Rem Sleep Disorder: Treatable Or Not?

REM sleep behaviour disorder (RBD) is a parasomnia disorder that affects between 0.5 to 1% of the population, most frequently older adults. People with RBD act out their dreams, which are often vivid and frightening, and can include shouting, punching, kicking, and jumping out of bed. The disorder can be dangerous, with up to 90% of spouses of people with RBD reporting sleep issues and over 60% experiencing physical injury. RBD is also strongly associated with synucleinopathy neurodegeneration, with 38% of men aged 50 or older eventually developing Parkinson's disease, Lewy body dementia, or multiple system atrophy.

The treatment approach to RBD is currently twofold: symptomatic treatment to prevent injury and prognostic counselling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders. Medications such as melatonin and clonazepam are typically used to control symptoms, with melatonin being the preferred, first-line medication due to fewer side effects. However, neither agent is likely to completely stop dream enactment behaviours. Other medications and lifestyle changes may also be used in treatment, and creating a safe sleep environment is crucial to prevent injury.

REM sleep behaviour disorder is a parasomnia disorder characterised by nocturnal complex motor behaviour and polysomnographic REM sleep without atonia

REM sleep behaviour disorder (RBD) is a parasomnia disorder characterised by nocturnal complex motor behaviour and polysomnographic REM sleep without atonia. It is a sleep disorder in which a person physically and/or vocally acts out their dreams while in the rapid eye movement (REM) stage of sleep. The person is unaware of their actions while they sleep. RBD can be either idiopathic or symptomatic. Idiopathic RBD occurs when the condition develops spontaneously without an underlying cause. Symptomatic or secondary RBD happens due to an underlying cause, such as Type 1 narcolepsy, or antidepressant use.

RBD is characterised by repeated episodes of dream enactment behaviour and REM sleep without atonia (RSWA) during polysomnography recording. RSWA is characterised by increased phasic or tonic muscle activity seen on polysomnographic electromyogram channels. RSWA is a requisite diagnostic feature of RBD, but may also be seen in patients without clinical symptoms or signs of dream enactment as an incidental finding in neurologically normal individuals, especially those receiving antidepressant therapy.

The core clinical feature of RBD is a history of witnessed dream enactment by the patient's bed partner, with or without recall of dream mentation by the patient themselves. Patients are often able to vividly recall their dreams and, when recalled, patients typically report that their dream mentation contains a theme of being chased or protecting themselves or a loved one from an attack. Collateral history obtained from the patient's bed partners is crucial in diagnosing RBD.

RBD signs reported by bed partner witnesses include coherent vocalisations such as shouting, screaming, laughing, crying, and swearing that most often matches any recalled dream content described by the patient. In addition, excessive, repetitive phasic muscle bursts develop into complex motor behaviours such as punching, kicking, and running. Behaviours can lead the patient to leave the bed, which can result in lurching out of bed and associated injuries. Due to the violent nature of dreams, injury often results in the form of bruises, head contusions, hair pulling, or fractures.

The prevalence of RBD has been estimated between 0.38% and 0.5% in large population-based studies. However, RBD patients represent up to 4.8% of patients presenting to sleep disorder clinics. The average age of onset is 61 years, and it predominantly affects men.

The minimal diagnostic criteria for RBD include:

• The presence of RSWA on polysomnogram.
• Sleep-related injurious or potentially injurious disruptive behaviours by history, and/or abnormal REM sleep behaviours during PSG.
• Absence of epileptiform activity during REM sleep unless RBD can be clearly distinguished from any concurrent REM sleep-related seizure disorder.
• Sleep disturbance is not better explained by another disorder.

The two most commonly used pharmacological treatments for RBD are clonazepam and melatonin. However, there are no U.S. Food and Drug Administration (FDA)-approved medications specifically for RBD.

The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counselling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders

REM sleep behaviour disorder (RBD) is a parasomnia disorder affecting between 1 and 7% of adults, most frequently older adults. RBD is characterised by nocturnal complex motor behaviour and polysomnographic REM sleep without atonia. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counselling, and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders.

Symptomatic Treatment to Prevent Injury

RBD can be treated with medication. However, it often occurs with other sleep problems or conditions, which may require additional treatment. Medication can help eliminate symptoms, and the most frequently used medicine is clonazepam (Klonopin). Melatonin, a dietary supplement, can also be prescribed, and is usually more tolerable than clonazepam. If you take clonazepam to treat RBD, you may experience side effects such as morning sleepiness, memory problems, confusion, or decreased balance. It can also make sleep apnea worse. If you notice side effects that are interfering with your daily life, speak with your doctor. Switching to melatonin might help relieve your symptoms of RBD, while causing fewer side effects.

Prognostic Counselling and Longitudinal Follow-Up Surveillance for Phenoconversion Toward Overt Neurodegenerative Disorders

RBD is strongly associated with synucleinopathy neurodegeneration. Due to the common co-occurrence of Parkinsonian syndromes and RBD, your doctor will also look for symptoms of Parkinson’s disease, such as hand tremors or muscle stiffness. In many cases, RBD precedes the development of neurodegenerative diseases. One study found that 38% of men aged 50 or older with RBD eventually developed Parkinson’s disease, Lewy body dementia, or multiple symptom atrophy, usually within 13 years. That number increased to nearly 81% in a follow-up study conducted 16 years later. These findings have been confirmed in subsequent research; 30% of individuals with RBD developed a Parkinsonian disorder or dementia within 3 years, and 66% did so within 7.5 years.

Melatonin and clonazepam are the most common treatments for RBD, but alternative therapies are available

Melatonin and clonazepam are the most common treatments for REM sleep behaviour disorder (RBD). However, they are not the only treatments available.

Melatonin is a natural hormone that is predominantly synthesised in the pineal gland and promotes sleep propensity across the brain. It is considered the first-line medication for treating RBD, as it rarely causes side effects. It has a short (30–50 min) elimination half-life, which lessens ‘hang-over’ effects the following morning. Due to its short half-life, melatonin might be suboptimal for the majority of REM sleep periods that occur in the second part of the night. A prolonged-release formulation that releases melatonin gradually over 8–10 h (Neurim Pharmaceuticals Inc.: Circadin) has, therefore, been proposed for treating RBD.

Clonazepam is a sedative and a long-acting benzodiazepine with a half-life of 30–40 h. It is rapidly absorbed after oral administration, with a bioavailability of 90%. It is not known exactly how clonazepam helps treat RBD, but it may suppress phasic bursts of muscle activity during REM sleep. It can cause unpleasant side effects, such as confusion, morning sedation, cognitive impairment and falls. Therefore, it may only be prescribed if melatonin does not help.

Alternative treatments for RBD include:

• Pramipexole: a dopamine agonist primarily prescribed to treat Parkinson's disease and restless leg syndrome. It is thought that this medication works because RBD may be a dopaminergic deficiency disorder.
• Paroxetine: a selective serotonin reuptake inhibitor (SSRI). There are, however, case reports of SSRI-induced RBD, so this treatment may not be suitable.
• L-DOPA: there are limited data demonstrating efficacy in treating RBD.
• Acetylcholinesterase inhibitors: circuitry controlling R sleep involves multiple neurotransmitters, including acetylcholine. Therefore, dysfunction of cholinergic nuclei or pathways are likely to be involved in RBD, even if they are only secondarily affected.
• Zolpidem, zopiclone, temazepam, lorazepam, alprazolam, ramelteon, agomelatine, cannabinoids, Yi-Gan San, desipramine, clozapine, carbamazepine, and sodium oxybate.

RBD is strongly associated with synucleinopathy neurodegeneration

REM sleep behaviour disorder (RBD) is a parasomnia disorder characterised by nocturnal complex motor behaviour and polysomnographic REM sleep without atonia. RBD is strongly associated with synucleinopathy neurodegeneration. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counselling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders.

RBD is a parasomnia, a term used to describe abnormal behaviours during sleep. During normal REM sleep, the body experiences temporary muscle paralysis, known as atonia, while the brain shows activity similar to wakefulness. Blood pressure rises, breathing becomes irregular, and the eyes dart in all directions rapidly. The temporary paralysis of REM sleep allows us to dream safely, lying still while the brain is active. This paralysis involves most skeletal muscles and excludes muscles that help us breathe, digest, and some muscles of the eyes.

For individuals with RBD, normal muscle paralysis does not occur, enabling the person to physically act out their dreams. RBD can manifest as small muscle twitches and quiet sleep talking to loud shouting, punching, kicking, grabbing their bed partner, and jumping out of bed. Interestingly, the dreams associated with RBD are often intense and frightening. Individuals may dream about being chased or attacked, and they can unknowingly enact the dream in real life.

The long-term follow-up of patients initially classified as having probable idiopathic RBD has shown the development of neurodegenerative diseases, mainly synucleinopathies such as Lewy body dementia, Parkinson's disease, or multisystem atrophy. The risk of developing a synucleinopathy is particularly high in men over 50 with RBD. One study found that 38% of men aged 50 or older with RBD eventually developed a synucleinopathy, usually within 13 years. That number increased to nearly 81% in a follow-up study conducted 16 years later. These findings have been confirmed in subsequent research; 30% of individuals with RBD developed a synucleinopathy within 3 years, and 66% did so within 7.5 years.

RBD is a rare condition, affecting less than 1% of the population

REM sleep behaviour disorder (RBD) is a rare condition, affecting between 0.5% and 1% of the population. It is characterised by nocturnal complex motor behaviour and polysomnographic REM sleep without atonia. This means that during sleep, the body's muscles are not paralysed, as is typical during REM sleep, and people with RBD act out their dreams. This can include shouting, punching, kicking, and jumping out of bed. RBD can be dangerous, as people may injure themselves or their bed partners.

RBD is more common in men and adults over 50, but it can also occur in children in higher-risk groups. It is often associated with other neurological conditions, such as Parkinson's disease, Lewy body dementia, and multiple system atrophy. In fact, RBD often precedes the development of these neurodegenerative diseases. One study found that 38% of men over 50 with RBD eventually developed one of these conditions, and a follow-up study 16 years later put this number at 81%.

Treatment for RBD involves a combination of lifestyle changes, medication, and injury prevention techniques. Medication options include melatonin and clonazepam, which are usually effective in reducing symptoms. However, clonazepam may cause side effects such as sleepiness, confusion, and impaired balance. Melatonin, on the other hand, has fewer side effects and is generally better tolerated. Creating a safe sleep environment is crucial for people with RBD to prevent injuries. This may include removing sharp objects and weapons from the bedroom, padding the floor and furniture, and even sleeping in a different room from one's bed partner.

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