What is Rapid Eye Movement Sleep Behavior Disorder?
Rapid eye movement behavior disorder (RBD) is a sleep condition where people act out their dreams due to a loss of muscle relaxation during rapid eye movement (REM) sleep. This condition can potentially cause harm to the individual and anyone sharing their bed. RBD has been connected to the use of antidepressants and narcolepsy, a sleep disorder that causes overwhelming daytime drowsiness. Also, there’s a notable connection between RBD and certain brain diseases, like Parkinson’s disease, dementia with Lewy bodies, and multiple system atrophy. Interestingly, symptoms of RBD may show up much earlier than these brain illnesses, which underlines the importance of a thorough medical history check when evaluating these patients.
For a confirmed diagnosis, a sleep study called polysomnography in a lab is required; this study records unusual behavior during REM sleep and checks for other sleep disorders. The management of RBD primarily focuses on preventing injury and treating any related diseases, in addition to using medication like melatonin or clonazepam, especially in severe cases. We will explore the causes, occurrence rates, development, clinical symptoms, evaluation process, management, and long-term outlook for adults with RBD.
What Causes Rapid Eye Movement Sleep Behavior Disorder?
Certain characteristics can make a person more likely to experience Rapid Eye Movement Behavior Disorder (RBD), which is a disorder where a person acts out their dreams. These traits include being older in age, male, having the sleep disorder narcolepsy, taking antidepressant medications, or having certain diseases that affect the nervous system.
We can broadly categorize RBD into three main types:
1. Idiopathic RBD: This type of RBD is not caused by any known factor and is often linked with diseases that involve the buildup of a protein called alpha-synuclein in the brain. Such diseases include dementia with Lewy bodies, Parkinson’s disease, and others. The primary cause seems to be unusual connections between the brain’s control of muscle stiffness and the outer layer of the brain.
2. Drug-induced RBD: This type of RBD occurs in individuals who take certain antidepressants. For instance, serotonin reuptake inhibitors (like fluoxetine), tricyclic antidepressants (like mirtazapine, protriptyline, amitriptyline, nortriptyline, desipramine, imipramine), and monoamine oxidase inhibitors (like phenelzine and selegiline).
3. Secondary RBD due to medical condition: This RBD occurs as a result of another medical condition. For example, it can sometimes happen due to temporary chemical imbalances in the brain, often related to alcohol use.
RBD can also show up together with narcolepsy, a sleep disorder that causes overwhelming daytime drowsiness. When RBD and narcolepsy occur together, they make up a unique variety of RBD which tends to start earlier in life, affects men and women equally, and involves less intense or complicated behaviors during REM sleep. This variant is typically diagnosed through a lab test that finds a deficiency of hypocretin (orexin), a neurotransmitter involved in wakefulness and appetite.
Risk Factors and Frequency for Rapid Eye Movement Sleep Behavior Disorder
Research has shown that Rapid Eye Movement sleep disorder (RBD) is not very common in general, with only about 0.5% of the population affected. However, the condition is more prevalent among older adults, between the ages of 60 to 99, where it affects between 5% and 13% of people.
About 60% of these older adults cases are of unknown cause, while the other 40% are thought to be linked to neurological conditions. Symptoms usually start to appear around the sixth or seventh decade of life. Men are more likely to have RBD in old age, but the disorder is equally common in men and women under the age of 50.
- RBD is strongly connected to mental health issues.
- RBD is found 5 times more commonly in patients taking antidepressants.
- RBD is 10 times more likely in patients with psychiatric disorders.
- There is some evidence of a relationship between childhood RBD and sleep disorders like narcolepsy and idiopathic hypersomnia.
- Almost 30% of young people with Narcolepsy Type 1 also have RBD.
- Having REM sleep without muscle weakness (atonia) but no other symptoms of RBD is not uncommon, affecting 2% of the general population.
- It is more common in people taking antidepressants (12%) and older men (25%).
Signs and Symptoms of Rapid Eye Movement Sleep Behavior Disorder
Rapid eye movement behavior disorder, or RBD, is a sleep disorder where individuals act out their dreams. This can sometimes include violent or purposeful movements during REM sleep, a stage where dreaming usually occurs. Unfortunately, these movements can sometimes lead to personal injury or harm to the person sleeping next to them. These behaviors can be so severe to the point where sleepwalk or even fall out of bed. Typically, these behaviors occur while the individual is having unpleasant or violent dreams, such as being chased or attacked.
The individual with RBD usually wakes up suddenly, but is able to quickly become alert and clearly remember their dream. Interestingly, many of these patients are actually aware that they act out their dreams. The weird behaviors can vary in frequency; they might happen every night or just once a year. They typically start about 90 minutes into sleep and are more likely to happen later on in the night. The patient’s eyes usually remain closed, and they don’t interact with their surroundings – they just move in response to their dream. Some other related sleep behaviors include repetitive hand movements, punching, or kicking.
Some more serious forms of RBD can be triggered by withdrawal from certain drugs that suppress REM sleep, like alcohol, certain medications, or antidepressants. This disorder can also be accompanied by neurological issues, such as abnormal walking or Parkinson’s disease symptoms. Lastly, the cognitive problems seen in RBD are similar to those seen in conditions such as Parkinson’s disease or dementia with Lewy bodies. However, when Parkinson’s disease and RBD occur together, cognitive decline usually happens faster and is less responsive to treatment.
Testing for Rapid Eye Movement Sleep Behavior Disorder
Rapid Eye Movement Behavior Disorder (RBD) is diagnosed by two main features: losing normal body relaxation during dream REM (Rapid Eye Movement) sleep and acting out your dreams. The symptoms usually revolve around acting out dreams, but to officially diagnose RBD, you would need to have a medical sleep study or polysomnography done in a lab along with video recording.
Polysomnography records many of your body functions at the same time during sleep, including your brain waves. This test cannot be done at home. The test is also important because it helps rule out other sleep disorders like breathing issues during sleep, seizures, or other sleep disorders unrelated to REM sleep or parasomnia (abnormal behavior or experiences during sleep). If odd behavior doesn’t occur during sleep in the medical test, demonstrating REM sleep without normal body relaxation is necessary for diagnosis.
REM sleep without atonia (RSWA), or REM sleep without loss of muscle tone, is noted when there’s an increase in muscle activity during REM sleep. This is observed using a test called electromyography (EMG) that measures muscle activity in the chin and/or limbs.
However, RSWA can also be detected in healthy people, especially those who take antidepressant therapy (SSRI), consume lots of caffeine or alcohol, or are elderly men. RSWA is often linked with brain diseases, such as Parkinson’s disease, Lewy body dementia, and multiple system atrophy.
To score RSWA, the American Academy of Sleep Medicine notes it must have at least one of these features:
1. Long-lasting muscle activity in the chin observed during REM sleep.
2. High levels of brief muscle activity in the chin or limbs during REM sleep.
The International Classification of Sleep Disorders provides these four diagnostic criteria for RBD:
1. Regular episodes of sleep-related behaviors that include noises and/or complicated muscle movements.
2. These behaviors are documented either by the medical sleep study during REM sleep or based on the patient’s medical history.
3. Medical sleep study recordings must demonstrate REM sleep without normal muscle relaxation.
4. The behaviors can’t be better explained by another sleep disorder, mental disorder, medication, substance use, or epilepsy.
There are approved questionnaires used to screen patients for RBD, including the Mayo Sleep Questionnaire and the RBD1Q. These questionnaires ask things like if someone has seen the patient “acting out dreams” while sleeping or if the patient themselves has ever suspected of acting out dreams while asleep.
However, diagnosing RBD just based on these questionnaires may not be reliable as RBD is not very common. So, the results from questionnaires with the highest reliability might not be accurate in the general population. This emphasises the importance of undergoing a polysomnography for evaluation.
Treatment Options for Rapid Eye Movement Sleep Behavior Disorder
The main goal of treating rapid eye movement behavior disorder (a sleep disorder where people physically act out their dreams) is to lessen the risk of injury to the patient and anyone who might share a bed with them. This can be quite a challenge, as it often requires changes to normal sleeping routines. It’s critical that patients and their bed partners understand just how important it is to reduce the chances of getting hurt.
Some steps to reducing risk of injury include:
* Lowering the bed so it’s closer to the floor (to prevent falls).
* Making sure guns, knives, and other weapons are safely stored away.
* Padding the floor or any sharp corners on furniture.
* Putting patients in sleep bags or clothes that restrict movement.
* Separating the patient and bed partner during sleep to prevent accidental injury.
According to guidelines from the American Academy of Sleep Medicine, there are several medications that can be used to treat rapid eye movement behavior disorder. One option is immediate-release melatonin, which is a type of hormone that affects our sleep patterns. Clonazepam and pramipexole are other possible treatments.
Ramelteon, a medication that acts similarly to melatonin, is also used to treat insomnia. Though it may not significantly reduce dream enactment or rates of the disorder, it has been reported to improve sleep quality with no noticeable side effects.
Clonazepam has long been considered a first-line treatment for this disorder. It’s a type of drug that helps to control electrical activity in the brain, and it has been very effective for treating rapid eye movement behavior disorder. Although it can have side effects like morning drowsiness, memory issues, and increased risk of falls, it generally has a low concern for abuse and tolerance due to the low dose used for treatment.
It’s also worth mentioning that several other medications, including L-DOPA, pramipexole, paroxetine, and certain types of drugs used to treat epilepsy or high blood pressure, may help with some aspects of rapid eye movement behavior disorder. However, these medications don’t usually offer a complete solution.
For people with this disorder due to other medical conditions, the recommended treatments are still melatonin, clonazepam, or a medication called rivastigmine that’s applied through the skin. It’s generally not recommended to use deep brain stimulation. Melatonin is usually the safest option, especially for older patients.
There are treatments currently being investigated, such as plasma exchange and deep brain stimulation. If the patient also has sleep apnea (a condition where breathing repeatedly stops and starts during sleep), continuous positive airway pressure treatment can help lower the intensity and frequency of symptoms related to rapid eye movement behavior disorder.
Doctors will need to look at all the medications a patient is taking to manage the disorder. Interactions with other drugs could potentially make the disorder worse, so it’s important to discuss any potential changes with healthcare providers.
What else can Rapid Eye Movement Sleep Behavior Disorder be?
Rapid eye movement (REM) behavior disorder brings on symptoms that may look similar to other conditions. To clarify the diagnosis, doctors usually take a detailed history of the patient and run in-lab video tests called polysomnography. For instance, isolated REM sleep without muscle relaxation, seen as increased tone in chin muscles or twitches in limb muscles, could be associated with a condition known as Obstructive Sleep Apnea (OSA), which can give the impression of having REM behavior disorder.
These limb twitches could also seem like periodic leg movements, which usually occur during non-REM sleep and don’t involve any abnormal behavior. Dream enactment behavior (acting out dreams), which is a major symptom of REM behavior disorder, does not just occur with this disorder. Several other conditions can bring about similar behavior, including:
- Substance use and/or withdrawal
- Benign childhood epilepsy
- Complex partial seizures
- Confusional arousals
- Delirium
- Type of epilepsy known as episodio partialis continua
- Epileptic encephalopathy
- Juvenile myoclonic epilepsy
- Faking symptoms (malingering)
- Obstructive sleep apnea (OSA)
- Issue referred to as parasomnia overlap syndrome
- Periodic limb movement disorder
- Posttraumatic stress disorder
- Psychogenic non-epileptic seizure
- Sleep terror
- Sleepwalking
- Trauma-associated sleep disorder
Non-REM sleep disorders that include confusional arousals, sleepwalking, and sleep terrors, are common and can mimic REM behavior disorder. These disorders, which usually affect children and occur during the first half of the night without dream recall, can sometimes occur alongside REM without muscle relaxation, a situation referred to as parasomnia overlap syndrome.
In contrast with REM behavior disorder, sleep terrors are predominant in children and are characterized by sudden screaming during sleep that lasts for several minutes. Sleep talking could be confused with REM behavior disorder, but should be distinguished by its regular conversational tone and occurs during both types of sleep — non-REM and REM. Nightmares, unlike REM behavior disorder, involve vivid dreams without any motor activity. Other sleep disorders that could potentially have links include sleep-related eating disorders, sexsomnia, or rhythmic movement disorder.
A new sleep disorder linked to traumatic experiences, referred to as trauma-associated sleep disorder, has recently been identified. This disorder, which is more common in young males, can bring about disturbing nighttime behaviors and nightmares. It may or may not coexist with post-traumatic disorders. It is characterized by REM without muscle relaxation. However, such disruptive behaviors are rarely observed in lab tests.
Lastly, it’s important to distinguish REM behavior disorders from nighttime seizures, including juvenile myoclonic epilepsy, grand mal seizure, benign rolandic, Landau-Kleffner syndrome, and sleep-related hyper motor epilepsy (previously known as nocturnal frontal lobe epilepsy). Those with epilepsy may show early or prodromal symptoms such as mood changes and unusual sensations such as irregular blinking or loss of control over bladder/bowel. Another difference between REM disorder and seizures are the states following seizures, which can include confusion, headaches, nausea, temporary neurological and sensory deficits, and/or reduced alertness.
What to expect with Rapid Eye Movement Sleep Behavior Disorder
The course of Rapid Eye Movement Sleep Behavior Disorder (RBD), a disorder involving unusual actions or behaviours during the rapid eye movement stage of sleep, can change depending on what’s causing it. When it’s tied to related brain disorders, or if it appears on its own (idiopathic RBD), it typically progresses slowly over time. However, when RBD comes about as a side effect of certain medications, it can start suddenly and usually gets better once the medication is stopped.
The progress of RBD also depends on the condition it’s linked to if it’s tied to brain disorders. For example, certain disorders called synucleinopathies are specifically linked with high rates of RBD. Up to 30-50% of people with Parkinson’s disease, 75% of people with a kind of dementia called Lewy-body dementia, and 70-90% of people with a condition called multiple system atrophy may also have RBD.
People with Parkinson’s disease who also have RBD are at a higher risk for dementia. Those with Lewy-body dementia and RBD have an increased risk of dying.
Once a diagnosis of RBD is confirmed, it’s important to talk about the potential increased risk for brain disorders, taking into account each person’s individual situation. Patients should also be carefully watched for signs of these brain disorders. For these people, it can be helpful to begin therapies that might protect the brain early. Regular exercise of around 120 to 150 minutes per week, for instance, can help reduce the risk of Parkinson’s disease, just like it does for heart disease.
Possible Complications When Diagnosed with Rapid Eye Movement Sleep Behavior Disorder
The main issues with Rapid Eye Movement (REM) Sleep Behavior Disorder (RBD) are the risk of injury and the early signs that it might be connected to neurodegenerative disorders caused by buildup of alpha-synuclein protein. Injuries that happen during an episode might necessitate prompt medical care and could even involve sleeping partners, raising legal concerns. Dealing with RBD mainly focuses on reducing the risk of injury through changes in behavior and/or medication. Identifying and managing RBD early on provides a chance to treat a possible underlying neurodegenerative condition.
Main Considerations:
- Risk of injury during an episode
- Link to neurodegenerative disorders caused by alpha-synuclein protein
- Possible need for immediate medical attention
- Potential legal implications involving sleeping partners
- Management includes behavioral changes and/or medication
- Early diagnosis and management provide an opportunity to treat potential underlying neurodegenerative conditions
Preventing Rapid Eye Movement Sleep Behavior Disorder
Patients suffering from a condition called rapid eye movement behavior disorder (RBD) – a sleep disorder where a person appears to be acting out their dreams, often violently – and their sleeping partners, are at risk of getting hurt during their sleep. In extreme cases, the sleep partner could wrongly assume that the patient’s violent behavior during a dream is intentional, which could result in the patient facing accusations of domestic assault. To prevent such misunderstandings and injuries, it’s essential for healthcare professionals to discuss how to reduce these risks with both the patients and their sleeping partners.
From an ethical standpoint, it’s crucial for healthcare practitioners to explain to patients diagnosed with RBD about the potential of future brain disorders. Clear communication with the patient’s family members could help improve their understanding of the condition and eliminate any mistaken beliefs about the disease. It’s reassuring to let patients know that Parkinson’s disease and other brain disorders, which can be linked to RBD, are treatable in many cases. An early diagnosis of RBD could open up opportunities for treatments aimed at protecting the brain’s functions (neuroprotective therapies).
Efforts to find better treatments for RBD are ongoing. The International Rapid Eye Movement Sleep Behavior Disorder Study Group is carrying out collaborative research to discover treatments that can control symptoms and protect the brain.
