Sleep Problems in Traumatic Brain Injury

Eilis Boudreau M.D., Ph.D.

Talk Overview

• Case

• Brain structures involved

• Sleep problems and acute TBI

• Chronic sleep problems associated with TBI

• Treatments

• Key Points

Case

• Mr. M. is a 50 yr-old gentleman with a history of severe traumatic brain injury 10 years ago. Immediately after the injury he complained of daytime tiredness which improved over the first year after the injury (but his daytime level of energy never returned to his pre-injury baseline). Over the past two years he has become increasingly tired, sleeping up to 16 hours per day.

Studies of Sleep and TBI (human)

02468

101214161820

2000 2002 2004 2006

# paperspublished

Possible Brain Structures Involved

• Brain stem

• Basal forebrain

• Hypothalamus

Possible Markers/Etiologies

• Hypothalamic-pituitary insufficiency (Belmont and co-workers, 2006)

• Significantly lower levels of hypocretin in CSF (Baumann and co-workers, 2007)

• Disruption of normal patterns of melatonin secretion (Paparrigopoulos et al., 2006)

Early Reports of TBI and Sleepiness

• First reports 1941 by Gill in Lancet: head trauma and narcolepsy

• Guilleminault and co-workers (1983) at Stanford reported on a series of 20 individuals with TBI and sleep complaints

Sleep Complaints Common

# Subjects Prevalence TBI Severity/

Acute vs ChronicAuthors

87 46% All/chronic Castriotta et al., 2007

514 1 mo. 55%

1 yr. 27%

All/acute & chronic

Watson et al., 2007

Wide Range of Sleep Disorders

Diagnosis Prevalence

(general pop.)

TBI Severity/

Acute vs ChronicAuthors

Insomnia 30% All/acute & chronic

Fichenberg, 2000

29.4% (9%) All/chronic Ouellet, 2006

OSA 30% All/chronic Verma, 2007

23% (4-20%) All/chronic Castriotta, 2007

CRSD 36% Mild/? Ayalon, 2007

Wide Range of Sleep Disorders

Diagnosis Prevalence(general pop.)

TBI Severity/

Acute vs ChronicAuthors

Parasomnias 25%; 13% with RBD

All/chronic Verma, 2007

Narcolepsy 6% (0.5%) All/chronic Castriotta, 2007

PTH 11% All/chronic Castriotta, 2007

PLMS 7% All/chronic Castriotta, 2007

Insomnia Has Widespread Effects(Ouellet and co-workers, 2006)

Mood

M/C

Activity Rx

0

10

20

30

40

50

60

70

80

Insomnia-Related Issue

% S

ub

ject

s

Arousal Problems Adversely Impact Rehabilitation

(Worthington and co-workers, 2006)

% Subjects with Arousal Problem

47%

Arousal Problems Adversely Impact Rehabilitation

(Worthington and co-workers, 2006)

% Subjects Whose Arousal Problem Interfered with Rehab

67%

Other Issues Complicate Sleep Problems

• Pain -> 2-fold increase in insomnia complaints (Beetar et al., 1996)

• Neuropsychological function being more intact greater sleep dysfunction (Mahmood et al., 2004)

• Older individuals and women more likely to have sleep problems (Clinchot et al., 1998)

Case Revisited

• Additional history obtained from his wife

• Increased snoring, witnessed apneas

• 30 lb weight gain• AM headaches• Sleep-onset insomnia

Diagnosis

• Screening in a sleep clinic

• Diagnostic polysomnography as indicated

Treatments

• Little data on response to treatments

• Direct treatments to underlying sleep issue– CPAP for sleep disordered breathing– Light and melatonin for circadian rhythm

disorders– Aggressively treat co-morbidities (eg. pain,

depression)

Key Points

• Many sleep complaints have an identifiable underlying cause

• Treatments are available