Nighttime Agitation in Persons with Dementia as a Manifestation of Restless Legs Syndrome

• Authors: Donald Bliwise, Emory University; Kathy C Richards, University of Texas Austin; Richard P Allen, Johns Hopkins University; Janet Morrison, University of Texas Austin; Liam Fry, University of Texas Austin; Christine R Kovach, University of Wisconsin-Milwaukee; Angelica Rangel, University of Texas Austin; Ana Loera, University of Texas Austin; Yanyan Wang, University of Texas Austin; Alexandra L Hanlon, Virginia Tech; Alicia J Lozano, Virginia Tech
• Journal Title: JOURNAL OF THE AMERICAN MEDICAL DIRECTORS ASSOCIATION
• Volume: Volume 22, Number 7
• Publisher: ELSEVIER SCIENCE INC | 2021-07-14, Pages 1410-1414
• Type of Work: Article | Post-print: After Peer Review
• Publisher DOI: http://doi.org/10.1016/j.jamda.2020.11.026
• Subjects: Health Sciences, Nursing; Biology, Biostatistics
• Keywords: Science & Technology; Life Sciences & Biomedicine; Geriatrics & Gerontology; Alzheimer's disease; sleep disorders; agitation; RLS; Behavioral Indicators Test-Restless Legs; IRON; PREVALENCE; GUIDELINES; BEHAVIORS; CRITERIA; FERRITIN; DISEASE; IMPACT

Abstract

Objectives: Nighttime agitation or “sundowning” is challenging for clinicians and caregivers to manage in older adults in the dementia stage of Alzheimer's disease (AD-D). Our research previously revealed that nighttime agitation might be a manifestation of restless legs syndrome (RLS). The current study aims to describe the characteristics of older adults with AD-D, nighttime agitation, and RLS, and to evaluate sleep disturbance and iron status in relation to nighttime agitation severity. Design: An observational study with baseline descriptive and correlational data from a clinical trial. Setting and Participants: Long-term care (n = 69) and independent living (n = 7); age 82.91 ± 9.46 years, with AD-D, nighttime agitation, and RLS. Measurements: Trained observers counted nighttime agitation behaviors. Independent variables were age; cognition measured by the Mini-Mental State Examination; minutes slept from actigraphy; transferrin saturation percentage (TS%) and transferrin from fasting blood samples; and illness severity using the Cumulative Illness Rating Scale for Geriatrics. Bivariate and multivariable linear regression models were generated. Results: In the multivariable model, sleep minutes (P = .002) and TS% (P = .003) were negatively associated with frequency of nighttime agitation behaviors, and they explained 20% of the variance. Seventy-nine percent received 1 or more medications that worsen RLS symptoms, such as antihistamines and serotonin reuptake inhibitors. Conclusions and Implications: We encourage clinicians to consider nighttime agitation as a manifestation of RLS. Treatment of iron deficiency indicated by low TS% and deprescribing medications that exacerbate RLS may decrease nighttime agitation, improve sleep, and enhance quality of life in older adults with AD-D.