What is the treatment for Non-Rapid Eye Movement (NREM) parasomnia?

Treatment of NREM Parasomnia

The treatment of NREM parasomnia should prioritize safety measures and behavioral interventions first, followed by pharmacotherapy with clonazepam as the most effective medication option when needed. 1, 2

First-Line Approach: Safety Measures and Behavioral Interventions

• Environmental safety modifications are essential for all NREM parasomnia patients to prevent sleep-related injuries, including:

  • Removing hazardous objects from the bedroom 1, 2
  • Securing windows and doors 1
  • Padding hard and sharp surfaces 2
  • Lowering bed mattress or placing it on the floor 2
  • Moving furniture away from the bed 3

• Behavioral interventions have shown effectiveness in approximately one-third of patients with NREM parasomnia 4:

  • Sleep hygiene optimization (13.2% effective as monotherapy) 4
  • Management of underlying sleep disorders (12.1% effective as monotherapy) 4
  • Psychological interventions such as cognitive behavioral therapy (CBT) or mindfulness-based stress reduction (5.8% effective as monotherapy) 4, 5
  • Hypnosis has been reported as beneficial in multiple case reports 5, 6

• Identify and address triggering factors that may precipitate episodes:

  • Sleep deprivation or irregular sleep schedule 1, 6
  • Stress and anxiety 4, 6
  • Medications that can induce or exacerbate parasomnias 1, 7
  • Underlying sleep disorders such as obstructive sleep apnea 1, 4

Second-Line Approach: Pharmacotherapy

• Clonazepam (0.5-1mg at bedtime) is the most commonly prescribed medication for NREM parasomnia, with effectiveness in approximately 90% of cases 2

  • May be taken 1-2 hours before bedtime if sleep onset insomnia or morning drowsiness occurs 2
  • Use with caution in elderly patients, as it appears on the American Geriatrics Society Beers Criteria list of potentially inappropriate medications 2
  • Also use with caution in patients with dementia, gait disorders, or concomitant OSA due to increased risk of falls and respiratory depression 1

• Alternative pharmacological options when clonazepam is contraindicated or poorly tolerated:

  • Antidepressants (11.7% of successfully treated patients) 4
  • Z-drugs such as zolpidem or zopiclone (9.2% of successfully treated patients) 4
  • Melatonin (10.7% of successfully treated patients) 4, 8

Special Considerations

• NREM parasomnias are more common in children, while REM sleep behavior disorder (RBD) is more prevalent in older adults 2
• Polysomnography may be needed to differentiate NREM parasomnia from other sleep disorders, particularly when the diagnosis is unclear or treatment-resistant 2, 5
• In a large retrospective study of 512 patients with NREM parasomnia, 97.2% reported adequate control of symptoms with appropriate treatment 4
• A case-conceptualization based, integrative approach to behavioral treatment has shown promising results in adult NREM parasomnias, with symptoms satisfactorily reduced after 3-6 sessions 6

Common Pitfalls

• Failing to address underlying sleep disorders that may trigger NREM parasomnia episodes 1, 4
• Not recognizing medication-induced parasomnias, particularly from serotonergic medications 1, 7
• Overlooking the importance of safety measures, which should be implemented regardless of pharmacological treatment 1, 2
• Using clonazepam without caution in vulnerable populations such as elderly patients or those with sleep apnea 1, 2