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Importance of Rapid Eye Movement Sleep Behavior Disorder to the Primary Care Physician

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Importance of Rapid Eye Movement Sleep Behavior Disorder to the Primary Care Physician CONCISE REVIEW FOR CLINICIANS Importance of Rapid Eye Movement Sleep Behavior Disorder to the Primary Care Physician Stuart J. McCarter, BA, and Michael J. Howell, MD From the University of Min- nesota Medical School, Min- CME Activity neapolis (S.J.M.); Department fi of Neurology, University of Target Audience: The target audience for Mayo Clinic Proceedings is primar- ensure balance, independence, objectivity, and scienti c rigor in its educa- ily internal medicine physicians and other clinicians who wish to advance tional activities. Course Director(s), Planning Committee members, Faculty, Minnesota Medical Center, their current knowledge of clinical medicine and who wish to stay abreast and all others who are in a position to control the content of this educational Minneapolis (M.J.H.); and of advances in medical research. activity are required to disclose all relevant financial relationships with any Minnesota Regional Sleep Statement of Need: General internists and primary care physicians must maintain commercial interest related to the subject matter of the educational activity. Disorders Center, Hennepin an extensive knowledge base on a wide variety of topics covering all body systems as Safeguards against commercial bias have been put in place. Faculty also will County Medical Center, Min- well as common and uncommon disorders. Mayo Clinic Proceedings aims to leverage disclose any off-label and/or investigational use of pharmaceuticals or instru- neapolis (M.J.H.). the expertise of its authors to help physicians understand best practices in diagnosis ments discussed in their presentation. Disclosure of this information will be and management of conditions encountered in the clinical setting. published in course materials so that those participants in the activity may Accreditation: Mayo Clinic College of Medicine is accredited by the Accred- formulate their own judgments regarding the presentation. itation Council for Continuing Medical Education to provide continuing med- In their editorial and administrative roles, William L. Lanier, Jr, MD, Terry L. ical education for physicians. Jopke, Kimberly D. Sankey, and Nicki M. Smith, MPA, have control of the Credit Statement: Mayo Clinic College of Medicine designates this journal- content of this program but have no relevant financial relationship(s) with based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s).ä industry. Dr Howell is a consultant to the Sleep and Performance Institute. Physicians should claim only the credit commensurate with the extent of Method of Participation: In order to claim credit, participants must com- their participation in the activity. plete the following: Credit Statement: Successful completion of this CME activity, which includes 1. Read the activity. participation in the evaluation component, enables the participant to earn up to 2. Complete the online CME Test and Evaluation. Participants must achieve 1 MOC points in the American Board of Internal Medicine’s (ABIM) Mainte- a score of 80% on the CME Test. One retake is allowed. nance of Certification (MOC) program. Participants will earn MOC points Visit www.mayoclinicproceedings.org, select CME, and then select CME arti- equivalent to the amount of CME credits claimed for the activity. It is the cles to locate this article online to access the online process. On successful CME activity provider’s responsibility to submit participant completion infor- completion of the online test and evaluation, you can instantly download and mation to ACCME for the purpose of granting ABIM MOC credit. print your certificate of credit. Learning Objectives: On completion of this article, you should be able to Estimated Time: The estimated time to complete each article is approxi- (1) recognize the clinical manifestations of rapid eye movement sleep mately 1 hour. behavior disorder, (2) describe the importance of early diagnosis and treat- Hardware/Software: PC or MAC with Internet access. ment of this disorder, and (3) identify which factors are associated with an Date of Release: 10/1/2016 increased rate of progression from rapid eye movement sleep behavior dis- Expiration Date: 9/30/2018 (Credit can no longer be offered after it has order to clinically overt neurodegenerative disease. passed the expiration date.) Disclosures: As a provider accredited by ACCME, Mayo Clinic College of Privacy Policy: http://www.mayoclinic.org/global/privacy.html Medicine (Mayo School of Continuous Professional Development) must Questions? Contact [email protected]. Abstract Sleep disorders and neurodegenerative diseases are commonly encountered in primary care. A common, but underdiagnosed sleep disorder, rapid eye movement sleep behavior disorder (RBD), is highly associated with Parkinson disease and related disorders. Rapid eye movement sleep behavior disorder is common. It is esti- mated to affect 0.5% of the general population and more than 7% of individuals older than 60 years; however, most cases go unrecognized. Rapid eye movement sleep behavior disorder presents as dream enactment, often with patients thrashing, punching, and kicking while they are sleeping. Physicians can quickly assess for the presence of RBD with high sensitivity and specificity by asking patients the question “Have you ever been told that you act out your dreams, for example by punching or flailing your arms in the air or screaming and shouting in your sleep?” Patients with RBD exhibit subtle signs of neurodegenerative disease, such as mild motor slowing, constipation, or changes in sense of smell. These signs and symptoms may predict develop- ment of a neurodegenerative disease within 3 years. Ultimately, most patients with RBD develop a neurode- generative disease, highlighting the importance of serial neurological examinations to assess for the presence of parkinsonism and/or cognitive impairment and prognostic counseling for these patients. Rapid eye movement sleep behavior disorder is treatable with melatonin (3-6 mg before bed) or clonazepam (0.5-1 mg before bed) and may be the most common, reversible cause of sleep-related injury. Thus, it is important to identify patients at risk of RBD in a primary care setting so that bedroom safety can be addressed and treatment may be initiated. ª 2016 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2016;91(10):1460-1466 1460 Mayo Clin Proc. n October 2016;91(10):1460-1466 n http://dx.doi.org/10.1016/j.mayocp.2016.07.019 www.mayoclinicproceedings.org n ª 2016 Mayo Foundation for Medical Education and Research RAPID EYE MOVEMENT SLEEP BEHAVIOR DISORDER leep disorders are common in the setting of autoimmune conditions.6,7 Further- general population and can lead to a more, women have less violent and, therefore, marked impairment in daytime func- less injurious DEB and thus are less likely to S 7 tioning and quality of life; however, they are receive medical attention. Another contrib- often underdiagnosed.1 Obstructive sleep uting factor to this discrepancy is likely due apnea (OSA), insomnia, restless legs to the sex difference in life expectancy; elderly syndrome, and excessive daytime sleepiness women are less likely to have bed partners are among the most commonly encountered than elderly men, leading to unwitnessed par- sleep problems in the primary care setting.2 asomnia behaviors. Rapid eye movement Furthermore, primary care physicians are sleep behavior disorder typically presents in often tasked with the challenge of unraveling either the sixth or the seventh decade; howev- the complexities of abnormal motor behaviors er, when questioned specifically, many pa- during sleep, ranging from sleepwalking to tients will report a long-standing history nocturnal seizures and confusional arousals. suggestive of DEB.8 Population-based However, an underdiagnosed sleep disorder, studies9,10 estimate that 0.5% of the general rapid eye movement (REM) sleep behavior population and 7.7% of individuals older disorder (RBD), is a potentially injurious para- than 60 years have probable RBD. However, somnia that should be considered in older pa- most individuals with RBD go unrecognized tients presenting to the primary care physician or underreported. Patients and bed partners complaining of abnormal activity during sleep. are often unsure how to broach the frequently Sleep is divided broadly into nonerapid taboo subject of out-of-control activities in eye movement (NREM) sleep and REM sleep, the bedroom. Furthermore, physicians often with unique nocturnal behaviors arising from interpret the behaviors as symptoms of an un- NREM and REM sleep, respectively. Under derlying mood disorder or conflict between normal physiological conditions, REM sleep spouses rather than a primary sleep is typified by active mentation (dreams) and disturbance. skeletal muscle paralysis. Rapid eye movement Despite the seemingly disruptive nature sleep skeletal muscle atonia is critical to pre- of punching, flailing, and screaming during vent dream enactment and promote a period sleep, up to 44% of patients with RBD are of quiescence for REM sleeperelated memory unaware of their DEB. In addition, it is not consolidation. Rapid eye movement sleep uncommon to identify a history of RBD as behavior disorder is characterized by dream a secondary symptom when evaluating a pa- enactment behavior (DEB) that emerges result- tient for other sleep problems such as OSA ing from the loss of REM sleep without atonia. or insomnia.3 Dream enactment behaviors Although RBD was initially thought to be sim- can range
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