Current Concepts and Controversies in the Management of REM Sleep Behavior Disorder

Area of Science:

• Neurology
• Sleep Medicine
• Neurodegeneration

Background:

• Rapid eye movement sleep behavior disorder (RBD) is characterized by dream enactment due to loss of muscle atonia during REM sleep (REM sleep without atonia, RSWA).
• RBD is often associated with synuclein-based neurodegenerative disorders, such as Parkinson's disease and Lewy body dementia, and can also occur in isolation (idiopathic RBD, iRBD).
• Injurious events are common in RBD patients, necessitating symptomatic treatment, typically with melatonin or clonazepam.

Purpose of the Study:

• To review current therapeutic concepts for RBD in light of existing challenges.
• To identify critical research questions for advancing RBD therapeutics and understanding its prodromal role in synucleinopathies.

Main Methods:

• Literature review of current concepts in RBD therapeutics.
• Analysis of challenges in diagnostic strategies, symptomatic treatments, disease-modifying trials, and biomarker development for RBD.

Main Results:

• Despite advances, progress in symptomatic and neuroprotective therapies for RBD remains limited.
• Recent clinical trials have highlighted significant challenges in RBD research, including diagnostic strategies, evidence for symptomatic therapies, potential subtypes, medication effects, objective severity markers, trial design, and disclosure of neurodegeneration risk.

Conclusions:

• Addressing the identified challenges is crucial for the development of effective symptomatic and disease-modifying therapies for RBD.
• Further research is needed to delineate RBD pathophysiology, identify biomarkers, and optimize clinical trial design for future therapeutic interventions.