Treatment options

The primary therapy for disorders of arousal is reassurance and prevention. For most, the disease course is usually benign and tends to resolve spontaneously with time. It is essential that both the patient and bed partner be educated about safety precautions for the home and bedroom environment, such as reducing or eliminating potential sources of injury (e.g., relocating the bedroom to a room on the ground floor, securing doors, using heavy draperies over the windows, removing mirrors, and keeping the floor free of objects that the sleepwalker might potentially trip over). Bed partners should be counseled not to attempt to stimulate the patient during an episode as this may trigger violent behaviour. A trial of sleep extension or scheduled awakening may be considered. With scheduled awakening, the patient is awakened just before the typical time of the parasomnia episode and thereafter allowed to return to sleep.

Relaxation training and guided imagery may be helpful strategies for some patients, especially those with disorders of arousal or rhythm movement disorders. When the events are frequent or particularly dramatic, medication with a long- or medium-acting benzodiazepine, such as clonazepam, at bedtime is effective therapy in most cases of non-REM disorders of arousal and REM sleep behavior disorder. In non-REM disorders, pharmacologic agents that have been used with some success include paroxetine and trazodone and low-dose benzodiazepines. Typically, medication should be used in combination with nonpharmacologic treatments after such techniques have been tried and found to be ineffective and only when the sleep disorder is affecting daytime function.

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