A 76-year-old woman consults you because of leg discomfort. Her legs are comfortable during the day, but in the evening she develops an uncomfortable creepy-crawly sensation that keeps her awake for hours. The feeling is temporarily relieved by movement; she will awaken, pace around, and sometimes run water on her legs to achieve relief.
Which of the following is the best initial treatment for her condition?
A. Zolpidem 5 mg po at bedtimeThis woman has restless leg syndrome, a common sensory complaint in the elderly. It is characterized by ill-defined leg discomfort that occurs in the evening when the patient is reclining or at night when the patient is trying to sleep. The uncomfortable sensation is relieved by movement. Examination is normal or shows at most mild distal sensory loss. There are no motor or reflex changes. Although most often idiopathic, RLS can be associated with iron-deficiency or renal insufficiency. Although several agents (benzodiazepines, opioids) can provide symptomatic relief, dopamine-enhancing drugs are most effective. Levodopa-carbidopa is effective but may lead to rebound effects, so direct dopamine agonists (pramipexole, ropinirole) are now preferred. Soporifics such as zolpidem or trazodone are usually ineffective. RLS is a sensory, not a motor, syndrome, so muscle stretching exercises or muscle relaxants rarely provide symptom relief.