Sleep Modules
Restless Leg Syndrome
Case Study
James A. Rowley, MD
for the Sleep Education for Pulmonary Fellows and Practitioners,
SRN ATS Committee
May 2015
Part 1: Case Presentation
AF is a 35 year old female who comes to your office with complaints of difficulty falling asleep at night for the last year.
Questions
- What are important components of a good history focused on insomnia?
- What is the differential diagnosis of insomnia?
Case Presentation
- Upon further questioning, AF states:
- Bedtime is at 11p and generally takes her 30-45 minutes to fall asleep
- Wake time is 7a weekdays, 8a on weekends
- When cannot fall asleep, generally stays in bed watching the clock
- While trying to fall asleep, feels restless and is constantly moving her legs
- Does not watch TV or read in bed
- Only drinks juices or herbal tea after dinner
- Does not smoke or consume alcohol
- Is generally sleepy when gets into bed at night
- Does not worry about her sleep during the day
- Feels fatigued during the day
Questions
- What additional questions should be asked to confirm the diagnosis of restless leg syndrome?
- Are there any questionnaires for RLS?
Case Presentation
- Upon further questioning, AF states that:
- The restlessness in her legs often feels like something is crawling up them
- The restlessness generally improves if she moves her legs around
- She occasionally notices the creepy-crawly feeling when watching TV in her living room if lying on couch
- Symptoms bother her at least 4 nights per week
- Had similar symptoms about 5 years ago during her pregnancy
- Her father and brother have similar symptoms
Part II: Diagnostic Testing
- Given the diagnosis of RLS:
- Which medications need to be checked for?
- What diagnostic testing is indicated?
Case Presentation
- Upon further questioning:
- AF only medication is omeprazole for GERD
- Ferritin level is 80
Questions
- What treatment options are available for RLS and what would you recommend for this patient?
- Is RLS associated with other medical conditions and long term health outcomes?
Part III: Treatment
You prescribe AF pramipexole 0.25 mg one hour before bedtime.
AF returns after 2 months with marked improvement in:
- Symptoms of restlessness: now only bother her about 1x/month
- Sleep latency most nights ~10 minutes
Question
- What is the relationship between RLS and periodic limb movements during wakefulness (Figure 1) and sleep (Figure 2) as observed on a sleep study?
Figure 1:
Tracing of PLMs during Sleep
Figure 2:
Tracing of PLMs during Wakefulness
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