Sleep-Wake Disturbances

Doctor image

More than 50% of patients report sleep disturbances following concussion, specifically insomnia, hypersomnia, obstructive sleep apnea, poor sleep maintenance, poor sleep efficiency, early awakening, delayed sleep onset, or alterations in circadian cycle. (see Appendix 7.1).1-5 In the immediate acute stage of concussion, there may be an increased need for sleep6, however, this decreases over time and insomnia is the most common form of sleep disturbance reported in the subacute and chronic stages of concussion. 

Obtaining a history from the patient to record the concussion, to rule out pre-existing sleep disorders, and to document symptoms after the injury is key. Once a thorough evaluation has been conducted, treatment of sleep disorders within the concussion population may take the form of both non-pharmacologic and pharmacologic methods. For insomnia, cognitive behavioural therapy (CBT) is recommended7-9. Referral to a professional with training and expertise in CBT for insomnia is ideal, however, while waiting for formalized CBT treatment for insomnia, or if this treatment is not available, behavioral recommendations (e.g., restriction of time in bed and stimulus control) can still be implemented by primary care providers2,8,10. Some online Referral to a sleep specialist is essential to evaluate and treat less common sleep problems associated with concussion, such as a sleep-related breathing disorder (e.g., obstructive sleep apnea), circadian rhythm shift, restless leg syndrome, periodic limb movement disorder, and REM sleep behaviour disorder.

Introduction-only references:

  1. Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems following traumatic brain injury: a meta- analysis. Sleep Med. 2012;13(7):898-905. 
  2. Baumann CR. Traumatic brain injury and disturbed sleep and wakefulness. Neuromolecular Med. 2012;14(3):205-212. 
  3. Wiseman-Hakes C, Colantonio A, Gargaro J. Sleep and wake disorders following traumatic brain injury: A systematic review of the literature. CriticalReviews in Physical and Rehabilitation Medicine. 2009;21(3-4):317-374. 
  4. Castriotta RJ, Wilde MC, Lai JM, Atanasov S, Masel BE, Kuna ST. Prevalence and consequences of sleep disorders in traumatic brain injury. J Clin Sleep Med. 2007;3(4):349-356. 
  5. Theadom A, Cropley M, Parmar P, et al. Sleep difficulties one year following mild traumatic brain injury in a population-based study. Sleep Med. 2015;16(8):926-932.
  6. Raikes AC, Schaefer SY. Sleep Quantity and Quality during Acute Concussion: A Pilot Study. Sleep. 2016;39(12):2141-2147.
  7. Ouellet MC, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia associated with traumatic brain injury: a single case experimental design. Arch Phys Med Rehabil. 2007;88(12):1581-1592.
  8. Ouellet MC, Morin CM. Cognitive behavioral therapy for insomnia associated with traumatic brain injury: a single-case study. Arch Phys Med Rehabil. 2004;85(8):1298-1302 23. 
  9. Espie CA, MacMahon KM, Kelly HL, et al. Randomized clinical effectiveness trial of nurse-administered small-group cognitive behavior therapy for persistent insomnia in general practice. Sleep. 2007;30(5):574-584.
  10. Castriotta RJ, Murthy JN. Sleep disorders in patients with traumatic brain injury: a review. CNS Drugs. 2011;25(3):175-185.

 

Assessment of Sleep-Wake Disturbances
7.1

Patients should be educated and reassured about the fact that sleep alterations are very common in the acute stages of concussion/mTBI.

Level of Evidence Not Applicable
Last updated  
7.2

Patients who have identified sleep alterations should be monitored for sleep/wake disturbances. Patients who have persisting sleep disturbances should be monitored for sleep-wake disorders (e.g., insomnia, excessive daytime sleepiness). (see Appendices 7.2 and 7.3).

Level of Evidence Not Applicable
Last updated  
7.3

Screen for pre-existing sleep disturbances/ disorders, medical conditions, current medication use, comorbid psychopathology and risk factors for sleep disturbances, which may influence the sleep/wake cycle (see Table 7.1).

Level of Evidence Not Applicable
Last updated  
7.4

Referral for a sleep specialist consultation and polysomnography (e.g., sleep study, Multiple Sleep Latency Test, Maintenance of Wakefulness Test) should be considered if sleep disturbances persist or if there is suspicion of sleep-related breathing disorders, nocturnal seizures, periodic limb movements, or narcolepsy.

Level of Evidence Not Applicable
Last updated  
Non-Pharmacologic Treatment of Sleep-Wake Disturbances
7.5

It is recommended to treat sleep-wake disturbances in patients with concussion/mTBI. Treatment of sleep disorders may help with:

  • Mood
  • Anxiety
  • Pain
  • Fatigue
  • Cognitive Problems
Level of Evidence Not Applicable
Last updated  
7.6

All patients with persistent sleep-wake complaints should be placed on a program of sleep hygiene. Behavioural interventions for sleep (e.g., cognitive-behavioral therapy techniques, mindfulness-based therapies) should also be considered. See Appendix 7.4 for a sleep hygiene program and Appendix 7.5 for behavioral recommendations for optimal sleep.

Level of Evidence Not Applicable
Last updated  
7.7

Cognitive behavioural therapy (CBT) for insomnia is established as the treatment of choice for either primary insomnia or insomnia comorbid to a medical or psychiatric condition.

Level of Evidence Not Applicable
Last updated  
7.8

Other non-pharmacologic treatment options that have been found to be useful in the treatment of insomnia include:

  • Melatonin (taken 2 hours before bedtime in conjunction with reduced evening light exposure and light therapy in the morning)
  • Magnesium and zinc supplementation
  • Acupuncture and mindfulness-based stress reduction therapy
Level of Evidence Not Applicable
Last updated  
Pharmacologic Treatment of Sleep-Wake Disturbances
7.9

When pharmacologic interventions are used, the aim is to establish a more routine sleep-wake pattern using agents with minimal risk of dependency and adverse effects in patients with concussion/mTBI.

Medications to be considered include low-dose trazodone and tricyclic antidepressants (e.g., Amitryptyline, Doxepine), as well as mirtazapine. Prazosin may be considered in patients with nightmares and PTSD. Benzodiazepines should generally be avoided; however, nonbenzodiazepine medications (e.g., Zopiclone, Exzopiclone) may have fewer adverse effects and may be considered for short-term use.

Level of Evidence Not Applicable
Last updated  
7.10

The use of Modafinil and Armodafinil can be considered in patients with excessive daytime sleepiness. (Level A is for Armodafinil)

Level of Evidence Not Applicable
Last updated  
Appendix 7.1
Brief Definitions of Sleep Disorders Most Frequently Reported Following TBI
appendix-7-1.pdf
Appendix 7.2
Short Clinical Interview for Sleep after Head Injury
appendix-7-2.pdf
 

EVALUATION

Title of Resource: Short Clinical Interview for Sleep after Head Injury

Reference: Ouellet MC, Beaulieu-Bonneau S Morin CM. Sleep-Wake Disturbances. In Eds. Zasler ND, Katz DI, Zafonte RD. Brain Injury Medicine: Principles and Practice. New York; Demos Medical Publishing LLC; 2012.

Description: The short clinical interview for sleep after head injury was designed to qualitatively assess for common sleep or sleep/wake disturbances and changes after brain injury as well as a history of the problem. 

Resource Criteria:

PopulationAdults with Head Injury 

Reliability/ Validity

NA

Proprietary?
Yes

Time to Administer

6-15 minutes

Method to Administer

Patient Interview 

Formal Instructions (Mention if special environment/ equipment is needed)

NA

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5  Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

Appendix 7.3
Sleep and Concussion Questionnaire
appendix-7-3.pdf
 

EVALUATION

Title of Resource: Sleep and Concussion Questionnaire 

Reference: Catherine Wiseman-Hakes & Marie-Christine Ouellet (Expert Consensus Members)

Description:   5-item self-report questionnaire used to determine severity of changes in sleep/wake patterns after a mild TBI/concussion.

Resource Criteria:

Population

Post-concussion sleep problems

Reliability/ Validity

The reliability/validity of the Sleep & Concussion Questionnaire is not yet available.

Proprietary?
No

Time to Administer

5 minutes

Method to Administer

Self-report questionnaire

Formal Instructions (Mention if special environment/ equipment is needed)

None

Instructional Video Available?
No

Ease of Use (By Patient)
Very Difficult   1     2     3     4     5   Very Easy


Ease of Administration (By Administrator)
Very Difficult   1     2     3     4     5   Very Easy


Other Comments
None

Appendix 7.4
Sleep Hygiene Program
appendix-7-4.pdf
Appendix 7.5
Behavioural Recommendations for Optimal Sleep
appendix-7-5.pdf
Appendix 7.6
Sleep Diary
appendix-7-6.pdf
Appendix 7.7
Limiting Time Spent in Bed
appendix-7-7.pdf
Appendix 7.8
Recreating a Time and Place for Sleep
appendix-7-8.pdf
Table 7.1
Important Components to Include in the Sleep-Wake Disturbances Screen
Algorithm 7.1
Assessment and Management of Persistent Sleep-Wake Disturbances Following mTBI
To learn more about strengths and limitations of the evidence informing each recommendation, click here.

Chan LG, Feinstein A. Persistent Sleep Disturbances Independently Predict Poorer Functional and Social Outcomes 1 Year After Mild Traumatic Brain Injury. J Head Trauma Rehabil. 2015;30(6):E67-75.
Country: Canada
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 13/32 *7 of the sections were not applicable

Theadom A, Cropley M, Parmar P, et al. Sleep difficulties one year following mild traumatic brain injury in a population-based study. Sleep Med. 2015;16(8):926-932.
Country: New Zealand
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 16/32 *5 of the sections were not applicable

Tkachenko N, Singh K, Hasanaj L, Serrano L, Kothare SV. Sleep Disorders Associated With Mild Traumatic Brain Injury Using Sport Concussion Assessment Tool 3. Pediatr Neurol. 2016;57:46-50.e41.
Country: USA
Design: Retrospective Cohort
Quality Rating: DOWNS & BLACK: 12/32 *7 of the sections were not applicable

Suzuki Y, Khoury S, El-Khatib H, et al. Individuals with pain need more sleep in the early stage of mild traumatic brain injury. Sleep Med. 2017;33:36-42.
Country: Canada
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 17/32 *4 of the sections were not applicable

Menn SJ, Yang R, Lankford A. Armodafinil for the treatment of excessive sleepiness associated with mild or moderate closed traumatic brain injury: a 12-week, randomized, double-blind study followed by a 12-month open-label extension. J Clin Sleep Med. 2014;10(11):1181-1191.
Country: USA
Design: Randomized Control Trial
Quality Rating: PEDro: 10/11

Waldron-Perrine B, McGuire AP, Spencer RJ, Drag LL, Pangilinan PH, Bieliauskas LA. The influence of sleep and mood on cognitive functioning among veterans being evaluated for mild traumatic brain injury. Mil Med. 2012;177(11):1293-1301.
Country: USA
Design: Prospective Cohort
Quality Rating: DOWNS & BLACK: 14/32 *6 of the sections were not applicable

Zollman FS, Larson EB, Wasek-Throm LK, Cyborski CM, Bode RK. Acupuncture for treatment of insomnia in patients with traumatic brain injury: a pilot intervention study. J Head Trauma Rehabil. 2012;27(2):135-142.
Country: USA
Design: Case-Control
Quality Rating: DOWNS & BLACK: 19/32 *1 of the sections were not applicable