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Suggest treatment for REM sleep disorder

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Posted on Mon, 25 May 2015
Question: My husband has not been diagnosed except by his internist with REM disorder. I have a guard by the bed and moved furniture. He has already broken his spine severely (the orthopedic said he could have been paralyzed the break is so bad). He has dreams of falling and will thrash about as if he is flying down on a fall. He pounds, kicks, screams fearfully and has active, scary dreams and some dreams are frustrating dreams. I have to leave as he could hurt me. He is exhausted. The internist prescribed Melatonin (12 mg. at night) It slowed the quantity down, to maybe half, but not the violence. He also prescribed Clonzepam which made him so sleepy I could not keep him up for more than one hour and he was awake but very drowsy only 4 hours that day. His dreams are so bad that he is getting short of breath. No wonder -if I was falling 2-3 times a night in terror, I guess my heart would be affected. Parkinson's is a possibility due to shaking hands. I don't know where to go from here as the internet only talks about those 2 drugs or solutions. When I interviewed him about dream content, there are other fears and frustrations connected with his former career and the crew's (he supervised building of hospitals as an Electrician) ability, safety and actions. I thought may a psychiatrist or specialist in PTSD might alleviate some of the problem.

He has "worked" on the job for 6 years after retirement just "pulling electrical wire" or having detailed and loud, clear conversations on the job while he dreams. It is only the past 3 years that this has accelerated to a danger point of thrashing out of the bed. He quit drinking (has cirrhosis of the liver and stopped 3 years ago.) I think the alcohol used to mask these dreams so it was not a problem.

He is also on some heavy drugs due to the liver problem and I wonder if they are not causing some of it also.

He is so tired, sleepy, shuffling his feet, not walking well, slumping his shoulders, all from exhaustion and such violent, loud, terrorizing dreams all night. They start about 2:30 a.m.and go to 10 or 11 when I wake him up just to stop the dreaming. If we go to a DR. what kind: psychologist or MD, specialist?
doctor
Answered by Dr. Shubham Mehta (3 hours later)
Brief Answer:
REM behavior disorder; neurologist opinion.

Detailed Answer:
Hello
Welcome to HCM.

I have gone through the details you have given in your query.
I can understand your concerns. You are going through really tough time.

The description is suggestive of REM sleep behaviour disorder (RBD).

You are right that drugs mentioned in the treatment are only melatonin and clonazepam.

The rationale behind giving benzos in RBD is that these drugs reduce REM sleep duration.

If your husband is not tolerating clonazepam, other benzos like lorazepam or etizolam(less sedating then clonazepam) (prescription drugs) in minimum doses can be tried.

Unfortunately, RBD is difficult to manage.

RBD is a harbinger of neurodegenerative disorders like parkinson disease or lewy body dementia.

You have mentioned that there are signs of parkinson's in your husband.

In my opinion, you must consult a neurologist for evaluation of parkinsonism in detail.
If needed, the parkinsonism would be treated with sinemet. This might alleviate the symptoms of RBD as well.

Hope you find my suggestions helpful.

I wish good health for you and your husband.

Take care.
Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Shubham Mehta (3 hours later)
You did not mention if a psychologist might help (not cure0 but lessen the symptoms. He is a veteran and I thought they might shed some light on any traumas he encountered.

Also someone told me about Sequel a prescription drug that is supposed to boost the melatonin- not sure if it is just to get to sleep or to help you stay in a deeper Rem stage. Have you heard of this?
doctor
Answered by Dr. Shubham Mehta (24 minutes later)
Brief Answer:
psychologist can be of some help.

Detailed Answer:
Hi again.

In my opinion, first person to visit should be a neurologist. I would be more concerned about development and progression of parkinsonism along with RBD. This has to be diagnosed and treated at the earliest.

A psychologist can help to lessen the symptoms. Some relaxation therapies like deep breathing, progressive muscle relaxation and biofeedback can prove helpful.

I think the drug must be seroquel rather than sequel. This drug also reduces the duration of REM sleep like benzodiazepines.
But in my clinical experience, I have observed that patients have tolerability issues with this drug. The sedation and hypotension with this drug are bothersome.

The evidence for effects of seroquel on melatonin are not convincing.

Hope this helps.

Feel free to ask further.

Kindly close the discussion if you are satisfied with the response and give your valuable feedback.

Thanks.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Shubham Mehta

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Practicing since :2008

Answered : 2109 Questions

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Suggest treatment for REM sleep disorder

Brief Answer: REM behavior disorder; neurologist opinion. Detailed Answer: Hello Welcome to HCM. I have gone through the details you have given in your query. I can understand your concerns. You are going through really tough time. The description is suggestive of REM sleep behaviour disorder (RBD). You are right that drugs mentioned in the treatment are only melatonin and clonazepam. The rationale behind giving benzos in RBD is that these drugs reduce REM sleep duration. If your husband is not tolerating clonazepam, other benzos like lorazepam or etizolam(less sedating then clonazepam) (prescription drugs) in minimum doses can be tried. Unfortunately, RBD is difficult to manage. RBD is a harbinger of neurodegenerative disorders like parkinson disease or lewy body dementia. You have mentioned that there are signs of parkinson's in your husband. In my opinion, you must consult a neurologist for evaluation of parkinsonism in detail. If needed, the parkinsonism would be treated with sinemet. This might alleviate the symptoms of RBD as well. Hope you find my suggestions helpful. I wish good health for you and your husband. Take care. Thanks.