Eric Marin, MD PGY-4 Neurology Resident Department of Neurology Saint Louis University School of Medicine St. Louis, Missouri
Shizuka Tomatsu, MD PGY-1 Psychiatry Resident Sandra and Leon Levine Psychiatry Residency Atrium Health Behavioral Health Charlotte Charlotte, North Carolina
Rita Khoury, MD Assistant Professor of Clinical Psychiatry Director, Psychiatry Residency Program Department of Psychiatry and Clinical Psychology Saint George Hospital University Medical Center University of Balamand, School of Medicine Institute for Development, Research, Advocacy and Applied Care (IDRAAC) Beirut, Lebanon
George T. Grossberg, MD Samuel W. Fordyce Professor Director, Geriatric Psychiatry Department of Psychiatry and Behavioral Neuroscience Saint Louis University School of Medicine St. Louis, Missouri
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
When evaluating a patient with parasomnias, it is important to review their drug and substance use as well as coexisting medical conditions. Drugs and substances that can affect sleep include prescription medications (second-generation antidepressants, stimulants, dopamine agonists), excessive caffeine, alcohol, certain foods (coffee, chocolate milk, black tea, caffeinated soft drinks), environmental exposures (smoking, pesticides), and recreational drugs (amphetamines).53-56 Certain medical conditions are correlated with specific parasomnias (eg, sleep paralysis and narcolepsy, REM sleep behavior disorder and Parkinson’s disease [PD], etc.).54 Diagnosis of parasomnias is mainly clinical but supporting evidence can be obtained through in-lab polysomnography.
Treatment. For parasomnias, treatment is primarily supportive and includes creating a safe sleeping environment to reduce the risk of self-harm. Recommendations include sleeping in a room on the ground floor, minimizing furniture in the bedroom, padding any bedside furniture, child-proofing doorknobs, and locking up weapons and other dangerous household items.54
REM sleep behavior disorder (RBD).This disorder is characterized by a loss of the typical REM sleep-associated atonia and the presence of motor activity during dreaming (dream-enacted behaviors). While the estimated incidence of RBD in the general adult population is approximately 0.5%, it increases to 7.7% among those age >60.57 RBD occurs most commonly in the setting of the alpha-synucleinopathies (PD, Lewy body dementia, multisystem atrophy), but can also be found in patients with cerebral ischemia, demyelinating disorders, or alcohol misuse, or can be medication-induced (primarily antidepressants and antipsychotics).58 In patients with PD, the presence of RBD is associated with a more impaired cognitive profile, suggestive of widespread neurodegeneration.59 Recent studies revealed that RBD may also be a prodromal state of neurodegenerative diseases such as PD, which should prompt close monitoring and long-term follow up.60 Similar to other parasomnias, the diagnosis of RBD is primarily clinical, but polysomnography plays an important role in demonstrating loss of REM-related atonia.54
Treatment. Clonazepam and melatonin have been shown to be effective in treating the symptoms of RBD.54
Depression, anxiety, and sleep disturbances
Major depressive disorder (MDD) and generalized anxiety disorder (GAD) affect sleep in patients of all ages, but are underreported in older adults. According to national epidemiologic surveys, the estimated prevalence of MDD and GAD among older adults is 13% and 11.4%, respectively.61,62 Rates as high as 42% and 39% have been reported in meta-regression analyses among patients with Alzheimer’s dementia.63
