**6. Treatment options**

The primary therapy for disorders of arousal is reassurance and prevention. For most, the disease course is usually benign and tends to resolve spontaneously with time. It is essential that both the patient and bed partner be educated about safety precautions for the home and bedroom environment, such as reducing or eliminating potential sources of injury (e.g., relocating the bedroom to a room on the ground floor, securing doors, using heavy draperies over the windows, removing mirrors, and keeping the floor free of objects that the sleepwalker might potentially trip over). Bed partners should be counseled not to attempt to stimulate the patient during an episode as this may trigger violent behaviour.

A trial of sleep extension or scheduled awakening may be considered. With scheduled awakening, the patient is awakened just before the typical time of the parasomnia episode and thereafter allowed to return to sleep.

Relaxation training and guided imagery may be helpful strategies for some patients, especially those with disorders of arousal or rhythm movement disorders.

When the events are frequent or particularly dramatic, medication with a long- or mediumacting benzodiazepine, such as clonazepam, at bedtime is effective therapy in most cases of non-REM disorders of arousal and REM sleep behavior disorder. In non-REM disorders, pharmacologic agents that have been used with some success include paroxetine and trazodone and low-dose benzodiazepines. Typically, medication should be used in combination with nonpharmacologic treatments after such techniques have been tried and found to be ineffective and only when the sleep disorder is affecting daytime function.

#### **7. Conclusion**

Although parasomnias can be distressing and it is important to recognize that parasomnias are diagnosable and treatable in the vast majority of patients. With recent understanding of the sleep stages and transition of these stages, many of the parasomnias are readily diagnosable and treatable.

Using devices such as bedwetting alarms and moisture alarms, combined with bladder muscle exercises, dietary changes, retention control training etc can also be helpful remedies in treating sleep enuresis. Education, encouragement, and patience are prudent approaches for younger children. For older children who may be embarrassed by the occurrences, and who may be affected by the emotional concerns, more aggressive treatment is recommended. Biofeedback, including enuresis alarms, arousal training and desmopressin have been tried with prominent success rates, although they are associated with high relapse rates. Hypnotherapy and imipramine have been somewhat helpful in the

Primary snoring is reported in 40% to 50% of people over the age of 65 and approximately 25% of the middle-age group. Snoring is usually a symptom of sleep disordered breathing. Oral appliances and otolaryngologic procedures, including velopharyngeal surgery, can effectively resolve snoring. Most of the studies on oral appliances are conducted for treatment of obstructive sleep apnea syndrome, with no clear data on primary snoring. They

The primary therapy for disorders of arousal is reassurance and prevention. For most, the disease course is usually benign and tends to resolve spontaneously with time. It is essential that both the patient and bed partner be educated about safety precautions for the home and bedroom environment, such as reducing or eliminating potential sources of injury (e.g., relocating the bedroom to a room on the ground floor, securing doors, using heavy draperies over the windows, removing mirrors, and keeping the floor free of objects that the sleepwalker might potentially trip over). Bed partners should be counseled not to attempt to

A trial of sleep extension or scheduled awakening may be considered. With scheduled awakening, the patient is awakened just before the typical time of the parasomnia episode

Relaxation training and guided imagery may be helpful strategies for some patients,

When the events are frequent or particularly dramatic, medication with a long- or mediumacting benzodiazepine, such as clonazepam, at bedtime is effective therapy in most cases of non-REM disorders of arousal and REM sleep behavior disorder. In non-REM disorders, pharmacologic agents that have been used with some success include paroxetine and trazodone and low-dose benzodiazepines. Typically, medication should be used in combination with nonpharmacologic treatments after such techniques have been tried and found to be ineffective and only when the sleep disorder is affecting daytime function.

Although parasomnias can be distressing and it is important to recognize that parasomnias are diagnosable and treatable in the vast majority of patients. With recent understanding of the sleep stages and transition of these stages, many of the parasomnias are readily

stimulate the patient during an episode as this may trigger violent behaviour.

especially those with disorders of arousal or rhythm movement disorders.

management Schenck et al., 1996).

**6. Treatment options** 

**7. Conclusion** 

diagnosable and treatable.

have decreased the frequency of snoring by 50%.

and thereafter allowed to return to sleep.

#### **8. References**


**1. Introduction** 

diagnosis and research of RLS (Allen RP et al., 2003).

**2. RLS description and diagnosis** 

**11** 

*Canada* 

**Risk Factors and Treatment of** 

John A. Gjevre and Regina M. Taylor-Gjevre *Department of Medicine University of Saskatchewan,* 

**Restless Legs Syndrome in Adults** 

Restless legs syndrome (RLS) is a common clinical entity consisting of an uncomfortable sensation in one's legs and irresistible urge or desire to move them usually occurring in the evening. This syndrome has been sub optimally diagnosed in the past and remains overall misunderstood and under-recognized by many primary health care providers. However, RLS is increasingly recognized to cause significant disease burden and decreased quality of life (Kushida C et al., 2007). The initial modern clinical description was published by Ekbom in 1945 but was largely ignored until the late 1980s when there was a resurgence of interest in RLS (Walters AS & Hening W, 1987). Because of ongoing clinical confusion and the need for more clear epidemiologic assessment, a research group was organized in 1995 and the original IRLSSG criteria were developed (Walters AS, et al., 1995). In 2003, the International Restless Legs Syndrome Study Group (IRLSSG) issued revised guidelines to assist in clinical

RLS is described by the RLS foundation as a neurological condition that is characterized by the irresistible urge to move the legs. Patients will describe an uncomfortable itching or "creepy-crawling" sensation on the legs in the evenings and report that it feels like "bugs crawling under the skin." The IRLSSG has listed 4 essential criteria to clinically diagnose RLS. Physical examination is usually normal. There is no single test used which will make the diagnosis although many patients suffer from iron deficiency with low ferritin levels. While overnight polysomnography (PSG) in a sleep laboratory is helpful to assess periodic limb movements of sleep (PLMS), a PSG is not necessary to make the clinical diagnosis of RLS. PLMS are defined as a repetitive or periodic bursts of leg (or arm) electromyographic (EMG) activity during sleep associated with discrete, stereotypical movements of the legs or arms. PLMS are felt to be a related but separate disease from RLS. Although most (80%) patients with RLS with have PLMS on PSG testing, approximately 12-20% of RLS patients will not have evidence for PLMS (Montplaisir J et al., 1997). Approximately 30% of patients with PLMS will have RLS symptoms. The revised 2003 IRLSSG essential criteria include 1) An urge to move the legs accompanied or caused by uncomfortable sensations in the legs, 2) The urge to move or unpleasant sensations beginning or worsening during periods or rest or inactivity such as lying or sitting, 3) The urge to move or unpleasant sensations are partially or totally relieved by movements such as walking or stretching, at least as long as

Schenck, C. H. & Mahowald, M.W. (2002). REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in sleep. *Sleep*, No: 25, pp. 120–130

Young, P. (2008). Genetic aspects of parasomnias. *Somnologie,* Vol:12, pp. 7–13
