Considering REM Sleep Behavior Disorder in the Management of Parkinson’s Disease

Abstract

Rapid eye movement (REM) sleep behavior disorder (RBD) is the result of the loss of physiological inhibition of muscle tone during REM sleep, characterized by dream-enacting behavior and widely recognized as a prodromal manifestation of alpha-synucleinopathies. Indeed, patients with isolated RBD (iRBD) have an extremely high estimated risk to develop a neurodegenerative disease after a long follow up. Nevertheless, in comparison with PD patients without RBD (PDnoRBD), the occurrence of RBD in the context of PD (PDRBD) seems to identify a unique, more malignant phenotype, characterized by a more severe burden of disease in terms of both motor and non-motor symptoms and increased risk for cognitive decline. However, while some medications (eg, melatonin, clonazepam, etc.) and non-pharmacological options have been found to have some therapeutic benefits on RBD there is no available treatment able to modify the disease course or, at least, slow down the neurodegenerative process underlying phenoconversion. In this scenario, the long prodromal phase may allow an early therapeutic window and, therefore, the identification of multimodal biomarkers of disease onset and progression is becoming increasingly crucial. To date, several clinical (motor, cognitive, olfactory, visual, and autonomic features) neurophysiological, neuroimaging, biological (biofluids or tissue biopsy), and genetic biomarkers have been identified and proposed, also in combination, as possible diagnostic or prognostic markers, along with a potential role for some of them as outcome measures and index of treatment response. In this review, we provide an insight into the present knowledge on both existing and future biomarkers of iRBD and highlight the difference with PDRBD and PDnoRBD, including currently available treatment options.

Rapid eye movement sleep behavior disorder and its relation to Parkinson's disease: The potential of graph measures as brain biomarkers to identify the underlying physiopathology of the disorder

“…Autonomic dysfunction, a common nonmotor symptoms in iRBD patients, includes decreased heart rate variability, urinary dysfunction, sexual and erectile dysfunction, orthostatic hypotension. Autonomic abnormalities can serve a potential diagnostic markers of α‐synucleinopathy but the role as biomarker of disease's progression needs to be further tested (Figoril, 2023 ; Šonka, 2022 ).…”

“…Regarding the fMRI and DWI, results have a considerable heterogeneity and so more longitudinal investigations need to be performed (Campabadal et al., 2021 ; Grimaldi et al., 2023 ). Concerning the investigation of misfolding and aggregation of α‐synuclein, promising findings have been observed but further longitudinal studies are needed (Figoril, 2023 ; Wang et al., 2022 ; Zitser et al., 2020 ).…”

Special Issue “Sleep Disorders: From Clinical Research to Daily Practice”

“…Further insights are provided by the effectiveness of other non-pharmacological tools, such transcranial direct current stimulation (tDCS) and transcutaneous direct spinal stimulation, thereby extending the therapeutic arsenal for this disorder. Regarding RBD, new methods that specifically explore and possibly measure other alterations beyond the brainstem are relevant to determine whether a prodromic neurodegenerative disorder (i.e., Parkinson’s disease and other alpha-synucleinopathies) underlies this condition occurring even at the stage of isolated RBD [ 10 , 11 ].…”