Taking steps to calm restless legs syndrome

Nursing, Sep 1999 by Sorrell, Jeanne

Your patient says her legs want to go when she wants to rest. Do you know how to help?

WHEN LUETTA MERKLE, 79, was in the hospital for a suspected stroke some years ago, she told the nurse that she had restless legs syndrome (RLS), which she described as a creepy, wormlike feeling inside her legs that made her get up and walk periodically during the night.

That night, Mrs. Merkle climbed over the bed rails to walk off the restless feelings in her legs. The nurse who found her walking in the hallway took her back to bed and restrained her.

This story made an impression on me because Mrs. Merkle is my mother. I knew she'd suffered from RLS for many years, but I'd never understood how devastating it is-or how few nurses have even heard of it. In this article I'll help you understand what a patient with RLS is going through and offer some effective strategies for keeping her safe and comfortable.

What is RLS?

Usually affecting otherwise healthy people, RLS is a motor restlessness of one or both legs (and sometimes the arms). Although the sensationoften described as a creeping, wormlike feeling-is unpleasant, it's not really painful. But it can trigger an irresistible urge to "walk off" the feeling.

Because the patient may be most conscious of the feeling after bedtime, she may get up many times during the night to walk-and suffer serious sleep deprivation as a result. During the day, RLS can interfere with many ordinary activities, including travel that requires long periods of sitting, working at a desk for long periods, or even watching a movie. Although RLS isn't caused by a psychiatric disorder, prolonged sleep deprivation and other lifestyle disruptions can lead to depression and even suicide.

Who's at risk?

Restless legs syndrome affects 5% to 10% of all adults over age 65, 30% to 50% of dialysis patients, and 11 % of pregnant women, especially those in their last 6 months of pregnancy. It's also slightly more common in women, although it can occur in anyone at any age.

The causes of RLS remain mysterious. About 30% of cases have a genetic component; this type may be more severe and harder to treat. Other possible culprits include iron deficiency (with or without anemia) and a low level of dopamine, a neurotransmitter that's also lacking in people with Parkinson's disease.

Detecting RLS

Symptoms of RLS can be vague, develop slowly, and occur on and off for years, making RLS hard to diagnose. The patient may be unaware that she has a medical condition and attribute her restlessness to other causes. So if a patient complains of unusual leg sensations or you witness her walking the floor when she should be sleeping, suspect RLS and investigate further.

First, explain RLS and ask if her legs jerk at night or during the day and if walking or standing relieves the sensations. Also ask if anything like this runs in her family.

Then, take a detailed sleep history to learn if her restlessness disrupts normal sleep. Ask her to describe her sleep patterns, including what keeps her awake or wakes her up, how many times she wakes up at night, how long she's experienced sleep disruptions, and what makes sleeping easier or more difficult. Also document her normal nightly routine, her strategies for falling back to sleep, and whether she naps during the day.

Then, evaluate factors other than RLS that could explain her trouble with sleep-for example, excessive alcohol or caffeine use or smoking. Note any chronic illnesses or medications that could cause sleep disturbance. Changes in her daily life, such as moving to new living quarters, a death in the family, or different exercise and eating habits can all affect sleep patterns.

If you think your patient has a sleep disorder but RLS isn't likely from her history, she may need evaluation by a sleep disorder specialist.

Therapy options

But suppose you identify RLS. How can you help? Unfortunately, no well-defined treatment for RLS has been developed. Sleeping pills and muscle relaxants don't work, but some patients report relief from aspirin or other over-the-counter pain relievers. Certain low-tech home remedies, such as hot baths, leg massages, ice packs, heating pads, nutritional supplements, and regular exercise, also seem to help some people.

In keeping with the theory that RLS may be related to iron deficiency, iron supplements may be in order. Maintaining recommended levels of folic acid may relieve symptoms in pregnant women.

If simple measures don't work, a clinician may prescribe medications that affect dopamine levels, such as carbidopa and levodopa, or a drug that enhances the body's use of dopamine, such as pergolide and gabapentin. Other drugs that are sometimes tried include benzodiazepines, such as clonazepam, diazepam, and carbamazepine. Although one of these treatments may help some patients, none of them have proved widely successful. And even if a patient finds an effective drug, she may periodically develop a tolerance to it and have to take a "drug holiday" for a month or longer. During the hiatus, RLS symptoms can return with greater intensity.