Rem Behavior Disorder

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The second sleep disorder that may mimic convulsive epileptic seizures is REM behavior disorder (RBD) (58,59). RBD is characterized by recurrent episodes of vigorous motor activity occurring during REM sleep, movements that often awaken the patient or spouse. The primary presenting complaints are interrupted sleep or injuries during sleep. RBD is more common in older adults, usually beginning after the age of 50. It is two to five times more common in men than in women. It is possible that rare episodes such as these occur in a large percentage of the population. I am familiar with people who have had rare such episodes throughout their adult life.

The movements seen in RBD vary from minor movements of an individual extremity to complex behavior, such as laughing, shouting, or throwing one's self from the bed (58,59). Commonly, the movements are related to a dream the patient is having during REM sleep, and the patient is often able to describe the dream. The frequency of episodes varies from many per night to one every few weeks. If more than one episode occurs in a night, the episodes tend to occur at least 90 min apart, most likely during separate REM sleep cycles.

The exact mechanism of RBD is not known. During episodes of REM sleep in normal subjects, there is complete atonia. It is thought that RBD may be secondary to impairment of the normal inhibition of muscle activity during REM sleep (59). Consistent with this hypothesis, patients with RBD have been shown to have muscle activity present even during asymptomatic episodes of REM sleep. It is hypothesized that when the muscle activity during REM sleep is especially prominent, a clinical episode results.

RBD has been associated with brainstem lesions caused by vascular disease, trauma, and multiple sclerosis (59). In addition, RBD is common in patients with Parkinson's disease (60-62), and it has been reported in patients with narcolepsy (63). Schenk et al. followed patients who were diagnosed with RBD and found that 38% developed Parkinson's disease at an interval of 3.7 ± 1.4 years (60).

Treatment for RBD with clonazepam (0-5-2.0 mg.h.s) is successful in 80 to 90% of patients (59). Clonazepam does not completely suppress the motor activity during REM sleep, but it usually eliminates the vigorous, coordinated movements characteristic of RBD episodes. This allows the patient to sleep without disruption. If clonazepam is unsuccessful or causes drowsiness, tricyclics, levodopa/carbidopa, clonidine, or carbamazepine may be tried. Donepezil, an acetyl-cholinecterase inhibitor, has been effective in some patients (64).

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