Exploring Rem Sleep Behavior Disorder: Treatment Options And Possibilities

REM sleep behaviour disorder (RBD) is a sleep disorder that causes people to physically act out their dreams, sometimes violently, while remaining asleep. This can result in injuries to the person with RBD or their bed partner. There is currently no cure for RBD, but there are treatments that can help reduce symptoms and prevent injury. These include medications such as melatonin, clonazepam, and pramipexole, as well as creating a safe sleeping environment by removing dangerous objects from the bedroom and padding the area around the bed.

Creating a safe sleeping environment

Remove Potential Hazards:

• Remove sharp objects, glass, and heavy items from the bedroom, especially those within arm's reach of the bed. This includes anything that could cause injury if the person falls out of bed or flails during an episode.
• Clear the floor of any furniture or objects that could cause injury if someone falls or moves around during sleep.

Add Protective Measures:

• Place pillows or cushions around the bed, especially near hard surfaces like headboards or nightstands.
• Consider padded bed rails to provide a soft barrier and prevent falling out of bed.
• Place a mattress or padding on the floor next to the bed as an extra precaution in case of falling out of bed.
• If possible, choose a bedroom on the ground floor, especially if the person tends to leave the bed during an episode.
• Sleeping in a sleeping bag can help restrict limb movements during sleep.

Separate Sleeping Areas:

If the symptoms are severe and pose a significant risk to the bed partner, it may be advisable for them to sleep in a separate bed or even a different room until the symptoms are well-managed.

Avoid Alcohol:

Alcohol consumption can trigger RBD episodes and worsen the condition. Therefore, it is essential to avoid drinking alcohol to create a safer sleeping environment.

Additionally, certain medications like melatonin, clonazepam, and pramipexole can help reduce symptoms in some cases. However, these medications are typically prescribed when safety measures alone are insufficient to prevent injuries.

Medication

While there are no medications specifically designed to treat REM sleep behaviour disorder (RBD), certain drugs can help to reduce symptoms. Melatonin is the preferred first-line medication for treating RBD. It rarely causes side effects and is considered effective in reducing symptoms. Dosages of 3-12 mg of melatonin at bedtime are recommended.

Clonazepam, a prescription sedative, has proven effective in reducing symptoms for 50-80% of individuals with RBD. However, it can cause side effects such as sleepiness, forgetfulness, and impaired balance. Due to these side effects, it is usually recommended only if melatonin does not help. Pramipexole, a drug used to treat Parkinson's disease and restless leg syndrome, has also shown promise in treating RBD symptoms.

Alternative second- and third-line therapies with anecdotal evidence of efficacy include temazepam, lorazepam, zolpidem, zopiclone, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate.

Lifestyle changes

• Avoid alcohol: Alcohol can trigger an RBD episode and make the condition worse.
• Reduce or eliminate certain prescription drugs: Certain prescription drugs, such as antidepressants, can contribute to RBD. Making lifestyle changes to reduce or eliminate their use may be part of a person's treatment.
• Improve sleep hygiene: This can include setting a consistent sleep schedule and making changes to promote sleep quality.
• Use melatonin: Melatonin is the preferred first-line medication for RBD. It usually has fewer side effects than other medications and is effective in reducing symptoms. The dosage for treating RBD is different from that for falling asleep, so consultation with a sleep physician is recommended.
• Use clonazepam: The prescription drug clonazepam has been proven effective in reducing symptoms for 50-80% of individuals with RBD. However, it can cause side effects such as sleepiness, forgetfulness, and impaired balance.

Diagnosis

To diagnose REM sleep behaviour disorder (RBD), a doctor will ask about symptoms and medical history, and may also ask any bed partners or housemates about the patient's sleeping behaviour. The patient will also undergo a physical exam and a neurological exam.

The most important diagnostic test for RBD is polysomnographic video recording, which is usually conducted in a sleep study centre. The test monitors the following parameters:

• Electrical activity of the brain (electroencephalogram, or EEG)
• Electrical activity of the heart (electrocardiogram, or ECG)
• Movements of the muscles (electromyogram)
• Eye movements (electrooculogram)
• Respiratory movements

The test records characteristic patterns from electrodes while the patient is awake and during sleep. Continuous video recording is also done to observe behaviours during sleep.

In people with RBD, the polysomnogram will show an increase in muscle tone associated with the EEG pattern of REM sleep. In healthy people, the EEG pattern of REM sleep is associated with an absence of muscle tone (atonia). The video recording will also show body movements coinciding with the EEG pattern of REM sleep.

Imaging studies such as a CT scan or MRI of the brain are not usually indicated in people who have no neurological cause of RBD, but they may be done if some abnormality is detected during the neurological exam. Imaging studies should also be considered in younger patients (under 40) where there is no known cause such as alcohol or medication use.

Complications

REM sleep behaviour disorder (RBD) can lead to several complications, the most notable being the risk of injury to oneself or one's bed partner. The violent nature of the physical movements and vocalisations during RBD episodes can cause harm to the sleeper and anyone sharing their bed. These injuries can be life-threatening, including head injuries and subdural hematomas. About 8 in 10 people with RBD experience sleep-related injuries, and up to 90% of partners of those with RBD have sleep issues, with over 60% experiencing physical injury.

The sleep disruptions caused by RBD can also affect the overall quality of sleep for the individual and their bed partner, potentially leading to relationship problems. Even when the risk of physical injury is reduced through safety measures, the sleep disruption can still be severe enough to cause issues in a relationship. However, many couples choose to continue sleeping together despite the risk of disturbed sleep.

The association between RBD and neurological conditions, such as Parkinson's disease, Lewy body dementia, and multiple system atrophy, is another significant complication. RBD often precedes the development of these neurodegenerative diseases by several years. In one study, 38% of people with RBD developed Parkinson's disease within an average of 12 to 13 years after the onset of RBD symptoms. Another study found that 66% of individuals with RBD developed a Parkinsonian disorder or dementia within 7.5 years. Therefore, individuals with RBD may need to undergo regular health checks to monitor for signs of these neurological conditions.

Frequently asked questions