Dear Dr. Roach: I am very concerned about an issue with my husband that is getting worse quickly. He is 76 years old, has some heart problems and has had artery and heart surgery and pulmonary problems primarily caused by toxic exposures to pesticides in the past.
The situation is that at night, after we have been asleep for a little while, he begins to move around in bed. Sometimes he is kicking, sometimes it seems he is running and sometimes I will wake to find he has hit me with his fist or is about to. Lately, he will actually travel over the bed (while sleeping) to bring his ankle down on my ankle hard, like hitting me with an ax. This is not his personality — he is not abusive; he is kind and gentle and beloved by everyone. He is so apologetic in the morning and tells me he was not running from me or hitting me and sometimes does not remember what he might have been dreaming. He is not a veteran and does not have PTSD.
He uses a CPAP breathing machine at night. We walk several times a day, work out twice a week in the gym and have a very healthy and mostly plant-based diet. We are in good health for our ages minus his continuing issues with pulmonary and heart and blood vessels that he sees a physician regularly about. He is embarrassed about this condition and has not mentioned this to his physicians. What in the world could be causing his nighttime violence?
It sounds very much like your husband has REM sleep behaviour disorder. This condition is not uncommon — it’s seen in approximately 2% of older adults — but is usually not recognized for what it is and never brought up with a physician. It is far more commonly diagnosed in men, although it may be just as common but even less reported in women. It is normally diagnosed between ages 60 and 70. Pesticide exposure is a known risk for this condition, as are some medicines, particularly antidepressants.
It is thought that these complex sleep behaviours are enactments of dreams, although many people do not recall the dreams, and just over half were aware of their sleep behaviours. The movements are short, less than 30 seconds. Punching and kicking are common: 60% of patients and 20% of bed partners sustained an injury among 200 patients followed over five years. Patients with SBD do not have more violent dreams than others, and they do not have an increased risk of being violent persons or have personality disturbances. The diagnosis can be confirmed by a sleep study with video. One underlying issue in SBD is a loss of the normal paralysis that happens when we dream.
Unfortunately, most people with SBD will be diagnosed with a neurological condition, with increasing frequency over time. Parkinson’s disease, multiple system atrophy and Lewy body dementia are commonly diagnosed after the diagnosis of sleep behaviour disorder has been made: 74% of people within 12 years.
There is effective treatment to reduce the behaviour, starting with making sure both you and he are safe while sleeping. It’s also important that the bed partner doesn’t become sleep-deprived. Medication, such as melatonin and clonazepam, have been useful to suppress the sleep-related behaviours. However, due to the probability of developing a progressive neurodegenerative disease, I would strongly recommend evaluation by a neurologist or sleep specialist.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu