From the Guidelines
Rapid eye movement (REM) behavior disorder is a sleep condition where people physically act out their dreams during REM sleep due to a lack of normal muscle paralysis, and treatment typically involves medication, with clonazepam (0.5-2mg at bedtime) being the first-line option, as recommended by the American Academy of Sleep Medicine in their 2023 clinical practice guideline 1.
Treatment Options
- Clonazepam is a long-acting benzodiazepine that promotes GABAergic inhibition by increasing the frequency of chloride channel opening, and has been the most commonly prescribed medication for RBD since its efficacy was described in the original 1986 report characterizing RBD 1.
- Melatonin (3-12mg at bedtime) is an effective alternative with fewer side effects, and binds to the M1 and M2 receptors, suppressing REM sleep motor tone and renormalizing other circadian features of REM sleep 1.
- Pramipexole, a dopaminergic agonist, and rivastigmine, an acetylcholinesterase inhibitor, may also be considered for treatment of RBD, although their mechanisms of action and efficacy are less well understood 1.
Safety Precautions
- Patients should create a safe sleeping environment by removing dangerous objects, padding hard surfaces near the bed, and considering separate sleeping arrangements if bed partners are at risk of injury, as recommended by the American Academy of Sleep Medicine in their 2023 clinical practice guideline 1.
- Clinicians should emphasize the importance of maintaining a safe sleep environment to prevent potentially injurious nocturnal behaviors as an adjunct to treatment with medications during sleep or as the sole therapy when medications are not indicated 1.
Monitoring and Follow-up
- Regular neurological follow-ups are important for monitoring potential development of neurodegenerative conditions, such as Parkinson's disease, which may occur in up to 80% of patients with RBD within 10-15 years of symptom onset 1.
- Patients with RBD should be advised to avoid alcohol, certain antidepressants, and sleep deprivation, as these can worsen symptoms 1.
From the Research
Definition and Prevalence of REM Sleep Behavior Disorder
- REM sleep behavior disorder (RBD) is a parasomnia disorder affecting between 1 and 7% of community-dwelling adults, most frequently older adults 2.
- The disorder has an estimated prevalence in adults of 0.4-0.5% 3.
- RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia 2.
Pathophysiology and Association with Neurodegenerative Diseases
- RBD is caused by a lack of normal REM muscle atonia and a lack of normal suppression of locomotor generators during REM sleep 3.
- The disorder is strongly associated with synucleinopathy neurodegeneration 2, 4.
- RBD can occur in the absence of diagnosed neurological diseases, but patients with this form of RBD may have subtle neurological abnormalities and often ultimately develop a neurodegenerative disorder 3.
Treatment and Management of RBD
- The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders 2.
- Melatonin and clonazepam are traditional therapeutic mainstays for RBD, with melatonin being more tolerable 2, 4.
- Pramipexole is a possible alternative treatment for RBD, but the evidence is inconclusive due to the lack of randomized controlled trials 5.
- Safety precautions and medications to reduce RBD symptoms should be considered for most patients, and a patient-centered shared decision-making approach to risk disclosure is recommended 6.
Treatment Options and Efficacy
- Melatonin dosed 3-12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25-2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable 2.
- Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate 2.
- A novel non-pharmacological approach is a bed alarm system, although this may be most useful in patients who also report sleep walking or a history of leaving their bed during dream enactment episodes 2.