Neuro chapter 11 Restless leg syndrome Flashcards

1
Q

Restless legs syndrome

A
  • chronic neurologic disorder characterized by an irresistible urge to move the legs.
  • accompanied by uncomfortable, unpleasant sensations in the legs.
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2
Q

Symptoms of RLS cannot be attributed to…

A
  • other medical conditions
  • behavioral conditions
  • the effects of drug abuse or medication.
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3
Q

Primary causes of RLS

A
  • idiopathic in most cases; possible dopaminergic system involvement, iron deficiencies, or genetics
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4
Q

early onset

A

age < 45 years; family clusters, slow progression

- tends to be more severe

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5
Q

late onset

A

age > 45 years, no family clusters
- more rapid progression of disease

often associated with

  • radiculopathy
  • neuropathy
  • myelopathy
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6
Q

secondary causes of RLS

may be associated with:

A

end stage renal disease/uremia

  • pregnancy
  • iron deficiency anemia
  • diabetic neuropathy
  • Parkinson’s disease
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7
Q

secondary causes of RLS

Pharmacologic

A
  • SSRI’s
  • SNRIs
  • diphenhydramine
  • dopamine antagonists
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8
Q

Patients with severe RLS generally have first symptoms…

A

before age 20, but are not diagnosed.

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9
Q

Women are affected…..

A

twice as often as men.

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10
Q

white patients affected ______ often than black patients

A

more

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11
Q

Incidence in children and adolescents is unknown, but consider….

A

in children who can express all diagnostic criteria in their own words.

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12
Q

Risk factors

A

family history
iron deficiency anemia
pregnancy

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13
Q

assessment findings

A
  • irresistible urge to move legs
  • urge worsens with periods of rest/inactivity
  • urge is partially or completely relieved by movement
  • urge worsens in the evening or night versus daytime OR occurs only in the evening/at night
  • symptoms occur at least 3 times/week OR have persisted > or equal to 3 months
  • use quiestionnaires to support diagnosis
  • physical examination evaluates for potential secondary causes such as neuropathy, radiculopathy, or Parkinsonian features
  • a normal neurologic exam rules out secondadry causes and supports RLS diagnosis
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14
Q

differential diagnosis

Adult

A
Periodic limb movement disorder (PLMD)
Volitional limb movements or physiologic movements during sleep
Akathisia
neuropathy
nocturnal leg cramps
pain in legs and when moving toes: involuntary flexion/extension of toes; associated with spinal cord injury
- vascular disease
- radiculopathy
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15
Q

differential diagnosis

pediatric

A
  • growing pains
  • motor tics
  • ADHD
  • Muscle pain
  • leg cramps
  • Osgood-Schlatter disease
  • chondromalacia patella
  • arthalgias
  • sleep-disordered breathing and periodic limb movements
  • akathisia
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16
Q

Diagnostic studies

A

serum iron levels
serum ferritin
transferrin saturation
TIBC

17
Q

Diagnostics

if secondary causes suspected:

A
CBC
BUN
Cr
FBG
Mag
TSH
Vit B12
Folate
18
Q

Diagnostics

if polyneuropathy or radiculopathy suspected

A

needle electromyography and nerve conduction studies

19
Q

Diagnostics

Polysomnography

A

consider if periodic leg movement syndrome suspected or if significant sleep disturbance occurs despite treatment

20
Q

Decline may be more rapid with…

A

presence of associated comorbid conditions such as neuropathy, radiculopathy, or parkinsonian features

21
Q

Prevention

A

none known
healthy lifestyle practices may assist with treatment (smoking cessation, regular exercise, moderate alcohol use, stress management)

22
Q

Nonpharmacologic management

A
Hot or cold bath
limb massage
compression stockings
counterpulsation devices
CBT
exercise
sleep hygiene measures
avoidance of caffeine, alcohol, and nicotine
relaxis vibrating pad (requires prescription)
23
Q

Pharmacologic management

A

Intermittent or daily, depending on nature of the symptoms
- discontinue medications causing symptoms when possible: SSRIs, SNRIs, diphenhydramine, and dopamine antagonists
- opioids and sedative hypnotics are not approved for RLS
iron replacement should be guided by lab results and not empirically prescribed

24
Q

Dopaminergic agents

A
  • dopamine agonists are considered first-line, reducing RLS symptoms and improving quality of life and sleep
  • extended-release forms are not approved for RLS
  • Pramipexole is not metabolized by the liver
  • half-lives for all drugs range 5-7 hours
  • short-term adverse effects include nausea, vomiting, somnolence, and fatigue
  • augmentation is common with this class
25
Q

Dopaminergic agents

Ropinirole

A

caution with pregnancy
caution with renal disease
XR is not approved for RLS

26
Q

Dopaminergic agents

Pramipexole

A

caution with pregnancy

  • increase dose by 0.125mg every 4-7 days
  • start with lower dose for CrCl 20-60 and increase only every 14 days
27
Q

Dopaminergic agents

Rotigotine transdermal

A

caution with pregnancy

  • may increase by 1mg/24hrs. every week
  • taper dose by 1 mg/24hrs QOD to discontinue
28
Q

Anti-convulsants: Alpha-2-delta ligands

A

exact mechanism unknown; prevents pain-related responses

  • prodrug of gabapentin
  • only anticonvulsant drug approved for RLS
  • metabolism not required by liver
29
Q

Gabapentin encarbil

A

caution with pregnancy

  • monitor baseline creatinine, signs and symptoms of depression, behavior changes and suicidality
  • give with food around 5 pm, per prescribing information
  • do not crush/cut/chew
  • not approved for children
30
Q

consultation/referral

A

referral to sleep or neurology specialist for RLS that is unresponsive or difficult to manage; always refer children

31
Q

follow-up

A

inquire about symptom relief and medication tolerance

- if symptoms improve, periodically reassess, especially with dopamine agonist therapy, due to augmentation effect

32
Q

expected course

A
  • RLS is a lifelong condition without a cure
  • therapy focuses on minimizing symptoms and improving restful sleep
  • symptoms gradually worsen with age; can be exacerbated by comorbid conditions
  • remission may occur, with symptoms disappearing for days, weeks or months, but eventually returning
33
Q

possible complications

A
  • sleep deprivation
  • insomnia
  • depression
  • daytime sleepiness