How is sleepwalking (somnambulism) managed?

Management of Sleepwalking (Somnambulism)

Safety interventions are the cornerstone of sleepwalking management, with clonazepam being the most effective pharmacological treatment for recurrent sleepwalking with risk of injury when other approaches have failed. 1

Safety Interventions (First-line Management)

Safety measures should be implemented for all patients with sleepwalking to prevent injury:

• Remove potentially dangerous objects from bedside 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 falls 1
• For severe cases, recommend sleeping separately from bed partners or placing pillows between them 1
• Secure windows and doors with alarms or special locks to prevent wandering outside
• Keep bedroom on ground floor if possible to prevent falls down stairs

Identify and Treat Underlying Causes

Sleepwalking may be triggered or worsened by:

• Sleep-disordered breathing: Treatment of underlying sleep-disordered breathing with CPAP has been shown to control sleepwalking in compliant patients 2
• Sleep deprivation: Establish regular sleep schedule and adequate sleep duration
• Medications: Review and possibly modify medications that may trigger episodes
• Stress and anxiety: Address through appropriate psychological interventions
• Medical conditions: Manage conditions like hypoglycemia that may trigger episodes 3

Pharmacological Treatment

For recurrent sleepwalking with risk of injury when other approaches have failed:

• Clonazepam: Start at low doses (0.25-1.0 mg) at bedtime 1, 4

  • Most commonly prescribed and effective medication for reducing sleepwalking episodes
  • Monitor for side effects including daytime sedation and potential for dependence

• Alternative medications (if clonazepam is ineffective or contraindicated):

  • Tricyclic antidepressants 5
  • Selective serotonin reuptake inhibitors 5

Non-pharmacological Approaches

For cases where medication is not preferred or as adjunctive therapy:

• Scheduled awakening: Waking the person approximately 15-30 minutes before the typical time of sleepwalking episodes 6
• Relaxation techniques: Deep relaxation exercises before bedtime 4
• Hypnosis: May be beneficial in some cases 4, 6
• Cognitive behavioral therapy: Particularly helpful when anxiety is a contributing factor 4

Special Considerations

• Children: Most childhood sleepwalking is benign and self-limiting, requiring only safety measures and reassurance 4
• Violent sleepwalking: May require impulse-control interventions in addition to standard treatments 6
• Chronic sleepwalkers: Should be evaluated for sleep-disordered breathing, as successful treatment of this condition may resolve sleepwalking 2

Follow-up and Monitoring

• Regular follow-up to assess effectiveness of interventions
• Adjust treatment plan based on response
• Consider polysomnography for persistent cases to identify potential comorbid sleep disorders 2

Caution

While it is commonly believed that waking a sleepwalker is dangerous, this is a myth. However, the person may be confused or disoriented when awakened 3.