Diagnosis and Management of Nocturnal Movement Disorders

Introduction to Nocturnal Movement Disorders

The American Geriatrics Society suggests that Periodic Limb Movements of Sleep (PLMS) is characterized by repetitive, stereotyped limb movements consisting of rhythmical extensions of the big toe and dorsiflexions of the ankle with occasional flexions of knee and hip 2
The European Urology association notes that patients with PLMS are typically unaware of these movements, though bed partners may report "twitchy legs" or kicking movements 1
The American Academy of Sleep Medicine recommends that polysomnography (PSG) with video-audio recording is mandatory for definitive diagnosis of REM Sleep Behavior Disorder (RBD) 5

The American Geriatrics Society recommends asking key clinical questions such as "Does your bed partner complain that you have twitchy legs or make kicking movements in your sleep?" to suggest PLMS 1
The American Academy of Sleep Medicine suggests asking "Do you recall dreaming during these episodes?" to suggest RBD if yes 1, 4
The Journal of the American Geriatrics Society notes that PLMS diagnosis requires PLMS Index >15 per hour on PSG plus clinical sleep disturbance or daytime fatigue 2

The American Geriatrics Society states that no FDA-approved treatment exists for PLMS, and treatment is only indicated if causing significant sleep disturbance or daytime symptoms 2
The American Academy of Sleep Medicine recommends melatonin (immediate-release) 3 mg at bedtime as first-line treatment for RBD, which can be increased to 15 mg 3
The American Academy of Sleep Medicine suggests that melatonin is preferred over clonazepam in patients with dementia, cognitive impairment, sleep apnea, or high fall risk 3, 4

The American Geriatrics Society notes that patients with idiopathic RBD have a 70% risk of developing α-synucleinopathy (Parkinson's disease, dementia with Lewy bodies, multiple system atrophy) within 12 years of diagnosis 3, 4

The American Academy of Sleep Medicine recommends referral to a sleep specialist when diagnosis remains uncertain after initial evaluation, initial treatment fails to control symptoms, or suspected underlying sleep disorders (sleep apnea, narcolepsy) 4