Treatment of REM Sleep Behavior Disorder

Youngsin Jung, Erik K St Louis

Research output: Contribution to journalReview article

19 Citations (Scopus)

Abstract

REM sleep behavior disorder (RBD) is a common parasomnia disorder affecting between 1 and 7 % of community-dwelling adults, most frequently older adults. RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia. RBD is strongly associated with synucleinopathy neurodegeneration. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders. The focus of this review is symptomatic treatment for injury prevention. Injury occurs in up to 55 % of patients prior to treatment, even when most behaviors seem to be infrequent or minor, so patients with RBD should be treated promptly following diagnosis to prevent injury risk. A sound evidence basis for symptomatic treatment of RBD remains lacking, and randomized controlled treatment trials are needed. Traditional therapeutic mainstays with relatively robust retrospective case series level evidence include melatonin and clonazepam, which appear to be equally effective, although melatonin is more tolerable. Melatonin also has one small randomized controlled crossover trial supporting its use for RBD treatment. Melatonin dosed 3–12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25–2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable. However, neither agent is likely to completely stop dream enactment behaviors, so choosing a moderate target dosage of melatonin 6 mg or clonazepam 0.5 mg, or the highest tolerable dosage that reduces attack frequency and avoids adverse effects from overtreatment, is currently the most reasonable strategy. Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate. A novel non-pharmacological approach is a bed alarm system, although this may be most useful in patients who also report sleep walking or a history of leaving their bed during dream enactment episodes. The benefit of hypnosis, especially in those with psychiatric RBD, also requires further study. RBD is an attractive target for future neuroprotective treatment trials to prevent evolution of overt parkinsonism or memory decline, but currently, there are no known effective treatments and future trials will be necessary to determine if RBD is an actionable time point in the evolution of overt synucleinopathy.

Original languageEnglish (US)
Article number50
JournalCurrent Treatment Options in Neurology
Volume18
Issue number11
DOIs
StatePublished - Nov 1 2016

Fingerprint

REM Sleep Behavior Disorder
Melatonin
Clonazepam
Therapeutics
zopiclone
Wounds and Injuries
S 20098
Randomized Controlled Trials
Somnambulism
Parasomnias
Sodium Oxybate
Independent Living
Lorazepam
Temazepam
Hypnosis
Cannabinoids
REM Sleep
Parkinsonian Disorders
Neurodegenerative Diseases
Cross-Over Studies

Keywords

  • Acetylcholinesterase inhibitor
  • Adverse effects
  • Bed alarm
  • Cannabinoid
  • Clonazepam
  • Hypnosis
  • Melatonin
  • Pramipexole
  • REM sleep behavior disorder
  • Safety
  • Treatment

ASJC Scopus subject areas

  • Clinical Neurology

Cite this

Treatment of REM Sleep Behavior Disorder. / Jung, Youngsin; St Louis, Erik K.

In: Current Treatment Options in Neurology, Vol. 18, No. 11, 50, 01.11.2016.

Research output: Contribution to journalReview article

@article{61abefbd37a145f09d39ab1ccc045dfa,
title = "Treatment of REM Sleep Behavior Disorder",
abstract = "REM sleep behavior disorder (RBD) is a common parasomnia disorder affecting between 1 and 7 {\%} of community-dwelling adults, most frequently older adults. RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia. RBD is strongly associated with synucleinopathy neurodegeneration. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders. The focus of this review is symptomatic treatment for injury prevention. Injury occurs in up to 55 {\%} of patients prior to treatment, even when most behaviors seem to be infrequent or minor, so patients with RBD should be treated promptly following diagnosis to prevent injury risk. A sound evidence basis for symptomatic treatment of RBD remains lacking, and randomized controlled treatment trials are needed. Traditional therapeutic mainstays with relatively robust retrospective case series level evidence include melatonin and clonazepam, which appear to be equally effective, although melatonin is more tolerable. Melatonin also has one small randomized controlled crossover trial supporting its use for RBD treatment. Melatonin dosed 3–12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25–2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable. However, neither agent is likely to completely stop dream enactment behaviors, so choosing a moderate target dosage of melatonin 6 mg or clonazepam 0.5 mg, or the highest tolerable dosage that reduces attack frequency and avoids adverse effects from overtreatment, is currently the most reasonable strategy. Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate. A novel non-pharmacological approach is a bed alarm system, although this may be most useful in patients who also report sleep walking or a history of leaving their bed during dream enactment episodes. The benefit of hypnosis, especially in those with psychiatric RBD, also requires further study. RBD is an attractive target for future neuroprotective treatment trials to prevent evolution of overt parkinsonism or memory decline, but currently, there are no known effective treatments and future trials will be necessary to determine if RBD is an actionable time point in the evolution of overt synucleinopathy.",
keywords = "Acetylcholinesterase inhibitor, Adverse effects, Bed alarm, Cannabinoid, Clonazepam, Hypnosis, Melatonin, Pramipexole, REM sleep behavior disorder, Safety, Treatment",
author = "Youngsin Jung and {St Louis}, {Erik K}",
year = "2016",
month = "11",
day = "1",
doi = "10.1007/s11940-016-0433-2",
language = "English (US)",
volume = "18",
journal = "Current Treatment Options in Neurology",
issn = "1092-8480",
publisher = "Current Science, Inc.",
number = "11",

}

TY - JOUR

T1 - Treatment of REM Sleep Behavior Disorder

AU - Jung, Youngsin

AU - St Louis, Erik K

PY - 2016/11/1

Y1 - 2016/11/1

N2 - REM sleep behavior disorder (RBD) is a common parasomnia disorder affecting between 1 and 7 % of community-dwelling adults, most frequently older adults. RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia. RBD is strongly associated with synucleinopathy neurodegeneration. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders. The focus of this review is symptomatic treatment for injury prevention. Injury occurs in up to 55 % of patients prior to treatment, even when most behaviors seem to be infrequent or minor, so patients with RBD should be treated promptly following diagnosis to prevent injury risk. A sound evidence basis for symptomatic treatment of RBD remains lacking, and randomized controlled treatment trials are needed. Traditional therapeutic mainstays with relatively robust retrospective case series level evidence include melatonin and clonazepam, which appear to be equally effective, although melatonin is more tolerable. Melatonin also has one small randomized controlled crossover trial supporting its use for RBD treatment. Melatonin dosed 3–12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25–2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable. However, neither agent is likely to completely stop dream enactment behaviors, so choosing a moderate target dosage of melatonin 6 mg or clonazepam 0.5 mg, or the highest tolerable dosage that reduces attack frequency and avoids adverse effects from overtreatment, is currently the most reasonable strategy. Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate. A novel non-pharmacological approach is a bed alarm system, although this may be most useful in patients who also report sleep walking or a history of leaving their bed during dream enactment episodes. The benefit of hypnosis, especially in those with psychiatric RBD, also requires further study. RBD is an attractive target for future neuroprotective treatment trials to prevent evolution of overt parkinsonism or memory decline, but currently, there are no known effective treatments and future trials will be necessary to determine if RBD is an actionable time point in the evolution of overt synucleinopathy.

AB - REM sleep behavior disorder (RBD) is a common parasomnia disorder affecting between 1 and 7 % of community-dwelling adults, most frequently older adults. RBD is characterized by nocturnal complex motor behavior and polysomnographic REM sleep without atonia. RBD is strongly associated with synucleinopathy neurodegeneration. The approach to RBD management is currently twofold: symptomatic treatment to prevent injury and prognostic counseling and longitudinal follow-up surveillance for phenoconversion toward overt neurodegenerative disorders. The focus of this review is symptomatic treatment for injury prevention. Injury occurs in up to 55 % of patients prior to treatment, even when most behaviors seem to be infrequent or minor, so patients with RBD should be treated promptly following diagnosis to prevent injury risk. A sound evidence basis for symptomatic treatment of RBD remains lacking, and randomized controlled treatment trials are needed. Traditional therapeutic mainstays with relatively robust retrospective case series level evidence include melatonin and clonazepam, which appear to be equally effective, although melatonin is more tolerable. Melatonin also has one small randomized controlled crossover trial supporting its use for RBD treatment. Melatonin dosed 3–12 mg at bedtime should be considered as the first-line therapy, followed by clonazepam 0.25–2.0 mg at bedtime if initial melatonin is judged ineffective or intolerable. However, neither agent is likely to completely stop dream enactment behaviors, so choosing a moderate target dosage of melatonin 6 mg or clonazepam 0.5 mg, or the highest tolerable dosage that reduces attack frequency and avoids adverse effects from overtreatment, is currently the most reasonable strategy. Alternative second- and third-line therapies with anecdotal efficacy include temazepam, lorazepam, zolpidem, zopiclone, pramipexole, donepezil, ramelteon, agomelatine, cannabinoids, and sodium oxybate. A novel non-pharmacological approach is a bed alarm system, although this may be most useful in patients who also report sleep walking or a history of leaving their bed during dream enactment episodes. The benefit of hypnosis, especially in those with psychiatric RBD, also requires further study. RBD is an attractive target for future neuroprotective treatment trials to prevent evolution of overt parkinsonism or memory decline, but currently, there are no known effective treatments and future trials will be necessary to determine if RBD is an actionable time point in the evolution of overt synucleinopathy.

KW - Acetylcholinesterase inhibitor

KW - Adverse effects

KW - Bed alarm

KW - Cannabinoid

KW - Clonazepam

KW - Hypnosis

KW - Melatonin

KW - Pramipexole

KW - REM sleep behavior disorder

KW - Safety

KW - Treatment

UR - http://www.scopus.com/inward/record.url?scp=84991575729&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84991575729&partnerID=8YFLogxK

U2 - 10.1007/s11940-016-0433-2

DO - 10.1007/s11940-016-0433-2

M3 - Review article

VL - 18

JO - Current Treatment Options in Neurology

JF - Current Treatment Options in Neurology

SN - 1092-8480

IS - 11

M1 - 50

ER -