Nocturnal leg cramps are common in all age groups including the elderly. They do need to be distinguished from other disorders e.g. restless legs syndrome (RLS) and periodic limb movements of sleep (PLMS). Although leg cramps can be associated with dehydration and electrolyte disturbance, most frequently they’re idiopathic or associated with structural disorders, e.g. flat feet, or abnormal leg positioning.

Quinine sulphate 200-300 mg at bedtime was routinely prescribed for the treatment of leg cramps a number of years ago. Although quinine has been found to be effective in some RCTs, there’s the potential for serious adverse effects secondary to quinine exposure. This includes thrombocytopenia and QT prolongation, and I have had a couple of patients develop granulomatous hepatitis. Non-pharmacological therapy is preferred for both prevention and treatment of nocturnal leg cramps including stretching exercises, keeping bed covers at the foot of the bed loose and maintaining adequate hydration, particularly for patients on diuretics or dehydrated for other reasons. For severe or persistent leg cramps, low calcium and magnesium states should be excluded.

Other medications that have been tried but with limited effectiveness include vitamin B₆, certain calcium channel blockers, e.g., Diltiazem 60-120 mg at bedtime and gabapentin 100-300 mg at hs. Benadryl, being an antihistamine with significant anticholinergic effects, is best avoided in the frail elderly, as it can cause confusional states. Joel Hurwitz, MD

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