A 65-year-old man punches his wife while asleep during a dream about fighting. He has no memory of the episode. PSG shows REM sleep without atonia. He has a history of mild anosmia for 3 years. What is the MOST important implication of his diagnosis?

• A He will likely develop obstructive sleep apnea
• B He requires immediate sodium oxybate treatment
• C This is a manifestation of PTSD-related sleep disturbance
• D REM Sleep Behavior Disorder is a strong prodromal marker for alpha-synucleinopathies (Parkinson's, DLB, MSA) ✓

Explanation

REM Sleep Behavior Disorder (RBD) is characterized by dream enactment behaviors during REM sleep due to loss of normal REM atonia. Crucially, RBD is now recognized as a strong prodromal marker—up to 80% of isolated RBD patients eventually develop an alpha-synucleinopathy: Parkinson's disease, Dementia with Lewy Bodies, or Multiple System Atrophy. Anosmia is another prodromal PD symptom. These patients should be informed about this association and monitored for early signs of neurodegeneration. Clonazepam and melatonin are used for symptomatic management of RBD.

Reference: Kaplan & Sadock's Synopsis of Psychiatry, 11th ed.

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Written and medically reviewed by the StethoPrep medical team.