January 13, 2022

Nighttime Agitation — Is It RLS?

By Kathy Richards, PhD, RN, FAAN; member of the RLS Foundation’s Scientific and Medical Advisory Board

For people in the dementia stage of Alzheimer’s disease (AD-D), the problem of nighttime agitation, defined as the presence or worsening of behaviors such as aggression or wandering in the afternoon or evening, is a management challenge for their caregivers. This problem often leads to more and more restrictive living environments for persons with AD-D, including placement in nursing homes. In addition to AD-D, nighttime agitation might be a manifestation of a common neurologic condition: restless legs syndrome (RLS). Symptoms of RLS match those of nighttime agitation – that is, not being able to remain still, and experiencing symptoms in the evening.

In a recent study published in the Journal of Post-Acute and Long-Term Care Medicine, the characteristics and behaviors of 76 older adults with AD-D, nighttime agitation, and newly diagnosed RLS were measured. RLS was diagnosed using the Behavioral Indicators Test – Restless Legs, a validated tool for diagnosis of RLS in persons with AD-D. The individuals in the study were unable to cognitively and verbally report their RLS symptoms. The older adults with AD-D were also observed for nighttime agitation behaviors. Assessment of iron status and sleep quality (using motion sensors) was conducted for these patients as well. The researchers found that fewer minutes of documented sleep and lower transferrin (iron) saturation were associated with more frequent behaviors of nighttime agitation. Over three-quarters of the patients with RLS and nighttime agitation had been prescribed medications that worsen RLS, such as antihistamines and serotonin reuptake inhibitors.

These findings support clinical consideration of nighttime agitation as a sign of RLS and highlight the need for further research to identify new management strategies. The findings also suggest that medical providers should take steps to identify and diagnose RLS; treat iron deficiency anemia if indicated by low transferrin saturation; and deprescribe medications that worsen RLS. The combination of these strategies will lead to a reduction in any RLS component of nighttime agitation in patients with AD-D. In addition, it is recommended that nursing homes change common practices that are likely to worsen RLS discomfort and nighttime agitation, such as restricting residents from evening walking and putting them to bed early.

Kathy Richards, PhD, RN, FAAN, is a research professor at The University of Texas at Austin, School of Nursing. As a UT Austin PhD graduate, Kathy has conducted sleep research in Alzheimer's disease for 20 years, and received over $25 million in NIH funding to support her research endeavors. Her recent project is the NightRest project and the Behavioral Indicators Test for Restless Legs Syndrome in older adults. In partnership with Christine Kovach, PhD, RN, FAAN, Richards received a $3.9 million five year grant from the National Institute on Aging to improve the treatment of nighttime agitation in those with Alzheimer's disease. They hypothesize that RLS may be a cause for nighttime agitation and sleep disturbance in these individuals. This study marks the very first time that a new diagnostic tool will be used in research on nighttime agitation.