Traumatic Brain Injuries and Sleep

Introduction

Traumatic brain injury (TBI) covers the varying symptoms and comorbidities that accompany an external injury to the head. People who suffer from TBI can have various health conditions associated with their injury; however, sleep issues are one of the most common.[1]

Most people who suffer from sleep-related issues due to TBI complain of excessive sleepiness, usually due to insomnia. This article discusses how to identify sleep disorders due to a TBI, how they may manifest, and how to treat them.

Epidemiology

In the initial phase after a TBI, sleep issues depend on the severity of the injury. Mild TBI patients report sleep problems up to 50% of the time. In comparison, severe TBI patients report sleep issues up to 84% of the time.[2]

As time passes, sleep problems associated with brain injury seem to dissipate. During the chronic phase, some sleep issues symptoms decrease to 27%, with insomnia and difficulty maintaining sleep being the most common at 50%.[3]

Physiological Changes 

The precise reasons for sleep issues following a TBI are not yet known; however, tests are ongoing, and current research shows that reasons for sleep trouble may be caused by pathophysiological changes.

1) Orexin levels

Orexin plays a vital role in regulating sleep, and TBIs are associated with lower orexin levels in the central nervous system. This lower level is similar to that found in narcolepsy and could increase sleepiness.[4]

2) Melatonin levels

Unusual levels of melatonin are found in people who suffer from TBI. Because melatonin is closely connected with circadian rhythms, a disruption in levels could lead to issues regulating sleep patterns.[5]

3) Brain Damage 

Damage to specific brain areas that have been shown to contribute to sleep patterns can also be a cause for excessive sleepiness. Loss of neuronal density in the basal forebrain, locus coeruleus, and tuberomammillary nucleus shows a correlation with the need for sleep in TBI patients. Additionally, TBIs that cause intracranial hemorrhaging are associated with neuronal loss and additional need for sleep.[6]

Symptoms

Symptoms of sleep issues following a TBI are person-specific and can vary depending on the severity of the injury; however, common symptoms can include:[7] 

• Excessive daytime sleepiness
• Increased need for sleep
• Delayed sleep onset

 Less common sleep-related symptoms include:

• Circadian rhythm disturbances (irregular sleep cycle)
• Abnormal sleep behaviors, including sleep talking, enuresis, and teeth grinding
  
  

Comorbidities

Comorbidity occurs when you have two associated chronic conditions. TBIs often cause and exacerbate other sleep-disrupting diseases. These other diseases have symptoms that can affect mood, mobility, and breathing, exacerbating sleep problems from a TBI. 

1) Insomnia

Insomnia is the inability to go to sleep, stay asleep, or sleep long enough. Insomnia can result in increased daytime sleepiness, a decrease in cognitive function, and decreased quality of life. Insomnia is common following the injury causing a TBI, with 50% of TBI patients reporting insomnia up to 20 years after the injury.[8]

2) Sleep-Related Breathing Issues

Breathing issues while sleeping is commonly reported amongst the general public and patients with a history of TBI.

Obstructive sleeping disorder (OSA) can be exacerbated by the incidence of a TBI but will be more likely in patients who are obese. TBI patients suffering from OSA complain of choking in their sleep, interrupted sleep, and daytime cognitive difficulties.

Central sleep apnea (CSA) shares similar symptoms with OSA; however, obesity has less of an impact.[9]

3) Depression and Anxiety

Like breathing issues, a TBI can exacerbate existing symptoms of depression and anxiety and cause it. People with depression and anxiety report high levels of sleep issues. Insomnia interrupted sleep, and daytime sleepiness commonly occurs. These symptoms could cause or worsen sleep-related issues associated with a TBI.[10]

4) Posttraumatic Stress Disorder

Due to the traumatic events that usually lead to a TBI, posttraumatic stress disorder (PTSD) is common among patients with a TBI. PTSD is often associated with nightmare disorders and dream reenactment, both of which interrupt quality sleep.[11]

5) Chronic Pain

Reduction of slow-wave sleep due to chronic pain occurs in about have of TBI patients. Slow-wave sleep is known as the restorative form of sleep, and without it, it limits the restfulness that sleep provides.[12]

Evaluation

Due to how common sleep disorders are with a TBI, family and physicians should watch for any signs of sleep troubles. When a patient with a history of TBI complains of sleep issues, the next step is parsing out the sleeping issue’s root cause.

First, a physician will ask for a history of sleep issues and ask the patient to rate how sleepy they are during the day. Questionnaires commonly used are The Pittsburgh Sleep Quality Index and The Epworth Sleepiness Scale.

A physician may also ask the patient to keep track of their sleep with a sleep diary. The diary would record, in detail, how they’re sleeping, what times they wake up, and what times they go to sleep. This same information may also be collected with an actigraphy record.

Finally, a physician may ask for psychiatric tests, laboratory tests, and sleep tests to rule out any additional reasons for sleep issues.

Treatment

Treatment for sleep disorders in patients with a history of TBI varies depending on the issue. For example, if the patient is experiencing excessive nighttime awakening due to PTSD, therapy and medication may solve the sleeping issue.

But, if the patient is found to suffer from an exacerbation of breathing troubles following a TBI, positive air pressure and an increased exercise routine would be the first course of action.

In most cases, sleep disorders brought on by TBIs are solved with a combination of therapy, pharmacology, and lifestyle changes. The best way to figure out what is right for you is to speak with your physician and decide on a plan.

References:

1. Duclos, C., Dumont, M., Wiseman-Hakes, C., Arbour, C., Mongrain, V., Gaudreault, P., . . . Gosselin, N. (2014, October). Sleep and wake disturbances following traumatic brain injury. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25110283
2. Chaput, G., Giguère, J., Chauny, J., Denis, R., & Lavigne, G. (2009). Relationship among subjective sleep complaints, headaches, and mood alterations following a mild traumatic brain injury. Sleep Medicine, 10(7), 713-716. Retrieved from https://pubmed.ncbi.nlm.nih.gov/19147402/
3. Mathias, J. L., & Alvaro, P. K. (2012, June 12). Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: A meta-analysis. Retrieved from https://pubmed.ncbi.nlm.nih.gov/22705246/
4. Saper, C., Scammell, T., & Lu, J. (2005, October 26). Hypothalamic regulation of sleep and circadian rhythms. Retrieved from https://www.nature.com/articles/nature04284/
5. Naseem, M., & Parvez, S. (2014, December 21). Role of melatonin in traumatic brain injury and spinal cord injury. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25587567/
6. Imbach, L., Valko, P., Li, T., Maric, A., Symeonidou, E., Stover, J., . . . Baumann, C. (2015, January 15). Increased sleep need and daytime sleepiness 6 months after traumatic brain injury: A prospective controlled clinical trial. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25595147/
7. Leng, Y., Byers, A., Yaffe, K., Li, Y., Peltz, C., & Barnes, D. (2021, March 30). Traumatic brain injury and Incidence risk of sleep disorders in nearly 200,000 US Veterans. Retrieved from https://pubmed.ncbi.nlm.nih.gov/33658328/
8. Beetar, J., Guilmette, T., & Sparadeo, F. (2004, May 25). Sleep and pain complaints in symptomatic traumatic brain injury and neurologic populations. Retrieved April, from https://www.sciencedirect.com/science/article/abs/pii/S0003999396901963
9. Ibid, 3
10. Kessler, R., Berglund, P., Demler, O., Jin, R., Koretz, D., Merikangas, K., Rush, A., Walters, E., Wang, P., (2003). The epidemiology of major Depressive disorder: Results from the National Comorbidity survey REPLICATION (NCS-R). Retrieved from https://pubmed.ncbi.nlm.nih.gov/12813115/
11. Pigeon, W., Campbell, C., Possemato, K., & Ouimette, P. (2013, December). Longitudinal relationships of insomnia, nightmares, and ptsd severity in recent combat veterans. Retrieved from https://pubmed.ncbi.nlm.nih.gov/24290044/
12. Nampiaparampil, D. (2008, August 13). Prevalence of chronic pain after traumatic brain injury. Retrieved from https://pubmed.ncbi.nlm.nih.gov/18698069/