Which department should patients with sleep behavioral disorders, such as sleepwalking or REM (Rapid Eye Movement) sleep behavior disorder, particularly those with dementia or cognitive impairment, consult for evaluation and treatment?

Sleep Behavioral Disorders: Department Referral

Patients with sleep behavioral disorders such as sleepwalking or REM sleep behavior disorder should be referred to a Sleep Medicine specialist for initial evaluation and diagnosis, with subsequent neurology referral if REM sleep behavior disorder is confirmed, particularly given the high risk of underlying or future neurodegenerative disease. 1

Initial Evaluation Pathway

Primary Care Assessment

• Screen for sleep disorders using validated questionnaires and in-depth questioning about dream enactment behaviors, nocturnal vocalizations, and complex motor behaviors during sleep 1
• Obtain detailed history of cognitive symptoms, extrapyramidal signs, and autonomic dysfunction 1
• Assess for medication-induced causes, particularly selective serotonin reuptake inhibitors and other antidepressants 1

Sleep Medicine Referral (First-Line Specialty)

All patients with suspected REM sleep behavior disorder or complex parasomnias require referral to a sleep medicine clinic for video polysomnography, which is mandatory for definitive diagnosis 1, 2. The sleep medicine specialist will:

• Perform video polysomnography to document REM sleep without atonia and confirm abnormal behaviors 1, 2
• Differentiate true RBD from mimics such as obstructive sleep apnea with arousals, periodic limb movements, or hallucinatory-like behaviors 3
• Initiate treatment with clonazepam or immediate-release melatonin 1

Neurology Referral Criteria

When to Refer to Neurology

If RBD is confirmed on polysomnography, referral to neurology is essential because 1, 2:

• Most older adults with idiopathic RBD will eventually develop an overt neurodegenerative syndrome, particularly α-synucleinopathies (Parkinson disease, dementia with Lewy bodies, multiple system atrophy) 2
• Cognitive decline occurs in up to 94% of RBD patients over time 1
• Baseline neurological examination with attention to cognition and extrapyramidal signs is warranted when RBD is diagnosed 1

Specific Neurology Indications

Immediate neurology referral is indicated for 1:

• New-onset severe lower urinary tract symptoms
• "Suspicious" neurological symptoms: numbness, weakness, speech disturbance, gait disturbance, memory loss, cognitive impairment, or autonomic symptoms 1
• Confirmed mild cognitive impairment in RBD patients (may benefit from transdermal rivastigmine) 1
• Orthostatic hypotension (fall of 20 mmHg systolic or 10 mmHg diastolic) suggesting autonomic failure 1

Special Considerations for Dementia Patients

Patients with Established Dementia

• RBD is particularly common in dementia with Lewy bodies, occurring in approximately 50% of patients with sufficient REM sleep 3
• Caution with clonazepam in dementia patients due to risk of cognitive worsening, gait disorders, and falls 1
• Consider melatonin as first-line treatment in patients with dementia and concomitant sleep apnea 1
• Up to 72.7% of RBD patients with dementia are unaware of their dream-enacting behaviors, requiring collateral history from bed partners 3

Sleepwalking vs. REM Sleep Behavior Disorder

Key Distinction

• Sleepwalking occurs during non-REM sleep and typically does not require specialty referral unless associated with violence, distress, or comorbid sleep disorders 4
• RBD occurs during REM sleep and mandates sleep medicine evaluation followed by neurology assessment due to neurodegenerative risk 1, 2

Sleepwalking Management

Most sleepwalking patients can be managed in primary care with 4:

• Sleep hygiene counseling 5
• Assessment for comorbid sleep disorders causing sleep fragmentation 4
• Scheduled awakening or hypnosis for distressing cases 4
• Impulse-control interventions if violence is present 4

Critical Pitfalls to Avoid

• Do not rely solely on clinical history for RBD diagnosis: The Mayo Sleep Questionnaire has only 50% sensitivity and 66.7% specificity, with false positives common in patients with severe obstructive sleep apnea, prominent periodic limb movements, or hallucinatory-like behaviors 3
• Do not delay neurology referral in confirmed RBD: In 63.7% of cases, RBD precedes cognitive impairment onset, representing a critical window for neuroprotective strategies 3
• Do not overlook EEG abnormalities: Marked EEG slowing (increased delta and theta activity) in central and occipital regions predicts short-term development of mild cognitive impairment in RBD patients 6