Synopsis
Recognise dream-enactment behaviour, confirm REM sleep without atonia, prevent injury, exclude mimics and medicines, and provide proportionate counselling and follow-up for associated synucleinopathy risk.
- REM sleep behaviour disorder causes vocalisation and complex movement that corresponds to vivid dreams because the normal skeletal-muscle atonia of REM sleep is lost.
- Events are often reported by a bed partner and may include shouting, punching, kicking, leaping or falling from bed, with rapid alertness and dream recall when awakened.
- Diagnosis requires a compatible history plus video polysomnographic evidence of REM sleep without atonia, with another sleep, neurological or substance cause excluded.
Key red flags
Strangulation, weapon use, major falls, head injury or risk to a bed partner requires immediate separation and environmental safety before diagnostic testing is complete.
Investigation priorities
Characterise timing, vocalisation, movement, dream recall, responsiveness, breathing and injury from a witness perspective.
Management branches
Dream enactment has caused or nearly caused harm before specialist diagnosis.
- Remove weapons, glass, sharp furniture and unstable bedside objects and pad nearby surfaces or place a mattress low to the floor.
- Use separate sleeping temporarily when the partner is at risk and avoid physical restraint, which can intensify injury during an event.
Key medicines
Modified-release melatoninUse an off-label or licensed-formulation dose selected by the sleep specialist, commonly starting low in the evening and titrating gradually to nocturnal behaviour and morning alertness.
ClonazepamA specialist may start 0.25–0.5 mg orally at bedtime and cautiously titrate only if dangerous behaviours persist and tolerability remains acceptable.