Referring For Rem Sleep Disorders: When To Act?

when to refer for rem sleep disorder

REM sleep behaviour disorder (RBD) is a parasomnia, a sleep disorder that involves abnormal physical events or experiences that interrupt sleep. It affects less than 1% of people and usually begins after the age of 50. People with RBD act out their dreams, often violently, causing injury to themselves or their bed partner. As RBD can be difficult to diagnose, and the symptoms are frequently severe, it is important to refer people who may have the condition to a healthcare provider.

Characteristics Values
Type There are two main types of RBD: isolated (idiopathic) and symptomatic (secondary)
Isolated RBD Occurs when the condition develops spontaneously without an underlying cause
Symptomatic RBD Occurs due to an underlying cause, such as Type 1 narcolepsy
Drug-induced RBD Caused by certain antidepressants due to imbalances in dopamine and serotonin
Age Most commonly affects people over the age of 50
Average age of onset 61 years
Gender Men are nine times more likely to be affected than women
Neurodegenerative disorders About 97% of people with isolated RBD will develop Parkinson's disease, Lewy body dementia, or multiple system atrophy (MSA)
Prevalence Affects about 1% of the general US population and 2% of people aged 50 or older
Diagnosis Requires a polysomnogram (PSG) or in-lab sleep study to confirm
Treatment Creating a safe sleeping environment, medication such as melatonin, clonazepam, or pramipexole
Prognosis Depends on underlying causes, severity of symptoms, treatment, and the presence of neurodegenerative conditions

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Diagnosis

If you suspect you may have REM sleep behaviour disorder (RBD), it is important to seek advice from a healthcare provider. They will ask about your symptoms and medical history, and may also ask your bed partner or housemates about your sleeping behaviour.

Your provider will also perform a physical and neurological exam. They may refer you to a sleep specialist or a dedicated sleep centre for further examination.

To receive a diagnosis of RBD, you will need to undergo an in-lab video sleep study, also known as a polysomnogram (PSG). Sleep studies record specific body functions during sleep, such as your breathing rate and airflow, brain wave activity, and muscle movements.

According to the International Classification of Sleep Disorders, a diagnosis of RBD requires the following criteria to be met:

  • Repeated episodes of sleep-related vocalisations and/or complex movement behaviours.
  • Episodes occur during REM sleep, as confirmed by the sleep study or your clinical history.
  • The sleep study shows that you experience REM sleep without muscle paralysis.
  • The sleep disturbances are not better explained by another sleep disorder, medical condition, medication side effects, or substance use.

If you have been diagnosed with RBD, your healthcare provider will likely recommend regular follow-up checks to monitor for signs of neurological conditions that are associated with the disorder.

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Risk factors

REM sleep behaviour disorder (RBD) is a parasomnia that causes people to act out their dreams physically and/or vocally during the rapid eye movement (REM) stage of sleep. The risk factors for RBD are outlined below:

Age and Sex

RBD is more common in men, and people over the age of 50, with an average onset age of 61 years. Among people over 50, men are nine times more likely to develop RBD than women.

Neurological Disorders

RBD often coexists with other neurological conditions, including Parkinson's disease, Lewy body dementia, multiple system atrophy, narcolepsy, or stroke. In many cases, RBD precedes the development of one of these neurodegenerative diseases.

Medication

Certain antidepressants and medications can induce RBD. Tricyclic antidepressants and serotonin-specific reuptake inhibitors are known to cause RBD.

Substance Use

The use of drugs or alcohol, or withdrawal from them, can increase the risk of RBD.

Mental Health

RBD has been linked to various mental health issues, including psychological distress, mental illness, and post-traumatic stress disorder (PTSD). Antidepressants used to treat these conditions may also be a factor.

Smoking

Current and past smokers are at a higher risk of developing RBD. The average cigarette pack-year smoking dose was slightly greater in the RBD group.

Education

Lower levels of education have been associated with a higher risk of RBD.

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Treatment

The treatment of REM sleep behaviour disorder (RBD) is very important to prevent sleep-related falls and injuries. While there is no ideal treatment, the main goal is to create a safe sleeping environment for the patient and their bed partner. This can involve safety measures and medication.

Safety Measures

  • Removing sharp, glass, and heavy objects from the bedroom.
  • Placing pillows between the patient and surrounding structures, such as the headboard or a nightstand.
  • Placing a mattress on the floor next to the bed in case the patient falls out of bed, or using padded bedside rails.
  • Sleeping in a sleeping bag.
  • If the symptoms are severe, it may be safest for the bed partner to sleep alone in a different room.
  • Avoiding alcohol, as it can trigger an RBD episode and make the condition worse.

Medication

If safety measures are not enough to prevent injury, medication may be prescribed to manage symptoms. While there are no U.S. Food and Drug Administration (FDA)-approved medications specifically for RBD, studies have shown that melatonin, clonazepam, and pramipexole can reduce symptoms in some cases.

Melatonin

Melatonin is a hormone that is naturally produced by the pineal gland and is essential for regulating the sleep cycle. It is considered the first-line medication for treating RBD as it rarely causes side effects. Treatment typically begins with a baseline dose, which is then increased until symptoms improve.

Clonazepam

Clonazepam is a sedative. It is not known exactly why it helps treat RBD, but most people with RBD who take a low dose before sleeping have fewer or no nightmares, vocalisations, or dream enactment behaviours. However, clonazepam can cause unpleasant side effects, so it is usually only prescribed if melatonin does not help.

Pramipexole

Pramipexole is a dopamine agonist, primarily prescribed to treat Parkinson's disease and restless leg syndrome. Recent research shows that it can also help treat the symptoms of RBD, as the disorder may be a dopaminergic deficiency disorder.

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Prevention

REM sleep behaviour disorder (RBD) is a parasomnia that involves acting out dreams during the rapid eye movement (REM) stage of sleep. While there is no definitive way to prevent RBD, there are strategies to reduce the risk of injury to oneself and one's bed partner. Here are some preventative measures:

Environmental Changes

  • Remove sharp, glass, and heavy objects from the bedroom to minimise potential injury.
  • Place pillows or padding around the bed and on sharp furniture edges.
  • Lower the bed so it's closer to the floor to reduce the impact of falls.
  • Consider placing a mattress on the floor next to the bed or using padded bed rails.
  • Move furniture and clutter away from the bed to create a clear space.
  • If necessary, sleep in a separate room from your bed partner to ensure their safety.

Lifestyle Changes

  • Avoid alcohol and prescription drugs that can contribute to RBD, such as certain antidepressants.
  • Establish a consistent sleep schedule and improve overall sleep hygiene.
  • Consult a doctor about any other medications you are taking to identify those that may induce RBD.

Medication

  • Melatonin is often recommended as the first-line medication for RBD due to its effectiveness and low side effect profile.
  • Clonazepam, a sedative, has been found to reduce nightmares and vocalisations in people with RBD, but it may cause side effects like sleepiness and impaired balance.
  • Pramipexole, a dopamine agonist, has shown promise in treating RBD symptoms in recent research.

While these strategies may help manage RBD, it is important to consult a healthcare professional for personalised advice and to explore the underlying causes of the disorder.

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Complications

People with RBD can put themselves and their bed partners at risk of injury due to the violent nature of their movements during sleep. This can include head injuries and subdural hematomas, which can sometimes be life-threatening. About 8 in 10 people with RBD experience sleep-related injuries, and up to 90% of partners of people with RBD have sleep issues, with over 60% experiencing physical injury.

The disorder can also cause frequent sleep disruptions, affecting the overall quality of sleep for both the person with RBD and their bed partner. This can lead to fatigue, irritability, and difficulty concentrating during the day.

In addition, RBD is strongly associated with certain neurodegenerative disorders, such as Parkinson's disease, Lewy body dementia, and multiple system atrophy (MSA). About 97% of people with isolated (idiopathic) RBD will develop one of these conditions within 14 years of their RBD diagnosis. As a result, people with RBD and a neurological condition often have a poorer prognosis and a lower quality of life.

Furthermore, RBD can be challenging to diagnose, as almost half of those with the condition are unaware they have it. This can delay treatment and increase the risk of injuries and other complications. Therefore, it is crucial to seek medical help if you or your bed partner exhibit any symptoms of RBD, such as acting out dreams, sleep disruptions, or unusual movements during sleep.

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Frequently asked questions

REM sleep behaviour disorder (RBD) is a sleep disorder where the individual physically acts out their dreams while being unaware that they are doing so. This can cause injury to themselves or their bed partner, especially if they are acting out a violent nightmare.

The symptoms of RBD can vary in severity, ranging from mild muscle twitches to jumping or falling out of bed. The person may talk, shout, or scream during sleep, and their sleep may be disrupted several times a night.

The cause of RBD is not fully understood, but researchers believe it is due to an issue in the brainstem that leads to a lack of temporary paralysis during REM sleep, allowing individuals to act out their dreams.

RBD is relatively rare, affecting about 1% of the general US population and 2% of people aged 50 or older. However, these rates may be higher as RBD can be challenging to diagnose, and nearly half of those with the condition may not realise they have it.

If an individual is displaying symptoms of RBD, such as acting out their dreams or experiencing sleep disruptions, they should be referred to a healthcare provider for further evaluation and potential treatment to prevent injury and ensure a safe sleeping environment.

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