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NEUROLOGY

Rapid Eye Movement Sleep Behavior Disorder

at time of writing, Psychiatric Pharmacy Resident, School of Pharmacy, University of Connecticut, Storrs, CT; The Institute of Living, Burlingame Research Center, Hartford, CT; now, Assistant Clinical Professor, College of Pharmacy and Allied Health Profesions, St. John's University, Jamaica, NY

Mary L Wagner, MS PharmD

Associate Professor, Ernest Mario School of Pharmacy, Rutgers—The State University of New Jersey, Piscataway, NJ

Reprints: Dr. Wagner, Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers—The State University of New Jersey, 160 Frelinghuysen Rd., Piscataway, NJ 08854, fax 732/445-2533, mlwagner{at}rci.rutgers.edu

OBJECTIVE: To describe the clinical features of rapid eye movement (REM) sleep behavior disorder (RBD), evaluate treatment options, and discuss management of patients with comorbid diseases.

DATA SOURCES: A MEDLINE search (1977-April 2007) using the terms REM sleep behavior disorder, narcolepsy, parkinsonian disorders, levodopa, dopamine agonists, clonazepam, benzodiazepines, and melatonin was used to retrieve relevant articles. The reference sections of all articles and texts were scanned for additional literature.

STUDY SELECTION AND DATA EXTRACTION: All articles published in English were evaluated. There were no specific criteria for inclusion of articles in this review.

DATA SYNTHESIS: RBD is characterized by enactment of dream content resulting from the loss of normal skeletal muscle atonia during REM sleep. RBD occurs mainly in geriatric patients and in patients with neurodegenerative diseases, especially parkinsonian diseases. The presence of idiopathic RBD may be a sign of an underlying parkinsonian syndrome. Development of RBD may be one of the first manifestations of Parkinson's disease or other parkinsonian syndromes. An acute form of RBD can be drug-induced or occur on drug withdrawal. The potential for injury to the patient and his or her bed partner is as high as 96%. Controlled trials are unavailable for most agents used in the treatment of RBD, although clonazepam is an effective first-line agent and can provide rapid and complete symptom remission based on evidence from 3 large case series. Patients who cannot tolerate clonazepam or who have a suboptimal response may benefit from melatonin alone or as an adjunct. Both drugs are generally well tolerated when taken at bedtime. Management of patients with RBD becomes complicated due to the high incidence of neurologic comorbidity.

CONCLUSIONS: Clonazepam is the treatment of choice for patients with RBD. The drug is efficacious and has a low incidence of adverse effects. Melatonin is a viable second-line or adjunctive treatment.

Key Words: clonazepam, melatonin, Parkinson's disease, rapid eye movement sleep behavior disorder

Published Online, October 9, 2007. www.theannals.com, DOI 10.1345/aph.1H587