Ecase # 11-C

Christopher H. Smith, M.D.

May 13-17, 2002

"Restless in Renton"

74 y.o. woman came in for a routine physical, and during the visit reported that her sleep was "terrible".  She notes nearly lifelong problem with insomnia, and blamed it on her legs.  She described an "irritable, unsettled feeling" in both legs that usually started in the evening around bedtime, or soon thereafter.  Her legs didn't hurt, but felt uncomfortable and the only thing that seemed to help was to get out of bed and walk or at least move her legs.  She noted that she always tossed and turned, and rarely slept for more than three hours at a stretch without getting up.  No myalgias or arthralgias were present.She denied snoring, morning headache or significant daytime somnolence, though felt chronically tired from not sleeping soundly.  There was no caffeine or alcohol consumption, and no anxiety or depression.

• PMH: Osteoporosis, HTN, A fib, LBP

• Meds: Atenolol, Coumadin, Premarin, calcium and MVI.  No dietary supplements.

• SH:  She works for Seattle Parks as a recreation specialist, is widowed with two grown children, and lives in Renton.

• Exam: Musculoskeletal and vascular exam of spine, lower extremities was unremarkable.

Do you recognize this condition?

How can you manage it?

Discussion

• When evaluating patients with sleep disorders, consider these common causes:

For excessive daytime sleepiness: depression, sleep apnea, medications, narcolepsy and periodic limb movement disorder

For inability to fall or remain asleep (insomnia): physical illness/pain, travel, psychological stress, poor sleep hygiene, restless leg syndrome, circadian rhythm disorder and pharmacologic substances (caffeine, alcohol, ephedra, decongestants etc).

• Restless leg syndrome is characterized by fidgety, unpleasant sensations in the legs that tend to occur more often in the evening or at night.  There is an irrepressible desire to move the legs, relieved momentarily by walking, pacing, or leg rubbing.

• Family history of the disorder is often present in effected individuals.

• Patients may not volunteer the symptoms unless directly asked about them because of the lack of common awareness and unusual nature of the problem.

• In some, there is an apparent association with iron deficiency, peripheral neuropathy or renal failure.  The cause is unknown.

• Dopamine agonists have been shown to be quite effective.  In this patient, primapexole (Mirapex 0.125 mg po QHS) was started with dramatic benefit.

References

Trenkwalder C, Walters AS, Hening W. Periodic limb movements and restless leg syndrome.  Neuro Clin. 1996;14:629-50.

Chesson AL Jr, Wise M, Davila D, Johnson S, Littner M, Anderson WM, et al. Practice parameters for the treatment of restless legs syndrome and periodic limb movement disorder. An American Academy of Sleep Medicine Report.  Standards of Practice Committee of the American Academy of Sleep Medicine.  Sleep.1999;22:961-8.