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REM Behavior Disorder (RBD) is a condition that involves violent movements and nightmares during REM sleep. RBD has been reported in a vast majority of MSA patients, with a prevalence ranging from in 69% to 100% of MSA patients. RBD symptoms can often precede other MSA symptoms by years.

1. Non-pharmacologic treatment of REM behavior disorder include:

  • Ensuring bedroom safety to prevent injury includes lowering the bed, padding bedside furniture and removing firearms is an important aspect to managing RBD.
  • bed alarm can also alert patients and caregivers when RBD causes patients to get out of bed.

2. Medications used to help with REM behavior disorder include:

  • Clonazepam, a benzodiazepine, has been shown to reduce frequency and severity and prevent injury in RBD. Residual daytime sleepiness and headache are two side effects of clonazepam therapy, as well as possible worsening of sleep apnea.
  • Melatonin, a naturally occurring hormone secreted by the pineal gland, has been shown to improve REM sleep and decrease RBD-associated injuries with few side effects.
  • Zopiclone is a benzodiazepine that decreases sleep disturbances and has been used to treat RBD.
  • Rivastigmine and donepezil, cholinesterase inhibitors, has proven effective among patients who have not had improvement with either clonazepam or melatonin.
  • Pramipexole, a dopamine agonist, has also been shown to improve RBD symptoms, although some studies have produced mixed results.


  1. Perez-Lloret S, Flabeau O, Fernagut PO, et al. Current Concepts in the Treatment of Multiple System Atrophy. Mov Disord Clin Pract. 2015;2(1):6–16.
  2. St Louis EK, Boeve BF. REM Sleep Behavior Disorder: Diagnosis, Clinical Implications, and Future Directions. Mayo Clin Proc. 2017;92(11):1723–1736.
  3. Videnovic A. Management of sleep disorders in Parkinson’s disease and multiple system atrophy. Mov Disord. 2017;32(5):659–668.
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