Management of RBD

When a patient presents with disruptive dream enactment behavior at night, a clinician’s first step is to establish therapeutic goals.

The most important goal that is relevant to almost every patient who presents with parasomnias is to minimize or prevent injury during sleep.

Clinicians may not be able to resolve 100% of all dream enactment episodes such as kicking, moving, talking, and shouting, despite pharmacologic treatment. Medical treatment often decreases the more aggressive and injurious behaviors such as jumping out of bed and punching the wall. Some individuals may still experience non-violent movements, talking, or shouting/swearing during sleep. While these experiences can be embarrassing or inconvenient, it’s important to keep RBD behaviors in perspective and focus upon eliminating opportunities for potential injury using safety interventions 

Safety interventions take into consideration affected patients as well as their bed partners. Examples include sleeping separately from bed partners and making the bedroom as safe as possible, such as by moving furniture away from the bed, or removing any potential weapons. 

For patients who require pharmacological treatment, most clinicians pursue treatment with melatonin, typically starting around 3-6mg, but higher doses may be needed to be effective.  Another option is clonazepam, or a combination of  melatonin with clonazepam. Rivastigmine, pramipexole, and other medications are used as second-line medications for RBD. All medications for RBD are used “off-label,” meaning they are not FDA-approved for RBD specifically. Furthermore,in the United States, melatonin is an over-the-counter agent; as such, there is greater variance of the actual amount of melatonin present between various formulations. Switching brands may help due to these potential differences in actual melatonin dosage. 

Patients are advised to have a close clinical follow up with their sleep doctor or clinician to make sure that treatment provides adequate control of disruptive movements while potential side effects are identified and addressed.

Some patients may have ongoing sleep-related problems despite what may be perceived to be adequate pharmacologic treatment. In these situations, it is important for clinicians and patients to clarify the goals and expectations of treatment. For example, some patients who start medication for RBD expect it to do more than address dream enactment. One sleep physician described a recent example of a patient who was acting out his dreams 3-4 times per week and his spouse needed to sleep in a separate bedroom . The patient started melatonin at 3mg per night, and after a month increased to 6mg.  After 2 months, he reported "melatonin is not working". On further inquiry, he indicated that melatonin does not help him fall asleep any easier and he does not feel better  in the morning. While his insomnia did not improve, he noted that his aggressive dream enactment was almost resolved, down to about one minor episode per month. This is an example of successful treatment RBD, and demonstrates why it is important to work with a sleep physician who can carefully tease apart RBD and other sleep disorders.