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)
20
18
16
14
12
10
8
6
4
2
0
# papers
published
2000
2002
2004
2006
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/
Authors
Acute vs Chronic
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/
Authors
Acute vs Chronic
Insomnia
30%
Fichenberg,
2000
29.4% (9%)
All/acute &
chronic
All/chronic
30%
All/chronic
Verma, 2007
OSA
CRSD
Ouellet, 2006
23% (4-20%) All/chronic
Castriotta, 2007
36%
Ayalon, 2007
Mild/?
Wide Range of Sleep Disorders
Diagnosis
Prevalence
(general pop.)
TBI Severity/
Authors
Acute vs Chronic
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)
80
M/C
% Subjects
70
Mood
60
50
40
Activity
Rx
30
20
10
0
Insomnia-Related Issue
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