Treatment of Severe Somnambulism (Sleepwalking)
The most critical first step is to screen for and treat sleep-disordered breathing (SDB), particularly obstructive sleep apnea, as this is the most common underlying cause of chronic sleepwalking in adults and treating it with CPAP resolves sleepwalking in compliant patients. 1
Diagnostic Evaluation
Before initiating any treatment, perform a focused assessment to identify underlying triggers:
- Polysomnography is essential to identify sleep-disordered breathing, upper airway resistance syndrome, restless legs syndrome, or periodic limb movements 1, 2
- Screen for nocturnal hypoglycemia in diabetic patients, as this can trigger sleepwalking episodes 3
- Assess for cardiac arrhythmias, epilepsy, and respiratory conditions like asthma 3
- Review all medications and substances that may precipitate episodes, including sedatives, narcotics, and alcohol 3
- Evaluate psychiatric comorbidities, particularly anxiety and depression, though treating these alone does not resolve sleepwalking 1
Treatment Algorithm
First-Line: Treat Underlying Sleep Disorders
Sleep-disordered breathing is present in the majority of chronic adult sleepwalkers and should be treated first 1, 2:
- Initiate nasal CPAP therapy for patients with obstructive sleep apnea or upper airway resistance syndrome 1
- All CPAP-compliant patients achieved complete control of sleepwalking at 12-month follow-up 1
- For CPAP non-compliant patients, consider surgical treatment for SDB, which also resulted in complete resolution of sleepwalking when successful 1
- Treat restless legs syndrome and periodic limb movements if identified, as addressing these conditions typically eliminates somnambulism 2
Second-Line: Pharmacotherapy (Only After Ruling Out/Treating Underlying Causes)
Pharmacotherapy should be reserved for cases where:
- No underlying sleep disorder is identified
- Underlying conditions have been treated but sleepwalking persists
- Immediate risk of injury requires urgent intervention while awaiting workup 2
Clonazepam is the most commonly used medication for isolated sleepwalking 2:
- Start with low doses and titrate based on response
- However, benzodiazepine-treated patients in prospective studies showed persistence of sleepwalking and high dropout rates 1
Alternative pharmacologic options include 2:
- Tricyclic antidepressants
- Selective serotonin reuptake inhibitors (SSRIs)
Critical Evidence Gap
There are no properly powered, rigorous controlled trials for sleepwalking treatment in adults 4. The strongest evidence comes from a prospective study showing that treating underlying SDB completely controlled sleepwalking, while benzodiazepine monotherapy failed 1.
Safety Measures (Implement Immediately for All Patients)
While pursuing diagnostic workup and treatment:
- Remove dangerous objects from the bedroom
- Secure windows and doors
- Consider ground-floor sleeping arrangements
- Install alarms on bedroom doors
- Avoid sleep deprivation, which can precipitate episodes 2
Common Pitfalls to Avoid
- Starting benzodiazepines without polysomnography to rule out sleep-disordered breathing, as this misses the most treatable cause 1, 2
- Treating psychiatric comorbidities alone without addressing underlying sleep disorders, which does not resolve sleepwalking 1
- Assuming sleepwalking is purely psychiatric when it is most commonly associated with respiratory sleep disorders in adults 1
- Discontinuing CPAP therapy prematurely, as non-compliance results in persistence of sleepwalking 1
Follow-Up Strategy
- Reassess at 3 months after initiating treatment for underlying sleep disorders 1
- For CPAP therapy, monitor compliance closely as this directly correlates with sleepwalking control 1
- If pharmacotherapy is used, plan 12-month follow-up to assess long-term efficacy, though evidence suggests poor outcomes with medication alone 1