What are the assessment and treatment options for somnambulism (sleep walking)?

Assessment and Treatment of Somnambulism (Sleepwalking)

Initial Assessment

Sleepwalking assessment begins with obtaining a detailed history from both the patient and bed partner, focusing on episode characteristics, timing, frequency, and potential triggers or associated conditions. 1

Key Historical Elements

• Episode characteristics: Sleepwalking typically occurs during the first three hours of sleep when stages 3 and 4 non-REM sleep are most prevalent, with episodes lasting 30 seconds to 30 minutes 1
• Frequency and duration: Document how often episodes occur and how long the condition has persisted, as chronic sleepwalking (affecting 2.5% of adults) requires different management than occasional episodes 2, 3
• Injury risk: Assess potential for self-injury or harm to bed partners, as this determines urgency of intervention 2, 3
• Associated symptoms: Screen for witnessed apneas, snoring, restless legs, or periodic limb movements during sleep 2, 3

Medication and Substance Review

• Identify precipitating medications: TCAs, MAOIs, and SSRIs can induce or exacerbate parasomnias 4
• Assess substance use: Alcohol and barbiturate withdrawal, as well as caffeine use, may trigger episodes 4
• Review sedating medications: Evaluate all medications that could fragment sleep architecture 3

Differential Diagnosis Considerations

• Rule out other sleep disorders: The differential includes partial complex seizures during sleep, REM behavior disorder, night terrors, nocturnal seizures, and medication effects 4, 1
• Screen for sleep-disordered breathing: This is critically important as obstructive sleep apnea frequently coexists with chronic sleepwalking in adults 2, 3
• Evaluate for restless legs syndrome and periodic limb movements: These conditions commonly trigger arousal parasomnias 3

Diagnostic Testing

• Polysomnography is indicated for chronic or injurious sleepwalking to identify underlying sleep disorders, particularly sleep-disordered breathing, and to capture episodes showing arousals from slow-wave sleep 2, 3
• Neurologic evaluation with brain MRI should be considered if there is evidence of abnormal neurologic activity or atypical features suggesting seizures 4

Treatment Approach

First-Line: Treat Underlying Sleep Disorders

The most effective treatment for chronic adult sleepwalking is identifying and treating associated sleep disorders, particularly sleep-disordered breathing, which when successfully treated often completely resolves sleepwalking. 2, 3

• Sleep-disordered breathing treatment: All patients with chronic sleepwalking and documented sleep apnea should be treated with nasal CPAP as first-line therapy, as this controls sleepwalking in compliant patients 2
• Surgical treatment for SDB: For CPAP-non-compliant patients, surgical treatment of sleep-disordered breathing also results in complete resolution of sleepwalking when successful 2
• Treat restless legs syndrome and periodic limb movements: Addressing these conditions eliminates somnambulism in many cases 3
• Address upper airway resistance syndrome: This subtle form of sleep-disordered breathing should be treated when identified 3

Conservative Management for Benign Cases

• Ensure adequate sleep: Maintain a regular sleep-wake schedule with sufficient sleep duration, as sleep deprivation precipitates episodes 1, 5
• Environmental safety measures: Remove dangerous objects, pad sharp surfaces, secure windows with heavy draperies, lock doors, and consider placing the mattress on the floor if fall risk is high 4
• Avoid triggers: Eliminate alcohol consumption, heavy evening meals, and sleep deprivation 1, 5
• Scheduled awakening: For children and some adults, waking the patient 15-30 minutes before typical episode timing may prevent events 5

Pharmacologic Treatment

Pharmacotherapy should be reserved for recurrent sleepwalking with risk of injury when conservative measures and treatment of underlying sleep disorders have failed. 3

• Clonazepam is the most commonly used medication for somnambulism when pharmacotherapy is indicated, though evidence is limited 6, 3
• Dosing in adults: Start at 0.25 mg at bedtime, which can be increased gradually; for elderly patients, use the lowest available dose due to fall risk and cognitive effects 6
• Alternative agents: Tricyclic antidepressants and SSRIs have been used, though these same medications can paradoxically trigger parasomnias in some patients 4, 3
• Benzodiazepine limitations: While clonazepam is used, patients often drop out of treatment and report persistence of sleepwalking, making this less effective than treating underlying sleep disorders 2

Special Considerations

• Hypoglycemia screening: In diabetic patients with nocturnal sleepwalking, evaluate for nocturnal hypoglycemia as a trigger 7
• Psychiatric comorbidity: When anxiety or depression coexists, these should be addressed, though psychiatric treatment alone does not reliably control sleepwalking 2
• Violence risk: Patients with violent sleepwalking may benefit from impulse-control interventions in addition to other treatments 5

Critical Pitfalls to Avoid

• Do not rely on benzodiazepines as primary treatment without first evaluating and treating underlying sleep disorders, as medication alone has poor long-term efficacy 2
• Do not dismiss snoring or witnessed apneas in chronic sleepwalkers, as sleep-disordered breathing is the most treatable cause and its resolution often eliminates sleepwalking 2, 3
• Avoid medications that can worsen parasomnias (TCAs, MAOIs, SSRIs) unless specifically indicated for comorbid conditions 4
• Do not attempt to forcefully restrain a sleepwalker during an episode; instead, gently guide them back to bed 1
• In elderly patients, exercise extreme caution with benzodiazepines due to increased fall risk, cognitive impairment, and prolonged drug effects 6