Sleeping disorders following traumatic brain injury

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Sleep disorder is a common repercussion of traumatic brain injury (TBI). [1] [2] It occurs in 30%-70% of patients with TBI. [1] [2] TBI can be distinguished into two categories, primary and secondary damage. Primary damage includes injuries of white matter, focal contusion, cerebral edema and hematomas, [3] mostly occurring at the moment of the trauma. Secondary damage involves the damage of neurotransmitter release, inflammatory responses, mitochondrial dysfunctions and gene activation, [3] occurring minutes to days following the trauma. Patients with sleeping disorders following TBI specifically develop insomnia, sleep apnea, narcolepsy, periodic limb movement disorder and hypersomnia. [1] [3] [4] Furthermore, circadian sleep-wake disorders can occur after TBI. [1] [3] [5]

Contents

Presentation

Consequences

Increased level of anxiety and depression is associated with higher levels of sleep disturbances in TBI patients. [5] [6] If depression or anxiety are not treated in these patients, successful treatment of sleep may be prevented. [7] TBI patients with sleepiness show impaired cognitive function and vigilance performance which impairs daily functioning. [8] Sleep is known for its neuroprotective role by elimination of neurotoxic waste products, the neural growth and plasticity, but furthermore, for a specific neuroplastic recovery effect from post mild TBI symptoms. [9] Therefore, sleep disturbance may have a negative effect on injury recovery, rehabilitation and outcomes, leading to long term disabilities. [3] [4] [5] [9] This may be related to less non-REM sleep due to a higher amount of stage 1 sleep. [3] [10] TBI patients with obstructive sleep apnea show reduced cardiac function and hypertension. [11] Obstructive sleep apnea is also associated with structural changes in the brain. [11]

Indirect consequences of sleep disorders after TBI can be the exacerbation of the many complications and comorbidities of TBI. [9] These include fatigue, post-traumatic stress symptoms or post-traumatic stress disorder (PTSD) and chronic pain. [9] [7]

Animal studies with rodents showed that sleep deprivation after traumatic brain injury has been associated with multiple, potentially negative effects on brain homeostasis, including changes in glutamate concentration and energy consumption as well as in brain temperature. [12]

In summary, sleep disorders occurring in TBI patients are associated with a low health-related quality of life and a shorter survival status. [13] [3] [8] [9]

Causes

There are different kinds of TBI that cause different brain dysfunctions. Research suggests that TBI results in damage to sleep-regulation centers including the reticular activation system, specifically damage to the suprachiasmatic nuclei (SCN) which leads to disturbances in the circadian rhythm. [5] Considering hypersomnia, mostly areas involving the maintenance of wakefulness are damaged, such as the rostral pons, caudal midbrain and thalamus. [1]

Sleep disorders are more frequently reported when patients have mild TBI (mTBI). [1] [3] [5] [14] Reasons for that could be the increased awareness of postinjury changes in mild TBI patients because they may be more determined to return to their preinjury life situation. [3] [5] All age groups can be affected from sleep disorders after TBI, including children [1] and adolescents. [6]

There are several risk factors that are associated with occurring sleep disorders, such as lower years of education, severity of head injury and occurrence of residuals symptoms, for example headache or dizziness. [1]

Further neurodegeneration such as impaired neurotransmitter function, cerebrovascular autoregulatory dysfunction, neuroinflammation and dysregulation of circadian hormones such as melatonin and adenosine [15] can also be a consequence leading to sleep disturbances. [9]

Treatment

In order to make a diagnosis, a subjective evaluation and objective sleep tests are assessed. [3] [6] Subjective evaluations include self-report questionnaires and sleep diaries to assess the sleep pattern from the patient's perspective. [9] Objective sleep tests include mental and physical examinations and laboratory tests to test the medical background, such as Polysomnography (PSG) and Actigraphy. [9] It is typically not possible to assess these tests prior to an injury. Therefore, it is often not clear whether the sleeping disorder is a result of pre-existing disorders. [9] Careful assessment of patients and determining the nature of their sleeping disorder is essential for finding the most effective treatment. [9]

There is no explicit treatment for sleep disorders following TBI. Several interventions for general sleep disturbance have been tested in patients with TBI. In order to provide the proper treatment, it is best to divide the injury and its recovery in stages, given that the treatments differs in the different stages. [9] It has been seen how a deterioration of sleep quality during the subacute phase of mTBI has been linked with the worsening of behavioural, neuropsychiatric and somatic outcomes. [16] [17] In general, treatment of sleep disorders following TBI can be distinguished in pharmacological and nonpharmacological interventions.

Pharmacological treatments

Phototherapy Phototherapy.jpg
Phototherapy

Pharmacological treatments have to be administered carefully. Some medication is highly addictive and the resulting withdrawal syndromes cause even more sleep disturbances, e.g. Insomnia. [13] Possible medications are Zopiclone and lorazepam, which have been proven effective in people with TBI. [3] Also Benzodiazepine hypnotics, [9] Benzodiazepine-receptor antagonists, antidepressants, psychostimulants [13] can be administered, especially in patients with insomnia. Some studies have shown negative effects of hypnotics, such as an increased risk of dementia. [9] In patients with hypersomnia, Modafinil, Armodafinil, Methylphenidate and amphetamines are often used as a treatment for day time sleepiness. [9] Medication should always be prescribed by an expert to make sure that the correct medicament is taken in an appropriate dose.

Nonpharmacological treatments

Nonpharmacological treatments involve different interventions, starting with sleep hygiene, [13] which includes sleep promoting activities such as maintaining a regular and strict sleep schedule and avoiding heavy meals before bedtime in order to restore the natural sleep-wake cycle. [9] Further treatments options are phototherapy [13] [3] and infrared light therapy, [9] which both, aim to treat circadian rhythm disorders such as delayed sleep phase disorder. Especially in patients with hypersomnia, bright light therapy in the morning has been proven to be effective. [9] A prolongation of slow-wave sleep increases glymphatic clearance of metabolic waste products, which can lead to improvements of sleep disorders. [9] Furthermore, studies showed ameliorated sleep pattern due to acupuncture [ citation needed ] of patients with TBI. Sleep apnea due to TBI can be treated through positive airway pressure, [9] which helps with the development of a regular breathing pattern during sleep and prevents waking up. Cognitive behavioral therapy for insomnia [6] [9] [13] also have been shown to effectively improve sleep in TBI patients. It aims to improve sleep habits and behaviors by identifying and changing the thoughts and the behaviors that affect the ability of a person to sleep or sleep well. The improvement of the quality of sleep and the decrease of depressive severity is associated with he use of near-infrared light for intracellular healing. [18]

Animal studies

Animals studies showed that sleep deprivation prior to a brain injury might have healthy effects. Five days of complete sleep deprivation in rats before the traumatic brain injury, acted as protection against ischemic injury [19] and a habitual deceased in total amount of sleep time before TBI reduced the severity. [20]

There are several theories on the protectional effects of sleep disturbances before an injury in rats. Firstly, it may alter the pattern of gene activation and deactivation. This could lead to a higher degree of neuroprotection. [9] Lack of sleep might increase the levels of extracellular adenosine, which is also mostly neuroprotective against the TBI sequelae. [9] Furthermore, sleep deprivation might lead to a form of "ischemic precondition" which habituates the brain to the byproducts of a cellular injury. [9] Studies have been run to assess the role of caffeine in rats with sleeping disorders. [21] While results regarding rats studies have come out positive, in humans caffeine is believed to worsen sleep fragmentation and insomnia. Lastly insufficient quantity and quality of sleep may cause a rebound sleep post injury and increase the sleep enhanced regeneration and recovery. [9] More research is needed to investigate how these findings can be transferred to the treatment of humans with TBI.

Related Research Articles

<span class="mw-page-title-main">Sleep disorder</span> Medical disorder of a persons sleep patterns

A sleep disorder, or somnipathy, is a medical disorder of an individual's sleep patterns. Some sleep disorders are severe enough to interfere with normal physical, mental, social and emotional functioning. Sleep disorders are frequent and can have serious consequences on patients' health and quality of life. Polysomnography and actigraphy are tests commonly ordered for diagnosing sleep disorders.

<span class="mw-page-title-main">Insomnia</span> Disorder causing trouble with sleeping

Insomnia, also known as sleeplessness, is a sleep disorder where people have trouble sleeping. They may have difficulty falling asleep, or staying asleep for as long as desired. Insomnia is typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. It may result in an increased risk of accidents of all kinds as well as problems focusing and learning. Insomnia can be short term, lasting for days or weeks, or long term, lasting more than a month. The concept of the word insomnia has two possibilities: insomnia disorder (ID) and insomnia symptoms, and many abstracts of randomized controlled trials and systematic reviews often underreport on which of these two possibilities the word insomnia refers to.

<span class="mw-page-title-main">Brain damage</span> Destruction or degeneration of brain cells

Neurotrauma, brain damage or brain injury (BI) is the destruction or degeneration of brain cells. Brain injuries occur due to a wide range of internal and external factors. In general, brain damage refers to significant, undiscriminating trauma-induced damage.

Somnolence is a state of strong desire for sleep, or sleeping for unusually long periods. It has distinct meanings and causes. It can refer to the usual state preceding falling asleep, the condition of being in a drowsy state due to circadian rhythm disorders, or a symptom of other health problems. It can be accompanied by lethargy, weakness and lack of mental agility.

Hypersomnia is a neurological disorder of excessive time spent sleeping or excessive sleepiness. It can have many possible causes and can cause distress and problems with functioning. In the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), hypersomnolence, of which there are several subtypes, appears under sleep-wake disorders.

Upper airway resistance syndrome (UARS) is a sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The symptoms include unrefreshing sleep, fatigue, sleepiness, chronic insomnia, and difficulty concentrating. UARS can be diagnosed by polysomnograms capable of detecting Respiratory Effort-related Arousals. It can be treated with lifestyle changes, functional orthodontics, surgery, mandibular repositioning devices or CPAP therapy. UARS is considered a variant of sleep apnea, although some scientists and doctors believe it to be a distinct disorder.

<span class="mw-page-title-main">Traumatic brain injury</span> Injury of the brain from an external source

A traumatic brain injury (TBI), also known as an intracranial injury, is an injury to the brain caused by an external force. TBI can be classified based on severity ranging from mild traumatic brain injury (mTBI/concussion) to severe traumatic brain injury. TBI can also be characterized based on mechanism or other features. Head injury is a broader category that may involve damage to other structures such as the scalp and skull. TBI can result in physical, cognitive, social, emotional and behavioral symptoms, and outcomes can range from complete recovery to permanent disability or death.

<span class="mw-page-title-main">Obstructive sleep apnea</span> Sleeping and breathing disorder

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder and is characterized by recurrent episodes of complete or partial obstruction of the upper airway leading to reduced or absent breathing during sleep. These episodes are termed "apneas" with complete or near-complete cessation of breathing, or "hypopneas" when the reduction in breathing is partial. In either case, a fall in blood oxygen saturation, a disruption in sleep, or both, may result. A high frequency of apneas or hypopneas during sleep may interfere with the quality of sleep, which – in combination with disturbances in blood oxygenation – is thought to contribute to negative consequences to health and quality of life. The terms obstructive sleep apnea syndrome (OSAS) or obstructive sleep apnea–hypopnea syndrome (OSAHS) may be used to refer to OSA when it is associated with symptoms during the daytime.

Post-concussion syndrome (PCS), also known as persisting symptoms after concussion, is a set of symptoms that may continue for weeks, months, or years after a concussion. PCS is medically classified as a mild traumatic brain injury (TBI). About 35% of people with concussion experience persistent or prolonged symptoms 3 to 6 months after injury. Prolonged concussion is defined as having concussion symptoms for over four weeks following the first accident in youth and for weeks or months in adults.

The International Classification of Sleep Disorders (ICSD) is "a primary diagnostic, epidemiological and coding resource for clinicians and researchers in the field of sleep and sleep medicine". The ICSD was produced by the American Academy of Sleep Medicine (AASM) in association with the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. The classification was developed as a revision and update of the Diagnostic Classification of Sleep and Arousal Disorders (DCSAD) that was produced by both the Association of Sleep Disorders Centers (ASDC) and the Association for the Psychophysiological Study of Sleep and was published in the journal Sleep in 1979. A second edition, called ICSD-2, was published by the AASM in 2005. The third edition, ICSD-3, was released by the AASM in 2014. A text revision of the third edition (ICSD-3-TR) was published in 2023 by the AASM.

<span class="mw-page-title-main">Sleep medicine</span> Medical specialty devoted to the diagnosis and therapy of sleep disturbances and disorders

Sleep medicine is a medical specialty or subspecialty devoted to the diagnosis and therapy of sleep disturbances and disorders. From the middle of the 20th century, research has provided increasing knowledge of, and answered many questions about, sleep–wake functioning. The rapidly evolving field has become a recognized medical subspecialty in some countries. Dental sleep medicine also qualifies for board certification in some countries. Properly organized, minimum 12-month, postgraduate training programs are still being defined in the United States. In some countries, the sleep researchers and the physicians who treat patients may be the same people.

<span class="mw-page-title-main">Sleep deprivation</span> Condition of not having enough sleep

Sleep deprivation, also known as sleep insufficiency or sleeplessness, is the condition of not having adequate duration and/or quality of sleep to support decent alertness, performance, and health. It can be either chronic or acute and may vary widely in severity. All known animals sleep or exhibit some form of sleep behavior, and the importance of sleep is self-evident for humans, as nearly a third of a person's life is spent sleeping.

Traumatic brain injury can cause a variety of complications, health effects that are not TBI themselves but that result from it. The risk of complications increases with the severity of the trauma; however even mild traumatic brain injury can result in disabilities that interfere with social interactions, employment, and everyday living. TBI can cause a variety of problems including physical, cognitive, emotional, and behavioral complications.

Idiopathic hypersomnia(IH) is a neurological disorder which is characterized primarily by excessive sleep and excessive daytime sleepiness (EDS). Idiopathic hypersomnia was first described by Bedrich Roth in 1976, and it can be divided into two forms: polysymptomatic and monosymptomatic. The condition typically becomes evident in early adulthood and most patients diagnosed with IH will have had the disorder for many years prior to their diagnosis. As of August 2021, an FDA-approved medication exists for IH called Xywav, which is oral solution of calcium, magnesium, potassium, and sodium oxybates; in addition to several off-label treatments (primarily FDA-approved narcolepsy medications).

Irregular sleep–wake rhythm disorder (ISWRD) is a rare form of circadian rhythm sleep disorder. It is characterized by numerous naps throughout the 24-hour period, no main nighttime sleep episode, and irregularity from day to day. Affected individuals have no pattern of when they are awake or asleep, may have poor quality sleep, and often may be very sleepy while they are awake. The total time asleep per 24 hours is normal for the person's age. The disorder is serious—an invisible disability. It can create social, familial, and work problems, making it hard for a person to maintain relationships and responsibilities, and may make a person home-bound and isolated.

An orexin receptor antagonist, or orexin antagonist, is a drug that inhibits the effect of orexin by acting as a receptor antagonist of one (selective orexin receptor antagonist or SORA) or both (dual orexin receptor antagonis or DORA) of the orexin receptors, OX1 and OX2. Medical applications include treatment of sleep disorders such as insomnia.

<span class="mw-page-title-main">TIK-301</span> Chemical compound

TIK-301 (LY-156735) is an agonist for the melatonin receptors MT1 and MT2 that is under development for the treatment of insomnia and other sleep disorders. Its agonist action on MT1 and MT2 receptors in the suprachiasmatic nucleus in the brain enables its action as a chronobiotic. It is in the same class of melatonin receptor agonists as ramelteon and tasimelteon.

Sleep is known to play an important role in the etiology and maintenance of bipolar disorder. Patients with bipolar disorder often have a less stable and more variable circadian activity. Circadian activity disruption can be apparent even if the person concerned is not currently ill.

<span class="mw-page-title-main">Behavioral sleep medicine</span>

Behavioral sleep medicine (BSM) is a field within sleep medicine that encompasses scientific inquiry and clinical treatment of sleep-related disorders, with a focus on the psychological, physiological, behavioral, cognitive, social, and cultural factors that affect sleep, as well as the impact of sleep on those factors. The clinical practice of BSM is an evidence-based behavioral health discipline that uses primarily non-pharmacological treatments. BSM interventions are typically problem-focused and oriented towards specific sleep complaints, but can be integrated with other medical or mental health treatments. The primary techniques used in BSM interventions involve education and systematic changes to the behaviors, thoughts, and environmental factors that initiate and maintain sleep-related difficulties.

Sleep epigenetics is the field of how epigenetics affects sleep.

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