Restless Legs Syndrome

Amara Naveed
Eshal Amir
Hussain Awan
Wania Bushra

Lahore School of Economics

Psychology

Ms. Hirra Rana

24th November, 2023

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 Table of Content (Amara Naveed)

Acknowledgment (Eshal Amir)…..……………………………………………………………… 3

Abstract (Amara Naveed)………………………………………………………………………… 4
Introduction (Wania Bushra)………………………………………………………………………6
Literature review (All Members)…………………………………………………………………..7
Methodology………………………………………………………………………………………12
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Case Study 1 (Eshal Amir)…………………………………………………………………
Case Study 2 (Amara Naveed)……………………………………………………………13
15
Case Study 3 (Wania Bushra)………………………………………………………………
Case Study 4 (Hussain Awan)…………………………………………………………… 16
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Results……………………………………………………………………………………………...
Case Study 1 Results (Eshal Amir)………………………………………………………..17
Case Study 2 Results (Amara Naveed)……………………………………………………18
Case Study 3 Results (Wania Bushra)……………………………………………………19
Case Study 4 Results (Hussain Awan)……………………………………………………20
Limitations (Eshal Amir)………………………………………………………………………….21
Recommendations (Hussain Awan)………………………………………………………………22
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References (All Members)…………………………………………………………………………

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 Acknowledgement

We are grateful to Allah Almighty for granting us the capacity to produce such an
extensive and innovative research report. This required a lot of effort, and we should also thank
all other authors and publishers for including facts and figures in articles on Restless leg
syndrome that helped us finish our research. We would like to thank the Lahore School of
Economics to providing us the opportunity of this academic research. We would also like to
extend our heartfelt gratitude to our instructor, Miss Hirra Rana and her TA, Sir Saad Ullah
Bajwa, who provided us constant guidance and supervised our research paper.

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 Abstract

Restless legs syndrome (RLS) is a neurological sensory-motor disorder which causes

intense restlessness and unpleasant creepy crawling sensations deep inside the lower legs. This
characterizes an instant and uncontrollable urge to continuously move the legs. The symptoms of
RLS are heightened when the legs are at rest and usually worsens during the night. The increased
symptoms during the night often also leads to RLS patients to develop sleeping disorders.
Periodic limb movements (PLMS) are also common during sleep amongst those suffering from
RLS, resulting in severe reduction in sleep efficiency. Sensations within the limb, rather than on
the skin, include crawling, creeping, pulling, throbbing, aching, itching, and electric feelings.
These descriptions encapsulate the diverse range of internal experiences, from subtle movements
to pulsating rhythms.

The cause of restless legs syndrome (RLS) remains uncertain, but it is believed to be
associated with the functioning of the basal ganglia, the part of the brain responsible for
movement. The basal ganglia utilize dopamine to regulate bodily movement, and a deficiency of
dopamine in this region can lead to inefficient movement regulation, resulting in RLS symptoms.
Research indicates potential contributors to RLS, including genetic inheritance, where a specific
genetic trait is passed down from one biological parent during conception. Moreover, iron
deficiency in the brain, despite normal blood iron levels, may contribute to RLS. Underlying
medical conditions and certain medications, such as antihistamines and antidepressants, are also
implicated. RLS often coexists with conditions like low iron levels, anemia, pregnancy, diabetes,
kidney disease, peripheral neuropathy, and substance use disorder. Additionally, various triggers
like alcohol, caffeine, nicotine, specific medications, and stress have been identified as
exacerbating RLS symptoms.

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 The treatment approach for restless legs syndrome (RLS) involves a combination of
medication and lifestyle adjustments to alleviate symptoms. Working collaboratively with
healthcare providers to address underlying health conditions may also contribute to symptom
reduction. During discussions with healthcare providers, various treatment options will be
explored, along with a thorough consideration of potential side effects. Medications such as iron
supplements with vitamin C, ant seizure medications like gabapentin and pregabalin, dopamine
agonists such as pramipexole and ropinirole, as well as dopamine precursors like levodopa, may
be recommended or prescribed to mitigate RLS symptoms.

Effectively addressing restless legs syndrome (RLS) necessitates a joint effort between
healthcare providers and patients to navigate its intricate origins and diverse manifestations. A
comprehensive understanding of the multifaceted contributors to RLS, ranging from genetic
predispositions to dopamine regulation and lifestyle triggers, is vital for devising a well-rounded
treatment strategy. Tailoring medications and lifestyle modifications to individual needs provides
avenues for alleviating symptoms. As ongoing research unveils the complexities of this
neurological disorder, promoting awareness and fostering support within the medical community
and society becomes essential. By combining knowledge, empathy, and innovative treatments,
significant strides can be taken toward improving the quality of life for individuals grappling
with restless legs syndrome.

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 Introduction

According to the Diagnostic Statistical Manual-5, the restless legs syndrome is a

neurological sleep disorder that can be described by an urge to move your legs and arms due to
uncomfortable or unpleasant sensations. These sensations may include tingling, itching, burning,
creeping, or crawling, leading to the movement of the legs as an effort for relief from these
feelings. These symptoms show themselves uncommonly during daytime, but more so in the
evening and night. They get the most intense usually during the night, when the individual is at
rest and is engaging in minimal physical activity. Because they occur mostly during the night,
they are likely to delay the onset of sleep for most individuals, hence taking its place as a sleep
disorder. Difficulty in sleeping, or difficulty to remain asleep, partnered with excessive daytime
sleeping support the diagnosis of RLS.

RLS usually occurs in the 20s or 30s of an individual. This early age onset is paired with
a steady increase in its prevalence until the age of 60, when it either decreases or becomes stable.
If, however, the age onset is relatively later, say after the age of 45, there is a rapid progression
of symptoms. The diagnosis of RLS is typically via self-report and history, though it becomes
more difficult to conduct with children. A child’s own words are required for diagnosis, and any
child below 6 years of age is usually unable to provide that. For the children at or above the age
of 6, the use of simpler language to describe their symptoms is more common.

RLS is more prevalent amongst women, although there are no diagnostic differences
according to gender. People become more susceptible to the disorder with advancing age, family
history of RLS, and genetic risk variants. RLS is generally associated with mental disorders
including depression, post-traumatic stress disorder, generalized anxiety disorder and panic
disorder. Among physical illnesses, RLS is more commonly associated with cardiovascular
disease, and less commonly with Parkinson’s disease, migraines, other sleep disorders and many
more. The symptoms of RLS are not, however, attributable to other mental disorders, medical
conditions, or the physiological effects of a drug of abuse, or medication.

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 Literature Review

According to Manconi et al. (2021), Restless Legs Syndrome (RLS) is a common

neurological disorder marked by an intense urge to move, especially during or after rest. The
symptoms usually appear in the evening or at night, and subside as you move. The degree,
frequency, and age at beginning of symptoms can all vary greatly, with more severe cases
affecting sleep, quality of life, and mood severely. Furthermore, many people with RLS have
recurring leg movements throughout sleep or times of restful even when they are awake.

RLS is recognized as a complicated disorder that is influenced by a variety of factors. It

has a genetic component, with a family history indicating a higher probability of acquiring the
illness. Comorbidities such as iron deficiency, renal illness, cardiovascular disease, diabetes
mellitus, and neurological, rheumatologically, and respiratory disorders can all contribute to the
emergence of RLS. The underlying cause of RLS is still being studied, with possibilities ranging
from brain iron shortage to dopaminergic dysfunction, nociceptive system malfunction, and
changes in adenosine and glutamatergic pathways. RLS has a substantial impact on sleep,
causing disruptions and periodic leg movements during sleep, which affects general health and
well-being.

Physicians' under recognition of Restless Legs Syndrome (RLS) is a significant barrier to

providing appropriate treatment for affected persons. This inability to recognize causes frequent
misdiagnosis and ineffective treatment. Treatment criteria recommend starting therapy with low
doses of dopamine agonists or 2 ligands, especially in severe cases. These drugs are primarily
intended to relieve symptoms and improve the overall quality of life for people suffering from
RLS. Long-term dopaminergic medication, on the other hand, raises serious concerns since it can
result in a phenomenon known as augmentation, which is the contradictory worsening of
symptoms over time, despite the treatment's early effectiveness.

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 Alternative therapy strategies are being studied in addition to dopaminergic medications.
In some circumstances, opioids with central nervous system depressant effects may be given to
treat RLS symptoms. Iron preparation can also help with treatment, especially if there is an iron
deficit. Consideration of these many treatment approaches emphasizes RLS's complicated nature,
which includes not only neurotransmitter abnormalities but also potential contributions from
genetic, environmental, and comorbid variables. The disorder's diverse characteristics highlight
the importance of continued study to better understand its underlying causes. More
understanding of the pathophysiology of RLS will most likely lead to more targeted and effective
therapy methods, ultimately enhancing clinical management of this difficult disorder (Manconi et
al., 2021).

According to Ekbom (2009), symptoms of RLS are supposed to be generated centrally

within the brain by local iron deficiency and dopaminergic dysfunction. In >50% of cases there
is a positive family history of RLS, and a number of molecular genetic investigations are now in
progress (Ekbom, 2009).

Restless legs syndrome is marked by feelings of unease, crawling, or creeping sensations

in the lower legs, usually occurring between the knees and ankles. These sensations may also
reach the thighs and, in uncommon cases, extend to the feet. While they may manifest on one
side, they frequently impact both legs and display a symmetrical pattern. The feelings can endure
for extended periods, and in some unfortunate individuals, they may persist until 3, 4, or 5 am,
with intermittent interruptions. Many patients find themselves having to frequently stand up and
move around to alleviate the discomfort, a behavior referred to as 'Night-walker syndrome.' The
consequential sleep loss is a significant concern for both patients and their spouses.

Restless legs syndrome is frequently associated with involuntary, rhythmic muscular

jerks in the lower limbs: dorsiflexion or fanning of toes, flexion of ankles, knees and hips, so-
called periodic limb movements (PLMS) (Coleman, 1982). Onset of RLS may occur from
childhood to >80 years of age (Allen, 2003). The natural clinical course varies widely but RLS is
generally regarded as a chronic condition with a successive increase of symptoms (Ekbom,
2009).

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 According to Allen (2003), there are four essential criteria and all of them must be
established to make a definite diagnosis of RLS which consists of:

1. An urge to move the legs, usually accompanied or caused by uncomfortable and unpleasant
sensations in the legs.

2. The urge to move or unpleasant sensations begin or worsen during periods of rest or inactivity
such as lying or sitting.

3. The urge to move or unpleasant sensations are partially or totally relieved by movement, such
as walking or stretching, at least as long as the activity continues.

4. The urge to move or unpleasant sensations are worse in the evening or night than during the
day or only occur in the evening or night.

Both age and genes seem to play an important role for the susceptibility and clinical
expression of RLS. Two subgroups of RLS phenotypes have been identified with regard to age
of onset: primary (idiopathic) and secondary (symptomatic) RLS (Allen, 2000). According to a
prevalent theory, Restless Legs Syndrome (RLS) may be linked to the dysfunction of dopamine
cells in the nigro-striatal regions of the brain. Pharmacological studies indicate a notable
improvement in RLS symptoms through the administration of levodopa, the precursor of
dopamine, or through the use of dopaminergic agonists that target dopamine receptors in the
brain (Ekbom, 2009).

Restless Legs Syndrome (RLS) is a significant contributor to insomnia, and it can

substantially disrupt the sleep patterns of those affected. The resulting sleep disturbances have a
profound effect on the overall health and daytime activities of individuals with RLS. Despite its
prevalence, RLS often goes undiagnosed in primary care settings, leading to the prescription of
insufficient treatments (Ekbom, 2009).

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 The article titled as "Restless leg syndrome in Pakistan: A Study on How Common It Is",
talks about the scarce and limited information available on how often Restless leg syndrome
takes place. All over the world around 2.5 percent of people are diagnosed with RLS and the
shocking thing is that this percentage goes up to 15 percent in western countries and other places
(Mahmood et al., 2015). Coming back to Pakistan, there isn't much research on how many
people are going through RLS and what factors and symptoms might be connected with RLS,
knowing the fact that this syndrome can affect one's quality of life. This article also discusses the
study which took place in different hospitals in Pakistan from August 2013 to August 2014,
which involved a total of 390 people. They were questioned in Urdu about their background and
if they have ever felt having RLS symptoms, using a checklist from the international Restless
Leg Syndrome Study Group (IRLSSG) (Mahmood et al., 2015).

The results, according to Mahmood et al. (2015), showed that 23.6 percent of people out
of 390 had restless leg syndrome and they weren't even aware of this syndrome. It was more
common in older people, females, people who smoke, have health issues or have less education.

Even after being told, the people diagnosed with RLS didn't take RLS seriously. It also
came into notice that when one was diagnosed with RLS, they never talked about their symptoms
to their doctors and were least concerned about the symptoms of RLS, even when these
symptoms used to worsen in the evening or the night. Overall, the study suggests that further
research is required on a varied group of people, plus more awareness of the RLS amount people
need, to really understand how common RLS is in Pakistan. Making awareness among people
will also help to diagnose and treat RLS in a better and faster way.

The article by Silber et al. (2004), discusses an algorithm for the management of Restless
Legs Syndrome (RLS) developed by the Medical Advisory Board of the Restless Legs Syndrome
Foundation. It emphasizes non pharmacological and pharmacological approaches for
intermittent, daily, and refractory types of RLS, providing a practical and comprehensive guide
for primary care physicians that helps in bridging the gap between scientific evidence and real-
world clinical management.

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 The management of Restless Legs Syndrome (RLS) has been a subject of increasing
interest within the medical community, given its prevalence ranging from 5% to 15% and its
significant impact on sleep quality.

The article is divided into 3 portions: intermittent RLS, daily RLS and Refractory RLS.
Firstly, intermittent Restless leg syndrome is defined as bothersome enough when present to
need medical attention, but does not happen frequently enough to require daily treatment. For the
management of intermittent Restless Leg Syndrome (RLS), nonpharmacological therapies are
crucial; these include activities that alert patients and assess the effects of medications. Deficits
are addressed by iron replacement treatment, and it is advised to abstain from alcohol, nicotine,
and caffeine. Moreover, medications such as benzodiazepines, levodopa, low-potency opioids,
and dopamine agonists may be considered too as per individual patient's needs and response to
treatment.

Secondly, in cases of daily Restless Leg Syndrome (RLS) is the one that requires daily
therapy and several pharmacological options may be considered that include non-
pharmacological strategies and medications such as low-potency opioids, dopamine agonists and
Gabapentin.

Lastly, when a daily dopamine agonist is used to treat RLS, it is known as refractory
restless legs syndrome and for its management 4 techniques are used that include switch to
gabapentin, switch to an alternative dopamine agonist, add an additional medication, such as an
opioid, benzodiazepine, or gabapentin and switch to tramadol or a high-potency opioid.

Considering this, the algorithm highlights the ongoing investigations into alternative
therapies like magnesium, intravenous and iron infusions that portray adapting to the evolving
nature of RLS treatment. (Silber et al.,2004).

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 Methodology

Case Study 1:

This case study deals with the experience of a 27-year-old male and after examining his
complete medical records, physical and neurological examination and complete blood tests he
was diagnosed with primary idiopathic Restless Legs Syndrome (RLS) a year ago.

He came to the clinic with a complaint of continuous urge to move his right leg for the
past 2 weeks, especially at night, leading to distress and poor sleep. As per the details the patient
did not smoke or drink alcohol and had no symptoms of anxiety and depression.

He was already undergoing treatment by taking tablets of carbidopa/levodopa and he

exercised regularly as prescribed by his physician. Despite adherence to the prescribed treatment,
the patient continued to experience distressing symptoms, highlighting the intricacies in
managing RLS. The patient's past history of tuberculosis, that was successfully treated by
completing a course of anti-tuberculosis therapy five years ago, and the familial occurrence of
mental retardation in his youngest brother add layers of complexity, suggesting potential genetic
and medical influences on RLS.

The patient's active engagement in self-education reflects the growing role of patient
involvement in managing chronic conditions. The fluctuating improvement observed in the
International Restless Leg Syndrome (IRLS) scores over follow-up visits indicates the dynamic
nature of RLS symptoms and underscores the need for continuous monitoring and tailored
interventions. Moreover, the patient's decision to discontinue self-education during a specific
period introduces a psychosocial dimension to treatment adherence.

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Case Study 2:

Alison, a 30-year-old female, was suffering from restless leg symptoms on and off for the
last 10 years. The restless leg syndrome had significantly increased the last year which had cause
immense amount of interruptions in her sleep. Due to which, her energy levels had fallen so low
where she would be consuming a cup of coffee after every hour in order to get through the day.

The increased regularity in the high intake of coffee had triggered in the rise of the
Celiac disease which had previously been asymptomatic for the last three years but had now
started aggravating her stomach.

Alison was diagnosed with Celiac from a very early age but had managed it well through
the incorporation of gluten-free diet in her daily life. Alison would yearly follow up with her
gastroenterologist.

Alison works as a yoga teacher and describes her lifestyle to be extremely health focused.
Her diet consists of a gluten-free, dairy-free, whole food, plant-heavy diet with occasional
homemade gluten-free treats. For the past three years, she has been dedicated to the Blue Zone
diet, with 80% of her weekly dietary intake consisting of plant-based foods and the remaining
20% comprising animal-based options, including occasional consumption of fish or chicken. Her
fitness routine involved exercising 4-6 times a week, and she ensured a daily water intake of 100
ounces through Brita-filtered water, maintaining a weight of around 110 pounds.

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 However, due to the increased severity of suffering from restless leg symptoms Alison
made sure to get tested. Her tests revealed that she was low on iron and ferritin (a protein that
stores iron) levels, along with low MCV (mean corpuscular volume) and MCH (Mean
Corpuscular Hemoglobin) observed in her CBC (complete blood count), which suggested the
presence of both current and previous instances of iron deficiency anemia. This was likely to be
a contributing factor to her existing fatigue and persistent Restless Leg Syndrome. The lab tests
also revealed low levels of beneficial commensal bacteria and high levels of gastrointestinal
inflammation.

The essential relationship between commensal microflora and the intestinal lining is
pivotal for preserving tissue integrity and the protective mucous membrane. When there is a
depletion in bacterial microflora levels and an increase in inflammation, the processes of
digestion and absorption are adversely affected. This disturbance can result in noticeable nutrient
deficiencies, especially in iron, due to the complex nature of absorption at the brush border of the
gut lining. Additionally, Alison also underwent Vitamin B deficiencies along with deficiencies in
magnesium and omega-3 fatty acids which hinder her ability to absorb and convert iron. This
again agonizes severe sleep issues and restless legs.

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Case Study 3:

A 72-year-old woman with severe restless legs syndrome (RLS) and difficulty sleeping
was admitted to the hospital for the first time. She had been suffering from minor symptoms of
RLS since she was approximately thirty years old, and her diagnosis was made four years prior
to her admission in the hospital. The patient reported that her toes hurt, her feet were heated, and
she had an uncomfortable heat wave that went from her legs to her head, interfering with her
sleep and day-to-day activities. Her trunk and upper limbs were also impacted by anxiety, but
movement of the limbs helped for relief.

Previously she has been receiving treatment with ropinirole, a drug used to treat RLS, but
even at large dosages, the drug was not very effective. It was discovered that RLS ran in her
family, and both her sister and her mother suffered from this disorder. She denied using
psychoactive substances and had other health issues like glaucoma, spine degeneration, joint
pain, stress urinary incontinence and varicose veins; swollen, twisted veins that bulge just under
the skin's surface. The patient initially referred to a psychiatrist to receive help with her
depressed mood, but the intake of the prescribed serotonin reuptake inhibitors led to symptoms
in the lower limbs worsening. This poor response to the medication resulted in a stop to it, and
lead to continued care with a psychologist.

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Case Study 4:

The case talks about the challenges which are faced when diagnosing and treating RLS
(Restless Leg Syndrome) in elderly people who suffer with dementia at the same time. Long
term care settings are highlighted in this study. The patient is an 87 years old woman; she has
trouble telling her symptoms because of cognitive decline. The RLS is diagnosed with the help
of the patient talking to doctors, but in this case study, the woman has dementia and therefore
can't communicate properly, which causes problems for proper treatment or diagnosis.

The tests of the patient also show low levels of Iron in the body, which can be connected
to one of the RLS symptoms in other patients, this can be checked with other patients that do
they have RLS and low levels of Iron at the same time or not. The case highlights the issues
faced when treating RLS in elderly people who also suffer with dementia and the need to find a
way of treatment for such patients with suspected RLS symptoms. More research is required to
develop a proper validated diagnosis of RLS in elderly people who can't communicate well
because of cognitive memory losses.

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 Results

Case Study 1 Results:

According to the findings to the case evaluation, despite the initial treatment with
carbidopa/levodopa and the exercise, the patient's symptoms didn't improve, which emphasizes
the complexity of managing RLS. The lab results of the patient showed a notable decrease in the
International Restless Leg Syndrome (IRLS) scale from 30 to 26 that shows a drop by 4 points.
During the examination the patient was frustrated and he frequently moved his legs this suggests
the ongoing distress.

Patient was advised to continue taking his carbidopa/levodopa tablets and with that self-
educate themselves on RLS by using Internet and open access medical journals. The patient
began utilizing the internet to research the causes, risk factors, prognosis, and course of therapy
for RLS. After this the patient had two follow up sessions, one after 8 weeks and 1 after 16
weeks.
On the IRLS scale, the patient received scores of nine out of 40 at the eight-week follow-
up and 12 out of 40 at the 16-week follow-up.

This shows us the overall 52.5% improvement in symptoms in the first eight weeks as he
actively engaged in self education. However, improvement slowed to 7.5% in the next eight
weeks when the patient stopped self-education.

This case encourages a holistic approach to RLS management, integrating biological,

psychological, and social factors to optimize patient outcomes.

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Case Study 2 Results:

Based on the lab results, Alison was recommended to consume a powdered multivitamin
and a liquid iron supplement twice daily for nutrient replenishment. Her current diet was also
reviewed, and was instructed to increase the intake of leafy greens (for iron), with lemons (for
Vitamin C) and black pepper (for absorption support). Moreover, the modifications to the diet
involved boosting the consumption of red meat to once a week, lowering daily water intake to 70
ounces while supplementing with electrolytes, incorporating extra magnesium to address a
deficiency, and limiting daily coffee consumption to two cups.

After the first follow-up, which occurred one month into the treatment, Alison required
assistance to adhere to the prescribed regimen. Despite reducing her coffee intake, she continued
to experience sleepless nights due to restless legs and high levels of daytime fatigue. After six
weeks of undergoing treatment, she observed positive changes.

After a four-month follow-up on Allison's laboratory results, it was observed that her test
values were returning to normal. Consequently, the dosage of her iron supplement and
multivitamin was decreased to once daily. During this stage of the treatment, Allison underwent
a notable transformation. Her energy levels demonstrated a remarkable improvement, and she
entirely substituted coffee with a chicory root-based alternative. Additionally, her digestive
system had stabilized, and she experienced effective sleep throughout the night. Allison received
guidance to persist with the ongoing dietary adjustments to ensure optimal intake of iron and
probiotics.

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Case Study 3 Results:

The patient was aware, focused, and conscious when she was admitted to the hospital.
During the screening evaluation, cognitive skills showed no variation from age-related norms.
The patient's speech was thorough, and her cognitive processes were clear, with no delusions or
hallucinations. While the patient's state of mind was moderately depressed, her appetite and
psychomotor functioning were unaffected, and she denied having any suicidal thoughts. She was,
however, undergoing a severe sleep disorder.

A physical examination found abnormalities such as mild leg swelling, skin changes,
sensory issues, and swollen, twisted veins that bulged just under her skin's surface. Her
symptoms worsened as she responded poorly to ropinirole, leading to the gradual stop of
dopaminergic drugs. Clonazepam was introduced temporarily, but due to significant worsening
upon the discontinuation of ropinirole, a combination of gabapentin and a low dose of ropinirole
was initiated after two weeks.

The patient was diagnosed with RLS as well as nerve damage, using clinical rating
scales, actigraphy, and neurography. Two weeks without dopaminergic medications resulted in
relative recovery, but depressive symptoms developed, resulting in the addition of agomelatine.
With better RLS symptoms and stable mental health, the patient was discharged. Ongoing
treatment with gabapentin and ropinirole, further neurological tests for polyneuropathy, and
fasting glucose monitoring were all advised.

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Case Study 4 Results:

Looking at what the study found, we can say that the patient (87 years old woman) had
been facing restless leg syndrome for a long time and her living in a long term care facility did
nothing but made it worse. She used to get disrupted in her sleep which disturbed other people in
the long term care facility, this also provoked her aggression towards the staff there. One thing
the team did was that they increased the pramipexole, which actually helped improve her
symptoms of agitation.

The main challenge was that the patient couldn't properly communicate her symptoms to
the doctors because of dementia. The study suggests that relying on what patients tell isn't
enough, especially when they have issues with memory. As talked early, the doctors tried
changing the medication of the patient to help them. The study also shows a link and connection
between RLS and low Iron levels, so one advice from doctors is to check low iron levels as a
symptom of RLS.

Overall the case shows that dealing with RLS in older people, especially the ones who
suffer from dementia at the same time too, is very complicated and difficult for RLS diagnosis,
therefore more and further research is required to find better methods and ways to diagnose and
treat RLS in elderly patients with memory issues.

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 Limitations

1. The study was only restricted to secondary data which limited the depth of our analysis as we
were not interacting with the patients in real life.

2. As our study was based on secondary research we had to conduct a detailed research and be very
particular about it to check for validity and reliability of the information we got as Internet
sources cannot be blindly trusted.

3. Many of our case studies were harder and time consuming to analyses as RLS has an evolving
nature for symptoms management.

4. The study was conducted in a limited time period so the study's scope and findings may not be
universally applicable due to the inherent limitations of internet-based data, potentially affecting
the generalizability of the results

5. Many online articles demanded subscriptions and was paid content which also became a
hindrance in our research

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