REM Sleep Behaviour Disorder: Care Staff Guide

REM sleep behaviour disorder, or RBD, is a sleep condition in which a person physically acts out their dreams. They may shout, thrash, punch or fall out of bed, and can injure themselves or a partner. It is also important for another reason: RBD can be an early sign of conditions such as Parkinson's disease and dementia with Lewy bodies. This guide, based on information from an NHS trust's neuropsychiatry service, explains what RBD is, how it is assessed and treated, and how staff can reduce risks. It links to our guides on Parkinson's disease, Lewy body dementia and insomnia and sleep disorders.

What is RBD?

The NHS trust source describes RBD as acting out dreams during rapid eye movement (REM) sleep, caused by a failure of the normal mechanism that keeps muscles still during dreaming. In normal REM sleep, the body is effectively paralysed, so dreams are not physically acted out. In RBD that protection fails.

Symptoms

The source lists the following features:

• talking, shouting, or moving the arms and legs during sleep
• recalling dreams of calling for help, hitting out or defending oneself
• poor quality sleep
• injuries to the person or their bed partner

Staff supporting someone who shares a room or whose partner sleeps nearby may be the first to hear about this. People in residential or hospital settings may be observed by night staff, who are well placed to describe what they see.

Who is at risk?

The source lists male sex and age over 50 as risk factors, along with neurological disorders such as Parkinson's disease, other sleep disorders such as narcolepsy, certain medicines, alcohol, drugs or withdrawal, and post-traumatic stress disorder. Because medicines can contribute, a prescriber should review the person's list. The source mentions antidepressants, beta blockers and some Alzheimer's medicines as examples that might be reviewed or stopped. Staff should never stop a medicine on their own initiative.

The link with Parkinson's disease and Lewy body dementia

The source explains that RBD can be an early sign of Parkinson's disease or Lewy body dementia, and that these conditions may develop many years, even decades, later. It advises discussing symptoms with a doctor. This does not mean that everyone with RBD will develop one of these conditions. It does mean that a person with RBD should be assessed, and that any new movement, memory or thinking changes should be reported.

Diagnosis

A detailed sleep history can sometimes be enough. Otherwise, the source describes a sleep study (polysomnography) over one or two nights in a unit, using sensors, where the key finding is muscle tension during REM sleep. Staff can help by recording what they see, noting when it happens and whether the person remembers a dream.

Treatment

The source says medication is used only if RBD is severe, distressing or causing injury. Melatonin has fewer side effects. Clonazepam is a sedative that may cause daytime tiredness, poor balance and slower breathing, so it needs careful consideration and monitoring in older or frail people. Our guide on falls prevention in care homes is relevant where balance is affected. Sleep hygiene also helps: a regular schedule, limiting caffeine and alcohol, relaxation and a comfortable environment.

Bedroom safety

The source suggests several practical measures that care staff can put in place:

• padding near the bed and soft barriers along its sides
• removing clutter and sharp-edged furniture
• putting a large pillow between partners

Also consider the position of the bed, floor coverings and any equipment. Raised bed rails can create their own risks, so follow your organisation's bed rail assessment before using them.

Practical support for care staff

• Do not wake the person abruptly. Waking someone mid-episode can lead to being struck, so call their name from a safe distance.
• Record episodes. Note the time, what was seen and any injuries.
• Report changes in movement, thinking or memory to the GP.
• Be reassuring. Acting out dreams is not deliberate, and people may feel embarrassed or frightened.

When to get help

Ask the GP to review anyone who is acting out dreams, particularly if they have been injured. If someone is seriously hurt, call 999.

Frequently asked questions

Is RBD the same as sleepwalking?

No. RBD happens during REM sleep and is linked to dreams. The source describes people acting out dream content.

Does RBD mean someone will get Parkinson's?

Not necessarily. The source notes it can be an early sign, with the other condition possibly appearing decades later, so assessment and monitoring are sensible.

Can it be treated?

Yes. Treatment includes safety measures, sleep habits and, where needed, medicines such as melatonin or clonazepam.

Where can staff build their knowledge?

The health and social care learning available through Learnsignal CPD can help you keep your knowledge of sleep and neurological conditions up to date.

This article is general information for care staff, based on information from an NHS trust neuropsychiatry service, and does not replace the advice of a person's own clinicians. If you are worried about someone's health right now, contact their GP, NHS 111 or, in an emergency, call 999.