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rapid eye movement sleep behavioral disorder (RBD)

Dream-enacting behavior during REM sleep. Etiology: - neurologic disorders (Parkinson's disease) [1] - parkinson plus syndrome [5] - multiple system atrophy, Shy-Drager syndrome [5] - Lewy body dementia - SSRI, SNRI [1] Epidemiology: 1) occurs primarily in patients > 50 years of age 2) men 2-5 fold more often affected than women Clinical manifestations: 1) may be acute, episodic or chronic 2) patients get up during REM sleep & engage in dream-like behavior, often violent, that may result in self injury 3) behaviors a) talking or laughing b) arm swinging c) punching, kicking d) yelling, cursing e) jumping out of bed 4) may occur several times nightly 5) episodes occur at approximately 90 minute intervals coinciding with REM sleep 6) patients are usually easily awakened 7) NO prolonged confusion upon awakening 8) often dim or no recollection of events Special laboratory: - polysomnography a) increased muscle activity during sleep b) loss of sleep-associated muscle atonia Radiology: - FDG-PET imaging may distinguish patients at increased risk for Parkinson's disease [12] Complications: - may be associated with narcolepsy - may precede synucleinopathy by 50 years [3] - Parkinson's disease, Lewy body dementia, multiple system atrophy or other synucleinopathy (risk is 45% within 6 years) [13] - increased risk of cognitive impairment in patients with Parkinson's disease [14] - risk factors for neurogenerative disease - abnormal olfaction (RR 2.6) - motor symptoms (RR 2.6) - subtle motor signs (RR 2.0) - abnormal quantitative motor testing (RR 3.5) - constipation (RR 1.6) - increased REM tone (RR 1.6) - abnormal DAT scan (RR 3.2) [10] - older age [13] - use of nitrates [13] - low caffeine use [13] Differential diagnosis: 1) nocturnal seizures 2) nocturnal panic disorder 3) nocturnal dissociative disorder 4) sleep walking 5) sleep terrors 6) nocturnal confusional state, resulting from a) dementia b) delirium c) post-traumatic stress disorder 7) nocturnal myoclonus (no association with Parkinson's disease) Management: 1) environmental safety a) padding of sharp edges b) removng objects near the bed 2) clonazepam 0.5-1.0 mg QHS - effective in 90% of patients [3] - may increase risk of confusion & falls in the elderly [1] - may exacerbate obstructive sleep apnea [1] 3) levodopa/carbidopa &/or dopamine agonists may be helpful [3] 4) melatonin 3-12 mg QHS - may be helpful [3] - initial treatment of choice in the elderly (GRS9 & GRS11) [1] 5) carbamazepine is second line agent 6 avoid SSRI& SNRI (sertraline, venlafaxine ...) - induces or increases motor activity during sleep & exacerbate REM sleep behavior disorder [1]

Interactions

disease interactions

Related

nocturnal myoclonus (periodic limb movement disorder, PLMD, periodic limb movements of sleep, PLMS) rapid eye movement (REM) sleep

General

parasomnia

References

  1. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004 - Geriatric Review Syllabus, 7th edition Parada JT et al (eds) American Geriatrics Society, 2010 - Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  2. Nightingale S, Orgill JC, Ebrahim IO, de Lacy SF, Agrawal S, Williams AJ. The association between narcolepsy and REM behavior disorder (RBD). Sleep Med. 2005 May;6(3):253-8. PMID: 15854856
  3. Olson EJ et al, Rapid eye movement sleep behoviour disorder: demographic, clinical and laboratory findings in 93 cases Brain 2000, 123(pt 2):331 PMID: 10648440 - Boeve BF, Silber MH, Ferman TJ, Lucas JA, Parisi JE. Association of REM sleep behavior disorder and neurodegenerative disease may reflect an underlying synucleinopathy. Mov Disord. 2001 Jul;16(4):622-30. PMID: 11481685 - Boeve BF et al, Melatonin for treatment of REM sleep behavior disorder in neurologic disorders: results in 14 patients. Sleep Med 2003, 4:281 PMID: 14592300 - Gagnon JF et al, Update on the pharmacology of REM sleep disorder. Neurology 2006, 67:742 PMID: 16966533 - Mahowald MW, Schenck CH. REM sleep behaviour disorder: a marker of synucleinopathy. Lancet Neurol. 2013 May;12(5):417-9. PMID: 23578776 - Postuma RB Prodromal Parkinson's disease--using REM sleep behavior disorder as a window. Parkinsonism Relat Disord. 2014 Jan;20 Suppl 1:S1-4 PMID: 24262156
  4. Claassen DO et al REM sleep behavior disorder preceding other aspects of synucleinopathies by up to half a century. Neurology. 2010 Aug 10;75(6):488-9. PMID: 20668263
  5. Medical Knowledge Self Assessment Program (MKSAP) 11, 17. American College of Physicians, Philadelphia 1998, 2017
  6. Alessi, C. In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 25-28, 2002
  7. Bodkin CL, Schenck CH. Rapid eye movement sleep behavior disorder in women: relevance to general and specialty medical practice. J Womens Health (Larchmt). 2009 Dec;18(12):1955-63 PMID: 20044857
  8. Chen MC, Yu H, Huang ZL, Lu J. Rapid eye movement sleep behavior disorder. Curr Opin Neurobiol. 2013 Oct;23(5):793-8. PMID: 23518139
  9. Aurora RN, Zak RS, Maganti RK et al Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010 Feb 15;6(1):85-95. PMID: 20191945 Free PMC Article
  10. Peever J, Luppi PH, Montplaisir J. Breakdown in REM sleep circuitry underlies REM sleep behavior disorder. Trends Neurosci. 2014 May;37(5):279-88. Review. PMID: 24673896
  11. Monaco K. Predictive Factors ID'd for Neurodegeneration in Idiopathic RBD. Opens the door to intervening with neuroprotective therapy. MedPage Today. April 24, 2018 https://www.medpagetoday.com/meetingcoverage/aan/72511 - Postuma R, et al Predictors of neurodegeneration in idiopathic REM sleep behavior disorder: A multicenter cohort study. American Academy of Neurology (AAN) 2018; Abstract CCI.002.
  12. Shin JH, Lee JY, Kim YK et al. Parkinson disease-related brain metabolic patterns and neurodegeneration in isolated REM sleep behavior disorder. Neurology 2021 May 19; [e-pub]. https://n.neurology.org/content/early/2021/05/19/WNL.0000000000012228
  13. Zhang H, Iranzo A, Hogl B et al. Risk factors for phenoconversion in rapid eye movement sleep behavior disorder. Ann Neurol 2022 Mar; 91:404; [e-pub] PMID: 34981563 https://onlinelibrary.wiley.com/doi/10.1002/ana.26298
  14. Jozwiak N, Postuma RB, Montplaisir J et al REM sleep behavior disorder and cognitive impairment in Parkinson's disease. Sleep. 2017 Aug 1;40(8):zsx101. PMID: 28645156 PMCID: PMC5806543 Free PMC article