Sleep plays a vital role in our health, and for people living with Parkinson’s, it becomes even more critical. One lesser-known, but very important condition linked to both sleep and Parkinson’s is REM Sleep Behaviour Disorder, also known as the acronym RBD. That’s why many neurologists routinely ask about sleep; it can be the window into early changes in the brain.

 What exactly is REM Sleep Behaviour Disorder?

Let’s start with the basics. REM (Rapid Eye Movement) is the sleep stage where dreaming occurs. During this phase, the brain typically sends signals to paralyse your muscles, stopping you from physically acting out your dreams. This protects you and your bed partner from getting injured.

However,  in REM Sleep Behaviour Disorder, that protective mechanism fails. Instead of lying still, people with RBD may move, speak, shout, or even leap out of bed while dreaming, often reacting to vivid or action-filled dreams. This can be startling or even dangerous.

Common signs of RBD include:

  • Sudden movements such as punching, kicking, or jumping from bed
  • Vocal sounds like shouting, talking, or crying out
  • A lack of awareness of these behaviours, making input from a bed partner especially helpful.

RBD can be idiopathic (no known cause) or secondary to other factors like medications. For example, in addition to neurological conditions and stress, antidepressants such as mirtazapine have been shown to trigger RBD in some cases (Onofrj M, 2003).

 The Link Between RBD and Parkinson’s

Idiopathic RBD isn’t just a sleep disorder… it can be an early warning sign of neurological conditions. One large study found that 81% of elderly males with idiopathic RBD eventually developed Parkinson’s or related syndromes, with parkinsonian motor symptoms appearing on average 10 years after the initial RBD diagnosis (Jin H et al., 2017).

This makes RBD one of the most powerful early predictors of Parkinson’s, well before tremors or stiffness begin.

My husband was dreaming he bowled a cricket ball and ended up hitting me over the head 20 years prior to his young onset Parkinson’s diagnosis. Since then, he’s regularly shouted out and talked in his sleep, fallen out of bed while dreaming of tackling something and punched out a few times. We’re still sharing a bed as he’s only acting out once in a while, but we are mindful about monitoring his sleeping habits and telling his neurologist about any incidents.

– care partner of someone living with young onset Parkinson’s & RBD

 How is RBD diagnosed?

Diagnosis begins with a detailed history. If you have one it often including your bed partner’s observations. If your doctor suspects RBD, they may refer you for a polysomnography (sleep study), which monitors your brain waves, muscle activity, and eye movements overnight. Some centres even record video during the study to capture dream-enactment behaviours. While usually done in a sleep clinic, some institutions may offer home-based testing.

 What are the treatment options?

Treatment depends on the underlying cause. If medications like mirtazapine or certain antidepressants are suspected triggers, your doctor may suggest changing them first.

When medical treatment is necessary, clonazepam and melatonin are commonly prescribed first-line options (Jiménez-Jiménez FJ, 2021). These medications help reduce the frequency and severity of dream-enactment behaviours. However, they must be used with care, especially in older adults or those with memory or balance issues.

Safety modifications are also essential:

  • Lowering the bed height
  • Removing sharp or hard objects from the room
  • Placing cushions around the bed
  • In some cases, if you sleep with a bed partner, sleeping in separate beds is recommended until symptoms are controlled.

These practical changes can help prevent injury to both you and your partner.

What should you do if you suspect RBD?

If you or someone close to you notices unusual movements during sleep, bring it up with your GP or neurologist. While RBD might sound straightforward, only a sleep specialist can confirm the diagnosis and distinguish it from other sleep disorders. You could get referred for a sleep study or asked to take the REM Sleep Behaviour Disorder (RBD) Screening Questionnaire.

If diagnosed, it may also be worthwhile to see a movement disorder specialist, a neurologist who specialises in movement disorders. They can monitor for early signs of Parkinson’s and guide future steps, including regular follow-ups.

While acting out dreams may seem like just an odd quirk of sleep, RBD can be a powerful clue into brain health. For some, it’s the first sign that something deeper may be going on. With early recognition and management, people (and their partners) can stay safer at night… and potentially catch neurological changes early, long before other symptoms appear.

References:

  • Mayo Clinic. (2018). REM Sleep Behavior Disorder.
  • Jin H, Zhang JR, Shen Y, Liu CF. (2017). Clinical significance of REM sleep behavior disorders and other non-motor symptoms of parkinsonism. Neurosci Bull, 33(5):576–584. doi: 10.1007/s12264-017-0164-8.
  • Jiménez-Jiménez FJ, Alonso-Navarro H, García-Martín E, Agúndez JAG. (2021). Current Treatment Options for REM Sleep Behaviour Disorder. J Pers Med, 11(11):1204. doi: 10.3390/jpm11111204.
  • MJFF https://www.michaeljfox.org/news/ask-md-acting-out-dreams-and-parkinsons-disease
  • Onofrj M, Luciano AL, Thomas A, et al. (2003). Mirtazapine induces REM sleep behavior disorder in parkinsonism. Neurology, 60(1):113-5. doi: 10.1212/01.wnl.0000042084.03066.c0.
  • PMD Alliance (2024) https://youtu.be/pVY1Mj2TAOw?si=qKdjWdsJdbc2cki7
  • Stiasny-Kolster, K., Mayer, G., Schäfer, S., Möller, J. C., Heinzel-Gutenbrunner, M., & Oertel, W. H. (2007). The REM sleep behavior disorder screening questionnaire–a new diagnostic instrument. Movement disorders : official journal of the Movement Disorder Society, 22(16), 2386–2393. https://doi.org/10.1002/mds.21740
  • RBD Sleep Disorder Questionnaire https://www.jotform.com/build/252187924384870?s=templates If you score 6 or more consul your GP for a sleep study referral to confirm diagnosis.

Thanks to our guest writer Asli Beyza Gul. Asli is a medical student at Aston University with a deep passion for neurology, particularly movement disorders like Parkinson’s. She is the first Parkinson’s Foundation ambassador in the UK. Asli has presented award-winning research on deep brain stimulation at international neurology conferences and actively raises awareness as a research champion for Parkinson’s UK. She also authors Parkinson’s Care, a neurology platform dedicated to advancing knowledge and improving Parkinson’s patient outcomes.

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