REM sleep behavior disorder (RBD) is characterized by a loss of atonia of skeletal muscles during REM sleep, associated with acting out behaviors during dreams. Knowledge of this pathology is important to predict neurodegenerative diseases since there is a strong association of RBD with diseases caused by the deposition of alpha-synuclein in neurons (synucleinopathies), such as Parkinson's disease (PD), multiple system atrophy (MSA), and dementia with Lewy bodies (DLB). Proper diagnosis of this condition will enable the use of future neuroprotective strategies before motor and cognitive symptoms. Diagnostic assessment should begin with a detailed clinical history with the patient and bed partner or roommate and the examination of any recorded home videos. Polysomnography (PSG) is necessary to verify the loss of sleep atonia and, when documented, the behaviors during sleep. Technical recommendations for PSG acquisition and analysis are defined in the AASM Manual for the scoring of sleep and associated events, and the PSG report should describe the percentage of REM sleep epochs that meet the criteria for RWA (REM without atonia) to better distinguish patients with and without RBD. Additionally, PSG helps rule out conditions that may mimic RBD, such as obstructive sleep apnea, non-REM sleep parasomnias, nocturnal epileptic seizures, periodic limb movements, and psychiatric disorders. Treatment of RBD involves guidance on protecting the environment and avoiding injuries to the patient and bed partner/roommate. Use of medications are also reviewed in the article. The development of neuroprotective medications will be crucial for future RBD therapy.

Chronic insomnia disorder (simplified in this document as insomnia) is an increasingly common clinical condition in society and a frequent complaint at the offices of different areas of health practice (particularly Medicine and Psychology). This scenario has been accompanied by a significant evolution in treatment, as well as challenges in approaching patients in an appropriately way. This clinical guideline, coordinated by the Brazilian Sleep Association and the Brazilian Association of Sleep Medicine and counting on the active participation of various specialists in the area, encompasses an update on the diagnosis and treatment of insomnia in adults. To this end, it followed a structured methodology. Topics of interest related to diagnosis were written based on theoretical framework, evidence in the literature, and professional experience. As for the topics related to the treatment of insomnia, a series of questions were developed based on the PICO acronym (P – Patient, problem, or population; I – Intervention; C – Comparison, control, or comparator; O – Outcome). The work groups defined the eligible options within each of these parameters. Regarding pharmacological interventions, only the ones currently available in Brazil or possibly becoming available in the upcoming years were considered eligible. Systematic reviews were conducted to help prepare the texts and define the level of evidence for each intervention. The final result is an objective and practical document providing recommendations with the best scientific support available to professionals involved in the management of insomnia.

The prevalence of Parkinson's disease (PD) tends to increase worldwide in the coming decades. Thus, the incidence of falls is likely to increase, with a relevant burden on the health care system. Objective: The objective of this study was to evaluate clinical factors and drug use associated with falls in PD patients. Methods: We conducted a cross-sectional study at the Movement Disorders outpatient clinic of a tertiary hospital in Northeast Brazil. We performed structured interviews to collect sociodemographic and clinical data. Functional capacity was assessed using the Schwab and England Activities of Daily Living Scale and the modified Hoehn and Yahr Staging Scale. We divided the study sample into non-fallers (no falls) and fallers (≥1 fall), and non-recurrent (≤1 fall) and recurrent fallers (>1 fall). Results: The study population comprised 327 PD patients (48% women), with a mean age of 70 years. The mean disease duration was 9.9±6.9 years. The most prevalent comorbidities were depression (47.2%), hypertension (44.0%), and type 2 diabetes mellitus (21.5%). The logistic regression analysis revealed that hallucinations, amantadine, and catechol-O-methyltransferase inhibitors (entacapone) were independently associated with falls in PD patients. Also, hallucinations, dyskinesia, and the use of amantadine were independently associated with recurrent falls. Conclusions: Health care providers play an essential role in fall prevention in PD patients, particularly by identifying older adults experiencing dyskinesia and visual hallucinations. Prospective studies should investigate the use of amantadine as a risk factor for falls in PD patients.

Obstructive sleep apnea (OSA) occurs in up to 66% of Parkinson's disease (PD) patients, higher than in the general population. Although it is more prevalent, the relationship between OSA and PD remains controversial, with some studies confirming and others denying the relationship of OSA with some risk factors and symptoms in patients with PD. Objective: To determine the factors associated with OSA in PD patients com DP. Methods: A cross-sectional study was performed with 88 consecutive patients with PD from the outpatient clinic. Participants underwent clinical interviews with neurologists and a psychiatrist, assessment using standardized scales (Epworth Sleepiness Scale, Parkinson's Disease Questionnaire, Pittsburgh Sleep Quality Index and, for individuals with a diagnosis of restless legs syndrome/Willis-Ekbom disease, the International Restless Legs Syndrome Rating Scale), and video-polysomnography. Results: Individuals with PD and OSA were older and had less insomnia than those with PD without OSA. Regarding the polysomnographic variables, we observed a lower percentage of stage N3 sleep, a higher arousal index, and a higher oxygen desaturation index in those individuals with OSA, relative to those without OSA. In the multivariate analysis, only the percentage of stage N3 sleep and the oxygen desaturation index were significantly different. Besides this, most of the PD patients with OSA had a correlation with sleeping in the supine position (58% of OSA individuals). Conclusion: The PD patients showed a high prevalence of OSA, with the supine position exerting a significant influence on the OSA in these patients, and some factors that are associated with OSA in the general population did not seem to have a greater impact on PD patients.

Introduction: A diagnosis of rapid eye movement sleep behavior disorder (RBD) currently requires confirmation with polysomnography (PSG). However, PSG may not be sufficiently available. In these situations, a clinical diagnostic measure might be useful. Objective: To validate the Brazilian Portuguese version of RBD screening questionnaire (RBDSQ) for patients with Parkinson’s disease (PD). Methods: Using detailed clinical interviews and PSG analysis (diagnostic gold standard), a convenience sample of 69 subjects was divided into the following subgroups: patients with PD and RBD (PD+RBD; n=50) and patients with PD alone (PD-RBD; n=19). Results: RBDSQ-BR showed adequate internal consistency (Cronbach’s α=0.809) and, except for item 8, adequate item-test correlation. The retest performed in a second sample (n=13, consecutive) showed high agreement for total score (intraclass correlation coefficient, ICC=0.863) and acceptable agreement for items 2, 3, 6.2, 6.3, 7, and 8 (K>0.60). The receiver operating characteristic (ROC) curve analysis had an area under the curve (AUC) of 0.728. A cut-off score of 4 enabled the correct diagnosis of 76.8% subjects and provided the best balance between sensitivity (84%) and specificity (57.9%), with a 2.0 likelihood ratio of a positive result (LR+) and a 0.3 likelihood ratio of a negative result (LR-). Items 2 and 6.2 had 84.2% specificity and 3.2 LR+. Combined items 1+2+6.2, 2+6.1, and 6.1+6.2 increased the specificity to 94.7%, with LR+ ranging from 6.1 to 7.6. Conclusions: RBDSQ-BR is a reliable instrument, which may be useful for RBD diagnosis of Brazilian patients with PD. The instrument is also valid and may help in a better selection of cases for a more detailed clinical evaluation or even PSG analysis.