From the Guidelines
REM sleep behavior disorder (RBD) is best managed through a combination of medication and safety measures, with the most recent and highest quality study recommending the removal of bedside weapons and objects that could inflict injury, as well as padding sharp furniture and placing a soft carpet or mat next to the bed to reduce the risk of injurious falls 1.
Key Management Strategies
- Creating a safe sleeping environment is crucial to prevent injuries, and this includes removing dangerous objects from the bedroom, padding the floor beside the bed, and considering separate sleeping arrangements to protect bed partners.
- Clonazepam and melatonin are effective medication options, with clonazepam typically starting at 0.5 mg taken 30 minutes before bedtime and melatonin usually at doses of 3-12 mg before bedtime.
- Patients with severe, uncontrolled RBD should be recommended to sleep separately from their partners or place a pillow between themselves and their partners to minimize the risk of injury.
Medication Considerations
- Clonazepam is a long-acting benzodiazepine with potential side effects including sedation, impotence, and memory dysfunction, and its use should be monitored carefully, especially in patients with neurodegenerative disorders or obstructive sleep apnea 1.
- Melatonin has been shown to be effective in reducing RBD symptoms with relatively few side effects, and its use is recommended as an alternative to clonazepam 1.
Safety Precautions
- Securing the bedroom environment to reduce the risk of injury is essential, including lowering the bed mattress, padding the corners of furniture, and installing window protection 1.
- Removing loaded firearms and other potentially dangerous objects from the bedroom is of paramount importance to prevent accidents during dream enactment episodes.
From the Research
REM Sleep Disorder Management
- REM sleep behavior disorder (RBD) is a parasomnia associated with dream enactment often involving violent or potentially injurious behaviors during REM sleep 2.
- Treatment options for RBD include melatonin and clonazepam, with melatonin appearing to be beneficial for the management of RBD with reductions in clinical behavioral outcomes and decrease in muscle tonicity during REM sleep 2.
- A study of 512 patients with Non-REM parasomnia or parasomnia overlap disorder (POD) found that 97.2% reported adequate control of their symptoms, with 60.1% treated with pharmacotherapy and 32.0% without 3.
- Benzodiazepines were the most common drugs prescribed (47.1%), and 37.7% of patients were receiving a benzodiazepine as part of their successful treatment 3.
- Non-pharmacological interventions, such as sleep hygiene, management of sleep-disordered breathing, and psychological interventions (cognitive behavioral therapy [CBT] or mindfulness-based stress reduction [MBSR]), were effective in one third of patients 3.
Pharmacological Management
- Melatonin is a commonly used therapy for the management of RBD, with a favorable safety and tolerability profile over clonazepam 2.
- Clonazepam is also a commonly used therapy for RBD, but has a higher potential for drug-drug interactions 2.
- Modafinil and caffeine are commonly used wake-promoting agents in the treatment of excessive daytime sleepiness (EDS) 4.
- Eszopiclone and melatonin are used for the management of insomnia, and calcium channel alpha-2-delta ligands and low-dose dopamine agonists (DA) are used for the management of restless legs syndrome (RLS) 4.
Non-Pharmacological Management
- Sleep hygiene is recommended for the management of poor nocturnal sleep quality and EDS 4.
- Optimization of dopaminergic treatment during nighttime is highly recommended for the proper management of insomnia 4.
- Cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) are promising new treatments for Non-REM parasomnias or POD 3.
- Treatment of concurrent sleep disorders, such as sleep-disordered breathing, and management of other priming factors like stress and anxiety, are also important for the effective treatment of RBD 3, 5.