REM Sleep Disorder | REM Sleep Behavior Disorder | REM Therapy

REM Sleep Disorder – Causes, Symptoms, Diagnosis, Treatment and Self Care

REM Sleep Disorder causes:

The exact cause of REM sleep behavior disorder (RBD) is unknown; although the REM sleep behavior disorder may occur in association with various degenerative neurological conditions such as multisystem atrophy, diffuse Lewy body dementia, Parkinson disease and Shy-Drager syndrome.

In 55% of persons the REM sleep behavior disorder cause is unknown, and in 45%, the cause is associated with alcohol or sedative-hypnotic withdrawal, tricyclic antidepressant (such as imipramine), or serotonin reuptake inhibitor use (such as fluoxetine, sertraline, or paroxetine) or other types of antidepressants (mirtazapine).

REM Sleep Disorder Symptoms:

The main symptom of REM sleep behavior disorder is dream-enacting behaviors, sometimes violent, causing self-injury or injury to the bed partner.

The dream-enacting behaviors are usually nondirected and may include kicking, leaping, punching or jumping from bed while still asleep.

  1. Brain waves are small and irregular, with big bursts of eye activity. The brain wave activity at this time resembles waking more than it does sleeping.
  2. Breathing becomes irregular and oxygen consumption increases.
  3. The four NREM phases are characterized by progressive relaxation. But during REM sleep phase, the body's activity perks up considerably.
  4. Pulse rates during REM sleep increase in an irregular way.
  5. Blood pressure may increase drastically.
  6. The sleeper with cardiac problems faces the greatest risk of heart attack at this time.
  7. The body seems to have abandoned its effort to regulate its temperature during the REM sleep phase.
  8. The sleepers' large muscles are literally paralyzed. They cannot move their torsos, arms, or legs.

The people with REM sleep disorder may be awakened or may wake spontaneously during the attack and vividly recall the dream that corresponds to the physical activity.

REM Sleep Disorder diagnosis:

Seek medical care if unusual behaviors, such as violent thrashing and kicking, occur during sleep.

REM - Polysomnography:

Polysomnographic video recording is the single most important diagnostic test in persons with REM sleep behavior disorder. This test is usually conducted in a sleep study center. The person undergoing testing is required to sleep at the center while the following parameters are monitored:

  • Multiple electromyography (EMG) channels utilizing chin, bilateral extensor digitorum, and tibialis anterior muscles
  • Electrical activity of the brain (electroencephalogram [EEG])
  • Eye movements (electrooculogram)
  • Respiratory movements
  • Electrical activity of the heart (electrocardiogram [ECG])

In persons with REM sleep behavior disorder, the polysomnogram shows an increase in the muscle tone associated with the EEG pattern of REM sleep, whereas in healthy persons, the EEG pattern of REM sleep is associated with an absence of muscle tone (atonia).

These parameters are monitored as the person passes through the various sleep stages. Characteristic patterns from the electrodes are recorded while the person is awake and during sleep.

Continuous video recording is done to observe behaviors during sleep. Additionally, the video recording shows body movements coinciding with the EEG pattern of Rapid eye movement sleep.

REM Neurologic Exanination:

The neurologic examination is often normal. However, symptoms and signs of Parkinson disease, such as hand tremor at rest, slowness in movement, and muscle stiffness (rigidity) that may suggest an underlying neurologic cause of REM sleep behavior disorder (RBD), should be considered.

REM Sleep Disorder Treatment:

The treatment of REM sleep behavior disorder can be challenging in some patients with underlying neurodegenerative conditions.

Clonazepam (Klonopin) is highly effective in the treatment of REM sleep behavior disorder (RBD), relieving symptoms in nearly 90% of patients with little evidence of tolerance or abuse. The initial dose is 0.5 mg at bedtime, with some persons requiring a rapid increase to 1 mg.

A persistent benefit was shown with melatonin with and without low dose of clonazepam beyond 1 year of therapy in 57%. The effective dose of melatonin was 3-6 mg. only 36% experienced side effects, which resolved with decreased dosing.

Other medications, such as tricyclic antidepressants, may be effective in some patients of REM sleep behavior disorder. However, tricyclics are known to precipitate RBD. Levodopa may be very effective in patients in whom REM sleep behavior disorder is the harbinger of Parkinson disease.

In addition, anecdotal reports exist of responses to carbamazepine, clonidine, and L-tryptophan.

REM Self care:

Because persons with REM sleep behavior disorder have a risk of injuring themselves and their sleep partners, safety of the sleeping environment is very important.

  • The bedmate should sleep in another bed until the symptoms resolve.
  • Clear the floor of furniture and objects that could injure the person if he or she fell from bed.
  • Remove potentially dangerous objects from the bedroom.
  • Have the person sleep in a bedroom on the ground floor if possible, especially for people who leave the bed during an episode.
  • A bed with padded bedrails can be considered.

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