One of the most fascinating sleep disorders I’ve treated is REM sleep behavior disorder. It is the sleep complaint most likely to be featured on television dramas, and an ailment that has the potential to be deadly.
Muscle atonia is a normal part of sleep that stops us from moving during REM sleep each night, but patients with REM sleep behavior disorder have an anatomic abnormality in the brainstem that enables movement. They may dream of being attacked or chased by animals or people, and then attempt to fight back.
Unfortunately, these patients or their bed partners may end up seriously wounded from the thrashing, punching or kicking that occurs in these situations. You may notice that medical attention is typically sought after such an injury.
Many patients have difficulty discussing these events and experience some degree of embarrassment or undeserved guilt when they realize that they have injured someone they care about. Reassuring these patients that this behavior is something they have no control over is important.
Unfortunately, neurodegenerative diseases, such as Parkinson’s, are also common in patients with REM sleep behavior disorder. Among those who experience both, sleep symptoms may manifest up to 10 years prior to neurologic symptom onset.
A diagnosis of REM sleep behavior disorder is the only parasomnia that mandates confirmation with a video polysomnogram. Arousals seen with obstructive sleep apnea can be mistaken for REM sleep behavior disorder, so it is important that a qualified sleep specialist review the video and supporting data to confirm the diagnosis.
Other sleep disorders can make the REM sleep behavior worse, so these should also be ruled out.
Clonazepam is the standard treatment for REM sleep behavior disorder. Melatonin may also be helpful. Most patients respond very well, with symptoms abating after treatment.
Because this disorder is common among 50- and 60-year-old patients, careful monitoring and education about fall risk is also important.
Advise patients to make their environment as safe as possible by padding corners of furniture, lowering bed height, and making sure that there are no objects close by that could unknowingly be used as a weapon.
Refer patients to a neurologist if they are already showing symptoms of neurodegenerative disease, and encourage them to see a professional if any signs of neurological change manifest. I generally encourage patients with REM sleep behavior disorder to see a neurologist regardless of whether symptoms are present, so they can be properly educated on what they may experience in the future. Also reassure patients that their symptoms may never progress any further.
Consider REM sleep behavior disorder when patients or the bed partner of patients, complain dreams are being acted out. As the U.S. population ages, this sleep disorder may be one we see more frequently in the future.
Sharon M. O’Brien, MPAS, PA-C, works at Presbyterian Sleep Health in Charlotte, N.C. Her main interest is helping patients understand the importance of sleep hygiene and the impact of sleep on health.