REM Sleep Behaviour Disorder (RBD) can be an early sign of brain changes linked to Parkinson’s.

RBD is where you act out dreams. This can include talking, shouting, punching, kicking, or jumping out of bed.

What is REM Sleep Behaviour Disorder (RBD)?

What is REM sleep?

Sleep is divided into different stages. One of these is Rapid Eye Movement (REM) sleep, which is the stage where we do most of our vivid dreaming.

Normally, during REM sleep, the brain sends a signal to paralyse your muscles (except for your eyes and those used for breathing). This is called muscle atonia. It is a protective mechanism that prevents you from physically acting out your dreams while you are asleep. But in REM Sleep Behaviour Disorder (RBD), this doesn’t happen.

What is REM Sleep Behaviour Disorder (RBD)?

In RBD, that muscle “switch off” doesn’t happen, so your body can move while you are dreaming. Movements can be sudden, small or strong. This can be unsafe for you and for anyone sharing your bed. Many people are not aware that it is happening, so a bed partner’s description can be very helpful for a diagnosis.

Common signs of RBD:

  • punching, kicking, or flailing your arms in sleep
  • sitting up, jumping, or falling out of bed
  • talking, shouting, swearing, laughing, or crying out
  • remembering a vivid dream if you wake up during an episode
  • bruises, cuts, or fractures of unknown origin when you awaken
  • injuring a bed partner.

RBD can occur on its own or with other conditions. It is strongly linked to Parkinson’s and related neurological conditions, called alpha-synucleinopathies. These conditions are associated with the buildup of a specific protein in the brain called alpha-synuclein. This protein forms “seeds” or clumps that damage the areas of the brainstem responsible for controlling atonia in sleep. RBD can occur before daytime Parkinson’s symptoms develop, or it may start after a diagnosis for some people.

Researchers now view RBD as a “prodromal” or early Parkinson’s symptom. This means it is often a warning sign that appears years or even decades before the typical tremors or walking problems of Parkinson’s begin.

It is also associated with what we call “body-first” Parkinson’s, where the disease pathology may start in the gut or nose and move toward the brain. Smell loss often occurs alongside RBD.

In people who already have Parkinson’s, RBD is linked with a higher chance of cognitive changes in some studies.

RBD can also be linked to medicines. Antidepressants have been reported to trigger RBD in some people.

n.b. Never stop or change any medications, including antidepressants, without medical advice.

Key Statistics

  1. Between 30% and 50% of people living with Parkinson’s will experience RBD at some point.
  2. Symptoms of RBD can begin 10 to 30 years before a person is officially diagnosed with Parkinson’s motor symptoms.
  3. RBD is more commonly diagnosed in men over the age of 50, though women also experience it, but may have less violent movements.
  4. People with Parkinson’s who also have RBD may have a higher risk of developing memory or thinking problems (cognitive decline) over time.

How is RBD assessed & treated?

Diagnosing RBD

A clinician will usually start with:

  • your description of symptoms
  • a bed partner’s description, if available
  • a review of medicines and alcohol use.

If RBD is suspected, you may be referred for an overnight sleep study (video polysomnography). This is the gold standard test to confirm RBD.

Treatment options

Treatment depends on your symptoms, safety risks, other health conditions, and medicines.

  • If a medicine may be contributing, your doctor may adjust the dose or change the medicine.
  • Medicines used for RBD symptoms
    • First-line medication: Low doses of Melatonin are often used first because it has very few side effects. Clonazepam is another option, though use it carefully as it can cause morning sleepiness or increase fall risks.
    • Alternative options: Other treatments being researched include rotigotine patches and cannabinoids, though more evidence is needed.

These medicines can reduce dream enactment behaviours in some people. Your care team will weigh benefits against risks, especially if you are older or have memory, balance, or falls risk.

n.b. Do not start or stop any medications without proper medical advice.

Safety recommendations at home:

  • lower the bed height
  • move bedside tables away
  • remove sharp or breakable objects
  • place soft mats or cushions near the bed
  • secure windows and doors if needed
  • consider sleeping in separate beds temporarily if there is a risk of harm.

Seek urgent medical advice if:

  • you or your bed partner is injured
  • you fall out of bed
  • episodes become frequent or violent
  • you have new confusion, hallucinations, or marked daytime sleepiness.

If you suspect, or have been told by a bed partner, that you act out your dreams, please speak to your specialist about further investigations. Some other sleep disorders may look like RBD, so it is important to seek medical advice to investigate other possible causes for your sleep symptoms.

Infosheet kindly reviewed by the Sleep Health Foundation

The Sleep Health Foundation (SHF) is a not-for-profit health promotion charity that aims to raise community awareness about sleep and its common disorders, and to improve public health and safety. The SHF strives to deepen community understanding of the importance of sleep for health and performance; why sleep disorders need professional diagnosis and treatment; and, to provide information about common sleep difficulties and how to address them. As Australia’s leading advocate for the sleep health of the community, the SHF also facilitates research, especially on topics relevant to its health promotion mission, both in the community and in the workplace. We have a number of factsheets on an array of topics: All Sleep Factsheets A-Z | Sleep Health Foundation

References:

Ask the MD, MJFF https://www.michaeljfox.org/news/ask-md-acting-out-dreams-and-parkinsons-disease

Czernicki, S., Millan, M. J., & Delobel, P. (2021). The role of melatonin in the treatment of REM sleep behaviour disorder. Journal of Sleep Research, 30(3), e13238. https://doi.org/10.1111/jsr.13238

Mayo Clinic. (2018). REM Sleep Behavior Disorder.

Jiménez-Jiménez FJ, Alonso-Navarro H, García-Martín E, Agúndez JAG. (2021). Current Treatment Options for REM Sleep Behaviour Disorder. J Pers Med, 11(11):1204. doi: 10.3390/jpm11111204.

Jin H, Zhang JR, Shen Y, Liu CF. (2017). Clinical significance of REM sleep behavior disorders and other non-motor symptoms of parkinsonism. Neurosci Bull, 33(5):576–584. doi: 10.1007/s12264-017-0164-8.

Onofrj M, Luciano AL, Thomas A, et al. (2003). Mirtazapine induces REM sleep behavior disorder in parkinsonism. Neurology, 60(1):113-5. doi: 10.1212/01.wnl.0000042084.03066.c0.

Postuma, R. B., Gagnon, J. F., & Montplaisir, J. Y. (2015). REM sleep behaviour disorder in Parkinson’s disease: A review. Parkinsonism & Related Disorders, 21(2), 89-95. https://doi.org/10.1016/j.parkreldis.2014.11.019

Schreeder, M. T., Rittman, T., & Grosset, D. (2019). REM sleep behaviour disorder and Parkinson’s disease: A meta-analysis of the prevalence and risk factors. European Journal of Neurology, 26(5), 742-748. https://doi.org/10.1111/ene.1399

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