Restless legs, a very annoying complaint

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nancysinatra

nancysinatra

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I would like to devote this thread to some annoying things, like a consult I got yesterday, asking me to evaluate a patient where the "consult question" turned out to be the patient saying, "I have restless legs. I have had this my whole life."

Does anyone else get this complaint very often? I hear about restless legs from patients a lot and never once have I been able to correlate it with a psych med. Yet a lot of people complain that their medications cause it. Aside from a medication side effect, I am stumped as to what this condition could possibly have to do with mental health.

I work hard to empathize with my patients, and sometimes it takes a lot out of me, but especially when they are complaining about their legs, which are nowhere near their brains - then it just bugs me. To get this as a consult question is even worse - all you need is general anatomy to know that it's not a psychiatric problem. I feel like an orthopedic surgeon being asked to provide DBT.
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nancysinatra said:
I would like to devote this thread to some annoying things, like a consult I got yesterday, asking me to evaluate a patient where the "consult question" turned out to be the patient saying, "I have restless legs. I have had this my whole life."

Does anyone else get this complaint very often? I hear about restless legs from patients a lot and never once have I been able to correlate it with a psych med. Yet a lot of people complain that their medications cause it. Aside from a medication side effect, I am stumped as to what this condition could possibly have to do with mental health.

I work hard to empathize with my patients, and sometimes it takes a lot out of me, but especially when they are complaining about their legs, which are nowhere near their brains - then it just bugs me. To get this as a consult question is even worse - all you need is general anatomy to know that it's not a psychiatric problem. I feel like an orthopedic surgeon being asked to provide DBT.
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You've never been able to correlate akathisia with psych meds? That's a common textbook side effect of the antipsychotics.

Also, saying the legs are nowhere near the brain isn't exactly sound logic either. The brain controls the legs. Strokes cause paralysis.

I understand that your specialist knowledge isn't hugely necessary for treatment of akathisia if it's not caused by an antipsychotic or an underlying anxiety disorder, but the primary team doesn't know that... that's why they consulted you. We call our fair share of seemingly dumb consults on inpatient psych too.
 
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shan564 said:
You've never been able to correlate akathisia with psych meds? That's a common textbook side effect of the antipsychotics.

Also, saying the legs are nowhere near the brain isn't exactly sound logic either. The brain controls the legs. Strokes cause paralysis.

I understand that your specialist knowledge isn't hugely necessary for treatment of akathisia if it's not caused by an antipsychotic or an underlying anxiety disorder, but the primary team doesn't know that... that's why they consulted you. We call our fair share of seemingly dumb consults on inpatient psych too.
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But I'm not talking about akathesia! I'm talking about people who move their legs a lot at night. And only at night. While in bed. Which by definition, since they're lying down, they're not apparently feeling the urge to ambulate excessively. And sometimes only one leg. I don't know if this qualifies as "restless legs syndrome" or not, but that's the "restless legs" complaint I'm referring to here.

If I am correct, EPS, also by definition, does not occur during sleep? I could be wrong but I thought this was the case. If I'm right they are mutually exclusive conditions.

Look I have been on this forum a long time and I have 5+ years of psychiatry experience. I know to look for akathesia not only from antipsychotics but from certain other meds too. Restless legs is a different phenomenon. It's a sleep disorder. (Granted yes that is a subspecialty of psychiatry and so maybe I should know it for that reason. But I will admit, I don't, not really.)

I would also think, that since this patient was not taking a single antipsychotic and never had, and since she specifically complained that she "kicked" her boyfriend a lot in bed and that's how she "knew" she had restless legs syndrome, that maybe the primary team could have screened the consult a bit more?

I agree, the brain controls the legs. It's a fantastic system, all harmoniously intertwined. But we in psychiatry don't really deal with "brain disorders," especially those of the peripheral nervous system. If we did we would be neurologists. A disorder of the legs, and only of the legs, hardly seems psychiatric to me. I'm happy to learn about it but I don't really get why I would be the first one consulted.
 
Again, the primary team consults if they don't know what to do. If they're consulting the wrong person, that falls under the umbrella of "not knowing what to do."

Of course you know about akathisia... I meant to say that the statement "I've never been able to correlate restless legs with psych meds" is fallacious because restless legs are a common manifestation of akathisia. Didn't mean to suggest that this is what's going on in this particular case.

Sounds like the primary team thinks that the restless legs are caused by anxiety. The consultant's role in that situation is to say "I don't think that the patient's symptoms are caused by an underlying psychiatric disorder. Please consider neurologic or other causes."
 
nancysinatra said:
I work hard to empathize with my patients, and sometimes it takes a lot out of me, but especially when they are complaining about their legs, which are nowhere near their brains - then it just bugs me. To get this as a consult question is even worse - all you need is general anatomy to know that it's not a psychiatric problem. I feel like an orthopedic surgeon being asked to provide DBT.
Click to expand...

RLS is listed as a parasomnic, sleep-wake disorder in DSM-5. I could think of better reasons for consults, though.
 
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nancysinatra, you kind of puzzle me. Seems like you have made a lot of posts previously about wishing you were in a more medical specialty or that you were bored with the scope of psychiatry or something like that. Then you seem to kind of throw your hands up in the air over this. Why not focus more on these cases that might be a little outside of what you typically do in psychiatry, but at the same time aren't so far out there that anyone would really blame you for doing some basic management of them?
Seems that many people here have had the experience of getting consulted about this as a psychiatrist, so seems there are a lot of people out there who wouldn't have a problem with you treating it. There are tons of physicians in all specialties who are perfectly comfortable treating things that weren't the focus of their training and instead they became comfortable with it through personal research and experience as an attending.
 
RLS is exacerbated by caffeine, nicotine, SSRI/SNRI, Antihistamines, etc.

We understand it as an overproduction of dopamine which follows the circadian rhythm - think of it as a tide in/tide out effect.
When the tide is out (circadian drops off), the DA follows along and the brain becomes irritable. The irritability is demonstrated as RLS.

Taking a detailed history of what their sleep cycle is, medications, and substance consumption can help in pinpointing symptoms. They typically begin between 5-10pm (if they have a normal sleep schedule). Often one may express symptoms beginning at bedtime (when they get sleepy).

Checking Ferritin levels is important as it is a marker for how well DA levels are in the brain (Iron production is necessary for creating dopamine). Iron supplementation with Vit. C can help with this. Using DA Agonist therapy (Ropinerole 0.25mg for instance) placed strategically can be helpful in eliminating symptoms. Changing SSRI/SNRI to Wellbutrin XL can be helpful in reducing symptoms.
May also consider getting a sleep study to screen for a sleep breathing disorder. Lastly, ensure they don't have a primary problem such as neuropathy or claudication causing the same symptoms (I've seen this and treatment of the disorder relieved the discomfort).
 
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OldPsychDoc said:
The primary team is just hoping that you'll talk to the patient long enough to figure out what's really going on.
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This. Not that I enjoy extra work, but I very rarely complain about consults. Just reframe it as trying to hell the patient. For this one:

Have they check a serum folate. First step in restless legs work up and it's often missed or forgotten, especially by hospital docs. Outpatient PCP's almost always remember.

Second: rule out delirium (worse at night) and Catatonia.

I got a consult on call last night for a guy whose ED doc called me because he was having strange movements at home. Turned out to be malignant Catatonia. Had to tell them and implement care. I could have easily blocked the consult saying that weird movements aren't our wheelhouse.

I always at least see them quickly to see if we can help. Sometimes they want talking. Sometimes they just want help. Sometimes they're totally wrong and missed something we would find obvious.

I think every hospital should have a "superficial consult psychiatrist" whose job is to just walk around and check in very quickly on all the inpatients to identify who we could help, and educate the medical docs about what we're seeing. I think, as a specialty, we excel in interdisciplinary coordination and in thinking outside the box with a broad differential, and often the overworked and stressed out medical teams can use our help but don't ask for it.
 
^ I agree it would be interesting to see what would happen if maybe there was some social worker or psych nurse that skimmed through charts looking for patients that could use a psych consult. As a medstudent being on so many different services there have been so many times where I have seen patients that could really use psych on board. Was outpatient, but saw a nurse with what obviously seemed like a delusional parasitosis (pt was amateur biopsying himself and bringing samples) and looking at the chart this person had been doing this for over a year w/ like 100 ID and Derm visits and judging from the notes this person had never even been attempted to be referred to psychiatry.
 
nancysinatra said:
I would like to devote this thread to some annoying things, like a consult I got yesterday, asking me to evaluate a patient where the "consult question" turned out to be the patient saying, "I have restless legs. I have had this my whole life."

Does anyone else get this complaint very often? I hear about restless legs from patients a lot and never once have I been able to correlate it with a psych med. Yet a lot of people complain that their medications cause it. Aside from a medication side effect, I am stumped as to what this condition could possibly have to do with mental health.

I work hard to empathize with my patients, and sometimes it takes a lot out of me, but especially when they are complaining about their legs, which are nowhere near their brains - then it just bugs me. To get this as a consult question is even worse - all you need is general anatomy to know that it's not a psychiatric problem. I feel like an orthopedic surgeon being asked to provide DBT.
Click to expand...
Was the patient on antidepressants, antipsychotics, or in withdrawal from a benzo or other sedative? These can all cause secondary RLS. You don't need to do the correlation yourself. You just have to trust the people who have already done it. What would the state of medicine be if each doctor waited to independently prove each established medical fact?
 
I had a patient start Latuda and get RLS, improved with lower dose.
 
Many, but not all, of RLS sufferers will also have periodic limb movements in sleep. The pearl for sleep boards is that PLMS will occur in about 80-90% of patients with RLS, especially when evaluated over more than one night.
 
watto said:
Many, but not all, of RLS sufferers will also have periodic limb movements in sleep. The pearl for sleep boards is that PLMS will occur in about 80-90% of patients with RLS, especially when evaluated over more than one night.
Click to expand...

Didn't know PLMS was that common with RLS. Good to know, thanks!
 
Ok I've been away for a few days and will address the replies individually soon I hope, but let me clarify - I would love to get a PROPER consult for restless legs syndrome. I was really complaining because this consult was improper.

The consult came from a drug abuse rehab unit that is known to house a lot of "psych" patients. How it works on that unit is that an internist sees the patient once at admission, does an H&P, and then never sees the patient again. It's all midlevels after that. A nurse called me for this consult. I believe the patient said, "nurse, I want to see a psychiatrist," and the nurse said, "sure" and called the internist, and said "can you order a psych consult?" and rather than saying "why?" the internist said "yes, of course." At no point did the internist look to see what was going on. (It's "just" a substance abuse patient and it's "just" a psych consult after all.) If I had called the internist, and asked what the consult was for, experience tells me their answer would have been, "I don't know, can you just see them?"

Normally our NP sees these consults. Our NP will take the vaguest of consults. But I object to vague consults. My rationale is - the internist wouldn't just consult orthopedic surgery or whatever just because a patient "told the nurse to." They would think about it for at least one second first, right? Similarly they should THINK about a psych consult first. They should do enough thinking to at least determine that they are consulting the specialty that deals with that anatomical part of the body. It isn't that hard.

If I really have to identify what's wrong with this situation, it's that the internist was disdainful of the patient being on a substance abuse floor and asking to see "psych" and hence failed to screen the consult at all. This is a violation of medical orthodoxy. Even substance abusers deserve high standards!

As to why I don't like restless legs complaints in outpatient psych - same reason I don't like "insomnia" - I don't like outpatient sleep medicine issues a ton. I don't like most outpatient neuro either but I think inpatient neuro is cool. Just personal preference.
 
Sleep medicine is all outpt. Rare are the issues requiring an inpt consultation - apart from the guy who's gases are through the roof and needs a stat split-night PSG to be started on BiPAP. Insomnia (which is treated with CBT), RLS, EDS, etc are all managed in the outpt setting.

Sounds like there is a lack of protocol in the institution for doing consults. Consults are meant to ask a specific question which requires a specialtys' input and then you're gone.
 
Shikima said:
Sounds like there is a lack of protocol in the institution for doing consults. Consults are meant to ask a specific question which requires a specialtys' input and then you're gone.
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This might be institution-dependent. Not all places do the over-the-wall-and-run.

At our location, some consults are one off questions (e.g.: capacity, etc.). But others require daily or every-other visits to track progress for treatment recs.
 
I want to put a stigma about RLS patients to bed. People (sometimes other clinicians) will joke with me that I must love getting RLS patients into my dance therapy practice. While this is a type of positive stereotype, it's still a stereotype and one that's just not true. I've had RLS patients who just have absolutely no rhythm. They just can't hear it. If anything when I think back to the few patients I had with RLS none of them were that remarkable. I want to be clear that movement is not the same thing as dance (although, there are people who will argue that any type of movement is dance, just as any type of sound is music—I do NOT subscribe to that line of thinking).
 
What's the going level for ferritin these days? Uptodate hedges and says < 50 or even less than 70 in like one study, even though that's within the normal lab range. In my area the PCP's seem not to do iron therapy for RLS unless it's either "low low" or very close to it, and usually do requip instead. Anyone have a good rule of thumb for ferritin levels?

Also what about asymptomatic PLMS discovered incidentally on a sleep study? Is it subtly impacting sleep, or could someone have it with no consequences at all?
 
Chrismander said:
What's the going level for ferritin these days? Uptodate hedges and says < 50 or even less than 70 in like one study, even though that's within the normal lab range. In my area the PCP's seem not to do iron therapy for RLS unless it's either "low low" or very close to it, and usually do requip instead. Anyone have a good rule of thumb for ferritin levels?

Also what about asymptomatic PLMS discovered incidentally on a sleep study? Is it subtly impacting sleep, or could someone have it with no consequences at all?
Click to expand...

I listen to UpToDate. I always check it for this kind of stuff in case it changes...as they keep it UpToDate, haha. I usually go with the 50 ish level I think.
 
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