Management of rapid eye movement sleep behavior disorder

REM sleep behavior disorder (RBD) occurs commonly in association with Parkinson disease, dementia with Lewy bodies, and multiple system atrophy. In younger adults (<40 years), it may occur in association with serotonergic antidepressants or narcolepsy. Isolated RBD in adults is often a prodromal symptom of Parkinson disease or related alpha-synuclein neurodegenerative disorders. Refer to UpToDate clinical content for further details and discussion of prognostic disclosure and counseling.

REM: rapid eye movement.

* Melatonin doses provided are for immediate release. Use of time-release melatonin has a theoretical but unproven advantage over immediate-release formulations. For time-release melatonin, a suggested starting dose is 5 mg orally at bedtime, titrating by 5 mg every 1 to 2 weeks to a maximum of 15 mg nightly.

Our preference for melatonin over clonazepam or a cholinesterase inhibitor as first-line therapy is largely based on tolerability and the desire to minimize benzodiazepines in older adults and those with cognitive dysfunction. A cholinesterase inhibitor (eg, rivastigmine patch) is a reasonable alternative to melatonin in patients with mild cognitive impairment or dementia with Lewy bodies who are not already taking one, as it may help treat both conditions.

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Management of rapid eye movement sleep behavior disorder