Management of REM sleep behavior disorder

This clinical practice guideline updates the previously published American Academy of Sleep Medicine (AASM) Best Practice Guide on the treatment of rapid eye movement (REM) sleep behavior disorder1 and reflects the current recommendations of the AASM.

Under normal physiological conditions, REM sleep is characterized by dream mentation combined with skeletal paralysis. This REM sleep atonia is lost in REM sleep behavior disorder (RBD), resulting in individuals acting out their dreams with potentially violent and injurious behaviors. RBD can have significant consequences on quality of life, including the risk of injury to patients and bed partners.

In 2010, the AASM published a best practice guide for the treatment of RBD.1 Without placebo-controlled studies for guidance, a consensus was formed based upon case series and small uncontrolled clinical trials. Since 2010, several clinical trials have been conducted regarding the management of RBD among patients with isolated (or idiopathic) RBD, RBD secondary to a medical disorder (most commonly the alpha-synuclein pathologies of dementia with Lewy bodies [DLB], Parkinson disease [PD], and multiple system atrophy), and drug-induced/exacerbated RBD (most commonly selective serotonin reuptake inhibitors). This expansion of the literature on RBD management substantially informed the task force in crafting the clinical practice guideline.

This guideline, in conjunction with the accompanying systematic review,2 provides a comprehensive update of the available evidence and a synthesis of clinical practice recommendations for the treatment of RBD.

It is intended to optimize patient-centric care by informing clinicians who care for patients with RBD. This clinical practice guideline provides practice recommendations for the management of RBD by identifying treatments that are most effective in specific circumstances (isolated RBD, secondary RBD, drug-induced/exacerbated RBD). However, we recognize that patients often do not segregate neatly across these conditions. Further, a significant degree of overlap frequently occurs, patients may move from one category to another, and appropriate treatments may change or emerge over time. Finally, this guideline provides advice for the counseling and disclosure of neurodegenerative risk for patients with RBD.

The following clinical practice recommendations are based on a systematic review and evaluation of evidence using the Grading of Recommendations, Assessment, Development and Evaluation process. The recommendations reflect only those interventions for which there was sufficient evidence to make a recommendation. Interventions for which literature was reviewed but it was determined that insufficient evidence existed to make a recommendation are discussed in the systematic review.2 “Insufficient evidence” to determine the effectiveness of a particular intervention does not mean that the intervention does not provide benefit but rather that evidence is lacking to guide decision-making. Additional research is needed to determine the effectiveness of these interventions.

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