- should advise lifestyle changes such as re- should not be based solely on the treating helps identify key RLS symptoms: nity health at the University of Miami. ducing or eliminating caffeine and alcohol physician’s experience with Parkinson’s, Ǡ An uncomfortable feeling in the legs, ac- In addition, 85% of RLS patients also intake and exercising. Even mental tasks, which is a different disease, she cautioned. companied by an urge to move. have a condition called periodic limb move- such as doing a crossword puzzle, help. In patients whose RLS occurs nightly, Ǡ Rest or inactivity make it worse. ments of sleep (PLMS), which is marked by Dopaminergic agonists, which include Dr. Tenzer advised avoiding levadopa-car- Ǡ Getting up and moving makes it better. spontaneous jerking of a limb. “A finding of pramipexole and ropinerole, are the sole bidopa therapy because long-term use of Ǡ Symptoms typically persist in the PLMS supports a diagnosis of RLS,” she said. FDA-approved class of drugs for the treat- these drugs can produce a worsening of evening, often making sleeping difficult. Other comorbidities include depression, ment of primary RLS. Another option is symptoms and symptom rebound. “I ask patients with suspected RLS is, ‘do anxiety, neuropathy, narcolepsy, and apnea. the dopamine precursor, levadopa. Seda- Dr. Tenzer is on the speakers’ bureau for your legs keep you up at night?’ That may “The last supporting criterion is to give tive-hypnotic agents often are prescribed, Boehringer Ingelheim, which manufactures be the first clue,” she said. If the patient the patient a test dose of dopamine, which and patients with painful RLS may be giv- and markets Mirapex (pramipexole). ■ Sleepless AD Patients and Caregivers After Concussion, Motor Benefit From Nondrug Interventions Skills, Neuropsychological Function Are Independent BY BRUCE K. DIXON Ǡ B: Define and observe the problem behavior. Who Chicago Bureau does it happen around, what is the current behavior, ognitive testing alone may be inadequate to assess the where does it happen most, and how often does it occur? Cneuropsychological functioning of patients with re- C HICAGO — Nonpharmacological strategies can Ǡ C: Identify the consequence. What happened after cently sustained concussions, based on neurological test- help bring relief to Alzheimer’s disease patients beset by the behavior, and how did others react? ing results that showed only a weak association with mo- sleep disturbances and those struggling to care for It’s important to identify who will carry out the plan, tor skills performance. them in the home setting. evaluate the progress, revise the plan or switch plans if Tonya M. Parker, Ph.D., and colleagues in the depart- “Behavioral and environmental approaches to main- necessary, said Dr. McCurry, emphasizing that the care- ment of human physiology at the University of Oregon, taining restorative sleep, such as improving physical fit- taker is ultimately the expert. “I’m not ... the person Eugene, studied two groups, each with 29 persons. One ness, adjusting sleep and dietary habits, increasing expo- who is having difficulty sleeping and the family mem- group included men and women (mean age, 22 years) who sure to light, and altering the home environment, often bers [must] help us figure out the best approach.” had each sustained a concussion in the last 48 hours. The can make life much better for the ill individual and his or As an example, Dr. McCurry described the case of control group consisted of persons (mean age, 21 years) her caretaker,” Sue McCurry, Ph.D., told a conference on Mrs. A, an 81-year-old living with her adult daughter. who had not sustained a head injury. Each group was test- dementia sponsored by the Alzheimer’s Association. She got out of bed and got dressed every morning be- ed for gait stability and neuropsychological performance. Dr. McCurry and her colleagues at the University of tween 3 a.m. and 4 a.m. and frequently wandered to the The researchers found that the scores on the neu- Washington have been developing psychosocial strate- bathroom where she would take off her undergar- ropsychological tests were not correlated with gait sta- gies to reduce affective and behavioral disturbances ments and leave them in the toilet or in the fish aquar- bility, with or without distraction via a verbal or arithmetic common to people with Alzheimer’s disease (AD). ium in the hallway. On a recent evening, Mrs. A walked task. For example, visual motor-processing speed in the Family members make up the majority of AD care- out of the house clad only in a thin nightgown. Her uninjured group improved through day 28 of the study, givers, yet proof of efficacy of such interventions has daughter had become exhausted and worried that she whereas in the injured participants, this ability improved come more slowly to the home setting than it has to would have to give up caring for her mother at home. through day 5 but not thereafter. At the same time, the nursing homes and other long-term facilities, said Dr. Dr. McCurry helped the daughter apply the ABC ap- concussion participants had significantly greater medial- McCurry, research professor at the Northwest Research proach. Mrs. A’s physician ruled out medications or ill- lateral sway velocity at day 5 and at day 28 when asked to Group on Aging and the Alzheimer’s Disease Research ness as possible causes; an alarm system was installed walk while distracted (Br. J. Sports Med. 2007;41:868-73). Center at the UW School of Nursing. on outside doors; in the event that Mrs. A was hungry The neuropsychological tests consisted of the Immedi- “My message is geared more to family members and at night, a prebedtime snack was considered; and she ate Postconcussion Assessment and Cognitive Testing (Im- aides ...those who are actually providing hands-on care was switched to an adult incontinence garment so that PACT) battery, which assesses attention, memory, concus- in the home, small board and care home, or assisted-liv- she wouldn’t feel the need to get up. sion symptoms, and reaction time and processing speed. ing facility,” she said in an interview. The daughter suggested eliminating her mother’s af- Tests of gait stability were done using eight cameras to The sleep problems experienced by people with de- ternoon and evening naps, moving the fish tank, setting record the movement of reflective markers placed on the mentia include getting up during the night and wan- consistent bed and rising times, and increasing daytime participant as he or she walked on a stationary surface. The dering, pacing or engaging in inappropriate activities; physical and social activity. Mrs. A was enrolled in an adult relationship between the center of mass and the center of waking the caregiver; sleeping excessively during the day program offering regular structured activities. pressure (that is, the length of stride) was then assessed, day; awakening too early in the morning; and having These changes helped to keep her active and awake along with center-of-mass displacement and peak velocity trouble getting to sleep, said Dr. McCurry. during the day. A baby monitor was put in Mrs. A’s room in the medial-lateral direction and average gait velocity. In a study of more than 200 caregivers, Dr. McCurry so her daughter would be alerted to redirect her quick- Neuropsychological parameters, such as memory, pro- found that the most common problem among those with ly back to bed. Finally, the daughter said she would stop cessing speed, and reaction time, “generally resolve with- AD was excessive sleeping (40%), whereas two-thirds of scolding Mrs. A and using an angry tone, which only in several days after injury,” the investigators concluded. caregivers were most disturbed by being awakened at made Mrs. A more agitated.