New AASM Guideline Advises on Management of REM Sleep Behavior Disorder

Bedroom safety, medication use and ethical dilemmas are addressed

Maintaining a safe sleeping environment for patients with rapid-eye movement (REM) sleep behavior disorder (RBD) and their bed partners is critically important to prevent injury from falling out of bed, thrashing limbs or even unknowingly using a readily available weapon. Fortunately, evidence indicates that, in addition to environmental changes that patients can make, medications may help remediate the condition.

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Recommendations from an American Academy of Sleep Medicine (AASM) task force of sleep medicine clinicians with expertise in managing RBD ― which involves physically enacting dreams ― were recently published in a clinical practice guideline in the Journal of Clinical Sleep Medicine (2023;19[4]:759-768). An accompanying article (2023;19[4]:769-810) provides a description of the process of evidence review and guideline creation.

“With an estimated 5% of older adults having this disorder, it’s important for primary care clinicians, geriatricians, neurologists and all sleep medicine providers to be able to confidently advise patients and their families on how to cope with it,” says AASM task force member Nancy Foldvary-Schaefer, DO, MS, a co-author of both articles and Director of the Sleep Disorders Center at Cleveland Clinic. “We were very rigorous in our review process to establish evidence-based recommendations.”

Crash course in RBD

Normal REM sleep involves motor paralysis while dreaming, caused by inhibitory brainstem pathways. RBD develops when these pathways are disrupted, usually attributable to alpha-synuclein degeneration, a hallmark of Lewy body dementia, Parkinson’s disease and multiple system atrophy.

RBD can also be secondary to type 1 narcolepsy, particularly among young patients. In others, RBD is medication-induced.

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“Idiopathic RBD” was the term formerly used when RBD cannot be identified as secondary to a disorder or to a medication. However, it has become well established that most patients affected in this way later develop one of the associated neurodegenerative disorders, so this category is now referred to as “isolated RBD.”

Guideline development

In the years since the previous AASM guideline on RBD was published in 2010, the literature on the subject has boomed. For this update, the task force reviewed 4,690 studies, although only 148 were deemed suitable for statistical analyses to develop the recommendations.

For the first time, the task force used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. Guidance recommendations were classified as either “strong” (based on good evidence and indicating that they are advisable under most circumstances) or “conditional” (based on weak evidence and indicating they should be considered in tandem with clinical judgement and patient input). Although 45 interventions are presented in the guideline, no drug treatment reached the level of a strong recommendation due to lack of evidence from randomized controlled trials.

Also new for this guideline process was the inclusion of two patients on the task force. Dr. Foldvary-Schaefer notes that the patients sometimes had different views from the clinicians, particularly on the ethical issue of how much to reveal about prognosis to patients with isolated RBD.

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Key management strategies

Dr. Foldvary-Schaefer highlights several takeaways from the guideline:

  • Create a safe environment for patients and bed partners. Padding sharp corners on nightstands, putting a soft mat on the floor next to the bed, and placing pillows between the patient and sleeping partner can help prevent injury. Most important is to remove heavy items and firearms from reach.
  • Try medications for situations involving high risk for injury. Clonazepam, immediate-release melatonin and transdermal rivastigmine are conditionally recommended for either isolated or secondary RBD. Evidence also indicates that pramipexole may be effective for isolated RBD.
  • If possible, discontinue implicated medications for drug-induced RBD. Likely culprits are beta-blockers and selective serotonin reuptake inhibitors.
  • Don’t treat RBD with deep brain stimulation. Although it is effective for Parkinson’s disease, there is no evidence that deep brain stimulation improves RBD, so it should not be considered for this indication. 
  • Talk to patients about the prognosis of isolated RBD with extreme care. More than 90% of patients with isolated RBD go on to develop a neurodegenerative disorder over the coming years. “Deciding how much to reveal to a patient requires careful consideration of their desire to know such alarming news,” Dr. Foldvary-Schaefer explains. “It could lead to years of anxiety and depression, even suicide.”

Further research needed

The guideline’s lack of strong recommendations underscore that more randomized controlled studies are needed, including direct comparisons of the currently used drugs. However, research is complicated by a dearth of objective evaluative measures. Cleveland Clinic is developing methods of collecting arm electromyography measurements, which are more specific for RBD than the currently used leg measurements, but the process is very labor-intensive.

Finally, don’t rush the diagnosis

Dr. Foldvary-Schaefer cautions clinicians not to overlook other more common parasomnias that can be confused with RBD. Sleepwalking and sleep terrors, for example, do not typically occur late in the sleep cycle during REM sleep.

Sometimes a patient actually has an obstructive sleep disorder, she adds, and “putting them on a continuous positive airway pressure machine often solves the problem.”