Case: A 74-year-old male with no major history, except for restless legs syndrome (RLS), is admitted to the ICU for community-acquired pneumonia. Patient is now recovering. The patient requested medicine for his insomnia in the ICU, and the resident prescribed zolpidem. Patient found to have hyperactive delirium in the early part of the next morning.
Discussion: As commonly said, restless legs syndrome and insomnia go hand in hand; most patients with RLS require some kind of pharmaceutical support for their insomnia. Precautions should be taken to prescribe selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), or antihistamines, as they can exacerbate RLS.
Particular care should be exercised in prescribing BZRAs (Benzodiazepine Receptor Agonists) such as zolpidem, as they increase the incidence of complex sleep-related behaviors.
Further readings/References:
1. Park YM, Shin HW. Zolpidem Induced Sleep-related Eating and Complex Behaviors in a Patient with Obstructive Sleep Apnea and Restless Legs Syndrome. Clin Psychopharmacol Neurosci. 2016 Aug 31;14(3):299-301. doi: 10.9758/cpn.2016.14.3.299. PMID: 27489385; PMCID: PMC4977817.
2. Mittal N, Mittal R, Gupta MC. Zolpidem for Insomnia: A Double-Edged Sword. A Systematic Literature Review on Zolpidem-Induced Complex Sleep Behaviors. Indian J Psychol Med. 2021 Sep;43(5):373-381. doi: 10.1177/0253717621992372. Epub 2021 Mar 9. PMID: 34584301; PMCID: PMC8450729.
3. Winkelman JW, Wipper B. Restless Legs Syndrome: A Review. JAMA. 2026 Feb 24;335(8):703-714. doi: 10.1001/jama.2025.23247. PMID: 41563785.
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