Transtorno comportamental do sono REM: atualização no diagnóstico e manejo

Sobreira- Neto, Manoel Alves; Stelzer, Fernando Gustavo; Gitaí, Lívia Leite Góes; Alves, Rosana Cardoso; Eckeli, Alan Luiz; Schenck, Carlos H.

Manoel Alves Sobreira- NetoAddress for correspondence Manoel Alves Sobreira-Neto (email: manoelsobreira@yahoo.com.br)

drafting

design

revision of the manuscript

Universidade Federal do Ceará, Faculty of Medicine, Division of Neurology, Fortaleza CE, Brazil.

https://orcid.org/0000-0001-9619-6551

Fernando Gustavo Stelzer

drafting

design

revision of the manuscript

Univeridade de São Paulo, Ribeirão Preto Medical School, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto SP, Brazil.

https://orcid.org/0000-0002-7261-0735

Lívia Leite Góes Gitaí

drafting and revision of the manuscript

Universidade Federal de Alagoas, Faculty of Medicine, Division of Neurology, Maceió AL, Brazil.

https://orcid.org/0000-0002-6223-0931

Rosana Cardoso Alves

conception and revision of the manuscript

Fleury Medicine Group, Sleep Medicine Center, São Paulo SP, Brazil.

https://orcid.org/0000-0003-4258-2320

Alan Luiz Eckeli

drafting and revision of the manuscript

Univeridade de São Paulo, Ribeirão Preto Medical School, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto SP, Brazil.

https://orcid.org/0000-0001-5691-7158

Carlos H. Schenck

wrote the final two sections and provided input and editing for the entire manuscript

Minnesota Regional Sleep Disorders Center; and University of Minnesota, Medical School, Departments of Psychiatry; and Hennepin County Medical Center, Minneapolis MN, United States of America.

https://orcid.org/0000-0002-0095-2680

Address for correspondence Manoel Alves Sobreira-Neto (email: manoelsobreira@yahoo.com.br)

Conflict of Interest

The authors have no conflict of interest.

CRITERIA A-D MUST BE MET

Repeated episodes of sleep-related vocalization and/or complex motor behaviors.
These behaviors are documented by polysomnography to occur during REM sleep, or based on clinical history of dream enactment, are presumed to occur during REM sleep.
Polysomnographic recording demonstrates RWA.
The disturbance is not better explained by another sleep disorder, mental disorder, medication, or substance use.

TECHNICAL SPECIFICATIONS FOR MONITORING
Time-synchronized, audio-equipped video PSG should be used to document complex motor behaviors and vocalizations during REM sleep. LMs - surface electrodes placed longitudinally and symmetrically in the middle of the anterior tibialis muscle so that they are 2-3 cm apart or one-third of the length of the anterior tibialis muscle, whichever is shorter. For monitoring LMs, the use of 60 Hz (notch) filters should be avoided. Impedances need to be < 10,000 Ω. 5,000 Ω is preferred but may be difficult to obtain. For monitoring movements of the upper limbs, surface electrodes should be placed longitudinally and symmetrically, so that they are 2-3 cm apart over the surface of the flexor digitorum superficialis or the surface of the extensor digitorum communis. Both legs and arms should be monitored. Separate channels for each leg and each arm are strongly preferred.
DEFINITIONS
Excessive sustained muscle activity (tonic activity) in REM: An epoch of stage R with at least 50% of the duration of the epoch having a chin EMG amplitude at least 2 times greater than the stage R atonia level (or lowest amplitude in NREM, if no stage R atonia is present). Multiple segments may contribute to the total duration, but each segment must be > 5 seconds. Excessive transient muscle activity (phasic activity) in REM: In a 30-second epoch of stage R divided into 10 sequential 3-second mini-epochs, at least 5 (50%) of the mini-epochs contain bursts of transient muscle activity in the chin or limb EMG. In RWA, excessive transient muscle activity bursts are 0.1-5.0 seconds in duration and at least 2 times as high in amplitude as the stage R atonia level. Any chin EMG activity. Activity with a minimum amplitude 2 times greater than the stage R atonia level.
CRITERIA
AN EPOCH EXHIBITS RWA WHEN ONE OF THE FOLLOWING IS PRESENT: Excessive sustained muscle activity in REM in the chin EMG. Excessive transient muscle activity during REM in the chin or limb EMG. At least 50% of 3-second mini-epochs contain any chin activity (as defined above) or limb EMG activity (bursts of EMG activity 0.1-5.0 seconds in duration and at least 2 times as high in amplitude as the stage R atonia level. SCORE THE RWA INDEX AS THE PERCENT OF STAGE R EPOCHS THAT MEET CRITERIA

Conditions

Alpha-synucleinopathy:
- Dementia with Lewy bodies (prevalence of RBD: 68–90%)
- Parkinson's disease (prevalence of RBD: 15–65%)
- Multiple system atrophy (prevalence of RBD: 60–90%)
Sleep disorders:
- Narcolepsy type 1 (prevalence of RBD: up to 60%)
Paraneoplastic and autoimmune encephalitis:
- Voltage-gated potassium channel complex (contactin-associated protein 2 [CASPR2], leucine-rich glioma-inactivated protein 1 [LGI1])
- Ma1 and Ma2 autoantibody-related encephalopathies. Anti-IgLON5 disease
Other neurologic diseases:
- Machado-Joseph disease (spinocerebellar atrophy type 3)
- Adult-onset autosomal dominant leukodystrophy
- Myotonic dystrophy type 2
- Autism
- Gilles de la Tourette syndrome
- Möbius syndrome
- Smith-Magenis syndrome
- Amyotrophic lateral sclerosis
- Progressive supranuclear palsy
- Huntington's disease
- Wilson's disease
- Creutzfeldt-Jakob disease
- Multiple sclerosis
- Astrocytomas
- Acoustic neuroma
- Vascular malformations
- Central nervous system vasculitis
- Cerebral infarcts
- Guadeloupean atypical parkinsonism

Medications

Antidepressants
- 1.a. Selective serotonin reuptake inhibitor:
  - Citalopram
  - Fluoxetine
  - Paroxetine
  - Sertraline
- 1.b. Serotonin-norepinephrine reuptake inhibitor:
  - Duloxetine
  - Venlafaxine
  - Mirtazapine*
  - * (atypical mechanism of action)
- 1.c. Selective norepinephrine reuptake inhibitor:
  - Reboxetine
- 1.c. Tricyclic antidepressant:
  - Amitriptyline
  - Clomipramine
  - Imipramine
  - Nortriptyline
Lithium
Monoamine oxidase inhibitor:
- Phenelzine
- Selegiline
Beta blocker:
- Bisoprolol
- Propranolol
Caffeine abuse
Withdrawal from substances:
- Barbituratesol
- Benzodiazepines (nitrazepam)ol
- Ethanolol
- Amphetaminesol
- Cocaine

Medication	Dose	Study type	Population
Clonazepam	0.25 - 2 mg	One open, randomized trial and observational studies (2,17,18)	Isolated RBD PD
Melatonin (immediate release)	1 - 15 mg	Two double-blind, placebo-controlled, trials (47,48)	Isolated RBD; PD; Narcolepsy
Rivastigmine	4.6–13.3 mg	Two placebo-controlled, cross-over, open trial (54,55)	PD; MCI
Pramipexole	0.125 - 0.375 mg	One open-label trial (56)	Isolated RBD
Safinamide	50 mg	One double-blind, randomized trial (61)	PD
Rotigotine	2–16 mg	Prospective open-label, trial (58)	PD

[1] Address for correspondence Manoel Alves Sobreira-Neto (email: manoelsobreira@yahoo.com.br)

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Transtorno comportamental do sono REM: atualização no diagnóstico e manejo

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