Treatment of Restless Legs Syndrome (RLS) in Older Adults - #79
Take QuizDiagnosis: The diagnosis of restless legs syndrome (RLS) is made based on the presence of clinical, patient self-reported symptoms of an urge to move the legs while at rest.1 The International Restless Legs Scale (IRLS) is the most frequently used clinical diagnostic tool. Laboratory testing for other causes of RLS should also be completed, including complete blood cell count, ferritin (assessing for iron deficiency anemia), markers of kidney and liver function, endocrine function (glucose and thyroid hormones) and vitamins (B12, D, and folic acid).2,3
In managing secondary RLS, the first goal is to treat any underlying disease or mitigate any symptoms caused by prescription or over-the-counter medications which could be exacerbating RLS. If a patient is taking an agent potentially exacerbating RLS, a change in the medication should be made, if possible. The common association between RLS and iron deficiency anemia mandates checking serum ferritin levels with iron replacement given if these levels are less than 50 ng/mL.2 See table below for medications which may contribute to exacerbation of RLS symptoms.
Drugs Potentially Exacerbating RLS
- Antihistamines
- SSRIs
- Certain Anticonvulsants
- Antiemetics
- Dopamine Antagonists
- Neuroleptics
- Lithium
- Beta Blockers
Treatment: RLS treatment begins when symptoms impair quality of life, functioning, or sleep and once other potential causes are excluded.1 First-line treatment is non-pharmacologic and includes avoiding caffeine and alcohol, taking hot showers, finding distracting activities and maintaining good sleep hygiene.1,2,4 While dopamine agents were the gold standard of RLS treatment until recently, this medication can lead to augmentation of symptoms for many patients, causing earlier daily onset of symptoms compared to before medication treatment. Similarly, caution should be taken if symptoms worsen as the dose of medication increases, as this may also be due to augmentation. Symptoms of RLS may be intermittent, chronic persistent, or refractory. The table below lists medications used for RLS treatment. Drugs should be used at the minimum dose required to control symptoms in order to minimize risk of sedation, falls, and adverse drug events.
Diagnosis and management of restless legs syndrome in a geriatric patient.
List treatment strategies for restless legs syndrome and choose an appropriate medication strategy for an individual patient.
Restless legs syndrome is also known as Willis-Ekbom disease (WED). The definition of RLS is “feelings of restlessness and paresthesia-like sensations in the lower legs while at rest that transiently improve with movement”. Symptoms are worse at night, as they typically follow a circadian rhythm and older persons typically present with insomnia complaints as a result. 1,5 Primary RLS represents a familial relationship and is generally diagnosed before age 40. Secondary RLS is more common in older adults and is most often associated with other age-related illnesses.
Restless legs syndrome is most common in patients with chronic kidney disease, iron deficiency anemia, pregnancy, and chronic neurologic disorders (e.g., migraine, dopaminergic treatment in Parkinson’s Disease, and polyneuropathy). Certain medications may exacerbate RLS. Restless legs syndrome occurs in 2%-4% of adults, with women twice as likely to be affected than men, and the mean onset age in the third or fourth decade of life.1,2
- Define restless legs syndrome and its frequent coexistence with other age-related illnesses.
- Identify strategies for treating restless legs syndrome in a geriatric patient.
- Garcia-Borreguero D, Cano-Pumarega I. New concepts in the management of restless legs syndrome. BMJ. 2017;356:j104.
- Bertisch S. In the Clinic: Restless Legs Syndrome. Ann of Internal Med. 2015.
- Trenkwalder C, Allen R, Hogl B, et al. Restless legs syndrome associated with major diseases: A systematic review and new concept. Neurology. 2016;86:1336-134
- Anguelova GV, Vlak MHM, Kurvers AGY, and Rijsman RM. Pharmacologic and Nonpharmacologic Treatment of Restless Legs Syndrome. Sleep Med Clin. 13 (2018) 219-230.
- Miner B, Gill TM, Yaggi HK, et al. Insomnia in Community-Living Persons with Advanced Age. J Am Geriatr Soc. 2018 May 21. [Epub ahead of print].