What are the management options for somnambulism (sleep walking)?

Management of Sleepwalking (Somnambulism)

The most effective approach to managing sleepwalking is to ensure a safe sleeping environment and treat any underlying sleep disorders, with pharmacotherapy reserved for cases with risk of injury.

Safety Measures (First-Line Approach)

Safety interventions are critical for all patients with sleepwalking to prevent injury:

• Remove bedside weapons or objects that could cause injury if thrown or wielded 1
• Move sharp furniture away from the bed or pad edges and headboards 1
• Place soft carpet, rug, or mat next to the bed to reduce risk of injurious falls 1
• For severe cases, recommend sleeping separately from bed partners or placing pillows between them 1
• Secure windows and doors with locks that are difficult to open while sleepwalking 2
• Consider lowering the mattress to the floor for high-risk patients 2

Identifying and Treating Underlying Causes

Sleepwalking is often triggered by underlying conditions that should be specifically evaluated:

• Sleep-disordered breathing: Obstructive sleep apnea and upper airway resistance syndrome are common triggers that, when treated, can completely resolve sleepwalking 3

  • Polysomnography should be performed to identify these conditions
  • Treatment with CPAP has shown complete resolution of sleepwalking in compliant patients 3
  • Surgical treatment of sleep-disordered breathing can also resolve sleepwalking in appropriate candidates 3

• Other sleep disorders: Evaluate for restless legs syndrome and periodic limb movements 4

• Metabolic causes: Consider hypoglycemia, particularly in patients with diabetes 5

Precipitating Factors to Address

Several modifiable factors can trigger sleepwalking episodes:

• Sleep deprivation: Implement regular sleep schedule and ensure adequate sleep duration 6
• Alcohol consumption: Advise avoiding alcohol, especially before bedtime 6
• Stress: Recommend stress management techniques 6
• Medications: Review current medications that may trigger episodes 6
• Fever/illness: Treat underlying medical conditions 6
• Jet lag: Advise gradual adjustment to new time zones 2

Pharmacological Treatment

Medication should be reserved for recurrent sleepwalking with risk of injury when other approaches have failed:

• First-line medication: Clonazepam (benzodiazepine)

  • Most commonly prescribed medication for sleepwalking 4
  • Effective for reducing dream enactment behaviors
  • Start with low doses (0.25-1.0 mg) at bedtime 1

• Alternative medications:

  • Tricyclic antidepressants 4
  • Serotonin selective reuptake inhibitors 4

Special Considerations

• Children: Typically managed conservatively without medications unless there is significant risk of injury 2

  • Focus on sleep schedule regularization and sleep extension
  • Avoid sleep deprivation and allow short naps when needed 2

• Adults with chronic sleepwalking: Higher risk of injury requires more aggressive management

  • Polysomnography is essential to identify underlying sleep disorders 3
  • Treatment focused on underlying sleep disorders rather than direct pharmacotherapy for sleepwalking has shown better outcomes 3

Follow-up and Monitoring

• Reassess sleepwalking frequency and severity after implementing interventions
• For patients on medication, monitor for side effects and efficacy
• Consider referral to a sleep specialist for persistent or severe cases

Treatment Algorithm

1. Implement safety measures for all patients
2. Evaluate for and treat underlying sleep disorders (especially sleep-disordered breathing)
3. Address modifiable precipitating factors
4. If sleepwalking persists with risk of injury, initiate clonazepam at low dose
5. Monitor response and adjust treatment accordingly

Sleepwalking affects 2-14% of children and 1.6-2.4% of adults 4, and while often benign, can lead to serious injuries including life-threatening falls 2. The focus should always be on creating a safe environment while addressing the underlying causes rather than simply suppressing symptoms with medication.