Impact of traumatic brain injury on sleep: an overview

Figures & data

Table 1 Summary of sleep disorders in TBI patients and their management

Disorders	Pathogenesis	Diagnosis	Management	Prognosis
Insomnia^Citation37	Trauma to inferior frontal and anterior temporal lobes. Increased sensitivity to noise and light (paroxysmal sympathetic hyperactivity).^Citation36 Psychological insult due to injury. Generalized anxiety.	History actigraphy	Ramelteon Caution with benzodiazepines (BZD) and non-BZDs due to cognitive impairment. Anti-depressants if the patient has co-morbid depression. Cognitive behavioral therapy (CBTI). Co-morbid PTSD – prazosin + CBTI Acupunture Table 2	Associated with mild TBI Worse health outcomes
Post-traumatic hypersomnia/narcolepsy^Citation38	Direct injury to histamine tubero-mammillary neurons	Polysomnogram (PSG) + MSLT	Stimulants	Associated with more severe TBI
Circadian rhythm disturbances^Citation31,Citation33,Citation39	Injury involving hypothamaus/suprachiasmatic nucleus	Actigraphy/sleep diaries – challenging and limiting due to the disease condition. Research tools – Salivary melatonin; body temperature monitoring	Combination or monotherapy of light and melatonin therapy depending on the type of the circadian rhythm disturbance	If by day 8 patient recovered the sleep/wake pattern – shorter ICU and hospital stay, less amnesia, less disability
Restless leg syndrome	Unclear	Clinical history	Similar to non-TBI patients	Contributes to increased fatigue, sleepiness and reduced concentration
Obstructive sleep apnea^Citation40^–^Citation42	Direct injury hypothalamus/satiety center causing weight gain. Weight gain due to immobilization. Injury to the upper airway musculature. Cranial neuropathies.	Polysomnogram	CPAP	If untreated; more memory impairment and concentration/attention
Central sleep apnea	Brain stem injury. Central acting medications – opiates/baclofen	Polysomnogram	CPAP/adaptive seroventilation

Table 2 Insomnia management in TBI patients

Treatment	Dosage	Results	Duration	Type of study
Ramelteon^Citation43	8 mg	Increase in total sleep time Improvement in executive functioning	3 weeks	RCT/Cross cover
Zopiclone^Citation44	3.75–7.5 mg	Improvement with no cognitive deficits	7 days	RCT
Lorazepam^Citation44	0.5−1 mg	Improvement with no cognitive deficits	7 days	RCT
CBT-I^Citation45	6 weeks	79% of patients improvement	6 months	Open label
Acupuncture^Citation46	10 sessions/5 weeks	Insomnia severity index improved in intervention arm	1 month	RCT

Abbreviation: RCT, randomized control trial.

Figure 1 Management of advanced sleep–wake phase disorder.

Figure 2 Management of delayed sleep–wake phase disorder.

Figure 3 Management of irregular sleep–wake phase disorder.

Kaufman Y, Tzischinsky O, Epstein R, Etzioni A, Lavie P, Pillar G. Long-term sleep disturbances in adolescents after minor head injury. Pediatr Neurol. 2001;24(2):129–134.11275462

 PubMed Web of Science ®Google Scholar

Elliott JE, Opel RA, Weymann KB, et al. Sleep disturbances in traumatic brain injury: associations with sensory sensitivity. J Clin Sleep Med. 2018;14(7):1177–1186. doi:10.5664/jcsm.722029991430

 PubMed Web of Science ®Google Scholar

Valko PO, Gavrilov YV, Yamamoto M, et al. Damage to histaminergic tuberomammillary neurons and other hypothalamic neurons with traumatic brain injury. Ann Neurol. 2014;77(1):177–182. doi:10.1002/ana.2429825363332

 PubMed Web of Science ®Google Scholar

Wolfe LF, Sahni AS, Attarian H. Sleep disorders in traumatic brain injury. NeuroRehabilitation. 2018;43(3):257–266. doi:10.3233/NRE-18258330347632

 PubMed Web of Science ®Google Scholar

Kendis H, Zee PC. Sleepless patient: circadian rhythm sleep–wake disorders. In: Malhotra RK, editor. Sleepy or Sleepless: Clinical approach to sleep patient. Basel: Springer International Publishing; 2015:133–149.

 Google Scholar

Duclos C, Dumont M, Blais H, et al. Rest–activity cycle disturbances in the acute phase of moderate to severe traumatic brain injury. Neurorehabil Neural Rep. 2013;28(5):472–482. doi:10.1177/1545968313517756

 Web of Science ®Google Scholar

Wilde MC, Castriotta RJ, Lai JM, Atanasov S, Masel BE, Kuna ST. Cognitive impairment in patients with traumatic brain injury and obstructive sleep apnea. Arch Phys Med Rehabil. 2007;88(10):1284–1288. doi:10.1016/j.apmr.2007.07.01217908570

 PubMed Web of Science ®Google Scholar

Castriotta RJ, Lai JM. Sleep disorders associated with traumatic brain injury. Arch Phys Med Rehabil. 2001;82(10):1403–1406. doi:10.1053/apmr.2001.2608111588744

 PubMed Web of Science ®Google Scholar

Lequerica A, Jasey N, Tremont JNP, Chiaravalloti ND. Pilot study on the effect of ramelteon on sleep disturbance after traumatic brain injury: preliminary evidence from a clinical trial. Arch Phys Med Rehabil. 2015;96(10):1802–1809. doi:10.1016/j.apmr.2015.05.01126026580

 PubMed Web of Science ®Google Scholar

Shan RSLP, Ashworth NL. Comparison of lorazepam and zopiclone for insomnia in patients with stroke and brain injury. Am J Phys Med Rehabil. 2004;83(6):421–427.15166685

 PubMed Web of Science ®Google Scholar

Ouellet M-C, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single-case experimental design. Arch Phys Med Rehabil. 2007;88(12):1581–1592. doi:10.1016/j.apmr.2007.09.00618047872

 PubMed Web of Science ®Google Scholar

Zollman FS, Larson EB, Wasek-Throm LK, Cyborski CM, Bode RK. Acupuncture for treatment of insomnia in patients with traumatic brain injury. J Head Trauma Rehabil. 2012;27(2):135–142. doi:10.1097/HTR.0b013e318205139721386714

 PubMed Web of Science ®Google Scholar