Objective: To present a patient with adolescent onset dream enactment behaviour who developed PD 48 years later.

Background: RBD typically occurs after age 50, and it is accepted that almost all will develop a synucleinopathy. However, the prognosis of young-onset RBD remains uncertain with conversion rates thought to be lower at 2.6% [1] Adolescent onset RBD converting to neurodegenerative disease after such a prolonged latency has not previously been reported.

Methods: Case report

Results: A 62-year-old male first experienced dream enactment behaviour at the age of 17; and recalled first dreaming that pallets were falling on his head whilst sleeping in a bunk bed and awakening the man above him in the processing of kicking. He had a history of occasional sleep talking and sleep walking beginning in childhood which persisted into his 50s. Dream enactment behaviour occured a few times a month. This history was collaborated by his wife to whom he had been married since the age of 21. At age 64, dream content became increasingly intrusive and violent. He would dream of being attacked and would injure his upper limbs. A full polysomnographic study performed captured three 10-20 second episodes of dream enactment behaviour arising from REM sleep consisting of upper limb punching and lower limb kicking. Melatonin 3mg resulted in resolution of RBD. At age 65, he developed a resting tremor in his right arm associated with cogwheeling rigidity and bradykinesia; which was consistent with a diagnosis of PD.

Conclusions: Neurodegeneration occurring after a long history of RBD beginning at a young age has been rarely reported; with one previous retrospective case note analysis describing a subject with probable RBD beginning in adulthood at age 27 before developing PD at the age of 77 after a 50 year latency. [2] In childhood and adolescents, RBD is commonly described in the context of narcolepsy, idiopathic hypersomnia, antidepressant use, and childhood neurodevelopmental disorders. Dream-like mentation with dream enactment has been occasionally reported in adults with sleep walking and sleep terrors. However, adult sleepwalking is not thought to be linked to future neurodegeneration. This case describes a patient with adolescent-onset RBD with frequent dream enactment behaviour developing PD after 48 years. The association of sleep walking in this individual most likely represents a chance association but raises the question whether dream enactment behaviour that can sometimes occur in a sleepwalker has the same prognostic significance as adult-onset isolated RBD.

References: 1. Bonakis A, Howard RS, Ebrahim IO, et al. REM sleep behaviour disorder (RBD) and its associations in young patients. Sleep Med 2009;10:641-5. 2. Claassen DO, Josephs KA, Ahlskog JE, et al. REM sleep behavior disorder preceding other aspects of synucleinopathies by up to half a century. Neurology 2010;75:494-9.

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MDS Abstracts - https://www.mdsabstracts.org/abstract/adolescent-onset-rbd-converting-to-pd-after-48-years/