From the Guidelines
Rapid eye movement (REM) behavior disorder is a sleep condition where individuals physically act out their dreams during REM sleep due to a lack of normal muscle paralysis, and treatment typically involves medication, with clonazepam (0.25-1.0 mg at bedtime) being a commonly prescribed option, as well as melatonin (3-15 mg at bedtime) as an effective alternative with fewer side effects, as recommended by the American Academy of Sleep Medicine 1.
Treatment Options
- Clonazepam: a long-acting benzodiazepine that promotes GABAergic inhibition, commonly prescribed at a dose of 0.25-1.0 mg at bedtime, with higher doses considered in the absence of response if well tolerated 1
- Melatonin: binds to the M1 and M2 receptors, suppressing REM sleep motor tone and renormalizing other circadian features of REM sleep, typically started at a dose of 3 mg taken at bedtime, with titration up to 15 mg as needed 1
- Pramipexole: a dopaminergic agonist, dosing typically starts at 0.125 mg administered orally at bedtime and can be increased to 2.0 mg nightly 1
- Rivastigmine: an acetylcholinesterase inhibitor, dosing typically starts at 4.6 mg applied every 24 hours and can increase to 13.3 mg daily, although its efficacy in isolated RBD without mild cognitive impairment is still unknown 1
Safety Precautions
- Patients should create a safe sleeping environment by removing dangerous objects, padding the floor beside the bed, and considering separate sleeping arrangements if a bed partner is at risk of injury, as recommended by the American Academy of Sleep Medicine 1
- 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 REM behavior disorder within 10-15 years of diagnosis 1
- Avoiding alcohol, certain antidepressants, and sleep deprivation is recommended as these can worsen symptoms 1
From the Research
Characteristics of REM Sleep Behavior Disorder
- REM sleep behavior disorder (RBD) is a common parasomnia disorder affecting between 1 and 7% of community-dwelling adults, most frequently older adults 2.
- RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia 2.
- RBD is strongly associated with synucleinopathy neurodegeneration 2, 3.
Treatment Options for 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.
- Traditional therapeutic mainstays with relatively robust retrospective case series level evidence include melatonin and clonazepam, which appear to be equally effective, although melatonin is more tolerable 2, 3.
- 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.
Management and Prognostic Counseling
- Management of RBD includes reducing injurious dream-enactment behaviors, risk of injury to self and bedpartner, and vivid or disruptive dreams and improving sleep quality and bedpartner sleep disruption 4.
- Medications to reduce RBD symptoms such as melatonin, clonazepam, pramipexole, and rivastigmine should be considered for most patients 4.
- Isolated RBD confers a high lifetime risk of neurodegenerative diseases with a latency often spanning many years 4.
- A patient-centered shared decision-making approach to risk disclosure is recommended 4.
Efficacy of Melatonin Therapy
- Melatonin appears to be beneficial for the management of RBD with reductions in clinical behavioral outcomes and decrease in muscle tonicity during REM sleep 5.
- Melatonin also has a favorable safety and tolerability profile over clonazepam with limited potential for drug-drug interactions, an important consideration especially in elderly individuals with RBD receiving polypharmacy 5.
- Prospective clinical trials are necessary to establish the evidence basis for melatonin and clonazepam as RBD therapies 5.