How to identify REM sleep behavior disorder

Violent thrashing and attacks during sleep may be a sign of REM sleep behavior disorder.

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Sleep Disorders

Treating REM sleep behavior disorder in the elderly population
Treating REM sleep behavior disorder in the elderly population

Rapid eye movement (REM) sleep behavior disorder is a fascinating sleep disorder because of the violence and grief it causes. Often, patients with REM sleep behavior disorder are unaware of their condition.

REM sleep behavior disorder often precedes neurological disease, most notably Parkinson disease. Its outcomes are usually seen in patients aged 50 to 60 years, and it most frequently occurs in men.

Because patients diagnosed with REM sleep behavior disorder thrash, kick, punch, hit, and fall out of bed in their sleep, those who share beds with patients experience unintentional violence. Between 33% and 65% of REM sleep behavior disorder patients have reported either injuring someone else or themselves during sleep.

Patients diagnosed with REM sleep behavior disorder recount being chased or harmed by people or animals in their dreams. The violent thrashing and kicking happens as a result of the patient trying to fend off the attack in their dream. Because REM sleep behavior disorder causes a lack of muscle atonia, the patients sometimes act out the dreams on their bed partners.

For the clinician, identifying REM sleep behavior disorder in patients is significant because 38% to 65% of patients diagnosed with the condition develop synucleinopathy within 10 to 29 years of initial presentation. Although Parkinson disease is the most common neurological manifestation of the condition, other diseases such as Lewy body dementia and multiple system atrophy may also develop.

REM sleep behavior disorder can be seen with other sleep disorders such as narcolepsy and obstructive sleep apnea. REM sleep behavior disorder may also be seen occasionally in patients withdrawing from some medications such as paroxetine, fluoxetine, imipramine, venlafaxine, and mirtazapine. When considering REM sleep behavior disorder in patients, be sure to ask if your patients have recently stopped any medications.

To diagnose REM sleep behavior disorder, a polysomnogram is needed. The patient will exhibit REM sleep without atonia, absence of seizure activity, and sleep-related injuries or potential injurious behaviors by history or abnormal REM behaviors documented by polysomnogram.

The cause of REM sleep behavior disorder is still unknown, but theories exist. Neuroimaging studies suggest that serotonin, norepinephrine, hypocretin, acetylcholine, and dopamine may play a role in the development of the condition. Most likely, the cause is multifactorial and includes both anatomical and neurochemical abnormalities.

Clonazepam is considered the gold standard of treatment in low doses of 0.5 mg -1 mg before bedtime. Although there is debate amongst sleep researchers on the topic of prescribing sedatives to elderly patients, current guidelines recommend continuing clonazepam to treat patients.

If a patient or his/her partner complains that the patient is "acting out his dreams," consider REM sleep behavior disorder, and question whether the patient has a family history of Parkinson disease.

Has the patient recently developed gait or balance problems, or have they developed tremors or any other signs of neurological disease? Then, order an overnight polysomnogram to evaluate for REM sleep behavior disorder. Also, consider a neurology consult to assess for neurological disease or to establish a baseline for future reference.

Most importantly, stress the importance of safety for the patient and his or her bed partner. Patients may need to place their mattress on the floor, bed partners may need to sleep separately, and the sharp corners of bedroom furniture may need to be padded or removed. Any firearms should be locked away, because there have been documented cases of patients killing their bed partners with no recollection of the incident.

Sharon M. O'Brien, MPAS, PA-C, is a practicing clinician with an interest in helping patients understand the importance of sleep hygiene and the impact of sleep on health.

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