From the Guidelines
Dream enactment associated with a neurodegenerative disorder is primarily characterized by physically acting out dreams during REM sleep, often with violent or aggressive movements, and is particularly concerning in older adults with frequent episodes and additional neurological symptoms such as tremors, cognitive decline, or movement difficulties. These symptoms are indicative of REM sleep behavior disorder (RBD), which can precede the diagnosis of conditions like Parkinson's disease, Lewy body dementia, or multiple system atrophy by years or even decades, making it an important early marker of neurodegeneration in the brain regions controlling sleep 1, 2. The main symptoms suggesting this association include:
- Physically acting out dreams during REM sleep, with violent or aggressive movements that match the dream content
- Vocalization during episodes, such as yelling, talking, or making other sounds
- Little to no awareness of these actions upon waking
- Reporting vivid, action-filled dreams
- Presence of other neurological symptoms, such as: + Tremors + Cognitive decline + Visual hallucinations + Movement difficulties These behaviors result from a breakdown in the normal muscle atonia (paralysis) that typically occurs during REM sleep, allowing dream content to be physically enacted. According to the American Academy of Sleep Medicine clinical practice guideline, patients with secondary RBD due to a medical condition, such as an alpha-synuclein disorder like DLB/PD, are more likely to occur in older patients (> 50 years old) 2. The guideline also recommends the use of clonazepam, immediate-release melatonin, and rivastigmine in the treatment of secondary RBD, with consideration of the patient's underlying disease and attendant symptoms 1, 2.
From the Research
Main Symptoms of Dream Enactment Associated with Neurodegenerative Disorder
The main symptoms suggesting that dream enactment is associated with a neurodegenerative disorder include:
- Enactment of dream content resulting from the loss of normal skeletal muscle atonia during REM sleep 3, 4, 5
- Complex behavioral manifestations in response to dream content that may cause sleep disruption or injuries to the patient or the bed partner 3
- Presence of idiopathic REM sleep behavior disorder (RBD) which may be a sign of an underlying parkinsonian syndrome 4, 5
- Development of RBD may be one of the first manifestations of Parkinson's disease or other parkinsonian syndromes 5
- Subtle prodromal neurodegenerative abnormalities including hyposmia, constipation, and orthostatic hypotension 6
Neurodegenerative Diseases Associated with Dream Enactment
Dream enactment is strongly associated with neurodegenerative diseases, especially synucleinopathies such as:
Treatment Options
Treatment options for REM sleep behavior disorder include: