A 70-year-old man comes to the office due to trouble sleeping. He has experienced a progressively worsening urge to move his legs when he watches television at night; the urge persists when he goes to bed and often prevents him from getting to sleep. The sensation to move his legs is not present during the day and disappears when he gets up and walks. There is no associated lower extremity numbness, tingling, or weakness. Medical history is notable only for mild hypertension treated with lisinopril.
Physical examination, including neurologic examination, is unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Question

A 70-year-old man comes to the office due to trouble sleeping.  He has experienced a progressively worsening urge to move his legs when he watches television at night; the urge persists when he goes to bed and often prevents him from getting to sleep.  The sensation to move his legs is not present during the day and disappears when he gets up and walks.  There is no associated lower extremity numbness, tingling, or weakness.  Medical history is notable only for mild hypertension treated with lisinopril.
Physical examination, including neurologic examination, is unremarkable.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9876_e9c1_853d_5dd4ea30ef72_MD0002_00 This patient with trouble sleeping and an uncomfortable urge to move his legs that is worse at night and relieved with movement has restless legs syndrome (RLS). RLS is a movement disorder that affects up to 15% of the population and is more common in the elderly, women, and white individuals. Iron deficiency is commonly associated with RLS, and ferritin should be measured in all patients. Low serum ferritin levels often correlate with the severity of symptoms, regardless of whether anemia is present. Patients with a ferritin level <75 µg/L or other evidence of iron deficiency should receive iron supplementation, which may alleviate symptoms. Additional interventions include avoiding medications that worsen RLS (eg, antidepressants, antidopaminergic agents) and behavioral interventions (eg, exercise, reduction of caffeine, massage). Patients who are refractory to conservative therapy may be treated with dopamine agonists (eg, pramipexole) or gabapentin (Choice B). (Choice A) Peripheral neuropathy due to diabetes mellitus (or other disorders) can be associated with RLS. However, this patient has a normal neurologic examination without peripheral numbness, making diabetic neuropathy unlikely. (Choice C) Selective serotonin reuptake inhibitors are useful for treatment of depression but may provoke or worsen RLS symptoms. (Choice E) Polysomnography can diagnose periodic limb movements of sleep that frequently accompany RLS. However, polysomnography is not necessary to diagnose RLS and is usually considered in patients who do not respond to empiric treatment. Educational objective: Restless legs syndrome is a movement disorder characterized by a sensation of lower extremity discomfort and an urge to move the legs that is relieved with movement. It is commonly associated with iron deficiency. Patients with a ferritin level <75 µg/L or other evidence of iron deficiency should receive iron supplementation, which may alleviate symptoms. __________ References: Restless legs syndrome: pathophysiology and modern management. (http://www.ncbi.nlm.nih.gov/pubmed/23524988) The treatment of restless legs syndrome and periodic limb movement disorder in adults--an update for 2012: practice parameters with an evidence-based systematic review and meta-analyses: an American Academy of Sleep Medicine Clinical Practice Guideline. (http://www.ncbi.nlm.nih.gov/pubmed/22851801)

A 70-Year-Old Man Comes to the Office Due to Trouble