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Home , Cramp, Tetany

Rest in the elderly

J- B. YOUNG, MB, MRCR Consultant Physician M. JAVID, MB, MRCR Registrar Department of Medicine for the Elderly, St Luke's Hospital, Bradford ]? GEORGE, MB, MRCR Consultant Physician Department of Medicine for the Elderly, Cumberland Infirmary, Carlisle

of are Table 1. A clinical classification (after Joekes). Clinical experience suggests that muscle cramps common in can be ascribed to elderly people. They rarely 1. Disease associated losses a specific cause and, as they commonly occur during Neuromuscular sleep, are usually labelled 'rest cramps' or 'night (eg motor neurone disease, cramps'. 'For a symptom so common and distressing, ) have attracted little night cramps surprisingly investiga- 2. Drug induced tive attention.' So wrote Gootnick in 1943 and his [1], 3. Effort cramp Swimming etc comments are equally pertinent nearly half a century 'Musician's cramp' so is our of this later, poor knowledge apparently simple 4. Rest cramp symptom. Why are rest cramps so common in elderly Post-exercise people? Why do they occur most often in the leg, and why Elderly (nocturnal) at night when the leg muscles are relaxed and warm? This review draws on the available evidence to respond to these questions and also outlines a practical management plan for the condition. feature, and for the runs of high-frequency discharges ranging from 200 to 300 impulses per second on electro- A for Clinical features myography recordings [5]. satisfactory explanation rest cramp must also encompass the clinical observations are nocturnal and affect distal Muscle cramps are a sudden painful involuntary contrac- that they predominantly it is a of the and tion of a muscle or muscle group, the involved muscles leg muscles. Moreover, syndrome elderly in tissues be becoming transiently locked in a violent of uncoor- this implies that age-related changes key may dinated muscular contraction. Cramps need to be distin- relevant in understanding the mechanism(s) for rest guished from due to low plasma concentrations of cramp. ionised , and also from the in which sleep is disturbed by unpleasant sensations in the Neuromuscular age-related changes legs, relieved by movement [2]. mass and muscle decrease with Joekes [3] has proposed a practical four-point clinical Muscle strength age [6,7]. Few studies have to describe the classification for cramps (Table 1). This emphasises the attempted histopatho- need to consider underlying neurological or muscular logy or neurophysiology of age-related muscle changes. disease and it stresses the role of drugs as precipitating However, a consistent finding has been evidence of substantial denervation and II fibre factors. Rest cramp is not just a residual category but type atrophy [8-10], constitutes a discrete clinical syndrome mostly confined to most marked in the distal musculature [9]. Changes are seen in the nerves with fall-out of Schwann elderly people, with cramp episodes occurring at night, also peripheral usually in the early hours, and generally affecting the foot cells and patchy loss or thinning of myelin sheath [11], or an reduction in of muscles. Although rest cramps have not attracted compounded by age-related density much clinical enthusiasm, they are often distressing myelinated peripheral fibres which preferentially affects fibres This loss enough for the patient to be eager to discuss them. It is the larger [12]. disproportionate of larger fibres seems to involve the anterior tibial and sural easy to pass them over as self-limiting and not life- longer threatening, but for some elderly people life is severely nerves but not the superficial radial nerve [13]. This disrupted because of their fear of falling asleep [4]. results in a slowing of nerve conduction [14]. Histopathologically the various ageing changes are seen to be in the Pathogenesis consistently greatest longest peripheral nerves and most distal muscles. This finding may be an in An adequate explanation of rest cramp must account for important component explaining why rest cramps the muscle which is often an antecedent predominantly affect the foot and calf muscles. A further is the fall-out of anterior Address for correspondence: DrJ. B. Young, Department of Medicine important age-related change for the Elderly, St Luke's Hospital, Bradford BD5 ONA. horn cells which occurs with increasing age [15], This has

Journal of the Royal College of Physicians of London Vol. 23 No. 2 April 1989 103 Table 2. associated with cramp. a parallel with motor neurone disease in which fascicula- Drugs and nocturnal are common tion cramps [16]. Purgatives Vascular age-related changes Liquorice Due to hypokalaemia Carbenoxalone Reports of rest cramp have generally emphasised that the Amphotericin B peripheral circulation is unimpaired, implying that it Clofibrate need not be an important factor in the mechanism for Danazol some of Cimetidine cramp production [1,4,17], However, degree atherosclerosis is universal in the elderly [18] and clinical Metolazone of circulation in the leg may be mislead- signs impaired Lithium arterial and flow fall seriously when the ing; pressure only cross-section area of a vessel is reduced by 75% [19]. Cytotoxics Thus moderate arterial disease be difficult to may quanti- adrenergic agonists fy by clinical factors alone. Physiological studies of lower limb blood flow using plethysmography or pulse-analysis is blood pressure [26] and by doppler have not yet been reported for patients with accompanied by decreasing cardiac factors that might be expected rest cramp. output [27,28], be further to the circulation. Thus, ageing It has been suggested that limb circulation may impair peripheral and the consequences of sleep disturbed in patients with rest cramp due to previous changes haemodynamic or without additional summate to to the venous system, leading to venous (with drug factors) damage deep in an noctur- tetanic resulting hypertension. The main evidence for this is that produce spontaneous activity foot of the of cramp 1). nal cramps may be alleviated by elevating the episode (Fig. This model, consistent with the available bed, so drainage [20]. It is likely, however, although improving leg and evaluation. It an factor rather is requires that venous hypertension is aggravating facts, necessarily speculative for instance, be of interest to determine if a fall-off than a prime mechanism. would, in leg circulation preceded an episode of rest cramp. Also, it would be to test the prediction that drugs which as possible factors an effective Drugs improve peripheral circulation should be treatment for the disorder. Muscle , stiffness and cramps represent one of several drug-related neuromuscular syndromes [21,22]. Various drugs have been incriminated (Table 2) and knowledge of Management these is important, for their selective withdrawal offers an treatment: opportunity to modify cramp symptoms. In addition, Physical preventative these into mechanisms for agents provide potential insight elevation of the foot of the bed may be effective in is one Simple cramp Drug-induced hypokalaemia venous in the production. those patients with signs of insufficiency such mechanism common to diuretics, carbenoxalone, A rather more bizarre but enthusiastically and B. Chronic legs [20,29]. amphotericin hypokalaemia a between the purgatives, proposed method is to place magnet most often painless weakness of produces generalised mattress and lower sheet. The first sign of cramp would but muscle aches and also be a muscles, cramps may was over immediately disappear if the affected leg moved feature and have been attributed to changes in the resting the of the muscle cell membrane magnet [30]. and excitability on potential Another simple preventative measure is based Enhanced neuromuscular excitability has also [21,22]. the calf msucles [31]. Patients are instructed to been the mechanism suggested for rest cramps due to nifedipine [23], metolazone [24], and the /32 adrenergic antagonist , particularly when it is given orally Fig. 1. Suggested relationship between the contibuting factors [25]. for rest cramp.

mechanism Suggested Drugs Sleep associated Consideration of the factors discussed above allows a circulation tentative unifying explanation for rest cramps to be changes advanced. It is evident that neuromuscular control is most in the most distal part impaired by ageing changes Muscle would the of the peripheral nervous system. This explain ischaemia predisposition of rest cramp to affect foot and calf mus- cles. The susceptibility of the distal leg musculature to involuntary contraction is aggravated by certain drug actions and by impaired peripheral circulation. In this latter respect it is relevant to consider the haemodynamic changes occurring during sleep. Increasing depth of sleep

No. 2 1989 Journal of the Royal College of Physicians of London Vol. 23 April stand with their shoes face a wall 2-3 feet away and off, CRAMP fhen lean forward, using the hands and arms to regulate their forward tilt and keeping the heels in contact with the floor, until a moderately intense, but not painful, pulling sensation develops in their calf muscles. The stretching is I Maintained for 10 seconds and repeated after 5 seconds 1. Identify causa Restless relaxation. The whole sequence is repeated up to three legs syndrome in this times daily. The ages of the 44 subjects described Appropriate Tetany Electrolyte losses report were not but it was inferred that the cramps intervention given, Neuromuscular diseases treated were related. In this situation being post-exercise Drug induced the is How- underlying muscle pathology complex [32]. i or ever, it is an attractive method which deserves further Rest cramp study. * 2. Treat treatment: alleviation Physical (a) Physical treatments (b) Drug treatments Two complementary methods to terminate an episode of cramp have been proposed on the basis of the neurophy- rest siological principle of reciprocal inhibition [33], The Fig. 2. An approach to the evaluation and management of methods involve either passive stretching of the contract- cramps in the elderly. mg muscle or active contraction of the antagonist muscle. The basis for the passive method is that an attack of calf when taken before to on and and of cramps retiring bed, cramp may be abolished by standing the foot severity also decreased the duration of the bringing the heel down hard to the ground [34], The and probably cramp continued strong stretching of the calf muscle during this episode. seems to be well tolerated in the low doses manoeuvre induces the anti-stretch reflex brought about used for and it has been that the by efferents from the Golgi organs in the tendon mediat- night cramps, suggested reason for an alternative treatment is the ing a spinal cord inhibitory reflex designed to prevent main finding risk of accidental or non-accidental overdose In rupture of contracting muscles. The active method in- [41]. is a toxic cardiac volves voluntary contraction of the opposing muscle overdose it highly compound, producing and blindness group, for example ankle dorsiflexion during spasm of the (often permanent) [42]. have been cited as treat- calf muscle. In this situation the active contraction brings Several other drugs potential about relaxation of the cramping muscle by an inhibitory ments for cramps: diazepam, dantrolene, phenytoin, there is spinal cord reflex. procainamide, and diphenhydramine. However, no evidence that these agents are effective. Drug treatments Conclusion Quinine sulphate is the recommended drug treatment for almost in was as a successful Rest cramps have been entirely ignored general rest cramp [35]. It initially used medicine texts. Yet much remains to be treatment for myotonia [36] and was subsequently found and geriatric learnt about this but syn- to be effective in open studies of rest cramp [1,4]. Quinine apparently simple distressing It is that are increases the threshold of stimulation of the motor end drome in elderly people. important cramps as a feature of neuromuscular plate, and also prolongs the refractory period of the not overlooked presenting disease and that are con- muscle, resulting in a diminished response to tetanic potentially aggravating drugs centred around stimulation. sidered (Fig. 2). Alleviation has mostly with but Quinine has been shown in a controlled study to be an treatments drugs, especially quinine, simple methods to and abolish attacks deserve effective agent for reducing the frequency of muscle physical prevent cause of more detailed evaluation. cramps in patients on haemodialysis [37]. The cramps in this situation is complicated, and suggested factors are blood volume contraction [38], dialysis related Acknowledgement deficiency [39], and impaired tissue oxygen deliv- We are for comments from Dr A. ery due to reduced red blood cell 2,3-DPG concentrations grateful helpful J. consultant in this or post-dialysis [40], In dialysis related cramps, Twomey, neurophysiologist, preparing therefore, quinine acts at the final common pathway for paper. cramp production, the muscle membrane, rather than influencing putative primary causative mechanisms. This References may be an analogous situation with rest cramp in elderly Here there is trial evidence for effectiveness people. again 1. Gootnick, A. (1943) Archives of Internal Medicine, 71, 555-62. of this agent. In 1983 Jones et al. studied 9 elderly people 2. Clough, C. (1987) British Medical Journal, 294, 262-3. with nocturnal cramps treated with quinine in a double- 3. Joekes, A. M. (1982) Journal of the Royal Society of Medicine, 75, 546- 9. blind crossover study [17]. Quinine reduced the number

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