Treatment outcomes in REM sleep behavior disorder

Abstract

Objective REM sleep behavior disorder (RBD) is usually characterized by potentially injurious dream enactment behaviors (DEB). RBD treatment aims to reduce DEBs and prevent injury, but outcomes require further elucidation. We surveyed RBD patients to describe longitudinal treatment outcomes with melatonin and clonazepam. Methods We surveyed and reviewed records of consecutive RBD patients seen at Mayo Clinic between 2008–2010 to describe RBD-related injury frequency/severity as well as RBD Visual Analog Scale (VAS) ratings, medication dosage, and side effects. Statistical analyses were performed with appropriate non-parametric matched pairs tests before and after treatment, and with comparative group analyses for continuous and categorical variables between treatment groups. The primary outcome variables were RBD VAS ratings and injury frequency. Results Forty-five (84.9%) of 53 respondent surveys were analyzed. Mean age was 65.8 years and 35 (77.8%) patients were men. Neurodegenerative disorders were seen in 24 (53%) patients, and 25 (56%) received antidepressants. Twenty-five patients received melatonin, 18 received clonazepam, and 2 received both as initial treatment. Before treatment, 27 patients (60%) reported an RBD associated injury. Median dosages were melatonin 6 mg and clonazepam 0.5 mg. RBD VAS ratings were significantly improved following both treatments (pm=.0001, pc=.0005). Melatonin-treated patients reported significantly reduced injuries (pm=.001, pc=.06) and fewer adverse effects (p=0.07). Mean durations of treatment were no different between groups (for clonazepam 53.9 +/− 29.5 months, and for melatonin 27.4 +/− 24 months, p=0.13) and there were no differences in treatment retention, with 28% of melatonin and 22% of clonazepam-treated patients discontinuing treatment (p=0.43). Conclusions Melatonin and clonazepam were each reported to reduce RBD behaviors and injuries and appeared comparably effective in our naturalistic practice experience. Melatonin-treated patients reported less frequent adverse effects than those treated with clonazepam. More effective treatments that would eliminate injury potential and evidence-based treatment outcomes from prospective clinical trials for RBD are needed.

Seeking Good Alternatives to Clonazepam: Suggestions for Future Treatment Trials in REM Sleep Behavior Disorder

“…8 In a previous retrospective melatonin study and clonazepam, the visual analog scale (VAS), a simple and clear subjective scale, was used to evaluate treatment efficacy, was used by a bed partner or family member to evaluate RBD frequency and severity in daily life. 9 Similarly, in our present ramelteon study, the VAS was found to have utility in evaluating efficacy, with a trend toward significance. 6 The possible effects of gabapentin and pregabalin on RBD remain unknown: These pharmacological agents may modulate sleep stages (including REM sleep), suppress abnormal motor function directly, or affect dream contents via psychotropic properties.…”

Effects of Rotigotine on REM Sleep Behavior Disorder in Parkinson Disease

“…3 No randomized, double-blind, placebo-controlled study has been reported regarding treatment of RBD. However, a few drugs have been reported as effective, such as clonazepam, 4 melatonin, 5 and pramipexole, 6,7 a dopamine agonist. However, little is known regarding the relationship between RBD and dopaminergic deficiency.…”

A 76 Year-Old Woman with Sleep and Waking Stridor, Sleep Talking, Orthostatic Hypotension, and Imbalance

“…Melatonin or clonazepam may be offered as therapies, with melatonin preferred to avoid exacerbating SDB and neurological dysfunction. 12 Taking a thorough medication history for any medications that could provoke or aggravate RSWA is important in all patients presenting with parasomnia behaviors. Several medications have been associated with RSWA, including tricyclic, selective serotonin reuptake inhibitors, and mixed mechanism antidepressants (i.e., mirtazapine and venlafaxine), and monamine oxidase inhibitors such as seligline.…”