Sleep after Traumatic Brain

Injury
a,b, c
Kris B. Weymann, PhD, RN *, Jennifer M. Rourke, MS, RN, AGCNS-BC, CCRN

KEYWORDS
 Traumatic brain injury  Sleep  Sleep–wake disorders  Insomnia  Fatigue

KEY POINTS
 Sleep disturbances are common after traumatic brain injury of all levels of severity, and
can arise early after injury and persist for years.
 Sleep disturbances interfere with functional recovery from traumatic brain injury.
 Preventing, recognizing, and addressing impaired sleep in the in-patient setting can pro-
mote recovery.
 Early and ongoing education about the importance of sleep and sleep hygiene strategies
should be included in care to improve recovery from traumatic brain injury.

INTRODUCTION

Sleep is essential for function.1 Some specific functions of sleep, such as memory
consolidation and learning, have been demonstrated.2,3 Yet overall functions of sleep
remain poorly understood. Four of 6 viable theories of sleep function reviewed by
Krueger and colleagues4 focus on brain health—promoting neural connectivity,
restoring neural networks to maintain cognitive and behavioral performance, allowing
for the flushing of substances from the brain tissue, and restoring brain energy stores.
The role of sleep in brain recovery from traumatic brain injury (TBI) may be important,
but it is not understood. TBI is defined as altered brain function from an external force,
rated as mild—such as concussion—or moderate or severe, usually determined by
score on the Glasgow Coma Scale. Although each TBI is unique, there are some com-
mon problems that arise from this heterogeneous disorder.
Sleep problems are among the most common complaints after TBI of all levels of
severity, and these problems can persist for years after injury.5–10 A meta-analysis
of 21 studies found that about 50% (95% confidence interval, 49%–51%) of people
had sleep disturbances after a TBI.11 In a prospective study of predominantly male

a
VA Portland Health Care System, Portland, OR, USA; b Oregon Health & Science University,
School of Nursing, SN-6S, 3455 Southwest US Veterans Hospital Road, Portland, OR 97239, USA;
c
VA Portland Health Care System, P2IESD, 3710 Southwest US Veterans Hospital Road, Port-
land, OR 97239, USA
* Corresponding author. Oregon Health & Science University, School of Nursing, SN-6S, 3455
Southwest US Veterans Hospital Road, Portland, OR 97239.
E-mail address: [email protected]

Nurs Clin N Am - (2021) -–-

https://doi.org/10.1016/j.cnur.2021.02.006 nursing.theclinics.com
0029-6465/21/Published by Elsevier Inc.
2 Weymann & Rourke

participants with a TBI, 72% and 67% had a sleep–wake disturbance 6 months and
3 years after injury, respectively.10 Among veterans, 56% of 527 participants reported
clinically significant poor sleep persisting for an average of 6 years, independent of a
variety of factors that could impair sleep.9 With 2.8 million emergency room visits in
2013 in the United States for TBI,12 and evidence of increasing rates of injury,13 under-
standing how to improve recovery from a TBI is critical. Preventing, recognizing, and
addressing sleep disorders after a TBI can contribute to promoting functional recov-
ery. The evidence of sleep importance after a TBI, along with clinical features and
management of the most common sleep disorders after a TBI in adults are presented
in this article.

IMPORTANCE OF SLEEP IN RECOVERY FROM TRAUMATIC BRAIN INJURY

There is increasing evidence indicating the importance of sleep for recovery from a TBI
(Fig. 1).14 In a study of 238 individuals evaluated within 24 hours after a TBI, those with
trouble falling asleep or with short sleep were more functionally impaired during the
first 6 months after injury than those with good sleep.15 In a study of 64 participants,
those with sleep features within the first 14 days after a TBI as determined by electro-
encephalography were found to have earlier participation in rehabilitative therapies
and better functional recovery, independent of Glasgow Coma Scale scores at admis-
sion.16 Disrupted sleep was found to predict agitation after a moderate to severe brain

Fig. 1. Restoring sleep after traumatic brain injury.54–56

 Sleep after Traumatic Brain Injury 3

injury,17 a concern given the risk of delirium in patients with a TBI.18 In a prospective
study, poor sleep in the intensive care unit increased the chance of developing
delirium by 10.7 times.19 In a study of 30 people in the acute phase of a moderate
or severe TBI, the reappearance of a normal sleep–wake cycle, measured with wrist
actigraphy, was found to be synchronous with the ability to follow commands with
appropriate verbal and motor responses. The authors suggested that a common un-
derlying brain mechanism may support both sleep–wake cycle and cognitive
function.20
The association of sleep with function and recovery was found to continue into the
rehabilitative period. Starting at admission to rehabilitation after a moderate to severe
TBI, sleep–wake cycle disturbance and weekly scores on the Cognitive Test for
Delirium were significantly associated, indicating that those with sleep–wake cycle
disturbance had greater cognitive impairment when matched for demographic and
injury variables.21 In a study of 59 patients with TBI recruited from a rehabilitation
unit, disrupted sleep measured both objectively and subjectively was associated
with poorer motor outcomes and a slower recovery.22
An association of sleep with function and recovery was found up to 2 years after
injury. In a study of 92 workers after an average of about 6 months after a mild TBI
(mTBI), insomnia was the only significant covariate in a fully adjusted work disability
model. The authors concluded the importance of diagnosis and management of
insomnia in persons with a mTBI to support higher function among workers.23
Comparing those with a mTBI with persistent sleep disturbances with those whose
sleep disturbances had resolved after injury, persistent sleep disturbance at 6 months
after injury, independent of psychological distress, predicted a poorer outcome.24 At
18 months after injury, Imbach and colleagues25 found that those with a TBI needed an
additional hour of sleep compared with matched controls, and 67% of those with TBI
had chronic objective excessive daytime sleepiness compared with 19% of controls.
Patients under-reported sleep need and excessive daytime sleepiness. The authors
concluded that untreated sleep–wake disorders in those with a TBI could impair qual-
ity of life and risk safety.25 At 5 years after TBI, there was a 1.36-fold increase in sleep
disturbance compared with non-TBI controls in a population-based cohort study
including 6932 with TBI and 34,660 matched controls.8
It is not known why sleep is so commonly disrupted after TBI. A variety of mecha-
nisms have been proposed, including neurotransmitter disruption to or from the hypo-
thalamus, brain stem, or pineal gland. This disruption could affect glutamate, galanin,
or melatonin signaling involved with sleep, and/or disruption of neurotransmitters
affecting wakefulness—including orexin, histamine, serotonin, dopamine, norepi-
nephrine, and other substancess.7 Some mechanisms have been elucidated by
studies in animal models, with more research after a TBI needed.5 Even without clear
diagnostic tools, recognizing and intervening to restore sleep after a TBI is an impor-
tant health and safety issue.

SLEEP CONCERNS IN ACUTE PERIOD AFTER TRAUMATIC BRAIN INJURY

An ongoing concern for patients hospitalized after a TBI is the overlap of risk factors
and presentation of impaired sleep and the bidirectional relationship with delirium,
particularly the hypoactive subtype characterized by lethargy and sedation.26 One-
half of patients with a mild to moderate TBI developed delirium within the first
4 days after injury, with 69.4% developing delirium during the hospitalization.18
The initial treatment of sleep–wake disorders after a TBI should include nonpharma-
cologic interventions to modify environmental and behavioral factors (Table 1).27 In a
4 Weymann & Rourke

Table 1
Clinics care points

Clinical Care Points to Promote Sleep in the Hospital

Daytime Nighttime
 Lights on during the day.  Minimize light in the evening and during
 Position near a window if possible. the night.
 Promote patient engagement—visitors,  Limit blue screen time in the evening.
hearing aids, and eye glasses as indicated.  Limit noise; consider white noise.
 Reorient the patient, provide clock.  Provide a sleep mask/ear plugs if not
 Minimize late afternoon naps. contraindicated.
 Eat meals at regular times.  Encourage a consistent bedtime routine.
 Exercise/progressive mobility.  Bundle tasks.
 Limit evening caffeine.  Complete procedures at the beginning or
the end of the shift.

review of sleep disruptions in the intensive care unit, 21% of disruptions were from
sound, with patient care activities, illness severity, and pain also associated with sleep
disruption.26
The success of nonpharmacologic interventions may be limited when there is
impaired cognition.26 A multifaceted and multidisciplinary approach including medica-
tion for sleep–wake disorders can improve patient outcomes by decreasing daytime
sleepiness, neurobehavioral impairments, and the risk of delirium.27,28 In a random-
ized, controlled, double-blinded study, daytime alertness improved in patients with
a mild to severe TBI after an evening dose of melatonin.29 Additional medications
for sleep–wake disorders may include antidepressants; GABA agonists such as zolpi-
dem; alpha-1 receptor adrenergic blockers such as prazosin, which can be beneficial
when post-traumatic stress disorder is associated with a TBI; and careful use of ben-
zodiazepines. Anticholinergic medication for sleep–wake disorders in a patient with a
TBI should be avoided for the first 3 months owing to adverse cognitive effects.29

COMMON SLEEP–WAKE DISTURBANCES AFTER TRAUMATIC BRAIN INJURY:

SUBACUTE AND CHRONIC PERIODS

Common sleep–wake disorders after TBI include hypersomnia, insomnia, sleep–wake

cycle disturbance, sleep apnea, excessive daytime sleepiness, and fatigue.6,11 These
disorders can overlap and likely contribute to excessive daytime sleepiness and fa-
tigue as symptoms of a sleep disorder.30 The frequency of occurrence in the subacute
and chronic periods; the clinical features are presented in Table 2.
Hypersomnia
Hypersomnia, or pleiosomnia, is an increased need to sleep, over a 24-hour period, as
compared with before the injury. Unrelieved pain after a mTBI was found to be asso-
ciated with a greater number of naps during the day at 1 month after injury.31 It should
be taken into account that the recommended amount of sleep for a healthy adult is 7 to
9 hours,32 which may not be reflected in the baseline sleep, because those with short
sleep are at increased risk of injury.33 Hypersomnia often manifests as sleep need dur-
ing the day, making it difficult to distinguish from excessive daytime sleepiness, which
is discussed separately.
Insomnia
Insomnia is delayed sleep onset, awakenings with difficulty returning to sleep, and/or
waking too early, resulting in distress and daytime subjective impairment. Insomnia
 Sleep after Traumatic Brain Injury 5

Table 2
Common sleep disorders after traumatic brain injury and frequency in subacute and chronic
time frames

Sleep Disorder Frequency Clinical Features

Increased sleep need 22%–49% Increased sleep need of 2 h over 24 h as compared
(hypersomnia/ with before injury. Other causes of increased sleep
pleiosomnia) need excluded.
Insomnia 29%–65% Difficulty falling asleep or staying asleep, resulting in
distress and daytime subjective impairment.
Consider possible circadian rhythm disorder.
Sleep–wake cycle 36%–84% Sleeping during the day and awake at night, or lacking
(circadian rhythm) a clear pattern of sleep and wake, or a delayed sleep
disturbance pattern
Sleep apnea 25%–49% Cessation or reduction of breathing while asleep.
May be preexisting.
Excessive daytime 42%–47% Decreased alertness or drowsiness during the day;
sleepiness possible unintentional sleep at inappropriate times.
Fatigue >60% Subjective feeling of tiredness not proportional to
recent activity and interfering with usual function.

can be assessed with the Insomnia Severity Index, a 7-item measure with a total score
of 28 points, with a score of 15 or more indicating clinical insomnia.34 Insomnia is a
common problem after a TBI, with a frequency of 33% to 65% in the subacute and
chronic time periods,35,36 and can result in decreased satisfaction in life, increased
disability upon return to work, anxiety, and depression.35 Insomnia can contribute
to excessive daytime sleepiness and symptoms of fatigue. In a sample of 334 patients,
those with insomnia after a TBI were found to have worse sleep hygiene, supporting
that strategy as an intervention.35 Insomnia can mask a circadian rhythm disorder,
which necessitates detection and treatment to support recovery.37

Sleep–Wake Cycle Disturbance and Circadian Rhythm Disturbance

A sleep–wake cycle disturbance can manifest as lacking a clear pattern of sleep and
wake, or being awake at night and sleeping during the day. It can also manifest as a
delayed sleep phase that can be overlooked and interpreted as insomnia,37 or as an
advanced sleep phase.38 The management of a sleep–wake cycle disturbance is
similar with and without a TBI, although prolonged hospitalization, poor light exposure,
sedative effects of medications, and decreased mobility increase the difficulty of man-
agement after TBI.38 Morning light therapy to treat delayed sleep phase and evening
light therapy to treat advanced sleep phase have been demonstrated to be effective,38
keeping in mind that individuals with a TBI frequently have increased sensitivity to
light.39 Exciting recent findings indicate improved retinohypothalamic function after
blue light therapy after a TBI, suggesting that addressing any sleep–wake cycle distur-
bance may have additional benefits in brain recovery.40
The frequency of sleep–wake cycle disturbance after a TBI ranges from 36%41 to
84% at admission to rehabilitation, and decreasing to 66% at 1 month after the
injury.42 The presence of moderate to severe sleep–wake cycle disturbance predi-
cated the duration of rehabilitation hospital length stay.42 Interventions to restore night
sleep in the hospital setting are important because disrupted sleep is associated with
delirium, which is common after a TBI.18 Supporting sleep hygiene and addressing
6 Weymann & Rourke

pain or discomfort that could interfere with sleep are important early interventions to
both prevent and address sleep–wake cycle disturbances.

Sleep Apnea and Sleep-Disordered Breathing

Sleep apnea is cessation or inadequate breathing while asleep. It might be newly
occurring after a TBI, or may be preexisting, and can arise from partial or complete
obstruction of the upper airway or a central cause. Both obstructive sleep apnea
(OSA) and central apnea are more prevalent in those with a TBI33 and may result
from brain injury, decreased arousal, impaired respiratory function, and surrounding
tissue pressure. If preexisting and not adequately treated, the excessive daytime
sleepiness or fatigue that results from poor sleep may be associated with the occur-
rence of the TBI, such as a motor vehicle crash or other injury resulting from decreased
alertness.33
Apneic or hypopneic events during sleep lead to decreased oxygenation and sub-
sequent activation of the sympathetic nervous system. Sympathetic nervous system
activation results in arousal and taking a needed breath, often without waking. It
also results in increased pulse and blood pressure, increased blood sugar, and
increased inflammatory signaling, which can increase cardiovascular risks and dis-
ease. The assessment of risk of OSA can include the STOP-BANG assessment tool,
which has 8 yes or no questions on snoring, being tired, observed apnea, high blood
pressure, a body mass index of more than 35 kg/m2, age older than 50 years, neck
circumference 16 inches or larger, and male gender. An answer of yes on 5 of the 8
questions indicates high risk of OSA.43,44 An overnight sleep test determines a diag-
nosis of OSA. A core component of treatment of OSA is positive airway pressure
(PAP) therapy, where pressurized air stenting open the airway prevents airway
collapse. Although the side effects of PAP therapy are minimal, adherence to PAP
therapy after a TBI can be low. This finding indicates an increased importance in ed-
ucation of those with sleep apnea about the importance of adequate treatment.45,46
Educational, behavioral, troubleshooting, and telemonitoring interventions were found
in a meta-analysis to significantly improve PAP adherence.47

Excessive Daytime Sleepiness

Excessive daytime sleepiness is the inability to remain alert during the day, perhaps
with unintentional sleep at inappropriate times, such as falling asleep when in a con-
versation or while driving. It can be a component of hypersomnia, but with the differ-
ence of a daytime focus and an intention to be awake. It is often associated with other
sleep disorders that result in poor sleep at night and disrupted wake during the day.
Using the criteria of a mean sleep latency of less than 10 minutes on the Multiple Sleep
Latency Test, 1 study with 71 participants in a rehabilitation center after TBI reported
that 47% had excessive daytime sleepiness. Participants with excessive daytime
sleepiness did not rate themselves with this disorder. In addition, there was no asso-
ciation of sleep disorders with psychopathology, including dysthymic disorder, major
depression, or anxiety in this selected cohort.48 Although people with excessive day-
time sleepiness might have an underlying sleep disorder, these participants had over-
night sleep evaluation for sleep apnea and other sleep disorders. OSA was diagnosed
in 4 patients, and probable narcolepsy in 1 patient, leaving 28 (39%) with excessive
daytime sleepiness with no likely underlying cause other than the TBI. In a study of
118 participants in rehabilitation 6 to 8 weeks after injury, excessive daytime sleepi-
ness determined by the Epworth Sleepiness Scale49 score of 10 or greater was found
in 41.7%. Anxiety was associated with excessive daytime sleepiness in a multivariate
analysis. The authors concluded that anxiety should be assessed and treated to
 Sleep after Traumatic Brain Injury 7

improve sleep outcomes in this population.50 Both studies found rates of excessive
daytime sleepiness after a TBI higher than the rate of 9% to 28% in the general
population.51

Fatigue
Fatigue is one of the most common symptoms after a TBI, often persisting for years.35
Fatigue, which is multidimensional, has been defined as a “distressing, persistent,
subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion.
that is, not proportional to recent activity and interferes with usual functioning.”52 Fa-
tigue can result from disrupted sleep from any cause. Fatigue after a brain injury can
be related to increased cognitive or motor effort, depending on the location of brain
injury, rather than, or in addition to, impaired sleep. Those with fatigue after a TBI
had greater daytime sleepiness, worse sleep hygiene, more profound disability, and
lower satisfaction with life.35 In a large cohort of community-based patients with a
TBI, fatigue after a TBI was not related to injury severity, age, orthopedic injury, or
employment status. Fatigue after a TBI was moderately associated with pain, taking
analgesic medication, female sex, depression, anxiety, and greater time after the
injury. In addition, impaired attention and information processing speed were also
associated with increased fatigue in those with TBI as compared with healthy
controls.53

INTERVENTIONS TO PROMOTE RECOVERY

Interventions to improve sleep after TBI improves recovery.54–56 Sleep apnea sus-
pected after TBI needs to be addressed, which is discussed in the section on Sleep
Apnea. In the acute period of TBI, bidirectional relationships between sleep and agita-
tion, post-traumatic confusion, and cognitive impairment seem to exist, and improving
sleep may help resolve these other symptoms during early recovery from a TBI.57
Interventions for sleep after a TBI have been tested in some studies that did not
separate the different sleep disorders. In an inpatient rehabilitation setting, sleep hy-
giene including 30 minutes of blue light in the morning, restricted caffeine after
noon, naps limited to 30 minutes during the day, lights out at an agreed upon time
based on pre-TBI preferences, and a restriction of centrally acting medications
were together found to significantly improve actigraph sleep metrics.54 Morning
blue light is known to advance sleep phase, which can restore circadian rhythm in
someone with a phase delay, which can occur after a TBI.38 In a review of interventions
to address sleep problems after TBI, sleep hygiene education, cognitive behavioral
therapy for insomnia, morning blue light therapy, problem solving treatment, and pra-
zosin were evaluated to be beneficial to improve sleep. There was mixed evidence in
this review supporting exercise interventions.55 Cognitive behavioral therapy for
insomnia has also been shown to be effective with Internet delivery, increasing the
availability of this intervention for treating insomnia.58
After a TBI occurring at least 3 months earlier, a randomized control trial of high-
intensity blue light therapy for 45 minutes each morning for 4 weeks decreased fatigue
and daytime sleepiness during the treatment period with evidence of a trend toward
preinjury levels 4 weeks after treatment cessation. These improvements were not
found in control groups (10 participants per group) receiving lower intensity yellow
light therapy or no treatment.59
The effects of morning blue light exposure, versus amber light exposure, was tested
in a randomized control trial of 32 adults with a mTBI within the previous 18 months,
but at least 4 weeks after injury. After 6 weeks of light exposure, those in the blue light
8 Weymann & Rourke

group had phase-advanced sleep timing, decreased daytime sleepiness, and

improved executive functioning. Participants in the blue light group also had an
increased volume of the brain posterior thalamus, increased thalamocortical func-
tional connectivity, and increased axonal integrity in these pathways. The authors
concluded that interventions targeting the retinohypothalamic system could improve
recovery from brain injury.40
Some studies reported benefits of modafinil in treating fatigue or excessive daytime
sleepiness, but a meta-analysis of modafinil reported inconsistent results in the small
studies.60
Assessing and treating anxiety, depression, and pain could help with improving
sleep and/or managing fatigue. Assessing cognitive impairment, and assistance
with tools to measure or limit cognitive burden, could also help with managing fatigue
after a TBI, because sensory overstimulation after a brain injury can be interpreted as
fatigue.61 In a pilot study of 24 participants to compare the efficacy of acupuncture
with medication in treating insomnia up to 5 years after a TBI, the authors reported
that acupuncture had a beneficial effect, improving cognition and the perception of
sleep quality even without a difference in sleep time between the acupuncture and
medication groups. Because acupuncture has been reported to decrease insomnia af-
ter a stroke and in other neurologic disorders, the authors concluded that a larger
study is warranted in those with a TBI.62

DISCUSSION AND SUMMARY

Sleep disturbances are common after a TBI and interfere with recovery. Some of the
sleep disorders, such as OSA, have known, effective therapies, although educational
and behavioral interventions are warranted to ensure adherence to prescribed PAP
therapy to treat OSA after a TBI.45,46 Taking the other sleep disorders together,
because there can be quite a bit of overlap, sleep hygiene interventions, including
morning blue light, restricted caffeine, time-limited daytime naps, limited use of blue
light screens in the evening before bed, and a consistent bed time with lights out,
were well-tolerated and improved sleep in inpatient rehabilitation and community
settings.54,55
There is increasing evidence supporting the use of morning blue light to address
sleep problems after a mTBI during rehabilitation between 1 and 18 months after
injury. However, a high-intensity light might not be appropriate in the acute care
setting within the first month after TBI owing to increased sensory sensitivity.39 Gen-
eral sleep hygiene practices that include at least 30 minutes of morning exposure to
sunlight through a window may improve sleep in the hospital setting if the clinical con-
dition allows.63
Participants with a TBI were found to have increased sleep 18 months after injury,
suggesting either a possible benefit of sleep in long-term recovery or persistent sleep
impairment.25 Sleep hygiene is a safe, well-tolerated, low-cost, effective approach to
improving sleep in a variety of populations. Early and ongoing education about man-
aging symptoms after a TBI, including sleep hygiene, can improve rehabilitation and
recovery.64 Systematic approaches and development of evidence-based educational
interventions supporting long-term recovery after a TBI are needed.64

DISCLOSURE

The authors have nothing to disclose. The contents do not represent the views of the
U.S. Department of Veterans Affairs or the United States Government.
 Sleep after Traumatic Brain Injury 9

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 Sleep after Traumatic Brain Injury 11

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