What is the treatment for somnambulism (sleep walking) and which medications can trigger or worsen it?

Treatment for Sleepwalking and Medications That Can Cause It

Sleepwalking (somnambulism) is best treated with sleep hygiene practices and safety measures, with clonazepam being the most effective pharmacological intervention for severe or dangerous cases. 1

Causes and Triggers of Sleepwalking

Sleepwalking is a non-REM sleep parasomnia characterized by complex behaviors during incomplete arousal from slow-wave sleep. Several factors can trigger or worsen sleepwalking:

Medications that can cause or worsen sleepwalking:

• Sedative-hypnotics (benzodiazepines, non-benzodiazepines)
• Antipsychotics
• Stimulants
• Antidepressants
• Alcohol (not a medication but commonly used substance)

Other common triggers:

• Sleep deprivation
• Stress and anxiety
• Fever or illness
• Sleep-disordered breathing (obstructive sleep apnea, upper airway resistance)
• Periodic limb movements
• Restless legs syndrome
• Hypoglycemia 2

Treatment Algorithm for Sleepwalking

Step 1: Non-pharmacological Interventions

1. Sleep hygiene measures:

   • Maintain a regular sleep-wake schedule 3
   • Avoid sleep deprivation
   • Limit alcohol and caffeine, especially before bedtime 3
   • Avoid heavy meals close to bedtime 3
   • Regular exercise, but not within 2 hours of bedtime 3

2. Safety measures to prevent injury:

   • Remove dangerous objects from the bedroom
   • Lock windows and doors
   • Consider sleeping on a mattress on the floor 3
   • Install alarms or motion detectors
   • Remove furniture with sharp corners near the bed 3

3. Treat underlying conditions:

   • Sleep-disordered breathing (OSA, UARS) 4
   • Restless legs syndrome
   • Periodic limb movements
   • Stress and anxiety

Step 2: Pharmacological Treatment (if non-pharmacological measures fail)

For frequent, dangerous, or distressing sleepwalking episodes:

1. First-line medication:

   • Clonazepam: 0.25-2.0 mg taken 30-60 minutes before bedtime 1, 5
     • Most effective and commonly used medication
     • Use with caution in patients with sleep apnea, dementia, or gait disorders 3

2. Alternative medications:

   • Tricyclic antidepressants 5
   • SSRIs 5
   • Trazodone (50-200 mg) 6

Special Considerations

Treatment of Underlying Sleep Disorders

• Sleep-disordered breathing: Treatment with CPAP has been shown to completely resolve sleepwalking in compliant patients 4
• Surgical treatment for sleep-disordered breathing can also resolve sleepwalking when successful 4

Monitoring and Follow-up

• Regular assessment of treatment efficacy
• Monitoring for medication side effects
• Adjustment of treatment as needed

Pitfalls to Avoid

1. Failing to address underlying conditions - especially sleep-disordered breathing, which is frequently associated with chronic sleepwalking 4
2. Attempting to forcefully awaken a sleepwalker - may cause confusion or agitation
3. Relying solely on medications without implementing safety measures and sleep hygiene
4. Using benzodiazepines in patients with sleep apnea without treating the underlying condition
5. Overlooking metabolic causes such as hypoglycemia, especially in diabetic patients 2

For most children and occasional adult sleepwalkers, reassurance and safety measures are sufficient. Pharmacological treatment should be reserved for frequent episodes, cases with risk of injury, or when sleepwalking significantly impacts quality of life through daytime fatigue, anxiety, or insomnia 1.