Insights about sleep-wake disturbances after concussion
By Hannah Hartmann. This article was initially published in our Concussion Update newsletter; please consider subscribing.
A review article by Stefanie Howell in the Psychiatric Times provides information to identify sleep-wake disturbances after traumatic brain injury (TBI), along with current diagnostic and treatment strategies. Although Howell writes generally about TBI (presumably of all severities), she notes that sleep-wake disturbances may develop after mild TBI (concussion), and several of the studies she references are specifically about mild TBI.
Sleep is essential for brain health and overall cognitive functioning. Following a TBI, sleep-wake disturbances (SWD) are common. SWD may be caused by primary damage to the sleep-wake circuitry or a “secondary consequence of a TBI-related” comorbidity such as emotional disturbances or pain. A proper sleep cycle is required to store memories in the hippocampus and learn motor skills. Disturbed sleep has been associated with increased daytime sleepiness, reduced mood, and impaired judgment. SWD may contribute to common persisting symptoms after a TBI, which include problems with learning and memory, executive functioning, social interactions, and emotional and behavioral responses.
When assessing for SWD, clinical interviews, sleep diaries, and self-reported questionnaires are helpful for diagnosis and treatment. Comorbid factors such as pain, mood disturbances, drugs, alcohol, and medications should be considered.
Other technological measurements to assess sleep quality include overnight actigraphy or polysomnography, which records brain, muscle, and respiratory activity. After a TBI, including concussion, there is a high rate of sleep apnea, which the patient should be screened for.
Treatment depends on the type of sleep disturbance present. Sleep hygiene is beneficial for all sleep disturbances. Sleep hygiene includes establishing a healthy sleep routine such as consistent bed and wake times, relaxing evening activities, limiting caffeine and alcohol, and managing stress. In addition, mental health therapies such as cognitive behavioral therapy and relaxation training can also help to increase sleep quality. Another treatment found to be beneficial in reducing daytime sleepiness and improving mood is red light therapy. Overall, a multidimensional treatment approach is often the most successful for improving sleep quality in TBI patients.
Although not mentioned in this article, Cognitive Behavioral Therapy for Insomnia, CBT-I, is an evidence-based treatment. We have information about this treatment; see our previous synopsis under Self Care, and check this section on sleep on our website.
