From the Guidelines
Association between REM Sleep Disorder and Geriatric Conditions
There is a strong association between Rapid Eye Movement (REM) sleep disorder and geriatric conditions, particularly alpha-synucleinopathies such as Dementia with Lewy Bodies (DLB) and Parkinson's Disease (PD), in the elderly 1.
Key Findings
- Secondary RBD is more likely to occur in older patients (> 50 years old) with underlying neurodegenerative disorders, such as DLB and PD 1.
- RBD is a suggestive feature for DLB and has been found in 70% of patients with Multiple System Atrophy (MSA), 40% of patients with DLB, and 15-33% of patients with PD 1.
- The treatment of RBD in geriatric patients should consider the patient's underlying disease and attendant symptoms, and may involve the use of medications such as clonazepam, immediate-release melatonin, and rivastigmine 1.
- Clonazepam is often used in lower doses (starting at 0.25 mg) in older patients with RBD and DLB or PD, due to the risk of cognitive disturbances and gait imbalance 1.
- Melatonin is a mildly sedating option for older patients with RBD and may be started at a dose of 3 mg, increasing by 3-mg increments to 15 mg as needed 1.
Clinical Implications
- Clinicians should consider the patient's underlying disease and attendant symptoms when choosing a medication for RBD in geriatric patients.
- RBD should be managed with a comprehensive approach, including sleep safety measures and pharmacotherapy, to reduce the risk of injury to the patient or bed partner 1.
From the Research
Association between REM Sleep Disorder and Geriatric Conditions
The association between Rapid Eye Movement (REM) sleep disorder and geriatric conditions in the elderly is a complex one. Studies have shown that REM sleep behavior disorder (RBD) is strongly associated with synucleinopathy neurodegeneration, which is a common feature of several neurodegenerative diseases, including Parkinson's disease (PD) and dementia with Lewy bodies (DLB) 2, 3, 4, 5, 6.
Epidemiology and Pathophysiology
RBD is characterized by the loss of normal atonia during the REM stage of sleep, resulting in overt motor behaviors that usually represent the enactment of dreams. The disorder predominantly affects older adults, with an estimated prevalence of 0.4-0.5% in adults 4. However, the frequency is much higher in certain neurodegenerative diseases, especially PD and DLB.
Clinical Management and Prognostic Implications
RBD can be diagnosed with a simple screening question followed by confirmation with polysomnography to exclude potential mimics. Treatment for RBD is effective and involves treatment of underlying causes, modification of the sleep environment, and pharmacotherapy with either clonazepam or melatonin 3, 5. An important finding is that almost all patients with idiopathic RBD will ultimately go on to develop PD or DLB, suggesting that idiopathic RBD represents a prodromal phase of these conditions 3.
Key Findings
- RBD is strongly associated with synucleinopathy neurodegeneration 2, 5
- RBD can occur in the absence of diagnosed neurological diseases, but patients with idiopathic RBD may have subtle neurological abnormalities and often ultimately develop a neurodegenerative disorder 4
- REM sleep without atonia on polysomnography may help diagnose Lewy body disease in middle-aged and older patients with somatic symptom disorder 6
- Treatment for RBD involves treatment of underlying causes, modification of the sleep environment, and pharmacotherapy with either clonazepam or melatonin 3, 5