Effective Treatments For Rem Sleep Behavior Disorder

REM sleep behaviour disorder (RBD) is a parasomnia disorder characterised by nocturnal complex motor behaviour and REM sleep without atonia. The current approach to managing RBD is twofold: symptomatic treatment to prevent injury and prognostic counselling and longitudinal follow-up surveillance for phenoconversion toward neurodegenerative disorders. While melatonin and clonazepam are the traditional therapeutic mainstays, there is a lack of sound evidence for their efficacy in treating RBD. Nevertheless, melatonin is considered the first-line therapy, followed by clonazepam if melatonin is ineffective or intolerable. However, neither agent is likely to completely stop dream enactment behaviours. Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate.

Melatonin and clonazepam are the first-line treatments for REM sleep behaviour disorder

Clonazepam is a benzodiazepine that enhances the neurotransmitter gamma-aminobutyric acid (GABA) and has antiepileptic properties. It is very effective in treating RBD in small doses. Its exact mechanism of action is unknown. There is little evidence of tolerance or abuse of the drug when it is administered in such small doses. The initial dose is 0.5 mg at bedtime, which can be increased to 1-2 mg if ineffective. Treatment should be continued indefinitely as violent behaviours and nightmares relapse promptly when medication is discontinued. In a minority of patients, particularly elderly persons, clonazepam may increase the risk of confusion or falls and may worsen obstructive sleep apnea.

Melatonin is a hormone that is secreted in a circadian rhythm from the pineal gland. It is generally well tolerated with minimal adverse effects. The effective dose of melatonin for treating RBD is 3-6 mg taken orally at bedtime. Melatonin's mechanism of action against RBD remains unclear but could be mediated by a combination of influences, including a direct impact on REM sleep atonia, modulation of GABAergic inhibition, stabilising circadian clock variability and desynchronisation, and increasing sleep efficiency.

Melatonin is often used to treat sleep disorders

Melatonin is a neurohormone primarily produced by the pineal gland, which is located in the brain. It is also available as a supplement, which is growing in popularity, with 3 million Americans using it in 2012. Melatonin is often used to treat sleep disorders, including REM sleep behaviour disorder.

How Melatonin Works

Melatonin is produced naturally by the body and helps to regulate the body's circadian rhythms, which are biological patterns that operate on a 24-hour clock. Melatonin plays a vital role in the sleep-wake cycle, causing an increase in sleepiness in the evening and helping a person stay asleep through the night. In the morning, melatonin levels drop to undetectable levels as exposure to light inhibits its production.

Benefits of Melatonin for Sleep

Melatonin supplements can help reinforce circadian rhythms and signal to the body that it's time to sleep. They may be beneficial for people who:

• Have naturally low levels of melatonin
• Are temporarily struggling to fall asleep due to stress or jet lag
• Take medications that interfere with sleep
• Are night owls but need to wake up early

It's important to note that while melatonin may help people fall asleep, it does not appear to be effective in helping them stay asleep. Therefore, it may not be the best choice for those seeking a solution to frequent nighttime wakings or long periods of wakefulness.

Melatonin for Sleep Disorders

Melatonin supplements are likely to benefit people with sleep disorders that affect their circadian rhythms, including:

• Non-24-hour sleep-wake rhythm disorder (N24SWD)
• Delayed sleep-wake phase disorder (DSWPD)
• Insomnia
• Shift work disorder

Supplemental melatonin may also be appropriate for children and adolescents with particular sleep, behavioural, and developmental disorders, such as attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). However, melatonin is rarely the right choice for children under five, and accidental overdoses by children have been on the rise, so caregivers should administer it only under a doctor's instructions.

Side Effects of Melatonin

While research suggests that short-term use of melatonin is safe for most adults, more studies are needed to confirm its long-term safety. Melatonin has relatively mild side effects, which may include:

• Nausea or stomachaches
• Dizziness and headaches
• Intense dreams or nightmares
• Temporary feelings of depression

It is important not to drive or use machinery for at least four hours after taking melatonin, as its effects can last for several hours.

Melatonin Dosage

Over-the-counter melatonin supplements come in a range of formulations and dosages, from 0.2 milligrams to 20 milligrams. The ideal dosage depends on the sleep problem being treated, as well as personal characteristics and health history. Doctors usually recommend dosages between 1 and 5 milligrams for adults and adolescents, and between 0.2 milligrams and 3 milligrams for children. It is recommended to start with the lowest possible dose and increase as needed, not exceeding 10 milligrams per 24-hour period.

Clonazepam is highly effective in treating REM sleep behaviour disorder

Clonazepam is a highly effective treatment for REM sleep behaviour disorder (RBD). It is a potent, intermediate-acting benzodiazepine with anxiolytic, anticonvulsant, and hypnotic properties. It is also one of the most widely prescribed medications of its class.

Clonazepam is effective in nearly 90% of patients with RBD, with complete benefit in 79% of patients and partial benefit in another 11%. The response usually begins within the first week, often on the first night. The initial dose is 0.5 mg at bedtime, which can be increased to 1–2 mg if ineffective. Treatment should be continued indefinitely, as violent behaviours and nightmares relapse promptly with discontinuation of the medication in almost all patients.

The exact mechanism of action of clonazepam in RBD is unknown but may be related to its serotonergic properties. It is ineffective in approximately 10% of patients. In a minority of patients, particularly elderly persons, clonazepam may increase the risk of confusion or falls and may worsen obstructive sleep apnea.

Tricyclic antidepressants may be effective in treating REM sleep behaviour disorder

REM sleep behavior disorder (RBD) is a parasomnia disorder characterised by vigorous and violent movements during the rapid eye movement (REM) stage of sleep. It is associated with synuclein-mediated neurodegenerative diseases such as Parkinson's disease and dementia with Lewy bodies. Antidepressants have been linked to an increased risk of RBD, particularly in older adults. Tricyclic antidepressants, such as amitriptyline, have been associated with a higher risk of RBD due to their effects on dopamine levels and receptor binding. This can disrupt muscle paralysis during REM sleep, allowing for excess movement and dream enactment.

While RBD can occur in people not taking any medications, understanding the link between antidepressants and RBD is crucial due to the high prevalence of antidepressant use. RBD triggered by antidepressants may be an early sign of underlying neurodegeneration. Those with antidepressant-associated RBD have a lower risk of developing neurodegenerative diseases than those without antidepressant use, but markers of prodromal neurodegeneration are still present. This suggests that antidepressants may trigger the early clinical presentation of RBD due to underlying neurodegeneration.

The management of antidepressant-induced RBD involves consulting the prescribing doctor to adjust dosages, switch medications, or prescribe RBD-specific treatments such as melatonin or clonazepam. Lifestyle changes, such as removing hazardous objects from the bed area and avoiding sleep deprivation, can also help reduce RBD episodes and prevent injuries. With proper medication management and safety precautions, many individuals can effectively control their antidepressant-induced RBD.

Non-pharmacological treatments include bed alarms and hypnosis

Non-pharmacological treatments for REM sleep behaviour disorder (RBD) are important to prevent sleep-related injuries to the patient or their bed partner. Bed alarms can be used to wake the patient up when they are acting out their dreams, and customised alarms with familiar voices delivering calming messages have been shown to reduce RBD symptoms and sleep-related injuries.

Hypnosis is another non-pharmacological treatment for RBD. Hypnosis can help people change behaviours that are hard to change otherwise, such as sleeping habits or negative thoughts that may cause insomnia. Hypnotherapists can direct a person's attention to their breathing or a specific object to help them shift into a proper state of focus for hypnosis. Once the person reaches a deeply focused state, the hypnotherapist may offer tailored guidance to help them sleep better. Hypnosis does not work for everyone, and it may take several sessions to see the benefits.

Frequently asked questions