Clinical, behavioral, and physiological characteristics of isolated rapid eye movement sleep behavior disorder patients with ambulatory dream enactment behaviors.
Su Min Kim, Tae-Gon Noh, J. Byun, J. Sunwoo, Jung-Won Shin, Tae-Joon Kim, J. Jun, C. H. Schenck, K. Jung
Sleep Medicine April 1, 2026 DOI: 10.1016/j.sleep.2026.108968 (opens in new tab)
Study at a glance
AI-extracted from the abstract| Characteristics | Retrospective observational study Peer reviewed |
|---|---|
| Sample size | 361 |
| Population | Patients with video-polysomnography-confirmed isolated REM sleep behavior disorder (mean age 66.9 years; 59.0% male) |
| Measures | RBDQ-KR, video-polysomnography (v-PSG), REM EMG amplitude |
| Key findings | Among 361 patients with isolated REM sleep behavior disorder, 31 (8.6%) exhibited ambulatory dream-enactment behaviors and were more frequently female, had higher RBDQ-KR Factor 1 scores, and showed elevated REM sleep without atonia and REM EMG amplitude compared with non-walkers, despite preserved sleep architecture. The authors suggest that ambulatory dream-enactment behaviors may arise from multifactorial mechanisms beyond simple REM-atonia loss. |
Abstract
STUDY OBJECTIVES Isolated rapid eye movement (REM) sleep behavior disorder (iRBD) involves dream enactment behaviors (DEBs) during REM sleep, accompanied by REM sleep without atonia (RWA). While most DEBs are bed-confined, a minority engage in ambulatory behaviors. This study investigated clinical, behavioral, and physiological characteristics of iRBD patients exhibiting ambulatory behaviors.
Methods: We retrospectively reviewed electronic medical records of 361 patients with video-polysomnography (v-PSG)-confirmed iRBD (mean age: 66.9 years; 59.0% males). Patients reporting at least one DEB episode involving ambulation out of the bedroom were classified as RBD-walkers; those without any ambulatory episodes as non-walkers. Clinical assessments, dream contents, behaviors, and PSG metrics were compared between groups.
Results: 31 patients (8.6%) were categorized as RBD-walkers, none with prior history of sleepwalking. RBD-walkers were more frequently female (64.5% vs. 38.0%, p = 0.006) and showed higher RBDQ-KR Factor 1 scores (15.7 vs. 12.6, p = 0.005). Combined clonazepam-melatonin use was more common among RBD-walkers (38.7% vs. 19.8%, adjusted residual = +2.443). Behaviorally, they frequently exhibited escape-related motor behaviors and object-interactive behaviors. PSG findings revealed preserved sleep architecture, along with elevated RWA and REM EMG amplitude (6.7 μV vs. 3.6 μV, p = 0.009) in RBD-walkers.
Conclusions: RBD-walkers represent a clinically and physiologically distinct iRBD subgroup, marked by complex ambulatory behaviors, increased treatment demands, and elevated RWA and REM EMG amplitude despite preserved sleep structure. These findings suggest that ambulatory DEB may arise from multifactorial mechanisms beyond simple REM-atonia loss, warranting further investigation for pathophysiology and clinical implications.