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Author: Ron Cridland, MD
REM is a stage of sleep where you do your most vivid dreaming. In addition, your voluntary muscles are paralyzed in REM sleep so you cannot act out your dreams. In REM Sleep Behavior Disorder (RBD) the muscle paralysis is lost at times enabling you to partially act out your dreams.
Symptoms typically consist of talking, yelling, kicking, punching, falling out of bed, sometimes running. The eyes are usually closed. The person with RBD often presents to the doctor because they are worried about harming their bed partner or because they have hurt themselves hitting something, falling out of bed or running into furniture. The person with RBD will often recall an unpleasant dream where they are being chased or are defending themselves from attack.
This condition usually occurs in adults over the age of 50 and in males more than females. The majority will go on to develop signs of an underlying neurodegenerative condition such as Parkinson’s Disease within 10 years of diagnosis of RBD. When RBD occurs in younger people there is a more equal male to female ratio. It is more often associated with Narcolepsy Type I, other neurological disease, or use of antidepressants.
Diagnosis
REM Behavior Disorder is suspected when there is a history of repeated episodes of sleep vocalization with or without complex motor behaviors. A nocturnal polysomnogram is required to demonstrate loss of muscle paralysis during REM sleep. It is also useful for identifying other underlying sleep disorders, such as obstructive sleep apnea, that may be triggering the episodes of REM behavior.
Management
Medical or neurological consultation should be considered to rule out underlying treatable causes of RBD such as antidepressant use. Signs or symptoms that might indicate an underlying neurological condition should be looked for. It is helpful to treat any other underlying sleep disorders that may be triggering the REM behavior.
As a minimum, non-pharmacological sleep hygiene measures will deepen sleep and reduce the intensity of the dreams that trigger REM behavior. If the behaviors are potentially harmful, the person with RBD should sleep alone. Steps to reduce injury could include putting the mattress on the floor, removing night tables and lamps away from the bed. If the person gets out of bed and runs, consider removing furniture from the room, keeping the door shut and putting heavy drapes over the windows to stop them from running into furniture, a door jam or out a window. Alternatively, some people will sleep in a zipped up sleeping bag.
Pharmacologically, Clonazepam 0.5 mg is quite helpful starting with ½ pill taken an hour before bed and increasing by ½ pill per week to control RBD up to a maximum of 2 mg per night. Keep in mind if you have untreated obstructive sleep apnea, clonazepam could make it a little worse. High dose melatonin at 5 – 10 mg may also be helpful.
