Insomnia and restless leg

Maureen is a 67 years old lady who had been referred with a history of difficult initiating and maintaining sleep, which had been present since her early thirties. She suffered postnatal depression at the time of the birth of her first child and she had anxiety and panic attack at the same time. She was treated with benzodiazepine, which after a few years she stopped of her own accord.

In the last 3 years Maureen reported more difficulty starting sleep mostly related to an uncomfortable sensation involving her calves and her thighs when she starts settling down in the evening to go to sleep. She described the sensation as a tension, sometimes as a soreness involving both calves. She feels the urge to move around which tends to relieve the unpleasant sensation for a few minutes. The discomfort is not described as a pain as such, however. She recalled similar symptoms many years before during her pregnancy, which subsided spontaneously after the birth of her child.

She goes to bed 10.30-11pm and it can take up to 1-1½ hours to fall asleep mostly because she has the need to get out of bed and walk around the room to relieve the discomfort in her leg. She finds the sheet covering her leg unpleasant to bear and she prefers having her leg exposed to the cool temperature of the room, which seems to relieve the symptoms at times. She snores intermittently but her husband does not report any stopping breathing. However, her husband reported frequent kicking of her legs in bed. He described it as if she is ‘riding a bicycle’ and sometimes being ‘kicked all night’. The leg movement appears to be intermittent and not every night.

She wakes between 6.30-7.30am feeling only partially refreshed. She can be somewhat drowsy during the day and she can fall asleep in the morning or afternoon if not busy.

Her current medications include blood pressure medication and an antidepressant (Effexor™).

Recent investigations revealed normal blood testing including normal iron levels. Iron deficiency is a common reason for restless leg syndrome.

In Maureen’s case the difficulty initiating and maintaining sleep seems likely to be related to two possible issues.

  • Depression
  • Restless leg and limb movement disorder during sleep.

However, depression appears to be well controlled on current medication and the symptoms over the last 2 years are more in keeping with increasing restless leg. Her husband’s description of ‘kicking at night’ strongly suggests limb movement disorder, in particular leg movement disorder. The condition is often associated with restless leg and made worse by most antidepressants such as the one Kerry is on.

Maureen did not undergo a sleep test, as the history was sufficient to make the diagnosis. She was started on Sifrol™ about on2 to 3 hours before going to bed with complete resolution of her symptoms as well as reduction in any movement at night.

Restless limb syndrome refers to the sensation of tension, tenderness (sometimes of actual pain), which can involve the legs (usually) but sometimes also the arm, head and trunk. The person may describe it as a creepy crawly sensation involving the calf and the thigh. Symptoms of restlessness usually occur at a particular time of the day usually in the evening, made worse by sitting quietly or when the person tries to quiet down to go to sleep in bed. Typically the sensation of restlessness is relieved by moving the legs around in bed or walking around the room.

Restless leg syndrome is a common complaint as we get older and an important cause of insomnia, both difficulty falling asleep and staying asleep. It often causes poor daytime function with fatigue, sleepiness and depressed mood. Memory and concentration can also be affected.

Patients with restless leg syndrome often have a family history of it suggesting there is a genetic predisposition. Among the reversible factors for restless leg iron deficiency is probably the most common one. In certain conditions such as long-standing diabetes or chronic kidney failure, restless leg can be associated with chronic damage to the nerve endings (called neuropathy). Vitamin B12 deficiency and other nutritional deficiency are also possible causes of restless leg syndrome.

As in Maureen’s case restless legs syndrome is common in pregnancy, in particular in the last trimester. It resolves in the majority of mothers after delivery with no need of any intervention.

People with spinal and lower back injury are also more likely to develop restless leg and periodic leg movement during sleep.

The use of certain medications can aggravate the restless leg. Most anti-depressants, both old and new, (for example amitriptyline, mirtazapine), anti-hypertension calcium channel blockers (for example nifedipine), excessive alcohol and caffeine make restless leg syndrome worse.

Treatment using simple self-help measures can be sufficient in mild cases. Stretching, relaxation exercises and massaging of the affected limb can lessen the discomfort. Cooling the legs by sleeping uncovered or by blowing a fan can be of help.

When simple interventions are not sufficient other treatment options for restless leg and limb movement disorder involve iron replacement in people who have iron deficiency or even low iron levels. Medications that can be used successfully include anti-Parkinson drugs, particularly the new generation (pramipexole, Sifrol®, ropinirole, Reprive®). However after a few weeks/months of using anti-Parkinson medications a side effect called “augmentation” may occur. It refers to progressively early onset of the restless leg symptoms in the evening, sometimes early afternoon, increase in the severity and spread of the restlessness to other part of the body (for example to the arms). The re-occurrence of restlessness in the morning when the person wakes up is also an unwanted side effect, called “rebound”. These problems can be corrected by reducing the amount of medication or changing to a different treatment. In these cases close consultation with your doctor is necessary.

A rare side effect also warrants attention. Medications which increase the activity of dopamine (anti-Parkinson medications) can be associated with compulsive behaviour such as gambling, something to be aware of, given the potentially damaging effect of such activity.

The use of long acting opioids (morphine and morphine like medications) is also very effective. Clinical experience suggests that dependence and tolerance (the need to increase the dose over time) do not occur. This is important to know, as people are often concerned of using morphine long term. Some health practitioners use opioids only in severe cases.

The reason why iron replacement, anti-Parkinson medication and opioids are effective is thought to be their role in the “dopamine system” in the brain. Dopamine is one of the important molecules that regulate the motor system, which is believed to be malfunctioning in restless leg and periodic leg movement in sleep.

The use of benzodiazepine, derivatives of Valium™ such as temazepam or clonazepam (Rivotril™) can also be successful. In patients with neuropathy (chronic damage to the nerve endings) usually associated with diabetes or chronic renal failure, the use of other medications such as Gabapentin (an anti-epileptic medication) can be useful.

Generally in these situations a thorough discussion with your GP or a sleep specialist is advisable before starting any of the above treatments.