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Sleep Care

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REM Behavior Disorder

Anna was startled awake one night by her husband Frank, who was tightly gripping her arm and trying to pull her out of the bed. “We have to get out of here!” he said frantically. “They’re chasing us!” When she wouldn’t move, he let go and rolled out of the bed, crashing into the nightstand. After a moment, he sat up by the edge of the bed and looked at her with a puzzled expression on his face. “How did I get down here?” he asked. Anna realized that Frank had been dreaming the entire time. After similar bizarre behavior occurred several more times over the next couple of months, Frank and Anna scheduled an appointment with a sleep specialist, who suggested Frank may be having episodes of REM behavior disorder during the night. An Alarming and Dangerous Problem When people dream during the night, the body’s muscles are generally paralyzed (a state known as “atonia”) while the brain is in a very active state. This is to prevent the body from physically acting out whatever events are occurring in the dream. For individuals suffering from REM behavior disorder (RBD), the body’s muscles fail to become paralyzed—as a result they will physically act out their dream, much as if they were performing the actions while they are awake and functioning during the day. The behaviors can range from relatively harmless—such as talking or yelling—to more violent displays like kicking, punching, grabbing, or jumping from the bed and running. REM behavior disorder primarily affects men: one study estimated that 90% of RBD patients are male. Symptoms typically don’t occur until an individual is older than 50, although there have been cases reported involving patients as young as nine years old. It’s estimated to affect between 0.38% and 0.5% of the general population. One of the biggest dangers of REM behavior disorder is the potential for injury to either the individual or a bed partner. Studies have found between 33% and 65% of RBD patients report sleep related injuries to either themselves or bed partners. For most cases of REM behavior disorder, the cause of the symptoms is unknown, although it does occur more often in individuals with degenerative neurological conditions—particularly Parkinson’s disease. RBD can also develop when going through periods of alcohol withdrawal or due to certain medications, such as serotonin reuptake inhibitors (i.e., fluoxetine, sertraline, paroxetine) or some types of antidepressants (i.e., mirtazapine). Getting a Safe Night’s Sleep Treating REM behavior disorder usually involves a combination of medication, dietary supplements and environmental changes. While these are being made, bed partners should consider sleeping in a separate bed or another room to avoid risk of injury during sleep. Clonazepam is a drug that is commonly prescribed for RBD and reduces or eliminates symptoms of the disorder about 90% of the time. It is effective since people generally don’t develop a tolerance for it, even after taking it for several years. Some individuals do experience side effects from Clonazepam, such as decreased balance or feeling sleepy the next day (despite resting all night). In these cases, dietary supplements melatonin and glycine, which are known to suppress muscle twitches, may be beneficial. Since these are naturally occurring elements found in the body and most foods side effects are minimal. In addition to promoting less physically active sleep, it also has been found to reduce the frightening aspects of the dreams (often nightmares) commonly associated with RBD. Melatonin is also beneficial when treating RBD patients who also have dementia or sleep apnea. Research comparing the two medications determined that while Clonazepam works by reducing excessive body movements during sleep (kicking legs, arms flailing, etc.), melatonin works to restore the body’s atonia state during REM. Clonazepam appears to be more potent and effective at reducing RBD symptoms than melatonin. Making changes in the sleeping environment is also an important part of dealing with REM behavior disorder. Remove any furniture or other objects with sharp edges from the room, or ensure that they’re sufficiently padded. The floor should be clear of items that could be stepped on or tripped over and cause harmful falls. The mattress can be moved to the floor (instead of elevated on box springs or a frame) to minimize the distance to the ground if an individual rolls out of bed. Keep the bed away from any windows or other glass surfaces. If possible, the bedroom should be on the first floor to avoid risks of individuals falling down stairs. Frank’s sleep specialist started him on Clonazepam, and it took several months to work out the correct dosage to resolve his RBD symptoms. “I slept in our guest room while we were getting the medicine figured out,” Anna says.

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“We also put some extra pillows around the bed during the night in case anything happened.” For his part, Frank is relieved to have everything back under control. “The scariest thing,” he says, “is that you’re doing this in your sleep and you have no idea what happened when you wake up. It’s a terrible feeling to think that I might have been hurting Annie during the night, and I had no idea. I’m glad it’s no longer a problem…the bed was lonely without her!”

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