REM sleep behaviour disorder — shouting, punching or kicking during vivid dreams — in someone over 50 without another cause is one of the strongest known predictors of later Parkinson disease, dementia with Lewy bodies or multiple system atrophy. Most people with isolated RBD develop one of these over the following decade or so. Ask the bed partner, because patients themselves often do not know. Bedroom safety comes first; melatonin or clonazepam can reduce episodes, and antidepressants can unmask or worsen it.
- Ask the bed partner about dream enactment in any older patient with a sleep complaint.
- Make the bedroom safe: move sharp furniture, pad the floor, consider separate beds.
- Review SSRIs, SNRIs and tricyclics, which can provoke or worsen RBD.
- Discuss the long-term risk honestly and arrange periodic neurological review.
Why it matters
It is often the earliest recognisable sign of a neurodegenerative disease, years before motor symptoms.
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