A 76 year old right handed woman presented with daytime tiredness and night time insomnia. She had been a good sleeper until she was diagnosed with breast cancer at age 65 and underwent a mastectomy. Afterwards, she complained of difficulty falling and staying asleep. Anemia was diagnosed post operatively. She was treated with the aromatase inhibitor, anastrozole 1 mg daily, but developed insomnia and it was changed to an anti estrogen, exemestane 25 mg daily. Because of anxiety related to the diagnosis of breast cancer, she was started on citalopram 20 mg in the morning.
In the last week, she complained of 2 nights with no sleeping and spent several hours wandering about the house. Melatonin 3-10 mg before bed did not help. She tried relaxation CDs but could not complete the exercises. On other nights, she stayed in bed feeling hot and uncomfortable with an annoying tingling in her feet. She awakens multiple times, and has to leave her bed to massage her legs, but by 3:30 AM she can finally return to sleep without further interruption. She denies palpable leg cramps.
She lives alone, but does not think she snores. In the family there are no similar problems. She lost 25 lbs since the cancer diagnosis. She has not used tobacco and has tried 1 glass of red wine before bed, but it increased the problem. She limits coffee to the morning and avoids snacks in the evening.
On physical exam she appears mildly depressed, is well nourished with a body mass index of 26 kg/m2. Her oral pharyngeal airway is mildly crowded. On neurologic exam there is no focal weakness or incoordination. However, vibration sense is diminished in her feet. The remainder of the physical examination is normal.
You have reviewed and reinforced sleep hygiene practices with no improvement in her symptoms.
Which of the following would be the most useful in the treatment of this patient?
measure serum ferritin
home sleep study
trial of autoPAP
cognitive behavioral therapy
Answer: A. measure serum ferritin
The patient has symptoms suggestive of restless legs syndrome1,2 with insomnia that may be related to periodic limb movements of sleep. She has had a recent onset of symptoms with a surgical procedure associated with a possible iron deficiency. There is a low probability of obstructive sleep apnea given the lack of snoring and her weight loss, but she does live alone. If treatment of restless legs syndrome does not result in improvement, a polysomnogram may be indicated in the future. Without a reasonable probability of obstructive sleep apnea, home sleep testing should not be ordered. Cognitive behavioral therapy is the best initial therapy for patients with a primary insomnia. However, her insomnia symptoms are most likely explained by restless legs syndrome.
She has described a problem with sleep initiation and maintenance. Pertinent additional information that would attribute these symptoms to restless legs syndrome include:
Is the need to move or wander more in evening hours or upon going to bed?
Was there a sensory symptom in the legs that she could describe?
Did moving walking or as she said “wandering” relieve symptoms?
Did symptoms return with immobility?
Were there signs of periodic limb movements (e.g., disheveled bed sheets)?
Were other diseases excluded?
If the ferritin is low < 50 mcg/dl, a course of iron replacement therapy is indicated.1 Otherwise treatment with a dopamine agonist such as ropinirole or pramipexole should be considered as initial therapy. If prescribed, it is important to warn patients of possible daytime sleep attacks and compulsive behavior (e.g., gambling). Gabapentin enacarbil or gabapentin are most useful if there are comorbid hot flashes or pain associated with the restless legs. Recently pregabalin was found effective with less augmentation than pramipexole.2 Opioids in the form of tramadol and oxycodone in low doses may be tried in refractory patients, or those with significant augmentation. A trial of venodyne compression boots may provide another approach without the need for medication.3
This was not an industry supported study. The authors have indicated no financial conflicts of interest. Work was performed at Brigham and Women's Hospital, Boston, MA.
Horowitz S, Quan SF. A case of insomnia in an elderly woman. J Clin Sleep Med 2014;10(6):699-700.
Aurora RN, Kristo DA, Bista SR, et al., authors. The treatment of restless legs syndrome and periodic limb movement disorder in adults—an update for 2012: practice parameters with an evidence-based systematic review and meta-analysis. Sleep. 2012;35:1039–59. [PubMed Central][PubMed]
Allen RP, Chen C, Garcia-Borreguerro D, et al., authors. Comparison of pregabalin with pramipexole for restless leg syndrome. N Engl J Med. 2014;370:621–31. [PubMed]
Lettieri C, Eliasson A, authors. Pneumatic compression devices are an effective treatment for restless leg syndrome. Chest. 2009;135:74–80. [PubMed]