Restless legs syndrome (Cognitively impaired adults)
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Signs of leg discomfort such as rubbing or kneading the legs and groaning while holding the lower extremities are present Yes No
Excessive motor activity in the lower extremities such as pacing, fidgeting, repetitive kicking, tossing and turning in bed, slapping the legs on the mattress, cycling movements of the lower limbs, repetitive foot tapping, rubbing the feet together, and inability to remain seated are present Yes No
Signs of leg discomfort are exclusively present or worsen during periods of rest or inactivity Yes No
Signs of leg discomfort are diminished with activity Yes No
Items #1 and 2 either occur only in the evening or at night or are worse at those times than during the day Yes No
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Restless legs syndrome (Cognitively impaired adults)

Restless legs syndrome (RLS) is a common sleep disorder, felt to be neurologic in origin, and includes:

  • An urge to move that is associated with unpleasant sensations
  • The symptoms are worst at rest
  • The symptoms are relieved by movement
  • The symptoms are most severe at night

This condition is common in Western countries and affects 5-10% of adults with 25% of these cases having onset before age of 20 years. RLS may be inheritable, as children with RLS have an affected biologic parent in 70% of cases, with both parents affected in ~16% of cases.

The Cognitively Impaired Essential Criteria based upon the 2003 NIH Workshop Diagnostic Criteria of RLS are:

  1. Signs of leg discomfort such as rubbing or kneading the legs and groaning while holding the lower extremities are present
  2. Excessive motor activity in the lower extremities such as pacing, fidgeting, repetitive kicking, tossing and turning in bed, slapping the legs on the mattress, cycling movements of the lower limbs, repetitive foot tapping, rubbing the feet together, and inability to remain seated are present
  3. Signs of leg discomfort are exclusively present or worsen during periods of rest or inactivity
  4. Signs of leg discomfort are diminished with activity
  5. Items #1 & 2 either occur only in the evening or at night or are worse at those times than during the day

All 5 items should be present for a diagnosis of RLS in a cognitively impaired adult.

Features that further support the diagnosis of RLS include:

  1. Family history
    RLS is 3-5 times higher in prevalence in first-degree relatives of patients with RLS.
  2. Response to dopaminergic therapy
    Almost all RLS patients will at minimum show an initial positive therapeutic response to either L-dopa or dopamine receptor agonists at low doses (the initial response is often not maintained with time).
  3. Periodic limb movement (during wakefulness or sleep)
    Periodic limb movements in sleep (PLMS) occurs in >85% of patients with RLS (often occurs in patients with other disorders and the elderly - is not specific; and is less common in children)

Features associated with RLS include:

  1. Natural clinical course (has significant variation)
    • Age of onset of symptoms <50 years often is with a more insidious onset of symptoms
    • Age of onset of symptoms >50 years is often associated with more abrupt onset of symptoms; often with higher severity
    • Symptoms can be intermittent and may also remit for years in some cases
  2. Sleep disturbance
    This is a common major complaint of those with RLS and is often the primary reason the patient with RLS seeks medical treatment
  3. Medical evaluation/physical examination
    • Typically is normal
    • Consideration of other related items may include
      • Iron status (decreased stores are a significant potential risk factor that is easily addressed)
      • Examination and history for presence of peripheral neuropathy and radiculopathy (often associated with RLS, but specific treatment is often unchanged but may require additional evaluation)

Non-cognitively impaired adults often describe their symptoms as:

  • Ants crawling
  • Burning
  • Crazy legs
  • Creepy-crawly
  • Electric current
  • Elvis legs
  • Fidgets
  • Grabbing sensation
  • Heebie jeebies
  • Itching bones
  • Jimmy legs
  • Jittery
  • Pain
  • Pulling
  • Shock-like feelings
  • Soda bubbling in the veins
  • The "gotta moves"
  • Worms moving
  • Tearing
  • Throbbing
  • Tight feeling

References:

  1. Allen RA, Picchietti D, Hening WA, et al. Restless legs: diagnostic criteria, special considerations, and epidemiology. A report from the restless legs diagnosis and epidemiology workshop at the National Institutes of Health. Sleep Medicine 2003;4:101-119.
  2. Picchietti D, Allen RP, Walters AS, et al. Restless Legs Syndrome: Prevalence and Impact in Children and Adolescents - The Peds REST Study. Pediatrics . 2007;120:253-66.