Case 6: Treatment of RLS With a Complicated Medical History
Case 6: Treatment of RLS With a Complicated Medical History
Paul is a 76-year-old man who is referred to the department of sleep medicine in a regional hospital for further evaluation and possible treatment of restless legs syndrome (RLS).
Paul has been experiencing "electric shocklike" sensations in his legs for more than 15 years. The symptoms were initially mild and intermittent but have become progressively more intense and consistent during the past 5 years. Paul has difficulties falling asleep without stretching or massaging his legs. At times, he needs to get out of bed and walk to relieve the symptoms.
Although worse in the evening, Paul also experiences discomfort during the day. He is unable to sit and watch television and avoids going to the theater because of his restlessness. He usually feels fatigued and sleepy during the day because his restless legs prevent him from getting more than 5-6 hours of sleep during the night.
Paul was diagnosed with RLS by his internist, who conducted an evaluation for secondary forms of RLS. Paul's neurologic exam was normal, and measurement of his nerve conduction velocities revealed no evidence of a peripheral neuropathy. Iron, ferritin, creatinine, hematocrit, and other serologic tests were normal. A polysomnographic study revealed severe periodic limb movement disorder (PLMD), with more than 800 periodic limb movements in sleep (PLMS) detected during sleep. Approximately one third of Paul's PLMS symptoms were associated with electroencephalographic (EEG) cortical arousals. No evidence of respiratory disturbances was found.
Allergies: Penicillin (hives).
Past medical history: Positive for 2 myocardial infarctions, peripheral vascular disease, stroke, hypertension, diabetes, hyperlipidemia, hypothyroidism, asthma, and depression.
Past surgical history: Angioplasty with placement of multiple drug-eluting stents.
Current medications: Clopidogrel, atenolol, lisinopril, metformin, lovastatin, niacin, mirtazapine, levothroid, and steroid inhalers.
Review of systems: Not contributory.
Social history: Paul is divorced with 3 grown children. He drinks 1-2 glasses of wine with dinner. He has smoked 1 pack of cigarettes daily for the past 40 years.
Family history: Paul reports that his father suffers from similar symptoms, although he has never been formally evaluated by a physician.
Paul suffers from RLS and PLMD. Essential diagnostic features of RLS include an urge to move the legs or arms after lying down in the evening with movement attenuating the symptoms. Supportive clinical features include a family history of RLS, a therapeutic response to dopaminergic drugs, and the presence of periodic limb movements during sleep or occasionally during wakefulness. Associated features include a variable clinical course, symptoms that are typically more severe with age of onset greater than 50 years, a major sleep disturbance, and an unremarkable neurologic examination.
Dopamine agonists, such as ropinirole or pramipexole, are considered first-line agents in the treatment of RLS by most sleep specialists. A secondary etiology for Paul's RLS was not detected (ie, iron deficiency, peripheral neuropathy, or renal insufficiency). Antidepressants, such as mirtazapine, can worsen RLS. Consideration should be made to switch Paul to an antidepressant, such as bupropion, that does not worsen RLS. Lifestyle choices, such as smoking or drinking, may also exacerbate RLS; thus, smoking cessation and abstinence from alcohol should be encouraged.
Paul listened to the various recommendations. He stated that although the RLS was bothersome, he was not interested in taking any more drugs because he was already taking a litany of medications. He added that he was too old to quit smoking or stop drinking and that his depression is difficult to control, with mirtazapine being the only antidepressant that has worked for him. Paul states that his main concern is his heart. He has had 2 recent myocardial infarctions and wants to know whether not treating RLS or PLMD will cause a heart attack or other serious health consequences.
Paul is a 76-year-old man who is referred to the department of sleep medicine in a regional hospital for further evaluation and possible treatment of restless legs syndrome (RLS).
Paul has been experiencing "electric shocklike" sensations in his legs for more than 15 years. The symptoms were initially mild and intermittent but have become progressively more intense and consistent during the past 5 years. Paul has difficulties falling asleep without stretching or massaging his legs. At times, he needs to get out of bed and walk to relieve the symptoms.
Although worse in the evening, Paul also experiences discomfort during the day. He is unable to sit and watch television and avoids going to the theater because of his restlessness. He usually feels fatigued and sleepy during the day because his restless legs prevent him from getting more than 5-6 hours of sleep during the night.
Paul was diagnosed with RLS by his internist, who conducted an evaluation for secondary forms of RLS. Paul's neurologic exam was normal, and measurement of his nerve conduction velocities revealed no evidence of a peripheral neuropathy. Iron, ferritin, creatinine, hematocrit, and other serologic tests were normal. A polysomnographic study revealed severe periodic limb movement disorder (PLMD), with more than 800 periodic limb movements in sleep (PLMS) detected during sleep. Approximately one third of Paul's PLMS symptoms were associated with electroencephalographic (EEG) cortical arousals. No evidence of respiratory disturbances was found.
Allergies: Penicillin (hives).
Past medical history: Positive for 2 myocardial infarctions, peripheral vascular disease, stroke, hypertension, diabetes, hyperlipidemia, hypothyroidism, asthma, and depression.
Past surgical history: Angioplasty with placement of multiple drug-eluting stents.
Current medications: Clopidogrel, atenolol, lisinopril, metformin, lovastatin, niacin, mirtazapine, levothroid, and steroid inhalers.
Review of systems: Not contributory.
Social history: Paul is divorced with 3 grown children. He drinks 1-2 glasses of wine with dinner. He has smoked 1 pack of cigarettes daily for the past 40 years.
Family history: Paul reports that his father suffers from similar symptoms, although he has never been formally evaluated by a physician.
Paul suffers from RLS and PLMD. Essential diagnostic features of RLS include an urge to move the legs or arms after lying down in the evening with movement attenuating the symptoms. Supportive clinical features include a family history of RLS, a therapeutic response to dopaminergic drugs, and the presence of periodic limb movements during sleep or occasionally during wakefulness. Associated features include a variable clinical course, symptoms that are typically more severe with age of onset greater than 50 years, a major sleep disturbance, and an unremarkable neurologic examination.
Dopamine agonists, such as ropinirole or pramipexole, are considered first-line agents in the treatment of RLS by most sleep specialists. A secondary etiology for Paul's RLS was not detected (ie, iron deficiency, peripheral neuropathy, or renal insufficiency). Antidepressants, such as mirtazapine, can worsen RLS. Consideration should be made to switch Paul to an antidepressant, such as bupropion, that does not worsen RLS. Lifestyle choices, such as smoking or drinking, may also exacerbate RLS; thus, smoking cessation and abstinence from alcohol should be encouraged.
Paul listened to the various recommendations. He stated that although the RLS was bothersome, he was not interested in taking any more drugs because he was already taking a litany of medications. He added that he was too old to quit smoking or stop drinking and that his depression is difficult to control, with mirtazapine being the only antidepressant that has worked for him. Paul states that his main concern is his heart. He has had 2 recent myocardial infarctions and wants to know whether not treating RLS or PLMD will cause a heart attack or other serious health consequences.