What is the first-line treatment for restless legs syndrome (RLS) in geriatric patients?

First-Line Treatment for Restless Legs Syndrome in Geriatric Patients

Alpha-2-delta ligands such as pregabalin or gabapentin are recommended as first-line treatments for restless legs syndrome (RLS) in geriatric patients due to their efficacy and favorable long-term safety profile. 1

Treatment Algorithm for RLS in Geriatric Patients

First-Line Therapy

1. Alpha-2-delta ligands

   • Pregabalin or gabapentin
   • Preferred due to lower risk of augmentation compared to dopamine agonists
   • Particularly beneficial in elderly patients due to favorable safety profile

2. Iron supplementation

   • Should be initiated concurrently if ferritin levels <50 ng/mL
   • Iron deficiency is a common secondary cause of RLS

Second-Line Therapy

1. Dopamine agonists

   • Ropinirole (starting dose: 0.25 mg orally 1-3 hours before bedtime) 2, 3
   • Pramipexole (starting dose: 0.125 mg orally 2-3 hours before bedtime) 2
   • Rotigotine patch
   • Important caution: Use for short-term management only due to high risk of augmentation
   • Special considerations in elderly patients:
     • Risk of orthostatic hypotension
     • Potential drug interactions
     • Risk of compulsive behaviors

2. Opioids

   • Consider for severe cases that fail to respond to first and second-line treatments
   • Use with caution due to risk of central sleep apnea and respiratory depression

Special Considerations in Geriatric Patients

Assessment

• Obtain serum ferritin (target >50 ng/mL) 2, 1
• Consider complete blood count, basic metabolic panel, and liver function tests
• Evaluate for common secondary causes:
  • Renal disease
  • Diabetes
  • Medication side effects
  • Thyroid disorders

Medication Management

• Start with lower doses and titrate slowly in geriatric patients
• Monitor for orthostatic hypotension, especially with dopamine agonists
• Be vigilant for augmentation with dopamine agonists, characterized by:
  • Earlier symptom onset during the day
  • Increased symptom intensity
  • Spread of symptoms to other body parts 2

Non-Pharmacological Approaches

• Moderate exercise
• Smoking cessation
• Alcohol avoidance
• Caffeine reduction or elimination
• Discontinuation of potentially exacerbating medications 2, 1

Clinical Pearls and Pitfalls

Pitfalls to Avoid

1. Prolonged use of dopamine agonists - While historically considered first-line, current evidence supports limiting their use due to high risk of augmentation (30-80% of patients)
2. Overlooking iron deficiency - Always check ferritin levels and supplement when <50 ng/mL
3. Inadequate dose titration - Elderly patients often require lower starting doses but may need adequate titration for symptom control

When to Consider Specialist Referral

• Symptoms refractory to first and second-line treatments
• Significant augmentation
• Uncertainty about diagnosis
• Presence of complex comorbidities

The treatment paradigm for RLS has evolved significantly, with alpha-2-delta ligands now preferred over dopamine agonists as first-line therapy, particularly in geriatric patients where the risk-benefit profile favors these agents due to lower risk of augmentation and favorable side effect profile 1.