Elder Care Interprofessional Provider Sheets

Restless Legs Syndrome

Darlene Moyer, MD, Javier Zayas-Bazan, MD, and Danielle Miller, DO, HonorHealth, Phoenix, AZ

October 2018

TIPS FOR DEALING WITH RESTLESS LEG SYNDROME
  • Always check a ferritin level in patients with suspected RLS, and give iron therapy if ferritin is <75 μg/L.
  • Recommend non-drug treatment as first-line therapy. It includes good sleep hygiene practices, daytime exercise, and avoiding substances that can aggravate RLS.
  • If drug therapy is needed, consider the newer agents, pramipexole and ropinirole, as they are less apt to cause rebound and augmentation than are levodopa/ carbidopa.
  • Prescribe chronic opioids or benzodiazepines only for severe cases that don't respond to other treatments.

Restless Legs Syndrome (RLS) is a common condition that geriatricians and primary care providers can easily manage. This issue of Elder Care will review the most important information needed to diagnose and treat RLS.

What is RLS?

Patients with RLS suffer from a strong urge to move their legs or other body parts. Since the urge is brought on by rest and is worse in the evening, it results in significant sleep disruption and can lead to debilitating daytime somnolence and diminished quality of life.

How Common is RLS?

RLS is estimated to affect 10% of all adults, and up to 25% of those over 65. Older adults with RLS tend to have more severe symptoms than younger people because of the natural progression of the disease.

Diagnostic Criteria

There are no physical exam or lab findings that definitively identify RLS, so expert panels have developed specific clinical criteria to help diagnose the condition. Diagnosis is based on history alone, and there are five "essential criteria" that must be present to make the diagnosis: 

  1. a strong urge to move the legs or other body parts that 
  2. is brought on by rest, 
  3. gets better with activity, 
  4. gets worse in the evening or night, and 
  5. cannot be accounted for by another medical or behavioral condition. 

These essential criteria are partially defined by the URGE mnemonic: U=urge to move, R=rest induced, G=gets better with activity, and E=evening or night-time accentuation.

In addition to the essential criteria, there are both supportive features that are not required but help with diagnosis. They include the presence of periodic limb movements, a response to dopaminergic therapy, family history of RLS, and a lack of expected daytime sleepiness.

RLS can be classified as "chronic-persistent" (untreated symptoms occur ≥twice weekly for a year) or "intermittent" (untreated symptoms that occur less than twice weekly). In addition, RLS can be classified as "clinically significant" or "not clinically significant," based on the amount of distress and impairment that results.

RLS must be differentiated from other disorders that can have similar symptoms. Table 1 summarizes a few other movement disorders that can be confused with RLS.

Table 1.  Some Conditions That Can Mimic RLS
Condition
What is Different than RLS
Conditions that occur during sleep
Hypnagogic jerks
Sudden, brief, involuntary jerks of arms or legs, typically at onset of sleep
Sleep-related cramps
Involve specific muscle groups. Relieved (or partially relieved) by stretching.
Pain syndromes
Neuropathic pain
Pain may occur during periods of activity, rather than only during rest
Peripheral vascular disease
Claudication (pain) evoked by activity, rather than by rest
Painful-legs/moving-toes syndrome
Continuous/semi-continuous involuntary toe movement with associated leg pain, usually in patients with spinal cord or foot/leg injuries
Drug-induced syndromes
Neuroleptic-induced akathisia
Day or nighttime restlessness (in patient taking neuroleptic) that is generalized, immediately relieved with movement, and recurs after stopping movement
Normal positional discomfort
Alleviated by change in body position without need for repetitive body movements

Secondary Causes

Occasional cases of RLS are due to one of four identifiable conditions: iron deficiency, renal failure, medication side effects and, in younger adults, pregnancy.  Screening for these secondary causes with a history, physical, and laboratory exams can eliminate these treatable causes of RLS. Ferritin levels should be checked in all patients with RLS symptoms and iron replacement therapy given if levels are <75 µg/L, even if the patient is not anemic. Consider checking TSH, vitamin B12, and vitamin D levels as well. There is also an association between RLS and mood disorders and patients should be screened for these conditions.

Non-Drug Treatment

Non-drug treatment options include instituting good sleep hygiene practices, increased daytime physical exercise, mentally stimulating activities, and avoiding stimulants and other substances that can exacerbate symptoms (Table 2). Patients might also consider trying pneumatic compression devices prior to the typical onset of symptoms. 

Drug Treatment

Drug treatment aims to control symptoms and avoid augmentation. First line options include dopamine agonists, and gabapentin-related medications (Figure 1). 

A major concern about drug therapy is augmentation, which occurs when patients on dopamine agonists begin to experience RLS symptoms earlier in the day compared to before therapy was started. Augmentation is not, however, associated with the gabapentin-related medications. Augmentation can be managed by switching agents or drug classes, decreasing dose, or implementation of a "drug holiday."

Alternative drug treatments include opioids. Therapy with these alternative medications must be reserved for severe cases, used with caution in older adults, and individualized to each patient's comorbidities, and medication tolerance and response. Figure 1 provides a stepwise approach to drug therapy based on symptom frequency and severity. 

Table 2.  Common Medications that Can Worsen Restless Legs Syndrome
  • Antihistamines
  • Caffeine and other stimulants
  • Calcium-channel blockers
  • Glucocorticoids
  • Anti-emetics
  • Phenothiazines
  • Selective serotonin reuptake inhibitors
  • Tricyclic antidepressants
  • Nicotine, alcohol

 

Figure 1.  Stepwise Approach to Treatment of Restless Legs Syndrome *
STEP 3
Refractory Symptoms
(Changing Therapy)
 
First: change to a different dopamine agonist
Next: consider changing to dopamine agonist or second-line agent
Also: If augmentation occurs, consider a "drug holiday" from dopamine agonists; use gabapentin-related agents or different dopamine agonist in the interim
Finally: consider opioids for severe/resistant cases 
STEP 2
Daily Symptoms
(Daily Therapy)
First-line treatments (level A evidence per American Academy of Neurology guidelines): 
  • dopamine agonists
  • gabapentin
Second-line treatments (level B evidence per American Academy of Neruology guidelines): 
  • other dopamine agonists (ropinerole)
  • pregabalin
STEP 1
Intermittent Symptoms
(As-Needed Therapy)
First-line treatment: non-drug treatment, avoidance of triggering substances, treatment of secondary causes
Second-line treatment: as-needed therapy with dopamine agonist (see step 2) 
 

References and Resources

  • Allen R. Restless legs syndrome/W-E disease diagnostic criteria: updated International Restless Legs Syndrome Study Group consensus criteria - history, rationale, description, and significance.  Sleep Med. 2014; 15:960-873.
  • Bogan R. Restless Legs Syndrome:  A review of diagnosis and management in primary care. Postgrad Med. 2013; 125(3): 99-109.
  • Garcia-Borreguero D. Guidelines for the first-line treatment of restless legs syndrome/W-E disease, prevention and treatment of dopaminergic augmentation; a combined task force of the IRLSSG, EURLSSG, and RLS-foundation.  Sleep Med.  2016; 21:1-11.
  • Muth CC.  JAMA Patient Page. Restless legs syndrome. JAMA 2017; 317:780.
  • Winkelman J., et al. Practice guidelines summary: Treatment of restless legs syndrome in adults. Neurology. 2016; 87:2585-2592.