Integrative strategies for REM behavior disorder

Photo Cred: Elizabeth Lies/Unsplash

By Catherine Darley, ND

I recently had a patient, Jorge, a 62-year-old man who came to the sleep center because he had been acting out his dreams while he sleeps. The dreams were violent, featuring Jorge fighting off an intruder, causing him to kick, shout, and even leap out of bed. Two to four nights per week, the episodes were severe, lasting for more than five minutes. After meeting with Jorge and discussing family history, which included dementia, I determined Jorge was suffering from rapid eye movement (REM) behavior disorder.

During REM sleep, the skeletal motor neurons are inhibited so we are unable to move during dream imagery. In REM behavior disorder (RBD), the skeletal motor neurons are not inhibited, therefore patients can act out their dreams. Though this is not always the case, another common feature of RBD is that the dreams tend to have unpleasant, aggressive content, and therefore provoke violent actions. It is very common for patients to seek help after a sleep-related injury to themselves or bedpartner.

RBD is one of the REM-related parasomnias, along with recurrent isolated sleep paralysis and nightmare disorder. The diagnostic criteria for RBD as per The International Classification of Sleep Disorders, is:

• Repeated episodes of sleep related vocalization and/or complex motor behaviors.
• These behaviors are documented by polysomnography to occur during REM sleep or, based on clinical history of dream enactment, are presumed to occur during REM sleep.
• Polysomnographic recording demonstrates REM sleep without atonia.
• The disturbance is not better explained by another sleep disorder, mental disorder, medication, or substance use.

Because the REM atonia needs to be documented, this is a situation where in-clinic polysomnography is required, as a home sleep test would not be adequate.

The idiopathic type of RBD is more common among men over 50-years-old, with an incidence of 0.38 to 0.5 percent of the general population. RBD can also be a feature of narcolepsy, appearing at a younger age and in both sexes. There are additionally a few medications which can precipitate RBD, among them serotonin specific re-uptake inhibitors (SSRIs), venlafaxine, mirtazapine, and some other antidepressants. Risk factors include smoking, pesticide exposure, farming, and head injury.

There is a significant connection with Parkinson’s disease, and other neurodegenerative disorders including multiple system atrophy, and dementia with Lewy bodies. Most important for the integrative practitioner is to know that RBD onset tends to precede the neurodegenerative disorder by approximately a decade. About 81 percent of those with idiopathic RBD eventually are diagnosed with Parkinson’s or dementia. Further, 33 percent to 46 percent of those with Parkinson’s disease have RBD. Awareness of this association gives the practitioner an opportunity to do preventive protocols, early screening, and interventions for Parkinson’s disease.  

The American Academy of Sleep Medicine has a series of clinical guidelines for sleep disorders. The clinical guideline of 2010 for RBD suggests several treatment options with varying degrees of evidence. The Level A recommendation is modification of the sleep environment for those who have sleep related injury. Level B recommendations include clonazepam for the treatment of RBD and to decrease sleep related injury, and melatonin. Level C recommendations have less evidence for their use and include pramiprexole, other benzodiazepines, zopiclone, Yi-Gan San, desipramine, clozapine, carbamazepine, and sodium oxybate. Note, this guideline is currently being updated, with expected publication in winter or spring of 2021.

For Jorge and his wife, Anita, we first started with modifying the sleep environment to improve safety for them both. Nightstands were removed from the bedside and the picture over the bed was securely attached. We discussed sleeping apart for Anita’s safety, though they value sharing a bed, so decided to try treatment first.

Jorge had previously been recommended clonazepam, which he did not want to try. We started him on 3 milligrams of melatonin. We also added in 3 grams of glycine to address some insomnia problems he was having. At the initial follow-up three weeks later, his wife reported he had no RBD episodes, not even talking in his sleep.

He asked to adjust the dose of melatonin as he is feeling sluggish in the morning. We switched to 1 milligram time-release melatonin at bedtime. With the glycine, he was sleeping much later into the morning, and able to return to sleep easily. We also implemented behavioral strategies to improve his sleep overall, including standardizing his bed and wake times, increasing daytime light, making the bedroom dark for sleep, and decreasing the size of his bedtime snack.

Two weeks on the lower dose of melatonin Jorge had a major RBD episode, with five minutes punching, kicking, and yelling loud enough to wake their daughter sleeping down the hall. The final dose he settles on is 2 milligrams melatonin at bedtime, which seems to control the RBD episodes, though it gives him vivid dreams. He also is following up with a neurologist for a Parkinson’s disease evaluation.

Yes, REM behavior disorder is a relatively rare condition. However, because of its’ association with Parkinson’s disease, and the way in which RBD can precede Parkinson’s symptoms, it is important for integrative practitioners to be aware of this disorder. This is yet another situation where the physician may need to lead the sleep conversation. Dreaming itself can be enjoyable, yet patients may not be aware of the negative significance of acting out their dreams.

References

Aurora R, Zak R, Maganti R, Auerbach S, Casey K, Chowdhuri S, Karippot A, Ramar K, Kristo D, and Morgenthaler T. (2010) Best practice guide for the treatment of remsleep behavior disorder (rbd). Journal of Clinical Sleep Medicine. Retrieved from: https://www.aasm.org/resources/bestpracticeguides/pp_rbd.pdf

The International Classification of Sleep Disorders, 3^rd Edition. (2014). American Academy of Sleep Medicine.

Jozwiak n, Postuma R, Montplaisir J, latreille V, Panisset M, Chouinard S, Bourgouin P, and Gagnon J. (2017) REM sleep behavior disorder and cognitive impairment in Parkinson’s disease. Retrieved from: https://www.ncbi.nlm.nih.gov/pubmed/28645156