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In the Spotlight

Sleep and Traumatic Brain Injury

Contributed by Dana Epstein, PhD, RN
Phoenix VA Health Care System

We spend about one-third of our lives asleep. A good night's sleep is important for maintaining a healthy lifestyle. However, many Americans do not get the sleep they need to function well during the day. Many things can keep us from healthy sleep. This may include work or family issues, other stress, medications we take, an illness or injury. One of the many conditions linked to sleep problems is Traumatic Brain Injury (TBI). Traumatic brain injury (TBI) is common among Veterans returning from Iraq and Afghanistan. Many persons with TBI also have sleep disorders such as insomnia and sleep-disordered breathing. Other sleep disorders found in TBI patients are circadian rhythm problems, narcolepsy and periodic limb movement disorder.

Insomnia is trouble falling asleep, or staying asleep and waking up too early. Over one-half of TBI patients complain of insomnia. Insomnia is most commonly treated with medication. TBI patients may be more sensitive to sleep medications because of their brain injury. There are effective non-medication treatments for insomnia. There have been only a few studies done to test non-medication treatments in TBI patients. The good news is the results were positive.

Persons with sleep-disordered breathing experience pauses in their breathing while asleep. Sleep-disordered breathing includes problems like sleep apnea. Thirty-five percent of TBI patients may have sleep apnea. Patients with sleep apnea that is moderate to severe have a couple of treatment options. One treatment used is continuous positive airway pressure (CPAP). Another one is Bilevel Positive Airway Pressure (BiPAP) therapy. Both CPAP and BiPAP use a stream of air through a mask worn while sleeping to keep the airway open.

Our bodies have an internal clock. This internal clock controls many of our body's processes, such as temperature and hormone production. They are controlled on a 24-hour cycle called circadian rhythms. Our sleep-wake cycle is also a circadian rhythm. Circadian rhythm sleep problems occur when a person's sleep-wake schedule (timing of sleep) does not match their work, school, or social schedule. An example of a circadian rhythm sleep problem is when a person cannot fall asleep until after 2 a.m. They then sleep through to mid-morning or late afternoon. If they do not have to wake up for work or school this pattern continues. There are several treatment options used for circadian rhythm sleep problems. These options include medication, rescheduling of the sleep-wake cycle, and bright light treatment.

People with narcolepsy have extremely strong urges to sleep during the day. The urge to sleep happens suddenly and without any warning . Persons with periodic limb movement disorder kick their legs and arms while asleep. It can happen quite often during the night. Often the bed partner is the one who notices the movements. These two disorders occur in about 6% of TBI patients. Medications are used to treat narcolepsy and periodic limb movement disorder.

It is difficult to know in what order the TBI and the sleep disorder occurred. Maybe the person with TBI had a sleep disorder before the TBI happened. Perhaps the sleep disorder contributed to the accident that caused the TBI. It is possible the sleep disorder started after the TBI. No matter what the order of events, people with TBI and sleep problems often have trouble with everyday living. Persons with TBI often report problems with thinking, reasoning, and remembering. Sleep difficulty can make these problems worse. Trouble sleeping can provoke symptoms such as irritability, pain, and fatigue. This can slow down recovery from TBI.

Many of the sleep disorders described above can be assessed in an overnight sleep study. These studies are done in a clinical sleep lab. Others can be diagnosed through a clinical interview and examination by your health care provider.

Some research has examined the night time sleep habits of persons with TBI using the sleep laboratory method. A few of these studies show that sleep is broken up during the night. When compared to persons without TBI, they found that TBI patients spend more time awake during the night and more time in light sleep and in dream sleep.

Sleep disorders are treatable. Treating sleep disorders may improve other health problems. It may also make a difference in your quality of life. If you have experienced a TBI and have problems with your sleep, it is important to talk to your health care provider. Also check out some of the tips for healthy sleep in the Healthy Sleep Center.

Learn More

Traumatismo cerebral y de cabeza (Medline Plus) (en Español)

Traumatic Brain Injury Learning Activity (Medline Plus) (Interactive Tutorial)

Traumatic Brain Injury: Hope Through Research (NINDS)

El Traumatismo Cerebral: Esperanza en la Investigación (NINDS) (en Español)

America's Heroes at Work (Job Accommodations Network)

Sleep Disorders (Medline Plus)

Dr. Epstein is the Associate Chief Nursing Service/Research at the Phoenix VAHCS. She is currently funded by the VA HSR&D QUERI program to test a preference-based insomnia treatment for OEF/OIF Veterans.

Updated/Reviewed: June 30, 2009