Caring burden of REM sleep behavior disorder - spouses' health and marital relationship

Sleep Disorders and Aging in Women

Women of advancing age can suffer from an array of sleep disorders. We review the changes in sleep architecture, the impact of hormonal changes on sleep, and the various sleep disorders in women of advancing age. A focused history in this population should include the temporal relation to menopause and comorbid conditions. Treatment options should involve patient preference and review of current medications and comorbid conditions to optimize sleep in this population.

Sex differences in rapid eye movement sleep behavior disorder: A systematic review and meta-analysis

Although rapid eye movement (REM) sleep behavior disorder (RBD) has been widely considered as a male-predominant parasomnia, the existing evidence for the sex difference in the risk of RBD in the general population was conflicting. The present study conducted a systematic review to explore the sex differences in the prevalence, comorbidities, clinical characteristics, and phenoconversion of RBD. One hundred thirty-five eligible studies were identified for the systematic review, and 133 were finally included in the meta-analysis. Males in the general population showed a trend for a higher risk of probable/possible RBD (pRBD), especially among the male older adults (aged ≥60). In the clinical populations, males showed a significantly higher risk of confirmed RBD, but not of pRBD. Among idiopathic RBD (iRBD) patients, males had a significantly earlier age onset of RBD compared with females. Male patients with Parkinson's disease (PD) had a higher risk of comorbid RBD. There was no significant sex difference in the risk of developing neurodegenerative diseases in iRBD patients. Large scale and prospective studies utilizing stringent diagnostic criteria for RBD are recommended to further verify the sex differences in RBD and to investigate the mechanism underlying the sex difference.

Sodium oxybate in treatment-resistant rapid-eye-movement sleep behavior disorder

STUDY OBJECTIVES

Symptomatic therapies for rapid-eye-movement (REM) sleep behavior disorder (RBD) are limited. Sodium oxybate (SXB), a gamma-aminobutyric acid (GABA)-B agonist, could be effective but has not been evaluated against placebo.

METHODS

This double-blind, parallel-group, randomized, placebo-controlled trial in 24 participants was conducted at the Stanford Sleep Center. Patients were adults with definite iRBD or Parkinson's disease and probable RBD (PD-RBD), and persistence of ≥ 2 weekly episodes despite standard therapy. Patients were randomized 1:1 to receive SXB during a 4-week titration followed by a 4-week stable dosing period. Primary outcome was number of monthly RBD episodes according to a diary filled by patients and partners. Secondary outcomes were severity, number of severe RBD episodes, and objective RBD activity on video polysomnography.

RESULTS

Twelve iRBD and 12 PD-RBD participated (mean 65.8 years), and 22 (n = 10 SXB, 12 placebo) completed the study. Although no significant between-group difference was found, SXB showed reduction of monthly RBD episodes by 23.1 (95% CI -36.0, -10.2; p = 0.001) versus 10.5 with placebo (95% CI, -22.6, 1.6; p = 0.087). Improvement from baseline was similarly observed for RBD overall severity burden (each episode weighted for severity), number of severe episodes, and objective RBD activity per video-polysomnography. Two participants receiving SXB withdrew due to anxiety and dizziness. The majority of adverse events are otherwise resolved with dose adjustment.

CONCLUSION

SXB could reduce RBD symptoms; however, response was inconsistent and a large placebo effect was observed across patient-reported outcomes. Larger studies using objective endpoints are needed.

CLINICAL TRIAL

Treatment of REM Sleep Behavior Disorder (RBD) With Sodium Oxybate https://clinicaltrials.gov/ct2/show/NCT04006925 ClinicalTrials.gov identifier: NCT04006925.

Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias

STUDY OBJECTIVES

This pilot study determined whether transdiagnostic cognitive behavioral therapy for parasomnias (CBTp) reduces parasomnia and activity levels during sleep in a sample of adult sleep clinic outpatients. A secondary objective was to assess whether treatment produces improvements in daytime fatigue/sleepiness, perceived cognition, mood, and depression/anxiety/stress, as well as functional impairment in work and leisure activities.

METHODS

This was a randomized controlled trial with CBTp and self-monitoring control conditions. Participants were 19 adults with a DSM 5 parasomnia disorder who received individual CBTp virtually from their homes. CBTp consisted of psychoeducation, sleep hygiene and safety instructions, relaxation training, parasomnia techniques, and relapse prevention in a 6-week manualized, structured program.

RESULTS

Using a repeated measures analysis of variance model, and relative to a self-monitoring control condition, results showed that CBTp produced statistically significant improvements in parasomnia frequency, severity, nocturnal activity, and sleep efficiency. There was a trend toward reduced sleep-onset latency and improved work and social adjustment. Of treated participants, 100% rated themselves as improved at study conclusion.

CONCLUSIONS

Implications of these findings are that cognitive behavioral interventions for parasomnias are effective in lessening parasomnias. More investigation into this type of treatment is warranted.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Impact of Cognitive Behavioral Therapy on Parasomnias; URL: https://clinicaltrials.gov/ct2/show/NCT04633668; Identifier: NCT04633668.

CITATION

Vincent N, Dirkse D, Giannouli E, McQuarrie A. Transdiagnostic cognitive behavioral therapy for nightmares and parasomnias. J Clin Sleep Med. 2023;19(3):499-509.

Ambulatory Detection of Isolated Rapid-Eye-Movement Sleep Behavior Disorder Combining Actigraphy and Questionnaire

BACKGROUND

Isolated rapid-eye-movement sleep behavior disorder (iRBD) is in most cases a prodrome of neurodegenerative synucleinopathies, affecting 1% to 2% of middle-aged and older adults; however, accurate ambulatory diagnostic methods are not available. Questionnaires lack specificity in nonclinical populations. Wrist actigraphy can detect characteristic features in individuals with RBD; however, high-frequency actigraphy has been rarely used.

OBJECTIVE

The aim was to develop a machine learning classifier using high-frequency (1-second resolution) actigraphy and a short patient survey for detecting iRBD with high accuracy and precision.

METHODS

The method involved analysis of home actigraphy data (for seven nights and more) and a nine-item questionnaire (RBD Innsbruck inventory and three synucleinopathy prodromes of subjective hyposmia, constipation, and orthostatic dizziness) in a data set comprising 42 patients with iRBD, 21 sleep clinic patients with other sleep disorders, and 21 community controls.

RESULTS

The actigraphy classifier achieved 95.2% (95% confidence interval [CI]: 88.3-98.7) sensitivity and 90.9% (95% CI: 82.1-95.8) precision. The questionnaire classifier achieved 90.6% accuracy and 92.7% precision, exceeding the performance of the Innsbruck RBD Inventory and prodromal questionnaire alone. Concordant predictions between actigraphy and questionnaire reached a specificity and precision of 100% (95% CI: 95.7-100.0) with 88.1% sensitivity (95% CI: 79.2-94.1) and outperformed any combination of actigraphy and a single question on RBD or prodromal symptoms.

CONCLUSIONS

Actigraphy detected iRBD with high accuracy in a mixed clinical and community cohort. This cost-effective fully remote procedure can be used to diagnose iRBD in specialty outpatient settings and has potential for large-scale screening of iRBD in the general population. © 2022 The Authors. Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Management of Sleep Disturbances in Parkinson's Disease

Parkinson's disease (PD) is defined by its motor symptoms rigidity, tremor, and akinesia. However, non-motor symptoms, particularly autonomic disorders and sleep disturbances, occur frequently in PD causing equivalent or even greater discomfort than motor symptoms effectively decreasing quality of life in patients and caregivers. Most common sleep disturbances in PD are insomnia, sleep disordered breathing, excessive daytime sleepiness, REM sleep behavior disorder, and sleep-related movement disorders such as restless legs syndrome. Despite their high prevalence, therapeutic options in the in- and outpatient setting are limited, partly due to lack of scientific evidence. The importance of sleep disturbances in neurodegenerative diseases has been further emphasized by recent evidence indicating a bidirectional relationship between neurodegeneration and sleep. A more profound insight into the underlying pathophysiological mechanisms intertwining sleep and neurodegeneration might lead to unique and individually tailored disease modifying or even neuroprotective therapeutic options in the long run. Therefore, current evidence concerning the management of sleep disturbances in PD will be discussed with the aim of providing a substantiated scaffolding for clinical decisions in long-term PD therapy.

Age of Diagnosis and Comorbid PLMD Predict Poor Response of REM Behavior Disorder to Clonazepam

Previous studies have shown the therapeutic effects of clonazepam for rapid eye movement sleep behavior disorder (RBD), but they had several limitations such as the lack of clear definition of treatment outcomes and little information about adjuvant therapy. The aims of this study were to evaluate the treatment outcomes with clonazepam and to explore possible determinants of treatment response. We performed a retrospective medical chart review of 171 patients with RBD. All the participants underwent overnight polysomnography and completed questionnaires. The positive treatment response was defined as the absence of disruptive behaviors causing sleep-related injuries during the last year of follow-up. Among the 171 patients presented with disruptive behaviors, 155 (90.6%) experienced positive treatment responses. Of the responders, 18 (11.6%) received adjunctive medication due to insufficient therapeutic effect of clonazepam monotherapy. After adjusted analysis, an earlier age of diagnosis (odds ratio [OR] = 0.74, 95% confidence interval [CI] = 0.64-0.86, P < .001) and comorbid periodic limb movement during sleep (OR = 4.96, 95% CI = 1.05-23.33, P = .043) were related to poor treatment response. Clinicians should recognize the predictors of poor treatment response and consider combination therapy for better prevention of sleep-related injuries in those who show unsatisfactory responses to clonazepam monotherapy.

Personalized prediction of depression in patients with newly diagnosed Parkinson's disease: A prospective cohort study

BACKGROUND

Depressive disturbances in Parkinson's disease (dPD) have been identified as the most important determinant of quality of life in patients with Parkinson's disease (PD). Prediction models to triage patients at risk of depression early in the disease course are needed for prognosis and stratification of participants in clinical trials.

METHODS

One machine learning algorithm called extreme gradient boosting (XGBoost) and the logistic regression technique were applied for the prediction of clinically significant depression (defined as The 15-item Geriatric Depression Scale [GDS-15] ≥ 5) using a prospective cohort study of 312 drug-naïve patients with newly diagnosed PD during 2-year follow-up from the Parkinson's Progression Markers Initiative (PPMI) database. Established models were assessed with out-of-sample validation and the whole sample was divided into training and testing samples by the ratio of 7:3.

RESULTS

Both XGBoost model and logistic regression model achieved good discrimination and calibration. 2 PD-specific factors (age at onset, duration) and 4 nonspecific factors (baseline GDS-15 score, State Trait Anxiety Inventory [STAI] score, Rapid Eye Movement Sleep Behavior Disorder Screening Questionnaire [RBDSQ] score, and history of depression) were identified as important predictors by two models.

LIMITATIONS

Access to several variables was limited by database.

CONCLUSIONS

In this longitudinal study, we developed promising tools to provide personalized estimates of depression in early PD and studied the relative contribution of PD-specific and nonspecific predictors, constituting a substantial addition to the current understanding of dPD.

REM sleep behaviour disorder

Rapid eye movement (REM) sleep behaviour disorder (RBD) is a parasomnia that is characterized by loss of muscle atonia during REM sleep (known as REM sleep without atonia, or RSWA) and abnormal behaviours occurring during REM sleep, often as dream enactments that can cause injury. RBD is categorized as either idiopathic RBD or symptomatic (also known as secondary) RBD; the latter is associated with antidepressant use or with neurological diseases, especially α-synucleinopathies (such as Parkinson disease, dementia with Lewy bodies and multiple system atrophy) but also narcolepsy type 1. A clinical history of dream enactment or complex motor behaviours together with the presence of muscle activity during REM sleep confirmed by video polysomnography are mandatory for a definite RBD diagnosis. Management involves clonazepam and/or melatonin and counselling and aims to suppress unpleasant dreams and behaviours and improve bedpartner quality of life. RSWA and RBD are now recognized as manifestations of an α-synucleinopathy; most older adults with idiopathic RBD will eventually develop an overt neurodegenerative syndrome. In the future, studies will likely evaluate neuroprotective therapies in patients with idiopathic RBD to prevent or delay α-synucleinopathy-related motor and cognitive decline.

Idiopathic REM sleep behaviour disorder and neurodegeneration - an update

So-called idiopathic rapid eye movement (REM) sleep behaviour disorder (RBD), formerly seen as a rare parasomnia, is now recognized as the prodromal stage of an α-synucleinopathy. Given the very high risk that patients with idiopathic RBD have of developing α-synucleinopathies, such as Parkinson disease (PD), PD dementia, dementia with Lewy bodies or multiple system atrophy, and the outstandingly high specificity and very long interval between the onset of idiopathic RBD and the clinical manifestations of α-synucleinopathies, the prodromal phase of this disorder represents a unique opportunity for potentially disease-modifying intervention. This Review provides an update on classic and novel biomarkers of α-synuclein-related neurodegeneration in patients with idiopathic RBD, focusing on advances in imaging and neurophysiological, cognitive, autonomic, tissue-specific and other biomarkers. We discuss the strengths, potential weaknesses and suitability of these biomarkers for identifying RBD and neurodegeneration, with an emphasis on predicting progression to overt α-synucleinopathy. The role of video polysomnography in providing quantifiable and potentially treatment-responsive biomarkers of neurodegeneration is highlighted. In light of all these advances, and the now understood role of idiopathic RBD as an early manifestation of α-synuclein disease, we call for idiopathic RBD to be reconceptualized as isolated RBD.