Does your sleepy patient have restless legs syndrome?

Eighty percent of patients with restless legs syndrome (RLS) experience periodic limb movements of sleep (PLMS). RLS alone causes sleep-onset insomnia and unpleasant sensations in the limbs; both RLS and PLMS cause sleep-maintenance insomnia and excessive daytime sleepiness. Look for a history of repeated uncomfortable sensations that induce the urge to move; in physical examination, look for neurologic findings. Rule out iron, vitamin B₁₂, and folate deficiencies, as well as thyroid and renal disease and medication side effects. Advise patients with RLS/PLMS to eliminate alcohol, caffeine, and smoking. Also consider a step-care approach, starting with a dopamine agonist or a benzodiazepine and progressing, if necessary, to a low- potency or high-potency opioid.