Sleep disorders after TBI
Traumatic brain injury (TBI) is a leading cause of death and injury worldwide. Many individuals who suffer TBI experience a number of post-concussive symptoms, which can diminish quality of life during and after the recovery period. Among the most detrimental of these symptoms are sleep disorders. Some researchers estimate that about half of people with TBI experience some form of sleep disorder – including insomnia, sleep-wake disturbances, obstructive sleep apnea, and nightmares – while other studies place the incidence rate as high as 84%.[i] Other negative psychological outcomes associated with TBI, such as depression and anxiety, can exacerbate sleep disorders; in turn, sleep disorders may cause or worsen these conditions. Sleep disorders may also be associated with higher risk of neurodegeneration in patients with TBI,[ii] potentially limiting an individual’s ability to make a full, healthy recovery. Because sleep problems can persist for years following injury, even after other symptoms have resolved, patients often do not connect their sleep disturbances with past TBI.[iii] However, diagnosis and treatment of sleep disorders is a critical component of TBI recovery, so patients are encouraged to practice vigilance for sleep problems after experiencing a head injury.
Sleep loss occurs when an individual regularly sleeps for fewer than seven hours per night. Insufficient or poor-quality sleep is a growing public health concern: sleep loss is detrimental to focus and attention, and it is associated with a wide range of diseases, such as psychological disorders, cardiovascular disease, and obesity. As the leading cause of motor vehicle accidents and work-related injuries, sleep loss also poses a serious threat to public safety.[iv] A single night of sleep loss can have dangerous health implications; for example, the rate of heart attacks increases by 25% at the start of daylight savings time, when millions of people experience disturbed sleep cycles.[v] On the other hand, sufficient sleep (about seven to eight hours for adults) boosts the immune system, strengthens learning and memory processes, and is protective against heart disease, obesity, and other health concerns. The value of restorative sleep cannot be overstated.
Because sufficient sleep is critical for healthy everyday functioning, clinicians have developed a number of tools for identifying sleep disorders. They rely primarily on self-report questionnaires (such as the Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index), clinician-conducted interviews, and sleep observation. By identifying specific symptoms and their detriment to daily functioning, these tools help clinicians evaluate the nature and extent of sleep disturbances. These assessments inform clinicians’ treatment protocols, which can be tailored to each patient’s needs.
Individuals with TBI may experience a wide array of sleep disturbances, ranging from difficulty falling asleep to more dangerous disorders like obstructive sleep apnea (OSA). OSA is characterized by disrupted breathing during sleep, and symptoms may include loud snoring, excessive daytime sleepiness, and abrupt waking accompanied by gasping or choking. Though researchers do not entirely understand the mechanisms underlying the disorder, many surmise that the physical impact associated with TBI causes spinal cord lesions, which can increase the risk of developing OSA.[vi] This condition is very dangerous, but a continuous positive airway pressure (CPAP) machine can effectively treat OSA by sustaining airflow during sleep.
Although OSA in TBI patients typically requires clinical intervention, most individuals experience significantly improvement by practicing sleep hygiene techniques, a set of behaviors and interventions that promote high-quality sleep. Most sleep researchers agree on a few cardinal rules of sleep hygiene:[vii]
- Maintain a regular sleep schedule. Going to bed and waking at the same time every day (including weekends) can help train the body to maintain consistent sleep cycles. Over time, falling and staying asleep becomes easier.
- Turn off screens one hour before going to bed and establish a relaxing bedtime routine. Research suggests that device screens emit a kind of “blue light” that can disrupt the brain’s production of melatonin, a natural chemical that helps regulate circadian rhythms.[viii] Furthermore, preoccupation with work, television, or internet can make it difficult to clear the mind before sleep. Instead, practice relaxing behaviors such as reading, meditation, or journaling before bedtime.
- Avoid caffeine in the afternoon. The stimulating effects of caffeine last hours after consumption, so avoid drinking caffeinated beverages (including coffee, soda, or caffeinated teas) at least six to eight hours before bedtime.
- Reduce alcohol consumption. Although alcohol is a sedative, allowing us to fall asleep more quickly, the process of metabolizing alcohol actually decreases quality of sleep and can disrupt sleep throughout the night.
- Exercise regularly. Studies suggest that as little as four weeks of regular exercise can help people with insomnia fall asleep and stay asleep.
- Keep your bedroom comfortable and cool. The bedroom should be a relaxing, calming environment. Studies suggest that warmer temperatures can contribute to nighttime waking, and experts suggest that 65 degrees Fahrenheit is the optimal temperature for achieving and maintaining deep sleep.
Sleep disorders can have serious implications for an individual’s ability to fully recover from TBI. After a head injury, remain vigilant for the signs and symptoms of sleep disorders, and talk to your doctor if you experience insufficient or poor-quality sleep.
[i] Mathias, J. L., and P. K. Alvaro. "Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta-analysis." Sleep medicine 13.7 (2012): 898-905.
[ii] Weymann, Kris B., and Miranda M. Lim. "Sleep Disturbances in TBI and PTSD and Potential Risk of Neurodegeneration." Current Sleep Medicine Reports 3.3 (2017): 179-192
[iii] Imbach, Lukas L., et al. "Sleep–wake disorders persist 18 months after traumatic brain injury but remain underrecognized." Neurology 86.21 (2016): 1945-1949.
[iv] Altevogt, Bruce M., and Harvey R. Colten, eds. Sleep disorders and sleep deprivation: an unmet public health problem. National Academies Press, 2006.
[v] Sandhu, Amneet, Milan Seth, and Hitinder S. Gurm. "Daylight savings time and myocardial infarction." Open Heart 1.1 (2014): e000019.
[vi] Leduc BE, Dagher JH, Mayer P, Bellemare F, Lepage Y. Estimated prevalence of obstructive sleep apnea-hypopnea syndrome after cervical cord injury. Archives of physical medicine and rehabilitation. 2007; 88(3):333–7
[viii] Tosini, Gianluca, Ian Ferguson, and Kazuo Tsubota. "Effects of blue light on the circadian system and eye physiology." Molecular vision 22 (2016): 61.