Case History

Maria was a fifty-seven-year-old former schoolteacher who developed progressive kidney disease and symptoms of restless legs syndrome at about the same time. As the kidney disease worsened, so did her RLS symptoms. She was constantly bothered by an itching sensation so severe she had to move around all evening to keep from being driven crazy. She never woke feeling rested and became more and more exhausted with each passing month.

Eventually Maria had a kidney transplant; this took care of her kidney problems but had no affect on her RLS symptoms. When she came to see me, she said she was so tired she rarely left the house. In fact, that morning she hadn't had enough energy to get dressed and arrived in her nightgown and robe, with rollers still in her hair.

A sleep study showed that severe periodic limb movement disorder was disturbing her sleep in addition to the RLS she experienced while awake. I started her on a dopamine agent to treat both.

When Maria returned a month later, she was a changed woman. She was well-dressed, beautifully coiffed, and wide awake. She said her leg discomfort was gone, she slept great at night, and she was no longer sleepy all day. She was feeling so good that she had booked herself on a cruise to see the Panama Canal and had to cut our visit short to catch her boat. I wished her bon voyage as she walked out the door.

the past, they were often misdiagnosed as having hypochondria, manic depression, or a stress-related disorder. Children who have RLS are often incorrectly diagnosed as having attention deficit disorder. Some people report that their symptoms started in adolescence and that adults attributed the problem to growing pains or back trouble. In the large study cited earlier, less than 10 percent of those who told their primary care physician about their symptoms were diagnosed with RLS.

The cause of RLS isn't known, but researchers suspect it's related to a malfunction in the pathways by which the brain controls movement reflexes and sensations. Several such pathways are affected by the brain's transmission of dopamine, a neurotransmit-ter that helps control muscle activity, natural opiate production, and body iron levels. Increasing the body's level of dopamine, iron, and opiate-like compounds can reduce RLS symptoms. We do know that RLS has a genetic basis, with as many as half of people with the condition noting that other members of their family have similar symptoms. Each child of an affected person has a 50 percent chance of inheriting the condition.

In some people, RLS has been linked to the presence of other medical conditions. Anemia due to iron deficiency may be a contributing factor, while it has also been linked to diabetes, arthritis, kidney failure, and neuropathy (nerve damage). In some people, caffeine, stress, nicotine, fatigue, prolonged exposure to a cold or very warm environment, and certain medications—including anti-histamines, antidepressants, or lithium—can exacerbate RLS. Women may find that symptoms flare up during menstruation, pregnancy, or menopause. At least one in four pregnant women experiences restless legs. Although RLS can occur at any time, it often worsens with age and tends to be more common and severe in people over fifty (see Figure 12.1).

There is no single diagnostic test for RLS, and standard neurological examinations often reveal no abnormality. Because of its unique symptoms—the strange sensations and the almost irresistible need to move the affected limb—a doctor's diagnosis is made based on the individual's description of symptoms. The doctor will also review the patient's medical history and family history; conduct a physical examination; and order routine blood tests to check for anemia, iron or vitamin deficiency, diabetes, or kidney problems.

figure 12.1 Prevalence of Restless Legs Syndrome by Age 61—

figure 12.1 Prevalence of Restless Legs Syndrome by Age 61—

20-29 I 30-391 40-49 1 50-59 I 60-69 I 70-79 ' 80+ Age (years)

20-29 I 30-391 40-49 1 50-59 I 60-69 I 70-79 ' 80+ Age (years)

RLS can occur at any age, but it tends to be more common and severe in people over fifty. Source: Adapted from R. P. Allen, et al., "Restless Legs Syndrome Prevalence and Impact." Archives of Internal Medicine 165, 2005: 1286-92.

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