Sleep and Traumatic Brain Injury Brian Greenwald, MD and Kathleen Bell, MD , Model Systems of Knowledge Translation Center Page 1 of 2

How common are sleep problems following at TBI?

Many people who have brain injuries suffer from sleep disturbances. Not sleeping well can increase or worsen depression, anxiety, fatigue, irritability, and one’s sense of well-being. It can also lead to poor work performance and traffic or workplace accidents. A review of sleep disorder studies and surveys suggest that sleep disorders are three times more common in TBI patients than in the general population and that nearly 60% of people with TBI experience long-term difficulties with sleep. Women were more likely to be affected than men. Sleep problems are more likely to develop as the person ages.

What are types of sleep problems?

Sleep disturbances have been found in people with all severities of brain injuries — from mild to severe. Sleep is a complex process that involves many parts of the brain. For this reason, and depending on the location and extent of injury, many different kinds of sleep disturbances can occur after brain injury.

Common sleep disorders include:

• Insomnia: Difficulty with falling asleep or staying asleep; or sleep that does not make you feel rested. Insomnia can worsen other problems resulting from brain injury, including behavioral and cognitive (thinking) difficulties. Insomnia makes it harder to learn new things. Insomnia is typically worse directly after injury and often improves as time passes.
• Excessive Daytime Sleepiness: Extreme drowsiness.
• Delayed Sleep Phase Syndrome: Mixed-up sleep patterns.
• Narcolepsy: Falling asleep suddenly and uncontrollably during the day.

Common sleep syndromes include:

• Restless Leg Syndrome (RLS): Urge to move the legs because they feel uncomfortable, especially at night or when lying down.
• Bruxism: Grinding or clenching teeth.
• Sleep Apnea: Brief pauses in breathing during sleep, resulting in reduced oxygen flow to the brain and causing loud snoring and frequent awakening.
• Periodic limb movement disorder (PLMD): Involuntary movement of legs and arms during sleep.
• Sleepwalking: Walking or performing other activities while sleeping and not being aware of it.

What causes sleep problems?

The brain directs sleep by putting your body to rest. Injury to the brain can lead to changes in sleep.

Physical and chemical changes
The “internal clock” in the brain controls when people sleep and wake every day. If injured, the brain may not be able to tell the body to fall asleep or wake up. There are chemicals in our body that help us to sleep. An injury can change the way that these chemicals affect the body. If brain mechanisms for starting and stopping sleep are injured, a condition called post-traumatic hypersomnia may result in which a person sleeps many hours more than normal.

Changes in breathing control
Sometimes the brain’s ability to control breathing during sleep becomes altered after a TBI, resulting in periods of apnea (when breathing actually stops for long enough for blood oxygen levels to drop). This is called sleep apnea. Other factors may affect the chance of having sleep apnea such as family history or being overweight.

Medications
Medications taken after a brain injury may cause problems going to sleep or staying asleep, or can make people sleepy during the day and unable to participate in activities.

• Prescription drugs for treating asthma and depression may cause insomnia. Also, stimulants that are meant to treat daytime sleepiness can cause insomnia if taken too close to bedtime. These problems can often be avoided by adjusting the timing of the medication or by substituting a different drug — of course, in consultation with your physician. Many other medications can cause sedation (sleepiness), as well.
• Most over-the-counter sleep aid medications contain an antihistamine (commonly diphenhydramine) and are not recommended for people with TBI because they may cause disturbances in memory and new learning. Retention of urine, dry mouth, nighttime falls and constipation are also possible side effects of this class of medications.

Daytime sleeping (napping) and physical inactivity
Napping during the day is likely to disturb sleep at night. Inactivity or lack of exercise can also worsen sleep.

Pain
Many people who have suffered brain injuries also experience pain in other parts of the body. This discomfort may disturb sleep. Medications taken to relieve pain may also affect sleep.

Depression
Depression is much more common in persons with traumatic brain injury than in the general population. Sleep problems such as difficulty falling asleep and early morning waking are common symptoms of depression.

Alcohol
While alcohol may help bring on sleep, drinking alcohol before bedtime is likely to interfere with normal sleep rather than improve it.

Caffeine and Nicotine
Nicotine from tobacco may cause sleep disturbances and is often overlooked. Caffeine can disturb sleep when consumed in the afternoon or evening.

What can be done to improve sleep?

Changes in behavior and environment are the first line to treating sleep difficulties.

Daytime Suggestions

• Set an alarm to try to wake up at the same time every day.
• Include meaningful activities in your daily schedule.
• Get off the couch and limit TV watching.
• Exercise every day. People with TBI who exercise regularly report fewer sleep problems.
• Try to get outdoors for some sunlight during the daytime. If you live in an area with less sun in the wintertime, consider trying light box therapy.
• Don’t nap more than 20 minutes during the day.

Nighttime Suggestions

• Try to go to bed at the same time every night and set your alarm for the next day.
• Follow a bedtime routine. For example, put out your clothes for morning, brush your teeth and then read or listen to relaxing music for 10 minutes before turning out the light.
• Avoid caffeine, nicotine, alcohol and sugar for five hours before bedtime.
• Avoid eating prior to sleep to allow time to digest, but also do not go to bed hungry, as this can also wake you from sleep.
• Do not exercise within two hours of bedtime but stretching or meditation may help with sleep.

Sleep and TBI was developed by Brian Greenwald, MD and Kathleen Bell, MD in collaboration with the Model System Knowledge Translation Center. Portions of this document were adapted from materials developed by the New York TBIMS, the Carolinas TBI Rehabilitation and Research System, and from Picking up the pieces after TBI: A guide for Family Members, by Angelle M. Sander, PhD, Baylor College of Medicine (2002).Copyright © 2010 by University of Washington/MSKTC. 

Please check the MSKTC site for any recent updates on this article.

 Comments

There are currently no comments for this article