Fast Five Quiz: Sleep Disorders

Helmi L. Lutsep, MD; Zab Mosenifar, MD; Stephen Soreff, MD

Disclosures

August 03, 2020

RLS is a neurologic movement disorder of the limbs that is often associated with a sleep complaint. Patients with RLS have a characteristic difficulty in trying to describe their symptoms. Diagnostic criteria from the International RLS Study Group (IRLSSG) are as follows:

  • An urge to move the legs that is usually, but not always, accompanied by or felt to be caused by uncomfortable and unpleasant sensations in the legs.

  • The urge to move the legs and any accompanying unpleasant sensations begin or worsen during periods of rest or inactivity, such as lying down or sitting.

  • The urge to move the legs and any accompanying unpleasant sensations are partially or totally relieved by movement, such as walking or stretching, at least as long as the activity continues.

  • The urge to move the legs and any accompanying unpleasant sensations during rest or inactivity only occur or are worse in the evening or night than during the day.

  • The occurrence of the preceding features are not solely accounted for as symptoms primary to another medical or behavioral condition, such as myalgia, venous stasis, leg edema, arthritis, leg cramps, positional discomfort, and habitual foot tapping.

The diagnosis of RLS is primarily based on the clinical history. Most patients with RLS have periodic leg movements of sleep [PLMS]). PLMS are characterized by involuntary, forceful dorsiflexion of the foot lasting 0.5-5 seconds and occurring every 20-40 seconds throughout sleep. PLMS noted on polysomnography alone do not warrant treatment. Clinicians should consider treating PLMS if they are causing frequent arousals.

RLS can be difficult to diagnose in children, especially younger ones. For a definite diagnosis, patients must endorse the diagnostic criteria and be able to describe leg symptoms in their own language. Alternatively, they must have the diagnostic criteria plus sleep disturbances, a sibling or parent with RLS, and a PLMS index higher than 5 on polysomnography. For a possible diagnosis, a PLMS index higher than 5 on polysomnography and a positive family history of RLS are required. These strict criteria are intended to prevent overdiagnosis of RLS in children.

All patients with symptoms of RLS should be tested for iron deficiency. At a minimum, a ferritin level should be obtained. A complete iron panel, including iron levels, ferritin, transferrin saturation, and total iron binding capacity, is preferable because the ferritin level can be falsely elevated in acute inflammatory states.

Treatment for RLS may not be necessary for patients with mild or sporadic symptoms or for those without significant impairment. Treatment should be tailored to the patient's specific symptoms and may involve pharmacotherapy and nonpharmacologic measures.

Drug therapy for primary RLS is largely symptomatic; cure is possible only for secondary RLS. Medications used in the treatment of RLS include the following:

  • Dopaminergic agents (eg, pramipexole, ropinirole, bromocriptine, levodopa-carbidopa, rotigotine)

  • Benzodiazepines (eg, clonazepam)

  • Opioids (eg, codeine)

  • Anticonvulsants (eg, gabapentin, pregabalin)

  • Presynaptic alpha2-adrenergic agonists (eg, clonidine)

  • Iron salt

The following medications have been known to cause or exacerbate the symptoms of RLS:

  • Antidopaminergic medications (eg, neuroleptics)

  • Diphenhydramine

  • Tricyclic antidepressants

  • Selective serotonin reuptake inhibitors

  • Serotonin-norepinephrine reuptake inhibitors

  • Alcohol

  • Caffeine

  • Lithium

  • Beta-blockers

Read more clinical information about RLS.

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