parkinson's disease

Restless legs – (RLS) -A higher risk for cardiovascular events in women: By Dr. De Leon

Happy 2018 to all my friends and followers- hope everyone is staying healthy and keeping a positive outlook for the new year.

This year I would like for you to join me in actively pursuing a lifestyle which will help us live better, happier, and healthier. This begins by recognizing what problems we have and actively finding solutions. For instance, my biggest challenge this year will be to mange my sleep deprivation better (more on this soon) trying new treatments to get my sleep wake cycle into a more normal state.

Now that I am almost done getting the house back in order after the holidays, I thought it was time to address a common problem found in nearly 50% of PD patients; as well as other parkinsonian syndromes such as MSA known as restless leg syndrome (RLS). This is a nervous system disorder that causes an urge to move the legs (arms, or other body parts) usually one limb at a time. This an extremely uncomfortable sensation in which only way to temporarily relief the urge is to move the limb or walk. These feelings are described as having ‘pins and needles‘  ‘creepy crawly sensation‘ as well as an ‘itching sensation‘ which occurs mostly at rest sitting or lying down. Because it occurs frequently at night it causes severe disruption of sleep – believe me it is nearly impossible to fall asleep when legs feel like they wont stand still although no involuntary movements present just an intense sensation of discomfort and need to move and walk about; hence it is also classified as a sleep disorder.

I have mentioned in the past that RLS is not only a symptom of the disease but can be a n initial problem even years before other motor symptoms developed. Plus, it also is a risk factor for developing PD. We may recall that RLS can be a familial disease and a secondary problem such as in PD but also as part of  iron deficiency, neuropathy, diabetes, kidney failure, and pregnancy (extremely frequent in third trimester). when i experience these symptoms is because my neupro patch has fallen off or i re-injured my back and is causing me radiculopathy- both of which i treat immediately.

But, until recently we were not aware that having RLS was a contributor of  cardiovascular events at a greater rate in women compared to men according to a robust study of  nearly 58,000 women from Nurse’s Heath study.

Rls affects about 10% of the population. but is more commonly seen in women than men. Perhaps this fact is skewing results and causing disparity in mortality rates. Nevertheless, we cannot ignore these new findings because as you know, I along with many others have been discussing for a while now the fact that there are great differences in PD presentation according to gender. I have also said that women are at higher risk for strokes and heart attacks from PD. Now we have another factor commonly seen in many PD patients which if not properly treated can accelerate the risk to death from one of these events. Although further research is needed into this area. it could be that not just women with RLS may be at higher risk  for strokes and heart attacks but more importantly those of us women with PD may also be at a much higher risk.

The theory behind the cause for this disparity is attributed to the autonomic and dopamine dysfunction particularly sympathetic stimulation which raises blood pressure.

In order to decrease risk of cardiovascular events, first we must diagnose and treat the problem.

RLS is diagnosed clinically.

Triggers for RLS:

certain medications can worsen symptoms

  • anti-nausea medications like phenergan, compazine ( same one that will worsen PD symptoms
  • cold and allergy medicines – dextrometomorphan
  • alcohol
  • sleep deprivation
  • withdrawal from neupro patch
  • caffeine

RLS treatments:

  • According to recent AAN Guidelines for treatment of RLS- first treatment should include mirapex ( in my professional experience as well as per guidelines this works much better than requip), Neupro patch (rotigotine) and Horizant (gabapentin enacarbil).
  • DBS may be the next thing in treating RLS; so far in a small study of 22 patients researchers have shown sustained relief /improvement of symptoms 2 years after surgery.
  • 24 hour infusion of duopa also has been shown to relieve symptoms

However, we still have to be cautious about new treatments on the horizon and over the counter/home remedies as a significant reliable treatment because there appears to be a greater than usual placebo effect. 48 out of 68 studied patients with rls showed marked improvement in sleep and quality of life on placebo although the daytime sleepiness  worsened.

So the moral of the story, there appears to be increase risk of mortality in women with RLS which may translate to the same risk or even higher in women with PD. Hence important to be treated – best by adjusting PD medicines in my experience and ruling out secondary causes if symptoms worsen or persist. Ok to try massages and other alternative treatments like leg pumps, soap bars in socks or mattress but if sleepiness is not improved than sure sign that root of problem is not being targeted and can still lead to increase mortality. Any questions concerns especially if already have history of risk factors for stroke like obesity, high blood pressure, diabetes, or smoking need to discuss treatment plan with PCP/neurologists asap.

lets us all do our best to be proactive in our health this year!

copyright @2018

all rights reserved by Maria De Leon MD

Sources:

http://www.medscape.com/viewarticle/890643 (women at higher risk of cv)

http://www.medscape.com/viewarticle/872681 (aan guidelines)

http://www.medscape.com/viewarticle/847146 (Dbs surgery)

http://www.medscape.com/viewarticle/865307 (dopa infusion)

http://www.medscape.com/viewarticle/865627 (placebo effect)

parkinson's disease, Parkinson's Health, Parkinson's tratamientos, Parkinson's treatment

Tips for Treating Restless Legs Syndrome (RLS): By Dr. De Leon

 

Restless Legs Syndrome (RLS) also known as Willis- Ekbom syndrome is described as a discomfort, creepy- crawly sensation, or an irresistible urge to move the legs arising from a profound feeling of ‘restlessness.’ These sensations only occur at rest and primarily at night. They are relieved by moving the legs and walking up and about. As the name implies they occur predominantly in the legs, however once treatment begins these abnormal sensations can spread to involve the arms due to augmentation. RLS occurs 2.5% to 15% in general population.

RLS can be familial (1/2 of the time, some have abnormality in chromosome 12) or secondary to another neurological or medical illness such as PD or pregnancy. RLS can occur for the first time in pregnancy and more common in the second and third trimester. The symptoms undergo spontaneous remission after delivery. It can occur at any age and slightly more common in women than men.

As we know RLS is often seen in advance PD as a result of ‘wearing off’ and low dopamine doses (but who is too say is not due to low levels of Vitamin D in these patients?); however there is still much debate whether the two are linked or simply coexist. The debate comes down to the fact that RLS is a disorder of relative iron deficiency while iron levels are found to be high in the substancia nigra from oxidative stress. So even though they share similar treatment they do not appear to share a common brain defect.

Despite the fact that many neurologists and sleep specialists have believe that RLS is more common in PD, there is no data to support this claim to date. Three studies conducted outside of the US have shown controversial findings thus far; two studies stating increase RLS in PD compared to controls while a third one showed the opposite.  Thus, uncertainty of risk of RLS in PD remains. Yet, if you suspect you have this go see an MDS because sleepless nights triggered by pacing the floor to relief symptoms is no life!

Causes:

Chronic diseases – Parkinson’s disease, diabetes, kidney failure, iron deficiency, vitamin D deficiency, folate deficiency (which happens to be one of the risk factors for PD).

Medications: some types such as nausea pills, anti-psychotics, some antidepressants, allergy medicines containing antihistamines can trigger these symptoms.

Pregnancy: In pregnancy the prevalence shoots up dramatically from 10% to 26%. This increase maybe due to an inherent iron and folate deficiency which are known risk factors for this condition.

Treatments:

Always TREAT UNDERLYING CONDITION FIRST!

  • Reduce alcohol
  • Exercise (especially yoga, tai- chi) 30- 60 minutes brisk walk or other type of exercise stretching and moving legs will improve symptoms and reduces night time fatigue, pain, restlessness, and help sleep better –this works best if followed by relaxation techniques like meditation.
  • Massage your lower legs or ask someone to rub /massage for you on a daily basis ( some of my patients would put soap in their socks or underneath the sheets so each time they moved essentially getting a massage- I think there are better ways) you can also get some massage boots at Wal- mart or other retail stores.
  • GET a Good night sleep – (sleep deprivation is a trigger)
  • Avoid sitting in one position for too long (same thing that makes us stiff with PD)
  • Medications- dopamine agonists – but I prefer as most movement disorder specialists a combined therapy plan to avoid augmentation and escalation of symptoms and increase drug dosage. Other medicines include Klonopin, Neurontin, Lyrica, Sinemet ( this is preferred treatment in pregnancy if symptoms are severe and iron and folate normal). Elderly patients with RLS should be ware of dopamine agonists especially advanced PD patients who may already be predisposed or have beginning of dementia.

Sources:

http://www.youngparkinsons.org/articles/restless-leg-syndrome-and-parkinsons-disease

Willis-EKbom Foundation

http://ghr.nlm.nih.gov/condition/restless-legs-syndrome

@copy right 2015 all right reserved Maria De Leon