REM Sleep Behavior Disorder: Symptoms, Causes, Risks, Complications, Diagnosis, Treatment and outlook

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Illustration of sleep disorder

1Overview

Most people believe that when they sleep, they just drift off to wonderland. The body and brain, however, are rejuvenating from a long day’s work. During sleep, the brain still works to maintain various body functions.

Sleep disorders interfere with than a person’s normal sleeping patterns, leading to various problems in his or her daily activities. One of the common sleep disorders is the REM (rapid eye movement) sleep behavior disorder (RBD), which is a type of parasomnia.

Parasomnias are sleep disorders wherein dangerous or strange incidents happen that affect sleep. For instance, people who have parasomnia experience nocturnal dissociative disorder, sleep talking and sleep, terrors.

REM sleep behavior disorder is a condition wherein those affected will move or talk during sleep, which will not happen in people with no sleeping disorders.

Normally, people do not move or talk during REM sleep, which is considered a normal phase of sleep. REM sleep behavior disorder could signal the presence of a psychiatric, mental or brain disorder. Research shows that about 80 percent of people with this sleep disorder develop a neurodegenerative disorder within ten years, such as Parkinson’s disease.

Thus, restful sleep is vital, especially for people who are at risk for Parkinson’s. RBD does not only affect the person with the condition but their bed partners as well. The symptoms of RBD can be dangerous and violent for the bed partner, but the patient is, in fact, unaware of the violence that occurs during sleep. The patient may also experience some sort of embarrassment and denial of the condition that may lead to social isolation.

2Symptoms

During an RBD episode, the patient may manifest movements or vocalizations. He may:

  • Shout
  • Talk
  • Grab
  • Flail
  • Kick
  • Punch
  • Jump

When the person wakes up, he or she does not remember any of the movements. However, they often link these movements to their dream. For instance, if the person has dreamt of being chased, he or she is more likely to jump out of bed or run away.

Usually, these symptoms occur about 90 minutes after the person has fallen asleep.
In other people, they experience the symptoms until the later stages of sleep. The person may even have as many as four RBD episode in one night.

Sleepwalking is not the same as RBD. People may experience the same movements while they’re sleepwalking but it’s harder to wake up from this than in RBD. Usually, people who sleepwalk will become disoriented upon waking up and unable to remember the dream. Also, in people who sleepwalk, they are more likely to walk around with their eyes open, leave the room and even eat or drink.

3Causes

REM sleep behavior disorder happens when there is an altered voluntary muscle movement atonia during REM sleep, leading to movements as a response to the dream the patient is experiencing.

The various nerve pathways in the brain avoid the muscles from moving when the person is sleeping. In fact, during the REM stage of sleep, the body is in a state of temporary paralysis. In RBD, these pathways do not work properly.

Idiopathic cause

The RBD is idiopathic when the sleep structure in the brain is normal, however, there is an increase in REM sleep density. Some experts have linked this to genetics.

Physiological cause

Many studies have shown that there are a central nervous system dysfunction and an altered cortical activity during REM sleep. Magnetic resonance studies have shown that the parts of the brain affected in people with RBD are the frontal lobe and pons.

Symptomatic cause

The symptomatic RBD causes have been linked to the presence of neurodegenerative disorders like Parkinson’s disease. About 15 percent of Parkinson’s disease patients also have RBD, 85 percent of people with Lewy body dementia also suffer from RBD, and 70 percent of those with multiple system atrophy have RBD. The other conditions that are linked to RBD are vascular encephalopathies, Shy-Drager syndrome, olivopontocerebellar atrophy, multiple sclerosis and Guillain-Barre syndrome.

4Risk Factors

There are risk factors associated with the development of RBD, which includes:

Having a neurodegenerative disorder

People with a neurodegenerative disorder like Parkinson’s disease, dementia, and multiple sclerosis, among others, are at a higher risk of developing RBD.

Narcolepsy

People with narcolepsy, another sleep disorder wherein the person has severe daytime drowsiness are more likely to have RBD.

Males and older adults

Being mail and over 50 years old may increase a person’s risk of RBD. However, young adults and even children can develop the disease, which is linked to antidepressant use, brain tumors or narcolepsy.

Medications

Taking some medicines may increase the risk of RBD such as antidepressants and other drugs used for psychiatric disorders. Also, when a person is experiencing withdrawal from alcohol or drugs, he or she might experience RBD.

5Complications

The most common complications associated with REM sleep behavior disorder include:

  • Possible injury to self and others, especially the bed partner
  • Embarrassment on the part of the patient
  • Social isolation because of fear that others may learn about the sleeping disorder
  • Distress for the sleeping partner and others who live in the house

6Diagnosis

Regarding diagnosing the condition, the patient should talk with a sleep doctor or specialist. The doctor will conduct a thorough medical, personal and family history interview. He may also request for a complete physical and neurological exam. He may refer the patient to a neurologist for further and more comprehensive testing.

Here are the usual tests performed:

Physical assessment and neurological examination

The doctor will perform a comprehensive physical assessment and neurological examination. He may also evaluate the patient based on the findings of these assessments. The doctor may learn from these tests about the presence of other sleeping problems like narcolepsy and another neurodegenerative disease.

Nocturnal sleep study

Also called polysomnogram, this test studies in a sleeping laboratory where the patient will sleep overnight. The doctor will observe the patient’s movements and behavior while sleeping. During the test, sensors will monitor the oxygen levels, movements of the arms and legs, vocalizations and breathing patterns. The device will also test for the person’s heart rate and brain activity. All these are videotaped to be shown to the patient too.

Interview with the sleeping partner

Sometimes, the bed partner or sleeping partner will be asked by the doctor on the movements the patient does when sleeping like punching, throwing the arms in the air and shouting.

To help diagnose RBD, diagnostic criteria should be met:

The doctors will use the International Classification of Sleep Disorders,
third edition (ICSD-3). They will diagnose the patient with RBD if:

  • There are repeated instances of movements or vocalizations during sleep
  • The patient can recall the dreams linked to these movements.
  • If the patient can wake up during the episode and does not appear disoriented.
  • The sleep study shows increased muscle activity during REM sleep
  • Another sleep problem does not cause the sleep disorder.
  • Possible injury to self and others, especially the bed partner
  • Embarrassment on the part of the patient

7Treatment

REM sleep behavior disorder tends to respond to treatment with medications. Usually,
the doctor will prescribe Clonazepam (Klonopin), which is the most commonly used medicine for RBD. Some doctors will prescribe melatonin, a dietary supplement that can help reduce the symptoms and promote a good night’s sleep.

However, talk to your doctor and learn more about these medicines and their side effects. Moreover, these medicines should only be prescribed by a licensed doctor to prevent overdose and misuse.

The patient can also promote good sleep and prevent injury to him and his partner through the following bedroom safety precautions:

  • Move the bed away from the window.
  • Move items and objects away from the bedside.
  • Place a large object such as a dresser in front of the window.

Other ways to treat RBD with the assistance of medications:

  • Maintain a normal sleep time with an average of seven hours per night. Sleep deprivation may increase the symptoms of RBD. Also, monitor for any sleepiness.
  • Set a sleep schedule. Sleep and wake up at the same time each day.
  • Avoid some medications that could alter sleep and avoid drinking alcohol.
  • Treat underlying conditions like sleep disorders and neurodegenerative diseases.
  • Manage other sleep disorders that will interfere with sleep and might increase the occurrence of RBD.
  • Visit the neurologist often and undergo monitoring for other neurologic symptoms. Watch out for tremors because these might signal the presence of Parkinson’s disease.

8Outlook

REM sleep behavior disorder can often be treated successfully with the use of medications. Patients who take clonazepam may experience side effects like memory problems, confusion, and morning sleepiness.

However, the use of these medicines has been linked with the success of treatment.
If the side effects are interfering with one’s daily activities, the patient can talk to the doctor and shift to melatonin, which can relieve the symptoms with fewer side effects.

The important thing about treatment is, it should be accompanied with the support of the patient’s family and friends, especially the sleeping partner. The success of the treatment can be linked to the support system the patient has.