EAN 2026 | Clinical features of REM sleep behavior disorder and insights into diagnosis

Well, REM sleep behavior disorder is a parasomnia of REM sleep where the patient may act out their dream and is associated with a specific neurophysiological marker which is REM sleep atonia. This means for the patient the risk of actually injuring him or herself during the night because they can act out their dream and when you act out your dream you are not aware of your surroundings. You could fall out of bed, you could hit the surrounding, you could hit the bed partner. And the important thing is that on the clinical part you have what are motor and vocal behaviors. So they are not just simple movements during sleep but the clinical suspicion should raise when the patient actually says that there are complex movements and complex behaviors during night which are not just kicks but are actually the making of what the patient is dreaming. Vocalization can be even simple muttering or could be more complex interaction depending on the dream content. Usually this patient also has a change in dream mentation or at least is the most reported where the patient can actually dream more action-filled dreams where they usually are chased, where they usually have to run away from someone who could make bad things to them, or they are fighting. And this increases the risk of injuries for these patients. It is very important in the clinical picture to interview also the bed partner. The bed partner could awaken the patient. The patient usually does these episodes in the latter part of the night, which is the part in which REM sleep is actually more frequent. And the patient, after awakening, is rapidly aware and ready to answer questions and usually the immediate dream recall right after the episode is actually much more informative rather than the dream report and the episode report in the clinic where the spouse or also the clinician during a video polysomnography could actually quite understand what is going on within the dream by means of what the patient is acting out. And this is called isomorphism. It is important to have a differential diagnosis as there are some conditions that can actually mimic the REM sleep behavior disorder. These are for example severe obstructive sleep apnea where at the end of the sleep apnea in severe patients can actually fragment sleep and make the limit between sleep and wakefulness actually thinner. And patients could actually have dream and acting behaviors at the end of an apnea even if they do not have actually a recurrent behavior disorder and it is important to screen for apnea in this patient and treat apnea first and see if these behaviors actually manifest also after apnea is treated. It is important also to distinguish these features from other parasomnias such as non-REM sleep parasomnias, where usually the patient is actually confused, is usually in the first third of the night, and the patient may also walk outside of the bed, which is actually much rarer in RBD. And in the end, other more rare conditions, such as sleep-related upper motor epilepsy.

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