eMedicine Specialties > Neurology > Sleep-Related Diseases
Somnambulism (Sleep Walking): Treatment & Medication
Updated: Mar 8, 2007
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Medical Care
- General guidelines
- Reassurance is the mainstay of treatment. The benign nature of the events and subsequent disappearance in most cases should be emphasized.
- If environmental or predisposing factors are discovered, an attempt should be made to eliminate them. Assure adequate sleep, regulation of sleep cycle, and treatment of underlying medical conditions (eg, gastroesophageal reflux, obstructive sleep apnea, periodic leg movements, seizures).
- Avoid auditory, tactile, or visual stimuli early in the sleep cycle. These have been shown to induce events in some patients with parasomnias.
- Instruct parents to lock windows and doors, remove obstacles and sharp objects from the room, and add alarms (if necessary) to decrease the likelihood of injury during an episode.
- Depending on the situation, comforting the child and gently redirecting him or her to bed may be appropriate. Attempts to confront or wake up patients during the events frequently lengthens the parasomnia episode and may induce resistance or violence from the patient.
- Pharmacological measures may be necessary in the following situations:
- The possibility of injury is real.
- Continued behaviors are causing significant family disruption or excessive daytime sleepiness.
- Unusual symptoms are present.
- Nonpharmacological interventions have proven to be inadequate.
- Benzodiazepines, tricyclic antidepressants, and serotonin reuptake inhibitors have been shown to be useful. Clonazepam in low doses before bedtime and continued for 3-6 weeks is usually effective.
- Medication often can be discontinued after 3-5 weeks without recurrence of symptoms. Occasionally, frequency of episodes increases briefly after discontinuing the medication because of rebound sleep.
- Nonpharmacological measures
- Relaxation techniques, mental imagery, and anticipatory awakenings are preferred for long-term management. The first 2 techniques should be undertaken only with the help of an experienced behavioral therapist or hypnotist.
- Anticipatory awakenings consist of waking the child approximately 15-20 minutes before the usual time of an event and then keeping him awake through the time during which the episodes usually occur.
Surgical Care
Sleepwalking associated with sleep-disordered breathing may improve or resolve with surgical treatment of the respiratory disorder.
Medication
The goal of pharmacotherapy is to reduce morbidity and to prevent complications. In addition to the agents listed below, up to 6 mg Melatonin may be used at bedtime.
Tricyclic antidepressants
These agents, comprising a complex group of drugs, have central and peripheral anticholinergic effects and sedative effects. They block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
Increases synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting reuptake at presynaptic neuronal membrane. Useful as analgesic for certain types of chronic and neuropathic pain.
Adult
30-100 mg/d PO hs
Pediatric
Children: 0.1 mg/kg PO hs; increase as tolerated over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO hs; increase gradually to 100 mg/d in divided doses
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine, quinidine) may increase levels; inhibits hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patients who have taken MAOIs in past 14 d
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; use caution in elderly persons
Nortriptyline (Aventyl HCl, Pamelor)
Has demonstrated effectiveness in treatment of chronic pain. Increases synaptic concentration of serotonin and/or norepinephrine in CNS by inhibiting their reuptake by presynaptic neuronal membrane. Additional pharmacodynamic effects such as desensitization of adenyl cyclase and downregulation of beta-adrenergic receptors and serotonin receptors appear to play role.
Adult
25 mg PO tid/qid; not to exceed 150 mg/d
Pediatric
<25 kg: Not recommended
25-35 kg: 10-20 mg/d PO
35-54 kg: 25-35 mg/d PO
>54 kg: Administer as in adults
Cimetidine may increase levels; may increase PT in patients stabilized on warfarin
Documented hypersensitivity; narrow-angle glaucoma; patients who have taken MAOIs in past 14 d
Pregnancy
D - Unsafe in pregnancy
Precautions
Caution in cardiac conduction disturbances, history of hyperthyroidism, or renal or hepatic impairment; because of pronounced effects in cardiovascular system, use caution in elderly persons
Benzodiazepines
A large group of compounds with a benzene ring nucleus fused to a 7-sided diazepine ring. Benzodiazepines bind to specific receptors in association with GABA-binding sites on chloride channels. The frequency of channel opening is increased, increasing flow of chloride ions into neurons. Their relatively high therapeutic index and lower abuse potential than many of other sedative-hypnotics have made them sedative-hypnotic drugs of choice.
Clonazepam (Klonopin)
Believed to enhance activity of inhibitory neurotransmitter GABA in CNS. Antiseizure and antipanic effectiveness has been demonstrated. Generally considered DOC for disorders of arousal.
Adult
0.5 mg PO hs initial dose for sleep disorders; may increase rapidly to 1 mg prn
Pediatric
0.25 mg PO 1 h before hs initial dose; increase cautiously prn
Cimetidine, disulfiram, isoniazid, and estrogens may increase plasma levels of 2-keto benzodiazepines; antacids and food may decrease absorption, and smoking may decrease metabolism; may increase plasma levels of phenytoin and digoxin; additive CNS depressant effects with other benzodiazepines and sedative drugs
Documented hypersensitivity; severe liver disease; acute narrow-angle glaucoma
Pregnancy
D - Unsafe in pregnancy
Precautions
In patients with multiple seizure types, may worsen generalized tonic-clonic seizures; abrupt withdrawal may cause status epilepticus; caution in renal impairment and those with difficulty handling secretions; tolerance of adverse effects rarely a problem; monitor for daytime sedation when increasing dose
More on Somnambulism (Sleep Walking) |
| Overview: Somnambulism (Sleep Walking) |
| Differential Diagnoses & Workup: Somnambulism (Sleep Walking) |
 Treatment & Medication: Somnambulism (Sleep Walking) |
| Follow-up: Somnambulism (Sleep Walking) |
| References |
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References
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Further Reading
Keywords
parasomnias of childhood, noctambulation, noctambulism, oneirodynia activa, sleepwalking, somnambulance, sleep walking, somnambulism, REM sleep, rapid eye movement sleep, NREM sleep, non-rapid eye movement sleep, slow wave sleep, SWS, sleepwalkers, disorders of arousal, sleep-disordered breathing, restless leg syndrome, sleep terrors
