From the Guidelines
Restless Leg Syndrome (RLS) in older adults should be managed with gabapentin enacarbil as the first-line treatment, as recommended by the American Academy of Sleep Medicine (AASM) with a strong recommendation and moderate certainty of evidence 1.
Treatment Approach
The treatment of RLS in older adults involves both non-medication and medication approaches. Lifestyle modifications are essential and include:
- Regular exercise
- Maintaining good sleep hygiene
- Avoiding caffeine and alcohol
- Practicing relaxation techniques before bedtime
Medication Options
For medication options, the AASM recommends the use of gabapentin enacarbil over no gabapentin enacarbil with a strong recommendation and moderate certainty of evidence 1. Other alternatives include:
- Gabapentin
- Pregabalin
- IV ferric carboxymaltose
- IV low molecular weight iron dextran
- IV ferumoxytol
Important Considerations
It is essential to note that some medications, including antidepressants, antihistamines, and antipsychotics, can worsen RLS symptoms. Regular follow-up is crucial to monitor symptom control and medication side effects. The treatment approach should prioritize the patient's quality of life, and the medication should be chosen based on the patient's specific needs and medical history.
Iron Supplementation
Iron supplementation with ferrous sulfate may be beneficial if ferritin levels are below 75 ng/mL, but the evidence is limited, and the recommendation is conditional 1. IV iron supplementation is recommended for patients with appropriate iron status, and IV ferric carboxymaltose receives a strong recommendation 1.
Dopamine Agonists
Dopamine agonists, such as pramipexole and ropinirole, are not recommended as first-line treatments due to the risk of augmentation and other side effects 1. However, they may be considered in certain cases, and the decision should be made based on the patient's individual needs and medical history.
From the FDA Drug Label
The effectiveness of ropinirole in the treatment of RLS was demonstrated in randomized, double-blind, placebo-controlled trials in adults diagnosed with RLS using the International Restless Legs Syndrome Study Group diagnostic criteria Across the 3 trials, the mean duration of RLS was 16 to 22 years (range: 0 to 65 years), mean age was approximately 54 years (range: 18 to 79 years), and approximately 61% were women. In all 3 trials, a statistically significant difference between the treatment group receiving ropinirole and the treatment group receiving placebo was observed at Week 12 for both the mean change from baseline in the IRLS scale total score and the percentage of patients rated as responders (much improved or very much improved) on the CGI-I
Ropinirole is effective in treating Restless Legs Syndrome (RLS) in adults, as demonstrated by statistically significant improvements in IRLS scale total score and CGI-I scores compared to placebo 2, 2.
- The mean age of patients in the trials was approximately 54 years, but the age range was 18 to 79 years, suggesting that ropinirole may be effective in older adults with RLS.
- However, caution should be exercised when using ropinirole in older adults, as they may be more susceptible to adverse reactions such as dizziness, somnolence, and nausea 2.
- Dosing should be individualized and titrated carefully to minimize the risk of adverse reactions and maximize efficacy.
From the Research
Restless Leg Syndrome in Older Adults
- Restless legs syndrome (RLS) is common in the elderly, with an estimated prevalence of 10 to 35% in individuals over 65 years of age 3.
- The symptoms of RLS occur at rest and result in motor restlessness, with movement often temporarily relieving the symptoms 3.
- RLS can be a primary disorder that develops in the young and includes familial cases, or secondary RLS that occurs in association with iron-deficiency anaemia, uraemia, and polyneuropathies 3.
Diagnosis and Management
- Diagnosis of RLS is based on a thorough history and examination, and iron measures, including ferritin and transferrin saturation, should be checked at presentation and with worsened symptoms 4.
- First-line management options include iron-replacement therapy, gabapentin, pregabalin, and dopamine agonists such as pramipexole, ropinirole, and rotigotine 4.
- Non-pharmacological interventions, such as repetitive transcranial magnetic stimulation, exercise, compression devices, counterstrain manipulation, infrared therapy, and standard acupuncture, may also be beneficial for reducing RLS severity and enhancing sleep 5.
Treatment Options
- Dopaminergic drugs, such as pergolide, pramipexole, and ropinirole, are effective in treating RLS, with the dopamine precursor levodopa also being an option 3.
- Anticonvulsants, such as gabapentin and carbamazepine, may be helpful in patients with painful symptoms 3.
- Opioids and hypnosedatives may be used in selected patients, but may have troubling adverse effects in the elderly 3.
- Gabapentin and ropinirole have been shown to be similarly effective in treating RLS, with significant improvements in International Restless Legs Syndrome Study Group questionnaire scores and polysomnographic data 6.