From the Guidelines
REM sleep behavior disorder (RBD) is diagnosed when patients act out their dreams during REM sleep due to a lack of normal muscle atonia, with diagnostic criteria including dream-enacting behaviors with vocalizations and/or complex motor movements, documentation of REM sleep without atonia on polysomnography, and absence of epileptic activity during REM sleep, as stated in the 2023 American Academy of Sleep Medicine clinical practice guideline 1.
Diagnostic Criteria
The diagnostic criteria for RBD include:
- Dream-enacting behaviors with vocalizations and/or complex motor movements
- Documentation of REM sleep without atonia on polysomnography
- Absence of epileptic activity during REM sleep These criteria are essential for accurately diagnosing RBD and distinguishing it from other sleep disorders.
Treatment Options
The treatment options for RBD include:
- Clonazepam at 0.25-1.0 mg taken at bedtime, which enhances inhibitory GABA activity in the brain 1
- Melatonin at 3-15 mg taken at bedtime, which suppresses REM sleep motor tone and renormalizes other circadian features of REM sleep 1
- Pramipexole, a dopaminergic agonist, which may help reduce dream enactment by treating an underlying sleep-fragmenting condition, periodic limb movement disorder 1
- Rivastigmine, an acetylcholinesterase inhibitor, which may be an appropriate choice for patients with RBD and cognitive impairment refractory to other treatments 1
Environmental Safety Measures
Environmental safety measures are essential for preventing injuries in patients with RBD, including:
- Removing dangerous objects from the bedroom
- Padding the floor beside the bed
- Considering separate sleeping arrangements if bed partner injuries have occurred
Monitoring for Neurodegenerative Disorders
Patients with RBD should be monitored for development of neurodegenerative disorders, particularly Parkinson's disease and other synucleinopathies, as RBD can be an early manifestation of these conditions, sometimes preceding motor symptoms by years or even decades 1.
From the Research
Diagnostic Criteria for REM Sleep Behavior Disorder (RBD)
- RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia 2
- Diagnosis can only be definitely confirmed on the basis of polysomnography 3
- The International Classification of Sleep Disorders (ICSD) includes cutoff values for scoring electromyography (EMG) activity during REM sleep 3
- A cutoff of 27 % muscle activity during REM sleep is suggested by the Sleep Innsbruck Barcelona (SINBAR) group 3
Treatment Options for RBD
- The best-researched treatments for RBD are clonazepam and melatonin 2, 3
- Melatonin dosed 3-12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25-2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable 2
- Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate 2
- Pramipexole, a dopaminergic D2-3 receptor agonist, has been shown to be effective in reducing RBD symptoms in a case series study 4
- The American Academy of Sleep Medicine recommends the use of clonazepam, melatonin, rivastigmine, and pramipexole for the treatment of RBD 5
Diagnostic Tools for RBD
- Diagnosis of RBD involves a clinical interview and a subsequent overnight polysomnography (PSG) evaluation to assess for REM sleep without atonia (RWA) and/or observe motor behaviors during REM sleep 6
- Sleep history may be sufficient for diagnosis of RBD in some populations, but PSG is necessary for a definitive diagnosis 6
- Questionnaires can be used as screening tools, but further validation in different populations is necessary 6