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  • Updated 12.08.2019
  • Released 04.22.1994
  • Expires For CME 12.08.2022

Posttraumatic sleep disturbance

Introduction

Overview

Sleep disturbances are common after traumatic brain injury, affecting 30% to 84% of individuals, with varying degree of head injury. Not only can they negatively impact neurocognitive rehabilitation, but they also add to morbidity and slow the course of recovery. Several sleep impairments are described including insomnia, fatigue, and excessive daytime sleepiness, which are the most frequent complaints after head injury. Circadian rhythm dysregulation, sleep apnea (obstructive or central), restless leg syndrome, and parasomnias have also been reported after trauma. In addition, depression, anxiety, and pain are common comorbidities with substantial influence on sleep quality and course of recovery. Diagnosis of sleep disorders after traumatic brain injury may involve meticulous history, polysomnography, actigraphy, and multiple sleep latency testing. Treatment is disorder specific and may include pharmacotherapy, positive airway pressure, behavioral modifications, or a combination of these. Unfortunately, treatment of sleep disorders associated with traumatic brain injury have met with little success in improving clinical outcomes mainly due to confounding psychiatric and neurobehavioral sequela of trauma. Nonetheless, some recent studies have demonstrated encouraging results, which highlight the need for further research and prospective studies to be able to standardize targeted management approach.

Table 1. Sleep Disturbances Associated with Traumatic Brain Injury

A. Insomnia

1. Sleep onset
2. Sleep maintenance

B. Disorders of hypersomnia

1. Posttraumatic hypersomnia
2. Narcolepsy secondary to other causes

C. Sleep-related disordered breathing

1. Obstructive sleep apnea (OSA)
2. Central sleep apnea (CSA)

D. Circadian rhythm disorder

1. Delayed sleep phase syndrome (DSPS)
2. Advanced sleep phase syndrome
3. Irregular sleep wake syndrome
4. Non-24 hour sleep disorder

E. Movement disorder

1. Restless legs syndrome (RLS)
2. Periodic limb movement disorder (PLMD)

F. Parasomnia

1. Non-REM parasomnia
2. REM sleep behavior disorder (RBD)

(Wolf 2018)

Key points

• Sleep disturbance after traumatic brain injury occurs in 30% to 84% of individuals.

• Insomnia, fatigue, and sleepiness are the most frequent complaints after head injury.

• Sleep disturbances impact neuropsychological and cognitive rehabilitation of TBI patients negatively.

• Diagnosis of sleep disorder after traumatic brain injury includes comprehensive history, polysomnography, actigraphy, and multiple sleep latency test.

• Treatment is disorder specific and may include the use of medications, continuous positive airway pressure, and behavioral modifications.

Historical note and terminology

Traumatic brain injury is a significant cause of disability and death in the United States and worldwide. It is most frequently classified as mild, moderate, or severe using the Glasgow Coma Scale (mild = 13 to 15; moderate = 9 to 12; severe = less than or equal to 8 out of 15) (60). Although there is paucity of literature on relationship between head trauma and sleep disturbances, there has been emerging evidence recognizing the association between sleep disturbances in brain injury and poor cognitive, behavioral, and psychiatric outcomes (42). Sleep disturbances after traumatic brain injury are thought to occur in 30% to 70% of patients and often impair the resumption of the individual’s normal activities (33).

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