Fixing Rem Sleep Disorder: A Comprehensive Guide

REM sleep behaviour disorder (RBD) is a parasomnia disorder that affects between 1 and 7% of adults, particularly older adults. People with RBD physically act out their dreams, which can lead to injury. The goal of treatment is to ensure safety during sleep, improve sleep quality, and enhance overall health and well-being. Treatment typically involves a combination of medication and lifestyle modifications, including creating a safe sleep environment. While there is no ideal treatment for RBD, melatonin and clonazepam are considered first-line therapies.

Create a safe sleeping environment

Creating a safe sleeping environment is crucial for individuals with REM sleep behaviour disorder (RBD) to prevent injuries to themselves and their bed partners. Here are some detailed instructions to create a safer sleeping environment:

Remove Potential Hazards:

• Remove sharp objects, glass, heavy objects, and weapons from the bedroom. This includes anything that could potentially cause injury if the person falls out of bed or moves around during an episode.
• Clear the floor of any furniture or objects that could cause injury if the person falls out of bed.
• Move furniture away from the bed to create a clear space.
• Add soft padding to the corners of any remaining furniture in the bedroom.
• Protect bedroom windows by securing and blocking them to prevent any potential falls or injuries.

Modify the Bed Area:

• Place pillows or cushions around the bed, especially on the floor next to the bed, to cushion any potential falls.
• Consider using a sleeping bag to restrict movement during sleep.
• Place the mattress on the floor next to the bed to reduce the impact of any falls.
• Alternatively, use a bed with padded bed rails to provide a soft boundary.

Consider Separate Sleeping Areas:

• If the symptoms are severe and the safety measures above do not provide sufficient protection, consider separate sleeping areas. The person with RBD can sleep in a ground-floor room, especially if they tend to leave the bed during an episode.
• The bed partner may need to sleep in a separate room, at least temporarily, until symptoms are well-managed through treatment.

These measures aim to create a safer sleeping environment for individuals with RBD and their bed partners. It is important to combine these environmental modifications with medical treatment and ongoing supervision by a healthcare provider or sleep specialist.

Medication to control symptoms

Medication is often used to control the symptoms of REM sleep behaviour disorder (RBD). The two most common medications are clonazepam and melatonin.

Clonazepam (Klonopin) has been the first-line therapy for many years, with two large case series reporting efficacy with few side effects in the majority of patients. It is highly effective in relieving symptoms in almost 90% of patients, with the response usually beginning within the first week, often on the first night. The initial dose is 0.5 mg at bedtime, with some people requiring a rapid increase to 1 mg. The standard dose is 0.25 mg to 2 mg, taken 30 minutes before bedtime. However, a dose as high as 4 mg has been reported. Long-term use of clonazepam can lead to moderate limb twitching with sleep talking and more complex behaviours. It can also cause significant side effects, including morning sleepiness, confusion, memory problems, and increased severity of obstructive sleep apnea. It should be used with caution in people with dementia or OSA.

Melatonin is also suggested for the treatment of RBD. It has fewer side effects than clonazepam, with only dose-related side effects including morning headache, morning sleepiness, and hallucinations. The effective dose may range from 3 mg to 12 mg at bedtime. Melatonin is particularly useful for those with coexistent cognitive impairment and mild obstructive sleep apnea.

Other medications that may be useful in treating RBD include tricyclic antidepressants, zopiclone, temazepam, lorazepam, zolpidem, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate. However, the evidence for the effectiveness of these medications is limited.

Sleep hygiene practices

• Placing your mattress on the floor
• Using a sleeping bag
• Moving furniture away from the bed
• Adding soft padding to the corners of furniture
• Securing and blocking windows
• Removing weapons and sharp objects from the bedroom
• Using a bed alarm system

Additionally, sleep hygiene practices should be coupled with medication and behavioural therapy to manage associated symptoms such as stress and anxiety.

Cognitive behavioural therapy

CBT for RBD falls into two categories: pharmacological and behavioural. As there is no cure for the disorder, management is symptomatic, with the highest priority placed on controlling extreme and potentially injurious motor behaviours. Many patients will, therefore, elect not to pursue any treatment, especially when the impact of the condition on their quality of life is low.

Behavioural recommendations focus on the creation of a safe sleep environment. This can include removing or padding bedside furniture, lowering the mattress, and placing pillows on the floor beside the bed in case of falls. In some cases, it may be recommended for the patient and bed partner to sleep in separate beds to minimise injury. These measures should be appropriate to the severity and nature of the patient's RBD symptoms.

Physicians should also encourage patients to observe good sleep hygiene and a healthy lifestyle. However, the lack of unique risk factors for RBD will limit the specificity and likely efficacy of this advice.

Bed alarms

The main goal when treating RBD is to create a safe sleeping environment for the patient and their bed partner. Bed alarms can be used as part of a wider strategy to prevent injury and reduce sleep disruption. This may involve removing sharp, glass, and heavy objects from the bedroom, placing padding on the floor, and securing windows. If the patient sleeps with a partner, it may be recommended that they sleep in separate beds or rooms until symptoms are treated.

In addition to bed alarms, medication can be used to manage RBD symptoms. Melatonin is the preferred first-line medication, as it rarely causes side effects. The prescription drug clonazepam has also proven effective in reducing symptoms for 50-80% of individuals with RBD, although it can cause side effects such as sleepiness, forgetfulness, and impaired balance.

Frequently asked questions