What is the treatment of REM (Rapid Eye Movement) and NREM (Non-Rapid Eye Movement) parasomnias?

Treatment of REM and NREM Parasomnias

The treatment of parasomnias should prioritize safety measures first, followed by behavioral interventions, and then pharmacotherapy, with clonazepam (0.5-2 mg at bedtime) being the most effective pharmacological treatment for both REM and NREM parasomnias. 1

General Principles for All Parasomnias

• Safety measures should be implemented for all parasomnia patients to prevent sleep-related injuries, including removing hazardous objects from the bedroom, securing windows, and using padded bed rails 1
• Underlying sleep disorders and triggering factors should be identified and treated as part of comprehensive management 1
• Medications that can induce or exacerbate parasomnias (such as TCAs, MAOIs, SSRIs, alcohol, and caffeine) should be identified and discontinued when possible 2, 1

Treatment of REM Sleep Behavior Disorder (RBD)

First-Line Pharmacotherapy

• Clonazepam (0.5-1 mg at bedtime) is the most effective drug therapy for RBD, with effectiveness rates of 70-90% in reducing violent behaviors 2, 1
• Clonazepam may be taken 1-2 hours before bedtime in patients who report sleep onset insomnia or morning drowsiness 2
• Melatonin (3-12 mg at bedtime) is an alternative first-line treatment with fewer side effects than clonazepam, particularly beneficial in elderly patients or those with comorbid OSA 1

Important Considerations

• RBD is often associated with neurodegenerative α-synucleinopathies (such as Parkinson's disease, progressive supranuclear palsy, multiple systems atrophy) and may precede these conditions by years 2, 1
• Diagnosis is confirmed through history and polysomnography evidence of increased electromyographic activity during REM sleep (lack of atonia) 2
• A full neurologic workup, including brain MRI, may be needed if there is evidence of abnormal neurologic activity 2

Treatment of NREM Parasomnias

First-Line: Safety Measures and Behavioral Interventions

• Environmental safety modifications are essential to prevent injury in patients with NREM parasomnia 1, 3
• Sleep hygiene improvements can be effective as monotherapy in approximately 13% of patients 4
• Treatment of concurrent sleep disorders (particularly OSA) can resolve NREM parasomnias in about 12% of patients 4, 5
• Psychological interventions such as cognitive behavioral therapy (CBT) or mindfulness-based stress reduction (MBSR) can be effective in approximately 6% of patients 4

Second-Line: Pharmacotherapy

• Clonazepam (0.5-1mg at bedtime) is the most commonly prescribed medication for NREM parasomnia, effective in approximately 90% of cases 3, 6
• Melatonin has shown promising results with 88% of patients reporting improvement 5
• Benzodiazepines should be used with caution in patients with dementia, gait disorders, or concomitant OSA due to increased risk of falls and respiratory depression 1, 3
• Other medications that may be effective include paroxetine for sleep terrors, and topiramate, pramipexole, and sertraline for sleep-related eating disorder 6

Treatment Algorithm

1. Implement safety measures for all parasomnia patients 1, 3
2. Identify and treat underlying sleep disorders (particularly OSA) 4, 5
3. Discontinue medications that may trigger or worsen parasomnias 2, 1
4. Implement behavioral interventions:
   • Sleep hygiene improvements 4
   • Psychological interventions (CBT, MBSR) for stress-related triggers 4, 7
5. Initiate pharmacotherapy if symptoms persist:
   • For RBD: Clonazepam 0.5-1 mg at bedtime or melatonin 3-12 mg at bedtime 2, 1
   • For NREM parasomnias: Clonazepam 0.5-1 mg at bedtime or melatonin 3, 5

Special Considerations

• NREM parasomnias are more common in children, while REM sleep behavior disorder is more prevalent in older adults 2, 3
• Polysomnography is essential for differentiating between parasomnia types and ruling out other sleep disorders 2, 3
• Patients with RBD should be monitored for emerging signs of neurodegenerative disorders 1
• Non-pharmacological interventions can be effective in approximately one-third of patients with NREM parasomnias 4
• Treatment of comorbid OSA has shown improvement in 52% of patients with NREM parasomnias 5