Introduction

Rapid Eye Movement (REM) sleep disorder is a parasomnia in which physical activity is present when a state of atonia should be manifest instead. The activity may vary from verbal behaviors (eg. talking or shouting) to more extreme motor behaviors (eg. moving in bed, fighting, standing, moving about, and falling). Men and older individuals are more likely to present with REM disassociation sleep disorders. REM sleep disorders can be a prodrome of a Parkinsonian disorder or Lewey body pathology [1].

Case description

Based on the patient’s history and a sleep study, the 66 year-old year old male described herein was diagnosed with preclinical Parkinsons and a REM sleep disorder. He was prescribed ropinirole. As active behaviors symptoms persisted he was prescribed melatonin and later clonazepam as well. According to the patient’s wife, these medications reduced his night time activity. However, episodes of shouting and aggressive behavior persisted with holes twice punched in the dry wall at the head of the bed (Figure 1). Falling from bed continued with one resulting in prominent bruising of the torso (Figure 2). One of the falls while sleep-walking at night resulted in a full thickness tear of his right subscapularis that required surgical repair (no image available). Another fall resulted in prominent ecchymosis of the left elbow on which he fell (Figure 3).

Figure 1: Hole punched in wall during sleep.

Figure 2: Bruising about the torso following a fall from bed during sleep.

Figure 3: Ecchymosis around left elbow after a fall while sleep-walking.

Discussion

The information presented heretofore shows how recalcitrant REM sleep disorders can be to amelioration. Falls are of particular concern as a cause for injury. Photographs are an objective way of documenting the nature of injury. Installation of a padded headboard has prevented further holes from punching the drywall. Pillows on the floor around the bed have eliminated injurious falls in proximity of the bed. Falls during sleep-walking persist.

References

1. Schenck CH and Mahowald MW. REM sleep behavior disorder: Clinical, Developmental, and neuroscience prospectives 16 years after its formal Identification in sleep. 2002; 25(2): 120-138.