Rapid Eye Movement Sleep Behavior Disorder and Other Rapid Eye Movement Parasomnias

Michael J. Howell, MD, FAAN Sleep Neurology p. 929-945 August 2020, Vol.26, No.4 doi: 10.1212/CON.0000000000000896
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PURPOSE OF REVIEW The discovery of rapid eye movement (REM) sleep and, in particular, REM sleep behavior disorder (RBD) have brought elusive nightmarish experiences to scientific scrutiny. This article summarizes a century of sleep research to examine the maladies of dreaming, their pathophysiologic significance, and management.

RECENT FINDINGS Under healthy physiologic conditions, REM sleep is characterized by vivid mentation combined with skeletal muscle paralysis. The loss of REM sleep atonia in RBD results in vivid, potentially injurious dream enactment to patients and bed partners. RBD is common, affecting at least 1% of the population and is primarily caused by α-synuclein pathology of REM sleep–related brainstem neurons. The majority of patients with RBD ultimately develop a neurodegenerative syndrome such as Parkinson disease, dementia with Lewy bodies, or multiple system atrophy. Among patients with Parkinson disease, RBD predicts an aggressive disease course with rapid cognitive, motor, and autonomic decline. RBD is diagnosed by the presence of dream enactment episodes (either recorded or clinically recalled) and physiologic evidence of REM sleep without atonia demonstrated on polysomnography. Bedroom safety is of paramount importance in the management of RBD while pharmacokinetic options include melatonin or clonazepam.

SUMMARY The injurious dream enactment of RBD is common and treatable. It is a syndrome of α-synuclein pathology with most patients ultimately developing Parkinson disease, dementia with Lewy bodies, or a related disorder.

Address correspondence to Dr Michael Howell, 420 Delaware St SE, MMC 295, Minneapolis, MN 55455, [email protected].

RELATIONSHIP DISCLOSURE: Dr Howell has received personal compensation for serving as an editor for MedLink Corporation, as a speaker for the American Academy of Dental Sleep Medicine, and as a speaker and consultant for the Sleep Performance Institute. Dr Howell has received grant support from the National Institute of Neurological Disorders and Stroke (1R01NS110613-01) and publishing royalties from UpToDate, Inc.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Howell discusses the unlabeled/investigational use of clonazepam for the treatment of rapid eye movement sleep behavior disorder.

© 2020 American Academy of Neurology.