Citation:
Dokkedal-Silva V, Kim LJ, Morelhão PK, Galduróz JCF, Tufik S, Andersen ML. Use of clonazepam in REM sleep behavior disorder: association with fall-related injuries and alternative treatments. J Clin Sleep Med. 2020;16(4):655–656.
Clonazepam is a potent, intermediate-acting benzodiazepine that is extensively prescribed due to its anxiolytic,1 anticonvulsant,2 and hypnotic properties.3 On the past few years, the use of clonazepam has increased, and it currently is considered one of the most widely prescribed medications of this class.4,5
Clonazepam is also suggested for the treatment of rapid eye movement sleep behavior disorder (RBD),6 a parasomnia that affects especially older populations. Reports indicate a strong association between occurrence of RBD and development of α-synucleinopathies, such as Parkinson disease (PD), dementia with Lewy bodies, and multiple system atrophy.7 A previous study that evaluated 93 older patients with RBD found a prevalence of neurological disorders of 57%, 47% of which corresponded to PD.8 Similarly, Schenck and colleagues9 reported the emergence of PD in 38% of patients with previous diagnosis of RBD. Findings of another report suggest a prevalence of 69% of RBD in patients with multiple system atrophy.10
Despite the high success rate of the treatment of RBD with clonazepam,6 some features should be considered with regard to the long-term use of benzodiazepines in older adults. Common side effects include daytime drowsiness, dizziness, and motor and balance impairments,11 which increase the risk of falling and fall-related injuries in elderly patients.12 As indicated by a meta-analysis, such fractures might contribute to an 8-fold increase in mortality among older adults.13 Specifically, in patients with RBD, the frequent association with neurodegenerative diseases may also potentiate this risk. In addition to the motor impairments, patients with α-synucleinopathies often show poor nocturnal sleep quality and excessive daytime sleepiness.14 The overlap between the side effects of clonazepam and the diurnal symptoms of patients with RBD could lead to episodes of falling and consequent hip fractures.
In this sense, the correct management of the dosage of clonazepam in older patients with RBD is essential in order to reduce the number of falls-related injuries in this population. The diagnosis and prescription process of clonazepam needs to be conducted carefully. Moreover, use of alternative strategies that could integrate treatment of RBD symptoms, such as physical activity, must be considered. Evidence demonstrates a lower occurrence of RBD in older volunteers who practice physical activity.15 Lower levels of physical activity were also identified as a risk factor for the development of RBD.16
While clonazepam has been extensively proven as an effective option for the treatment of RBD, its well-known side effects deserve attention. Timely clinical evaluations should be performed, aiming to reduce residual effects and initiate treatment of α-synucleinopathies as soon as possible. These approaches could improve daytime activity of older patients, which is normally affected by clonazepam, and would reduce the number of falls, related injuries, and mortality rates of this population. Moreover, health professionals must be responsible for advising older patients about the risk of falls and seek alternative treatment options, such as the practice of physical activity to improve RBD symptoms and balance in older adults to prevent falls. Future studies investigating the effectiveness of physical activity in improving the clinical presentation of RBD must be conducted. Findings of such efforts will certainly contribute to a better quality of life of individuals afflicted by this condition.
DISCLOSURE STATEMENT
All authors have seen and approved the present version of this manuscript. Our studies are funded by grants from the Associação Fundo de Incentivo à Pesquisa (AFIP) and São Paulo Research Foundation (FAPESP) (#2015/19136-5; to L.J.K.). S.T. and M.L.A. received National Council for Scientific and Technological Development (CNPq) fellowships. The authors report no conflicts of interest.
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