The correlation between restless leg syndrome and sleep disorders among hospitalized patients with acute coronary syndrome

Abstract

Aims: Restless leg syndrome is a sensorimotor disorder characterized by
restlessness and irritability in legs mainly during nighttime immobility. It can
occur secondary to cardiovascular disease. The aim of this study was to
examine the correlation of restless leg syndrome with sleep disorders among
hospitalized patients with acute coronary syndrome.
Methods: This descriptive-analytical study was conducted in 2012. A random
sample of 221 patients with acute coronary syndrome was drawn from the
coronary care unit of Imam Ali Hospital, Kermanshah, Iran. Sleep disorders
and restless leg syndrome were evaluated by using the researcher-made Cardiac
Patients’ Sleep Disorders Inventory. The SPSS16 was used for data
management and analysis.
Results: The mean of participants’ age and the prevalence of restless leg
syndrome among them were 61.27 years and 65.1%, respectively. Most of the
patients (61.5%) were male. The prevalence of restless leg syndrome among
patients with and without sleep disorders was 70.8% and 20%, respectively.
Restless leg syndrome was significantly correlated with sleep disorders
(p<0.001).
Conclusions: Restless leg syndrome is rather prevalent among cardiac patients.
However, it usually remains undiagnosed and untreated. Consequently,
performing diagnostic screening tests for identifying cardiac patients with this
syndrome as well as implementing interventions such as muscular relaxation,
massage, and sleep promotion techniques for managing it are recommended.

Full text

The correlation between restless leg syndrome and sleep disorders among
hospitalized patients with acute coronary syndrome
Elham Sepahvand*, Mohammad Daneshmandi1, Rostam Jalali2, Maryam Mirzaeii3
*. University of Social welfare and Rehabilitation, Tehran, Iran
1. Department of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran
2. Department of Nursing, Kermanshah University of Medical Sciences, Kermanshah, Iran
3. Department of Nursing, Jahrom University of Medical Sciences, Jahrom, Iran
A R T I C L E I N F O
Article type:
Original article
Article history:
Received: 6 May 2013
Revised: 5 May 2014
Accepted: 9 Jun 2014
Key word:
Restless leg syndrome
Sleep disorders
Acute coronary syndrome
Coronary care unit
A B S T R A C T
Aims: Restless leg syndrome is a sensorimotor disorder characterized by
restlessness and irritability in legs mainly during nighttime immobility. It can
occur secondary to cardiovascular disease. The aim of this study was to
examine the correlation of restless leg syndrome with sleep disorders among
hospitalized patients with acute coronary syndrome.
Methods: This descriptive-analytical study was conducted in 2012. A random
sample of 221 patients with acute coronary syndrome was drawn from the
coronary care unit of Imam Ali Hospital, Kermanshah, Iran. Sleep disorders
and restless leg syndrome were evaluated by using the researcher-made Cardiac
Patients’ Sleep Disorders Inventory. The SPSS16 was used for data
management and analysis.
Results: The mean of participants’ age and the prevalence of restless leg
syndrome among them were 61.27 years and 65.1%, respectively. Most of the
patients (61.5%) were male. The prevalence of restless leg syndrome among
patients with and without sleep disorders was 70.8% and 20%, respectively.
Restless leg syndrome was significantly correlated with sleep disorders
(p<0.001).
Conclusions: Restless leg syndrome is rather prevalent among cardiac patients.
However, it usually remains undiagnosed and untreated. Consequently,
performing diagnostic screening tests for identifying cardiac patients with this
syndrome as well as implementing interventions such as muscular relaxation,
massage, and sleep promotion techniques for managing it are recommended.
Please cite this paper as:
Sepahvand E, Daneshmandi M, Jalali R, Mirzaeii M. The correlation between restless leg syndrome and sleep disorders
among hospitalized patients with acute coronary syndrome. Iran J Crit Care Nurs. 2015;8(2):95-102.
1. Introduction
Restless leg syndrome (RLS) is a sensorimotor
disorder characterized by restlessness and
irritability in legs mainly during nights when
the afflicted person is immobile [1]. It is a
common disorder which was first explained by
Willis in 1672 [2]. The mechanism of the
disorder is yet unknown. However, evidence
shows that dopaminergic system disorders can
Iran J Crit Care Nurs. 2015;8(2):95-102
* Correspondence Author: Elham Sepahvand
University of Social welfare and Rehabilitation, Tehran, Iran.
TEL:+988318282102
Email el.sepahvand@yahoo.com

96 Sepahvand E. et al. The correlation between restless leg syndrome and sleep disorders among hospitalized …
Iran J Crit Care Nurs. 2015;8(2):95-102
be an underlying cause. Genetic studies have
also revealed that genetic factors may
contribute to RLS [1,3]. About half of patients
with RLS report having a positive family
history [1]. Moreover, diabetes mellitus,
hypertension, and cardiovascular diseases are
the most prevalent underlying conditions
among patients with RLS [4]. Mehanna and
Jankovic (2013) reported that RLS can be
secondary to cardiovascular diseases [5].
The prevalence of RLS has increased during the
recent years [4] and is currently 1–24%,
depending on race and assessment methods.
Winkelman et al. (2006) reported a prevalence
rate of 10.6% for the disorder [1]. It is more
common in northern Europe compared with
southern Europe and Asia. Moreover, it is more
common among people with older ages as well
as among women [1,3].
The manifestations of RLS include irresistible
urge to move the legs, abnormal sensations in
the legs which are aggravated while sitting,
lying, or taking a break, as well as worsening of
the manifestations in the evening or at night.
Periodic intentional movements of the legs
during sleep (such as repetitive flexion of the
hip, knee, and ankle) are present in about 90%
of patients with RLS [6]. Mandatory
movements of the legs during sleep causes
sleeplessness, low sleep and life quality, fragile
general health, daily sleepiness, social function
disorders, high blood pressure, and increased
risk for cardiovascular disease [1,7]. The length
of sleep among patients with RLS is less than
five hours [8].
Compared with the general population, RLS is
more common among patients hospitalized in
critical care units. For instance, Habibzadeh et
al. (2011) and Kim et al. (2008) reported that
the prevalence of RLS in critical care units was
36.3% and 28%, respectively [9,10]. However,
this disorder usually remains undiagnosed
because of critical care patients’ lack of
knowledge about it. According to Zamani et al.
(2008), patients do not provide information
about this disorder during physical
examinations and hence, it is usually taken for
granted by physicians [7].
Ensuring adequate sleep for patients is among
the most basic responsibilities of nurses. Nurses
need to assess patients’ sleep disorders,
determine their causes, and employ appropriate
nursing measures for managing them [11,12].
However, despite the commonness of RLS
among patients with heart problems, there is
little information about the relationship of RLS
with afflicted patients’ sleep disorders. The aim
of this study was to examine the correlation of
RLS with sleep disorders among hospitalized
patients with acute coronary syndrome.
2. Methods
This descriptive-analytical study was conducted
in 2012 on patients with acute coronary
syndrome hospitalized in the coronary care unit
of Imam Ali teaching hospital, Kermanshah,
Iran. The inclusion criteria were suffering from
coronary artery disease, having an age of
eighteen or higher, and being desired for
participating in the study. Patients with chronic
or unstable conditions (such as congestive heart
failure) or sensory-cognitive and cognitive
problems (such as hearing or visual
impairments) were excluded. Patients were
recruited by using the simple random sampling
technique.
The data collection tool was a researcher-made
questionnaire whose validity and reliability had
been assessed and reported elsewhere [13]. The
first part of the study tool was a demographic
questionnaire consisting of items on patients’
age, gender, educational status, employment,
and previous history of heart problems,
hypertension, or hospitalization in critical care
units. The second part of the study tool was the
Cardiac Patients’ Sleep Disorders Inventory
(CPSDI) [13]. The 25 items of the CPSDI are
scored on a five-point scale from 0 (Never) to 4

The correlation between restless leg syndrome and sleep disorders among hospitalized … Sepahvand E. et al. 97
Iran J Crit Care Nurs. 2015;8(2):95-102
(Always). Consequently, the total score of the
CPSDI can range from 0 to 100. Scores of 0–
24, 25–49, 50–74, and 75–100 are interpreted
as no sleep disorder, mild sleep disorder,
moderate sleep disorder, and severe sleep
disorder, respectively.
The five main domains of the CPSDI are
difficulty falling or staying asleep, daytime
dysfunction, sleep disorders due to
environmental factors, sleep disorders due to
heart problems, and sleep movement disorders.
One of the domains of the CPSDI assesses
RLS. Scores of 9 to 12 on this domain reflect
the presence of RLS. We invited the eligible
patients to complete the study questionnaires
three days after their admission to hospital.
Study participants were informed about the aim
of the study and were ensured of the
confidentiality of their personal data. The SPSS
v. 16.0 was used for data management and
analysis.
3. Results
In overall, 221 cardiac patients with a mean age
of 61.27 years were studied. About 61.5% of
the participants were male. The educational
status of the participants was as follows;
illiterate: 48%; below-diploma educations:
33.5%; high school diploma: 8.1%, and higher
educations: 10.4%. Almost half of the patients
(48.4%) had a previous history of
hospitalization in critical care units.
About 80.99% of the participating patients
reported having sleep disorders. Sleep disorders
were mainly mild (64.54%) or moderate
(35.46%). Most of the participating patients
(65.1%) had RLS. The prevalence of RLS
among the participating men and women was
Table 1: Participants’ demographic characteristics and their correlation with RLS
RLS
Demographic characteristics
N
%
P value
χ2 , , df
Gender
Male
136
61.5
0.002
35.4, 3
Female
85
38.5
Educational status
Illiterate
106
48
0.15
3.68, 3
Below-diploma
74
33.5
High school diploma
18
8.1
Higher educations
23
10.4
History of hypertension
Yes
109
49.3
0.13
2.34, 1
No
112
50.7
History of Diabetes mellitus
Yes
90
40.7
0.21
1.66, 1
No
131
59.3
Previous history of hospitalization
in critical care units
Yes
104
48.4
0.12
2.67, 2
The Fisher’s exact test

98 Sepahvand E. et al. The correlation between restless leg syndrome and sleep disorders among hospitalized …
Iran J Crit Care Nurs. 2015;8(2):95-102
57.4% and 77.6%, respectively. The relative
frequency of RLS among patients with previous
history of hospitalization in critical care units
was 70.1%. RLS was not significantly
correlated with age, educational status, and
previous history of hospitalization in critical
care units (p<0.05) while its correlation with
gender and sleep disorders was statistically
significant (p=0.002 and <0.001, respectively).
More than one third of the patients with RLS
(40.7%) were diabetic. Compared with patients
with no history of diabetes mellitus, RLS was
more prevalent among patients suffering from it
(34.4 vs. 65.6%). However, this difference was
not statistically significant (p=0.21). Moreover,
the correlation of RLS with the history of
diabetes mellitus was not statistically
significant (Table 1). Most of the patients
suffered from difficulty falling or staying asleep
(table 2). About 49.3% of patients suffered
from hypertension. However, there was no
significant correlation between RLS and the
history of hypertension (p=0.13). Most of the
patients with acute coronary syndrome (70.8%)
reported suffering from sleep disorders (Table
3).
Table 3: Cross-tabulation of RLS and sleep disorders
Sleep disorders
RLS
Yes
No
N
%
N
%
Yes
138
70.8
5
20
No
57
29.2
20
80
Total
195
100
25
100
Chi-square test
χ2 =44.9 , df=3 , p< =0/0001
Table 2: The mean of the participants’ sleep quality
Sleep quality indices
Mean
N
%
Difficulty falling sleep
2.43±1.085
130
58.8
Frequent nighttime awakenings
2.60±0.983
138
62.5
Early awakening in the morning
2.50±0.934
134
60.6
Daytime fatigue
2.19±1.274
114
51.6
Sleep duration
2.00±0.871
160
72.4
Using hypnotics
1.25±1.45
71
32.1
Low sleep quality
1.92±1.003
143
64.7
Total score
4.58±13.9
221
100

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Iran J Crit Care Nurs. 2015;8(2):95-102
4. Discussion
Patients with acute coronary syndrome who are
hospitalized in critical care units suffer from
sleep disorders due to factors such as RLS.
Most of the patients suffered from difficulty
falling or staying asleep (Table 2). Johansson et
al. (2010) also reported that 21% of patients
with myocardial infarction have difficulty
falling or staying asleep [14]. Tembo and
Parker (2009) also found that all patients in
intensive care units suffer from frequent
awakenings and decreased duration of rapid-
eye-movement (REM) sleep [15]. Generally,
cardiac patients, particularly those who are
hospitalized in critical care units, suffer from
sleep disorders which negatively affect their
health [16]. Sleeplessness increases heart rate,
the force of myocardial contractions, and
myocardial oxygen demand [17]. On the other
hand, the stressful environment of critical care
units, the acuteness of cardiac problems, and
frequent medical and nursing procedures
disturb patients’ sleep and cause sleeplessness
among them [18,19].
Study findings revealed that 32.1% of patients
(71 ones) used hypnotics. The commonness of
sleep disorders among cardiac patients and their
inability to have adequate sleep require them to
use hypnotics for promoting their sleep.
However, Johansson et al. (2010) found that
most patients with myocardial infarction who
suffered from sleep disorders did not use
hypnotics because they were afraid of drug
dependence and the aggravation of their sleep
problems after discontinuing hypnotics [14].
We also found that the sleep duration of most
of the participating patients had been decreased
significantly. Al-Otair et al. (2011) also
reported that nighttime sleep duration among
patients hospitalized in coronary care unit was
significantly less than the average normal sleep
[20]. According to Drouot et al. (2008),
inadequate and interrupted sleep are the
commonest sleep disorders among patients who
are hospitalized in coronary care units [21].
Inadequate sleep is associated with increased
risk for cardiovascular disease [22] and heart
attack [23].
About 60.6% of our patients (134 ones) had
experienced early awakening. According to
Yen et al. (2010), early awakening is common
among cardiac patients [19]. Most cardiac
patients suffer from reduced duration of the
REM sleep as well as early awakening in the
morning [24].
Study findings also revealed that 51.6% of
patients (114 ones) complained of daytime
fatigue and sleepiness. Johansson et al. (2010)
also found that after developing an acute
coronary syndrome, one third of patients often
or always feel fatigued [14]. Generally, lack of
vitality, fatigue, and sleepiness are among the
most common complaints of patients with
coronary disorders [14 and 25]. Daytime
fatigue and sleepiness are secondary to
decreased amount of the REM and the non-
REM sleep as well as sleep interruption [26].
Caska et al. (2009) noted that cardiac patients
are irritable and nervous due to having a low-
quality sleep [27].
We also found that the prevalence of RLS
among patients participating in the present
study was 65.1%. Habibzadeh et al. (2011)
reported an RLS prevalence of 36.3% for
patients hospitalized in critical care units while
Kim et al. (2008) found it to be 27% for Korean
patients receiving hemodialysis [10].
Kuchukhidze et al (2012) also reported that the
prevalence of RLS in Georgian primary
healthcare setting was 11.3%. The contradiction
among the findings of these studies regarding
the prevalence of RLS can be attributed to the
difference in their samples.
The study findings also indicated that 70.8% of
patients with RLS suffered from sleep
disorders. Moreover, there was a significant
correlation between RLS and sleep disorders
(p<0.001). All individuals with sleep disorders
participating in a study conducted by Bhowmik
et al. (2003) also suffered from RLS [28]. Other
studies also revealed that most patients with
RLS had sleep disorders such as difficulty

100 Sepahvand E. et al. The correlation between restless leg syndrome and sleep disorders among hospitalized …
Iran J Crit Care Nurs. 2015;8(2):95-102
falling asleep and inadequate sleep [29–33].
These studies also reported that about one third
of patients with RLS experience severe sleep
disorders. According to Bogan et al. (2013),
RLS is manifested by delayed onset of sleep,
short sleep duration, frequent nighttime
awakenings, and daytime fatigue [34].
Moreover, irresistible urge for moving the legs
can disrupt sleep among patients with RLS
[34].
We also found that the prevalence of RLS in
female patients was significantly higher than
males (77.6% vs. 57.4%; p = 0.002). This is in
line with the findings of the previous studies [2,
5, 35, and 36]. However, Ghanei et al. (2011),
Salamipour et al. (2012), and Alidosti et al.
(2013) found no significant correlation between
gender and RLS [4,33,37). The conflict among
different studies regarding the correlation of
gender with RLS can be related to differences
in their sample structures.
In the present study, there was no significant
correlation between RLS and hypertension (p =
0.31). Szentkiralya et al. (2013) also found no
significant correlation between these two
variables [38]. We also found that RLS was not
significantly correlated with the history of
diabetes mellitus while Ghanei et al. (2011) and
Loes et al. (2005) reported that RLS was
significantly more common among patients
with diabetes mellitus [4,39]. This contradiction
between the findings of the studies is probably
due to the small number of patients with
diabetes mellitus in our study (40%). Finally,
the findings of the present study revealed that
RLS was not significantly correlated with
previous history of hospitalization in coronary
care unit. However, this correlation was
significant in a study conducted by Habibzadeh
et al. (2011) [8]. Racial and environmental
differences can be the reasons behind such a
conflict between the findings of these two
studies.
5. Conclusions
Study findings indicate that RLS is rather
common among cardiac patients. Moreover,
RLS is significantly correlated with sleep
disorders among these patients. Consequently,
performing diagnostic screening tests for
identifying cardiac patients with RLS as well as
implementing interventions such as muscular
relaxation, massage, and sleep promotion
techniques for managing it are recommended.
6. Acknowledgments
We would like to thank the participating
patients as well as the personnel of the coronary
care unit of Imam Ali hospital, Kermanshah,
Iran, who supported us throughout conducting
this study.
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