Disorders That Disrupt Sleep (Parasomnias) (cont.)
Sleep Disorder Treatment
These sleep hygiene measures are important for all parasomnias:
- Go to bed at the same time each night.
- Use the bed only for sleeping and intimacy.
- Avoid napping.
- Avoid stress, fatigue, and sleep deprivation.
- Avoid vigorous activity prior to bedtime, though a brief period of aerobic activity 4 hours before bedtime may be helpful.
- Avoid cigarettes, alcohol, and excessive caffeine.
In general, when a person has been diagnosed with sleepwalking, the following precautions need to be taken:
- Remove potentially dangerous items.
- Have the person sleep in a bedroom on the ground floor if possible.
- Lock the doors and windows.
- Cover glass windows with heavy drapes.
- Place an alarm or bell on the bedroom door.
Benzodiazepines, which are used for insomnia situations where an individual awakens after falling asleep, such as estazolam (ProSom), have been found to be safe and remarkably effective in adults with sleepwalking and sleep terrors.
REM sleep behavior disorder
Treatment for REM sleep behavior disorder is initiated with clonazepam (Klonopin) at 0.5-1.5 mg taken at bedtime. Clonazepam is remarkably effective in controlling both the behavioral and the dream-disordered components of REM sleep behavior disorder. This drug has been shown to be beneficial in the long term. Drug discontinuation often results in prompt relapse.
Tricyclic antidepressants are occasionally used in the treatment of REM sleep behavior disorder. Imipramine has been used, but the effects are unpredictable.
Several reports of levodopa/carbidopa, gabapentin, pramipexole, and clonidine have been published, but the benefit of these drugs has not been systemically evaluated.
Restless legs syndrome and periodic limb movement disorder
Restless legs syndrome and periodic limb movement disorder are treated with 3 classes of medications. Treatment guidelines are as follows:
- Anti-parkinsonian drugs, such as levodopa/carbidopa, bromocriptine, ropinirole (Requip), pergolide (Permax), and pramipexole (Mirapex), have been used.
- Benzodiazepines, especially clonazepam have been effective. Other benzodiazepines used have included diazepam, temazepam, and lorazepam.
- Opiates, such as codeine, oxycodone, methadone, and propoxyphene, are other drugs that have been used.
- Dopamine agonists, such as levodopa or pergolide, may be effective, but the effectiveness may not last, and some individuals are unable to tolerate side effects.
- Other drugs that have shown effectiveness include clonidine or anticonvulsants, such as carbamazepine, valproate, and gabapentin.
- Several studies have reported efficacy of different medications belonging to the aforementioned groups, but comparative studies between various classes of drugs or even individual drugs do not exist. Therefore, persons should receive one drug, and, if no response is noted, they should be placed on another drug of the same class or a different class.
- A combination of drugs may be required in more severe cases. Some persons who do not respond to benzodiazepines alone, levodopa alone, or a combination of both may be treated with opiates.
- One should receive the smallest possible dose and should be closely observed for the development of dependency. Experience reveals that the incidence of abuse, tolerance, or addiction to opiates or benzodiazepines in persons with severe restless legs syndrome appears to be insignificant. The disabling condition of severe restless legs syndrome must be treated aggressively.
- Restless legs syndrome and periodic limb movement disorder are chronic conditions that require long-term drug therapy. Some persons may develop symptoms of restless legs during the daytime, and this may be treated with controlled release of levodopa/carbidopa administered in the evening and morning.
- Avoidance of certain drugs, such as tricyclic antidepressants, fluoxetine, or lithium, may be helpful because these drugs generally worsen the symptoms of restless legs syndrome and periodic limb movement disorder.
- A decrease in body iron stores, as indicated by serum ferritin (an iron-protein complex) levels less than 75 mcg/L, should be corrected with iron supplementation. Oral iron is preferred but takes a long time to provide improvement, because gastrointestinal absorption is low. However, replenishment is an effective treatment strategy for iron-deficiency anemia and may also relieve symptoms of restless legs syndrome and periodic limb movement disorder (if present).
Sat Sharma, MD, FRCPC, FCCP
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