Traumatic brain injury (TBI) is a significant cause of disability and death in the United States and worldwide. Each year, it is estimated that there are between 1.6 – 3 million cases. Head injuries are usually caused by falls, motor vehicle accidents, impact from an object or assaults. There is also increasing awareness of TBI in military personnel. Among those deployed, 11–23% have suffered from TBI, often from explosive device blasts. Mental health problems may be particularly noticeable symptoms of TBI. For patients like athletes and military personnel, PTSD and depression are extremely common comorbidities.
The Glasgow Coma Scale (GCS) is the most common scoring system used to describe the level of severity sustained after a TBI.
- Mild = 13-15
- Moderate = 9-12
- Severe = 3-8
| Criteria | Mild | Moderate | Severe |
| Structural Imaging | Normal | Normal or abnormal | Normal or abnormal |
| Loss of Consciousness | < 30 minutes | 30 minutes to 24 hours | >24 hours |
| Alteration of Consciousness/Mental State | A moment to 24 hours | >24 hours | >24 hours |
| Post-traumatic Amnesia | 0–1 day | >1 and <7 days | >7 days |
| Glasgow Coma Scale (best available score in 24 hours) | 13–15 | 9–12 | 3–8 |
Chart reference: https://www.ncbi.nlm.nih.gov/books/NBK98986/table/introduction.t1/
TBI can result in significant motor, sensory, cognitive, and emotional impairments. Even mild TBI can be associated with headaches, dizziness, nausea/vomiting, impaired balance & coordination, vision changes, tinnitus, mood and memory changes, difficulty with memory and attention, and fatigue and/or sleep disturbances.
Additional abnormalities on formal testing in survivors of TBI include excessive daytime sleepiness, increased sleep need, and sleep-related breathing disorders. The type of sleep disturbance resulting from a TBI depends on the location of injury. These regions include the brainstem reticular formation, posterior hypothalamus and the area surrounding the third ventricle. High cervical cord lesions have also been known to cause sleepiness and Obstructive Sleep Apnea (OSA).
The prevalence of sleep-wake disturbances after TBI (30-70% of people affected) varies depending on the phase and severity of injury.
- Insomnia
- OSA
- RLS
- Difficulty maintaining sleep & poor sleep efficiency (shown on PSG)
- Early morning awakenings
- Nightmares/Sleep terrors
- Sleepwalking
- Narcolepsy
- Parasomnias
- Dementia
Those with more severe head injuries are less aware of their deficits and may underreport sleep issues. They may also have greater pressures to reintegrate into their daily life more quickly leading to increased stress and sleep issues.
Unfortunately, the majority of adult TBI sufferers are never investigated for sleep disorders. In children, 10–38% with TBI experience sleep disturbances, the highest being in the critical period immediately following the injury. Studies have shown that closed head injuries can lead to the disturbance of circadian rhythms.
When a TBI patient tries to conform to traditional sleep/wake times, they struggle with insomnia, as they may have gone to bed out of sync with their internal biological clock. The TBI patient has multiple irregular sleep/wake bouts throughout the night with no link to traditional light/dark cycles.
Fatigue is another complaint associated with TBI (up to 53% & more women than men). Depression and anxiety are common after TBI. Patients with mild TBI and sleep complaints reported feeling depressed at 10 days and 6 weeks after their injury. In addition, pain is a common comorbid condition, contributing to sleep disturbances and mood disturbances. Emotional and behavioral problems in children are prevalent, leading to social and academic challenges. Because sleep disorders affect people’s quality of life, it is important to develop strategies to identify these disorders early, as well as prevent them from worsening over time.
Sleep symptoms are often amenable to pharmacological or psychological interventions. Treatments for sleep disorders associated with TBI can include the use of medications, behavioral therapy/modifications, CPAP and/or oral appliance therapy.
For more information on various treatments for sleep disorders, please contact our office.
References
Leng Y, Byers AL, Barnes DE, Peltz CB, Li Y, Yaffe K. Traumatic brain injury and incidence risk of sleep disorders in nearly 200,000 US veterans. Neurology. Published online March 3, 2021. doi:10.1212/WNL.0000000000011656
Albrecht JS, Wickwire EM. Sleep disturbances among older adults following traumatic brain injury. Int Rev Psychiatry. 2020 Feb;32(1):31-38. doi: 10.1080/09540261.2019.1656176. Epub 2019 Sep 23. PMID: 31547739; PMCID: PMC6986451.
McKeon AB, Stocker RPJ, Germain A. Traumatic brain injury and sleep disturbances in combat-exposed service members and veterans: Where to go next? NeuroRehabilitation. 2019;45(2):163-185. doi: 10.3233/NRE-192804. PMID: 31707378.
Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol. 2015 Jul;14(7):746-57. doi: 10.1016/S1474-4422(15)00068-X. PMID: 26067127.
Wickwire EM, Schnyer DM, Germain A, Williams SG, Lettieri CJ, McKeon AB, Scharf SM, Stocker R, Albrecht J, Badjatia N, Markowitz AJ, Manley GT. Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda. J Neurotrauma. 2018 Nov 15;35(22):2615-2631. doi: 10.1089/neu.2017.5243. Epub 2018 Aug 24. Erratum in: J Neurotrauma. 2019 Dec 1;36(23):3316
Imbach LL, Büchele F, Valko PO, Li T, Maric A, Stover JF, Bassetti CL, Mica L, Werth E, Baumann CR. Sleep-wake disorders persist 18 months after traumatic brain injury but remain underrecognized. Neurology. 2016 May 24;86(21):1945-9. doi: 10.1212/WNL.0000000000002697. Epub 2016 Apr 27. PMID: 27164676.
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 Oct;88(10):1284-8. doi: 10.1016/j.apmr.2007.07.012. PMID: 17908570.
