What is the best approach to manage Restless Legs Syndrome (RLS) in a hospice patient with Coronary Artery Disease (CAD) and dementia?

Managing Restless Legs Syndrome in a Hospice Patient with CAD and Dementia

Start with gabapentin enacarbil or gabapentin as first-line therapy, as this approach improves both nighttime agitation and sleep in dementia patients with RLS while avoiding the psychiatric complications of dopamine agonists. 1, 2

Initial Assessment

Before initiating pharmacological treatment, check the following:

• Obtain morning fasting iron studies (ferritin and transferrin saturation) after avoiding iron supplements for 24 hours, as iron deficiency directly correlates with nighttime agitation severity in dementia patients with RLS 1, 3
• Review and deprescribe medications that worsen RLS, including antihistamines, serotonergic antidepressants (SSRIs), and antipsychotics—79% of dementia patients with RLS receive at least one RLS-exacerbating medication 1, 3
• Assess for untreated sleep apnea, as this can worsen RLS symptoms 1

Iron Repletion Strategy

• Supplement with oral ferrous sulfate if ferritin ≤75 ng/mL or transferrin saturation <20%, as low transferrin saturation independently predicts more frequent nighttime agitation behaviors 1, 3
• In hospice settings where oral intake is challenging, IV ferric carboxymaltose is strongly recommended for appropriate iron parameters 1

First-Line Pharmacological Treatment

Gabapentin enacarbil (Horizant) is the optimal choice for this specific population:

• Start with 600 mg once daily at 5 PM, as this FDA-approved formulation demonstrated significant reduction in nighttime agitation (estimate -1.67, P=0.003) and increased total sleep time by 48 minutes at 8 weeks in dementia patients with RLS 2, 4
• This agent avoids the visual hallucinations and psychiatric worsening that dopamine agonists commonly cause in dementia patients, particularly those with Lewy body features 5
• Benefits appear within 2 weeks, with sustained improvement through 8 weeks and lower relapse rates in maintenance studies 2, 4

Alternative if Gabapentin Enacarbil is Unavailable

• Use immediate-release gabapentin 300 mg at bedtime initially, titrating up to 900-1800 mg/day divided into 2-3 doses if needed for daytime symptoms 1, 6
• Gabapentin demonstrated significant reduction in periodic leg movements (P=0.003) and was well-tolerated in RLS patients 6

Critical Safety Considerations for Hospice Patients

• Monitor for falls risk, as the gabapentin enacarbil group showed a trend toward more falls (P=0.066) in the dementia trial, though overall serious adverse events were similar to placebo 2
• Somnolence and dizziness are the most common side effects but are typically mild to moderate and may actually be beneficial for nighttime agitation in hospice settings 1, 4
• Gabapentin is safe in CAD patients, as it lacks cardiovascular contraindications unlike dopamine agonists which can cause orthostatic hypotension 1

Medications to Absolutely Avoid

• Do not use dopamine agonists (pramipexole, ropinirole, rotigotine) in dementia patients, as they cause visual hallucinations, metamorphopsia, and psychiatric worsening, particularly in Lewy body dementia 1, 7, 5
• Avoid clonazepam, which has very low evidence for RLS efficacy, causes sedation, and increases fall risk without reducing periodic leg movements 1
• Do not use antipsychotics like lurasidone for agitation management, as dopamine antagonism will worsen RLS symptoms 1

Expected Outcomes in Hospice Context

The primary goal is improving quality of life through better sleep and reduced nighttime agitation:

• Sleep time increases by approximately 48 minutes with gabapentin enacarbil treatment 2
• Nighttime wake time decreases by 11-12 minutes at 2 and 8 weeks 2
• Nighttime agitation behaviors significantly decrease, improving caregiver burden and patient comfort in the final stages of life 2, 3

Common Pitfall to Avoid

Do not attribute nighttime agitation solely to dementia progression or "sundowning" without assessing for RLS, as this treatable condition is frequently overlooked and directly contributes to agitation severity in 79% of cases where RLS-exacerbating medications are prescribed 3