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 Neurological Sciences journal articles on RBD 
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Post Neurological Sciences journal articles on RBD
The Italian journal Neurological Sciences published a supplement in January '07 where all the articles examine sleep disorders in PD. I've looked at six articles so far, and found the three on RBD (REM sleep behavior disorder) interesting.

The citation and abstract for the first article I read is:

Idiopathic rapid eye movement sleep behaviour disorder
M.L. Fantini, L. Ferini-Strambi
Sleep Disorders Center, Department of Neurology,
Universita Vita-Salute San Raffaele, Milan, Italy
Neurol Sci (2007) 28:S15­S20

"Rapid eye movement (REM) sleep behaviour
disorder (RBD) is a parasomnia characterised by elaborate
behaviours during REM sleep usually associated with
action-filled dreams. Typical behaviours are screaming,
grasping, punching, kicking and occasionally jumping out
of bed, which are potentially harmful for the patient and
their bed partner. Polysomnographic (PSG) recording
reveals a loss of atonia and an excessive phasic motor
activity during REM sleep. RBD affects mainly men over
50 years and its prevalence in the general population is
estimated around 0.5%. It may occur in acute or chronic
forms. The latter may be isolated (idiopathic RBD), or
associated with other neurological diseases (symptomatic
RBD), especially with a group of neurodegenerative disease
called alpha-synucleinopathies, which includes
Parkinson’s disease, dementia with Lewy bodies (DLB)
and multiple system atrophy. The idiopathic form accounts
for up to 60% of the cases reported in the literature. Small
clinical follow-up studies revealed that a proportion of
these patients will eventually develop a parkinsonian syndrome
and/or a DLB in the years following the RBD diagnosis,
while some patients will remain idiopathic for
decades. Recent studies found evidence of neural dysfunction
during both wakefulness and sleep in iRBD, such as
an impairment of the cortical activity, specific neuropsychological
deficits, signs of autonomic dysfunction, deficit
of colour discrimination, subtle abnormalities in quantitative
measures of motor and gait speed and an olfactory
impairment. The notion of 'idiopathic' RBD is currently
challenged and the use of a more conservative term of
'cryptogenic' RBD has been suggested."
PubMed ID: 17235428

Some interesting excerpts include:

"RBD affects mostly men over the age of 50 years.
(The) reason for the male predominance is unclear."

"(S)everal authors believe that iRBD represents, at least
in a proportion of cases, a pre-clinical stage (Stage 2) of a
Lewy body disease (LBD)."

"Olfactory deficit is documented in LBD from the early stage. The
demonstration of both autonomic and olfactory deficit in
iRBD is in agreement with the model of Braak and strengthens
the notion of iRBD as an early stage of LBD."

"(F)urther potential early markers of PD have been recently
found in (approximately half of) iRBD patients, namely an
impairment in colour discrimination and subtle abnormalities
on quantitative testing of motor and gait speed."

"A recent study quantified the dream content in RBD and found a
very high proportion of aggressive interactions and animals
characters, with a reduced sexual content in RBD
patients, besides normal or even reduced levels of daytime

Here are some excerpts from the Treatment section:

"Maximising the safety of the sleeping environment...
must be recommended. Clonazepam...administered at bedtime
in doses ranging from 0.5 to 2 mg, significantly controls both the
behavioural manifestations of RBD and the disturbed
dream content, and therefore is considered the first-choice
(Clonazepam = Klonopin)

"Recently, administration of melatonin in doses
ranging between 3 and 9 mg at bedtime was found to be
effective in controlling both behaviour and dream disturbances
in RBD."

Here's the citation and abstract the second article from that Italian journal:

Sleep disorders in Parkinson’s disease: facts and new perspectives
Manni R, Terzaghi M, Pacchetti C, Nappi G.
Sleep Medicine Unit, Mondino Institute of Neurology, Pavia, Italy
Neurol Sci. 2007 Jan;28 Suppl 1:S1-5.

"Awareness of the clinical and pathophysiological
importance of sleep disorders in Parkinson’s disease (PD)
has been growing in recent years. Sleep disorders are now
regarded as important among non-motor symptoms in PD
and as a significant variable of PD-related quality of life.
Furthermore, some sleep disorders, namely REM behaviour
disorder (RBD), has been hypothesised to herald PD
by years. Subjective reports of disrupted nocturnal sleep
and daytime sleepiness appear to be supported by descriptions
of several sleep alterations at nocturnal polysomnographic
investigation and Multiple Sleep Latency Test
findings. Sleep alterations in PD are to be viewed from the
multifactorial perspective of a framework of reciprocally
interacting factors: pathophysiology of the disease itself,
sleep-related motor symptoms, dopaminergic treatments,
ageing, depression, restless legs, periodic limb movements
(PMLs) and sleep-disordered breathing. Ad hoc questionnaires
and scales such as the Parkinson’s Disease Sleep
Scale and the Short and Practical (SCOPA) Sleep Scale are
now available for the evaluation of disordered sleep in PD
patients and have been proved to be useful for preliminary
screening of sleep disorders in PD. However in a few cases
a video-polysomnography (V-PSG) is needed in order to
confirm a diagnosis of sleep disorder in PD, particularly in
diagnosing RBD. As for treatment of sleep disorders, combined
pharmacological and non-pharmacological protocols
appear to be particularly suitable in their treatment in PD."
PubMed ID: 17235427

One item I found very interesting in the article is the idea that visual hallucinations could actually be dreams or "sleep-related phenomena":

"A few lines of evidence in the literature suggest that
some of the nocturnal and daytime visual hallucinations
occurring in non-demented PD are sleep-related phenomena...
Arnulf et al. in 2000 put forward the hypothesis
that some visual hallucinations in PD may consist of
dream imagery intruding abruptly into wakefulness...
Together, these data stress the potential relevance of REM
dysfunction in the genesis of some visual hallucinations in PD...
PD patients with RBD more frequently experience, or ultimately
develop, visual hallucinations than those without RBD."

Other interesting excerpts:

"(Only) 40% of neurologists in primary neurological
settings adequately investigated and treated sleep disorders
in PD."

"...RBD...has been estimated, purely on the basis of clinical
reports, to occur in 25%­-30% of PD patients."

"Visual hallucinations are frequently encountered in PD,
especially in the advanced stages of the disease. Antiparkinsonian
drugs, such as anticholinergics, L-dopa and
DAs, are thought to play an important role in the occurrence
of hallucinations in PD. However, it is possible that
the PD itself may also play a role: recent literature data
document a strong relationship between visual hallucinations
and the presence of Lewy body disease in PD
and others prove the existence of visual hallucinations in
PD patients in the pre-dopaminergic era."

The citation and abstract for the third article are:

Symptomatic REM sleep behaviour disorder
Thomas A, Bonanni L, Onofrj M.
Neurophysiopathology, Movement Disorders Center, University "G. D'Annunzio" Chieti and Pescara, Italy.
Neurol Sci. 2007 Jan;28 Suppl 1:S21-36

"Rapid eye movement (REM) sleep behaviour
disorder (RBD) precedes or accompanies many neurodegenerative
disorders. In synucleinopathies, including
dementia with Lewy bodies, Parkinson’s disease and multiple
system atrophy, the prevalence of RBD varies from
19% to almost 77% in different reports. In tauopathies,
including Alzheimer’s disease, corticobasal degeneration,
progressive supranuclear palsy and frontotemporal dementia,
the prevalence is rare, ranging from 0% to 27%. RBD
has however also been described in amyotrophic lateral
sclerosis, limbic encephalitis, Guillain-Barré syndrome,
Tourette’s syndrome, autism, epilepsy and post-traumatic
stress disorder. The present paper reviews the current literature
on symptomatic RBD and on RBD induced by drug
administration, antidepressants, tricyclics and newer
drugs, which are often described as precipitating factors
for RBD. Controversial findings, flaws in categorisation
and hypothetical aetiological mechanisms are also discussed."
PubMed ID: 17235429

The article notes that RBD is a newly-described disorder, dating from 1986. Diagnostic criteria include: "movements of the body or limbs associated with dreaming and at least one of the following criteria: potentially harmful sleep behaviour, dreams that appear to be acted out and sleep behaviour that disrupts sleep continuity."

The article addresses LBD specifically:

"...Dementia with Lewy bodies (DLB) now thought
to be the second most common type of degenerative
dementia in older people, accounting for 10%­15% of
cases at autopsy. Although no study has systematically
assessed the frequency of RBD in patients with DLB, a strong
association between these two disorders has been reported.
Reports by Boeve et al. suggested a prevalence
of RBD in almost 77% of the studied cases."

"On the basis of these observations, RBD is now a suggestive
criterion for DLB also in the absence of parkinsonism
and hallucinations. ...For cases in which there is a
diagnostic dilemma with absence of (visual hallucination) or parkinsonism,
sleep-laboratory investigation is highly recommended in
order to confirm the presence of RBD in patients with probable

The treatment section refers to Klonopin and melatonin as two sole therapies for RBD. Besides these two medications, there is conflicting evidence as to whether other medications -- including dopaminoagonists (pramipexole) and Aricept -- improve or worsen RBD symptoms. The authors note that Seroquel and Clozaril are considered effective in treating RBD but this needs to be studied more systematically.


Tue Jan 30, 2007 2:49 am
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