SLEEP DISTURBANCE

AFTER TRAUMATIC
BRAIN
INJURY: NEW INSIGHT
 ABSTRACT

Disruptions in sleep-wake cycles are particularly prevalent after a Traumatic

Brain Injury (TBI). Sleep disruptions may occur as a main impact of brain damage or as a
result of other neuropsychiatric sequelae of TBI, such as anxiety disorder, depressive
disorders, substance abuse, chronic pain, and/or medication consumption. Chronic
discomfort (headache and broad pain, presumably of central origin) and/or sleep difficulties
(insomnia, disturbed breathing, periodic limb movements) occur in about one in five people
with TBI. Disruptions in sleep-wake cycles linked with TBI need therapy. Although data
specific to individuals with TBI is currently limited, cognitive-behavioral treatment and
medication may be beneficial in alleviating sleep-wake problems in people who have
sustained a TBI. This article aims to raise awareness of sleep disturbance after TBI to
enhance diagnosis, assessment, and therapy and disclose new research opportunities.

Keywords: Sleep disturbance, traumatic brain injury, hypersomnia, insomnia

Introduction
Indicator Traumatic brain injury (TBI)

After traumatic brain injury, sleep disruption has a poor

01 correlation with the first Glasgow Coma Scale (GCS).

After a TBI, 50% of patients experienced some sort of

02 sleep disruption and 25%–29% had a documented
sleep disorder (insomnia, hypersomnia, or apnea)

Additionally, they were two to four times as likely to

have difficulty maintaining sleep quality and efficiency,
03 nightmares, excessive drowsiness, early awakenings,
and sleep walking
Sleep and TBI
• Sleep disruption following TBI is objectively defined as frequent overnight
awakenings, increased proportions of stage 1 and stage 2 sleep, reduced
percentage of rapid eye movement (REM) sleep, and shorter REM sleep
latencies

• It is shown that 7–10% of people who initially experience Insomnia have a

disruption in their circadian rhythm; nevertheless, this disruption may go
unrecognized by both patients and physicians

• Insomnia is more prevalent in mild TBI patients than in severe TBI patients.
Repeated mild TBI significantly increases the risk
Pathophysiology of Sleep
Disturbance
after TBI
• TBI-related neuropsychiatric problems such as
depression, anxiety, drug abuse, chronic pain, and/or
medication use may all have an influence on sleep,
whether as a direct result of brain injury or as a
secondary consequence

• Traumatic brain injury is most often caused by coup-

countercoup, which frequently happens towards the
base of the skull in regions with bony prominences,
frequently injured the inferior frontal regions, anterior
temporal and, aswell as the base of forebrain. Due to
the fact that the basal forebrain is involved in sleep
initiation, damage to this area may result in insomnia
symptoms.
 Insomnia
Insomnia
Insomnia is defined as affects between 30% and 60%
troubles sleeping and/or of patients who have had a
TBI, irrespectively of severity
staying asleep

Patients usually Treatments

complains:
 Difficulties falling asleep,  cognitive behavioral
fragmentation of sleep, therapy,
and/or waking up too  sleep hygiene,
early in the morning,  treatment of
 Resulting in exhaustion, psychiatric
 Sleepiness, comorbidities,
 Poor mood  medication,
 Low performance
throughout the day.
 Hypersomnia

Hypersomnia, often known as excessive daytime sleepiness (EDD), is a

sleep disorder characterized by recurrent bouts of excessive daytime
sleepiness or involuntary sleepiness at unexpected times.

TBI patients tend to underestimate their symptoms of daytime sleepiness in

the same way as they underestimate their symptoms of insomnia.

The pathogenesis of posttraumatic hypersomnia is most likely connected to

direct injury to the tuberomammillary histaminergic wakefulness neurons,
which drop by around 40% after a severe traumatic brain injury. The test is
referred to as the multiple sleep latency test (MSLT). Treatment for this
disorder may include the use of stimulant medications.
 Circadian Rhythm Disorder

• TBI-induced hypothalamic and suprachiasmatic nucleus damage is

thought to be the primary cause of circadian rhythm disruption

• There are two common abnormalities in the circadian rhythm of

sleep that might be unnoticed following a traumatic brain injury:
delayed sleep phase syndrome and irregular sleep-wake rhythm.

• As a result, insomnia may be misdiagnosed when a patient

complains of difficulties getting to sleep, staying asleep, and
problems waking up at their typical time.
Treatment Pharmacological
 Benzodiazepine Sedative-Hypnotics

Benzodiazepines might hinder neuronal

recovery in patients with brain damage,
thus they should be administered with
care

Lorazepam (0.5–2.0 mg), temazepam

(7.5–30 mg), and clonazepam (0.25–
2.0 mg) are among the
benzodiazepines routinely used at
bedtimes as hypnotic

The most common use is to treat short-

term Insomnia or temporary insomnia
 Nonbenzodiazepine Sedative-Hypnotics

Anterograde amnesia and rebound

insomnia have also been
recorded.
 Zaleplon (5–10 mg at bedtime)
 Zolpidem (5– 10 mg at bedtime)
Are both nonbenzodiazepines that
are often used to treat temporary
insomnia
Modafinil and Armodafinil
● Taking 100- 200 mg/day of modafinil in
the morning has been shown to be both
safe and effective for improving
sleepiness.
● Patients receiving 250 mg armodafinil,
the R-enantiomer of modafinil, saw a
substantial reduction in sleep latency
compared to placebo
Melatonin
• Melatonin has also been shown to lessen
symptoms of anxiety and tiredness in
individuals, as well as boost their perceptions
of their own vitality and cognitive abilities
• Melatonin is a serotonin metabolite. Melatonin
synthesis is enhanced in the dark, whereas its
secretion is suppressed in the light.
• It is critical for maintaining the biological
rhythm of the body and for coordinating the
sleep-wake cycle with the surroundings.
 Treatment
Non-pharmacological
 Sleep Hygiene and Behavioural Therapy

Late afternoon is the ideal time to avoid caffeinated beverages, such as tea, coffee, and
soda. When it comes to nighttime routines, it's best to avoid using television, tablets, or
smartphones in the bedroom.

If you've been awake for more than 20 minutes, it's time to get out of bed and do
something calming like listening to music or reading a book

CBT for insomnia (CBTi) is regarded as the first-line treatment for insomnia management.
Aims at changing sleep-related beliefs and attitudes by identifying and correcting their root
causes
 Light therapy

• Stimulant and antidepressant effects have both been found in the utilization
of certain wavelengths of ocular light exposure

• Studies have shown that exposure to blue or blue-enriched light improves

alertness and mood the most. As a consequence, sleep quality may be
improved by increasing sleep duration and lowering nocturnal awakenings

• Treatment with blue light 45 minutes/day for four weeks resulted in

decreased daytime sleepiness and fatigue, with a return to baseline after
treatment cessation.
Conclusion
 Conclusion

Insomnia, hypersomnia, sleep-wake cycle irregularities, and

parasomnia are a few of the most common sleep disorders associated
with TBI. Sleep disturbances may manifest as a unique trait or as a
symptom of various mental, medical, or neurological conditions. Patients
with TBI may experience a variety of sleep disturbances at different
points after the injury.
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