A man and his wife present to the sleep clinic looking for answers to explain some troubling sleep behaviors the man has been experiencing. During the day, he is a quiet older gentleman who has been married to his wife for 50 years. At night, during REM sleep, he fights battles in his sleep and wakes to find his wife beaten and bruised.

The man states that he loves his wife and would never hurt her. As I was taking his history, I noticed that the patient has a tremor in both of his hands. He has been told that he has an essential tremor, but I was not convinced. I was concerned this patient could be exhibiting early symptoms of Parkinson’s disease.

During REM sleep, we experience muscle atonia to protect us from acting out our dreams. REM sleep behavior disorder (RBD) causes loss of muscle atonia, which can result in dream-enacting behavior that is sometimes violent. The exact cause is unknown but animal experiments suggest that there may be damage to the area of the brain called the pons.

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Patients with RBD are unaware of movement or their aggressive behavior during sleep but will remember vivid dreams in which they were fighting off attackers or wild animals. They flail their arms, kick, punch, scream and frequently fall out of bed.

The illness predominantly affects men older than fifty years (85%). The frequency and severity of these sleep events usually increases over time, and studies suggest that 60% to 70% of those with RBD will develop Parkinson’s disease or other neurological abnormalities. REM sleep behavior disorder is often seen 10 years before the development of Parkinson’s, which can give a family the opportunity to plan ahead in case the disease appears.

Certain medications may also induce RBD. Patients receiving tricyclic antidepressants, monoamine oxidase inhibitors and serotonin specific reuptake inhibitors are known to experience loss of muscle atonia. Therefore, it is important to monitor patients who may be taking these medications for RBD.

Clonazepam is the treatment of choice for RBD and it works very well. A documented polysomnogram is important to rule out obstructive sleep apnea or other sleep abnormalities that could mimic RBD. Advise patients to remove any dangerous objects from their bedroom, consider padding edges of furniture and place mattresses directly on the floor if they report they have been falling out of bed. Refer patients with RBD to a neurologist in your area for further workup, especially if they are exhibiting neurological symptoms.

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.