Neurological Sleep Disorder (REM Sleep Behaviour Disorder)
Patient Profile
Field | Details |
Age | 52 years |
Gender | Male |
Occupation | School Principal |
City | Bangalore |
Presenting Complaint | Wife reported husband acting out dreams during sleep for 18 months: shouting, punching, kicking, and falling out of bed on two occasions |
Diagnosis | Idiopathic REM Sleep Behaviour Disorder (iRBD); early Parkinson’s Disease confirmed at 14-month follow-up |
Duration of Issue | Sleep behaviour symptoms present for approximately 18 months before neurology consultation |
Previous Treatments | General physician attributed symptoms to stress; no neurological referral made |
Date of Initial Consultation | February 2025 |
Outcome | Excellent: Parkinson’s disease detected at pre-disability stage; treatment commenced with good motor response |
The Problem
Condition
The patient’s wife first noticed something was wrong approximately 18 months before the couple came to see Dr. Guruprasad Hosurkar, a leading neurologist in Bangalore specialising in Parkinson’s disease and neurological sleep disorders. During what appeared to be vivid, disturbing dreams, the patient would shout, swing his arms, kick, and on two occasions fall out of bed. He had no memory of these episodes in the morning.
The episodes were not occasional. They were happening multiple times per week, always in the second half of the night, and escalating in intensity. The patient had sustained a minor shoulder bruise from one fall and had started sleeping in a separate room to protect his wife. A general physician had attributed the behaviour to work stress with no neurological referral made.
Emotional and Psychological Impact
Consultation and Treatment Plan
What Was Assessed
- Sleep history from both patient and spouse: episode frequency, timing, content, and any injury sustained
- Full neurological examination: motor, sensory, coordination, cranial nerve assessment
- Smell testing (UPSIT): hyposmia is a recognised prodromal Parkinson’s feature
- Constipation and autonomic symptom history: both are prodromal markers
- MoCA cognitive screening
- Medication review: some drugs can mimic or worsen RBD
- Video-polysomnography (video-PSG) to confirm REM sleep without atonia
- DaTscan to assess baseline nigrostriatal dopaminergic integrity
- Blood panel: CBC, thyroid, renal, liver, metabolic
Why This Approach Was Chosen
The clinical picture fit REM sleep behaviour disorder precisely: behaviours confined to the second half of the night, no confusional state on waking, and escalating frequency. Video-PSG was arranged to confirm loss of normal REM atonia objectively, which is the definitive diagnostic criterion for this sleep disorder. The additional baseline investigations were chosen because iRBD carries a well-established conversion risk to a synucleinopathy in approximately 80% of cases over 10 years. A baseline DaTscan, smell function, and MoCA score created a reference point for serial comparison at every follow-up visit.
“REM sleep behaviour disorder is one of the most important early warning signs we have for Parkinson’s disease. In many patients it precedes motor symptoms by a decade or more. That window is an opportunity to monitor closely, counsel the patient, and intervene the moment motor signs appear. We are not watching helplessly; we are watching purposefully.” — Dr. Guruprasad Hosurkar. Learn more about treatment for neurological sleep disorders in Bangalore.
Baseline Clinical Assessment
Video-PSG confirmed the diagnosis: REM sleep without atonia was documented on chin and limb EMG channels, with video footage showing the patient vocalising and making repeated arm movements during REM sleep. No seizure activity on EEG.
Motor examination: Normal. No tremor, rigidity, or bradykinesia detectable.
MoCA: 27/30, within normal range; mild visuospatial difficulty noted.
Smell test: 28th percentile for age and gender, consistent with early hyposmia.
DaTscan: Mild asymmetric reduction in putaminal dopamine transporter binding on the left — below normal range for age but not yet meeting Parkinson’s diagnostic threshold.
Constipation history: Present for approximately 3 years; not previously considered clinically relevant by the patient.
The constellation of iRBD, hyposmia, mild DaTscan asymmetry, and longstanding constipation placed this patient in a high-risk prodromal Parkinson’s category.
Treatment Details
Phase 1: RBD Management and Neuroprotective Surveillance
Motor symptoms were not yet present, so dopaminergic therapy was not yet indicated.
- Clonazepam 0.5 mg at bedtime: first-line pharmacological treatment for RBD
- Bedroom safety: mattress lowered, padding on bedside furniture, pillow barrier between patient and wife
- Structured 6-monthly neurological follow-up with motor assessment
- Annual DaTscan to monitor dopaminergic change
- Aerobic exercise encouraged: evidence supports neuroprotective benefit in synucleinopathy risk
Phase 2: Parkinson’s Disease Confirmed at 14 Months
At the 14-month review, the patient’s wife had noticed his right arm swinging less when he walked. Examination revealed mild right-sided cogwheel rigidity and subtle bradykinesia on finger tapping. A repeat DaTscan confirmed progression of dopaminergic deficit. Early Parkinson’s disease was diagnosed. Levodopa-Carbidopa 100/25 mg three times daily was initiated and the patient responded well within two weeks.
Treatment Facts
Field | Details |
Phase 1 | Diagnosis to 14-month follow-up: RBD management and surveillance |
Phase 2 | Ongoing: Parkinson’s disease management from month 14 |
Setting | Outpatient: KIMS Hospital, Mahadevapura, Bangalore |
RBD Medication | Clonazepam 0.5 mg at bedtime |
Parkinson’s Medication | Levodopa-Carbidopa 100/25 mg, three times daily |
Allied Input | Physiotherapy, aerobic exercise programme |
Complications | None |
Post-Treatment Results
RBD episodes reduced from multiple times weekly to approximately once per month within two weeks of starting Clonazepam. The patient returned to sharing the bedroom and sleep quality improved for both.
When Parkinson’s disease was confirmed at 14 months, Dr. Guruprasad Hosurkar initiated Levodopa-Carbidopa and the motor response was excellent. Mild right-sided rigidity and bradykinesia resolved within three weeks. The patient remained fully active at work throughout and experienced no functional disruption.
The defining outcome: Because RBD was correctly identified and investigated, Parkinson’s disease was caught at its earliest detectable motor stage before the patient had any functional limitation. That is the clinical value of treating RBD as a serious prodromal neurological marker.
Outcomes at a Glance
| Outcome | Result |
| RBD Episode Control | ✔ Frequency reduced from multiple times weekly to rare with Clonazepam |
| Sleep Quality | ✔ Returned to shared bedroom; both patient and wife sleep well |
| Parkinson’s Detection | ✔ Diagnosed at pre-disability stage through structured surveillance |
| Motor Recovery | ✔ Full response to Levodopa-Carbidopa; no functional limitation |
| Professional Function | ✔ Continued as school principal throughout; no work disruption |
| Complications | ✔ None |
Patient Feedback
Google Review ★★★★★ 5.0 | Verified Patient (Name withheld)
“My wife had been telling me for over a year that I was behaving strangely in my sleep. I kept dismissing it. When we finally came to Dr. Hosurkar, he took it seriously from the first appointment and explained exactly why it mattered. Eighteen months later, he caught early Parkinson’s before I had any symptoms that affected my daily life. That early detection has made all the difference.”
Post-Treatment Care and Recovery
Instructions Given to Patient
- Continue Clonazepam 0.5 mg nightly; review if episodes recur or worsen
- Continue Levodopa-Carbidopa at optimised dose on the Parkinson’s disease treatment programme, timed relative to meals
- Physiotherapy twice weekly: gait, posture, upper limb dexterity
- Minimum 150 minutes of aerobic exercise per week
- 6-monthly neurological review with motor scoring
- Annual DaTscan to monitor Parkinson’s disease progression
- Annual MoCA for cognitive monitoring
Follow-Up Timeline
Timepoint | Progress |
Month 0 | iRBD confirmed on video-PSG; Clonazepam started; bedroom safety measures in place |
Month 1–2 | RBD episodes reduce significantly; patient returns to shared bedroom |
Month 6 | Surveillance review: no motor signs; DaTscan unchanged |
Month 12 | Surveillance review: no motor signs; mild smell test decline noted |
Month 14 | Right-sided rigidity and bradykinesia detected; DaTscan shows progression; Parkinson’s diagnosis made |
Month 15–16 | Levodopa-Carbidopa started; full motor response within 3 weeks |
Month 18 | Fully active at work, no functional disability; long-term plan established |
Frequently Asked Questions
1. What is REM sleep behaviour disorder?
2. Does RBD always lead to Parkinson's disease?
3. How is RBD diagnosed?
4. Can RBD be treated?
5. Why does early RBD detection matter for Parkinson's?
Disclaimer:
This case study is for educational purposes only and does not replace professional medical advice. Patient identity has been withheld throughout in line with confidentiality guidelines.