Mary K. Voegeli FNP-BC,
MSN,CRRN
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A naturally occurring altered state of
consciousness, characterized by
decreased awareness and
responsiveness to stimuli, and
distinguished from abnormal states of
consciousness by being easily
reversible.
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Sleep disorders in brain injury includes
problems with initiating sleep, frequent
nocturnal awakening, early awakening, sleep
cycle shift, non-restful sleep, decreased total
sleep time, excessive daytime somnolence,
and excessive sleep.
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- 70% in acute TBI
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- 50% in post acute TBI
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Anoxic encephalopathy
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Dyssomnias- disorders that result in
insomnia. (apnea)
Parasomnias- disorders of arousal or sleep
stage transition. (nightmares, sleep-walking)
Sleep disorders caused by medical or
psychiatric illness.(TBI, Stroke, Depression,
Chronic Pain)
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Sleep and wakefulness is regulated by
interaction between the ventrolateral pre
optic nucleus of the hypothalamus and
arousal centers in the hypothalamus and
brainstem.
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Melatonin producing cells in the
suprachiasmatic nucleus of the hypothalamus
induce sleep and regulate circadian rhythms.
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Serotonin and norepinephrine pathways
promote wakefulness and are thought to play
a role in regulating the stages of non REM
sleep.
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Acetylcholine helps maintain arousal and
plays a role in REM sleep.
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Normal Sleep:
Non Rapid Eye Movement(NREM)
Stage 1- Beginning of sleep cycle. ( light
sleep)
Stage 2- Lasts 20 minutes. Brain begins to
produce rapid, rhythmic activity known as
sleep spindles.
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Stage 3- Delta Sleep. Transitional period
between light sleep and very deep sleep.
Stage 4- REM Sleep. Sleep is also referred to
as paradoxical sleep. Brain is more active,
muscles more relaxed. Most dreaming occurs
during REM sleep.
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Definitions:
Insomnia: The experience of inadequate
quantity or poor sleep, characterized by
difficulty falling asleep, difficulty maintaining
sleep, waking up too early, or non refreshing
sleep.
Occurs at least 3 nights per week resulting in
impairment in daytime functioning.
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Sleep latency: The time it takes to fall asleep
after going to bed.
Sleep efficiency: The amount of time asleep
divided by the total of time in bed.
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Patients with more rapid return to a
consolidated rest-activity cycle were more
likely to emerge from PTA and have lower
disability at hospital discharge.
(Duclos et al. 2014)
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TBI patients with insomnia had poorer
vocational outcomes, more behavioral
problems, cognitive and communicative
dysfunction and a higher incidence of anxiety
and depression.
(Mollayev et al. 2013)
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Worse sleep- wake cycle consolidation and
evolution were associated with higher TBI
severity and longer duration of ICU/hospital
stay.
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Are they sleeping?
Self report sleep pattern is unreliable.
Sleep flow charts needed.
Sonogram usually not necessary.
Identify possible causes and eliminate when
feasible.
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Premorbid history of sleeping.
Current sleep patterns.
Difficulty maintaining sleep.
Difficulty initiating sleep.
Feelings of unrest despite adequate amount
of sleep.
Amount of caffeine consumed
Alcohol use
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Tobacco use.
Illicit drug use.
Psychiatric history.
Current medications
Naps
Work History ( shift worked)
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Pain
Impaired mobility ( normal person changes
position 30 times a night
Noise
Lights (circadian rhythm affect)
Restraints
IV’s
Urinary incontinence or frequent nocturia
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Seizures
Sleep apnea (hypoxia)
Pruritus
Sleep myoclonus
Restless leg syndrome
Periodic leg movement disorder
Hyperthyroidism (rare)
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Daytime napping
Bipolar disorder
Medications
Damage to sleep promoting area of the brain
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Beta Blockers
Anti-cholinergics (Ditropan,
Scopalamine,Diphenhydramine)
Dilantin
Selective Serotonin Reuptake Inhibitors
Stimulants
Caffeine
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Clonidine
Diuretics
Ginseng
Levadopa
Decongestants
Nicotine
St. John’s Wort
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Theophylline
Thyroid replacement
Medroxprogesterone
Metaclopramide
Steriods
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Impairment of attention and concentration
Irritability, agitation
Emotional lability
Impairment of memory
Anxiety
Fatigue, lethargy
Lowered seizure threshold
Delusions, paranoia
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Hallucinations
Excessive daytime sleep
Increased risk of depression
Impaired immune system
non-specific somatic complaints
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The severely sleep deprived patient must be
treated before he or she can benefit from the
rehabilitation setting. This may require
aggressive pharmacological intervention.
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Evaluation and treatment of other comorbid
medical and psychiatric conditions.
Sleep hygiene measures, relaxation exercises
and sleep restrictions.
Use hypnotics judiciously.
Those with chronic insomnia and depression
would benefit with treatment for insomnia
and depression.
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Benzodiazepines
All benzodiazepines act by potentiating the
inhibiting neurotransmitter (GABA)
All increase stage 2 sleep by causing slight
decrease in slow wave sleep and in REM
sleep, increasing total sleep time and reduce
awakenings
All cause respiratory depression.
Benzodiazepines (continued)
 Short, intermediate, and long acting.
 With short acting benzodiazepines, you are
more likely to see rebound insomnia with
discontinuation.
 With long acting benzodiazepines, you are
more likely to see residual daytime sedation,
decreased coordination.
en
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Short acting: Triazolam- half life 2 – 4 hours,
Oxazepam 3 – 6 hours
Intermediate acting: Temazepam, estazolam,
alprazolam, lorazepam, chlordiazepoxide half
life is generally 8 – 24 hours.
Long acting: half lives >24 hours. Diazepam,
Flurazepam, and Clonazepam.
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Zolpidem
Act on some of the same receptors as the
benzo’s but do not muscle relaxant,
anxiolytic or anti convulsant properties.
No tolerance and no withdrawal effects
No respiratory suppression
Does not suppress REM sleep
Produce physiologic sleep patterns
Half life 2 -4 hours
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Chloral Hydrate
Tolerance develops quickly
Rebound insomnia occurs
Cannot be used in renal or liver failure
Useful but only for 1,2 or 3 nights maximum
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Melatonin
No good studies document efficacy
Not FDA approved
Available over the counter
Studies show that higher doses may be
associated with some degree of hypothermia
although clinical implication is uncertain
One tenth of standard dosing (3mg) maybe
effective.
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Antidepressants
In general antidepressants can be somewhat
helpful with sleep, but because if the side
effects and because of REM suppression, they
should be used when there is concurrent
depression. They can be used short term in
the very difficult to treat cases.
SSRI’s
 Most SSRI’s are more activating than sedating
– more likely to cause insomnia than improve
sleep.
 Decreased REM sleep
 Trazodone has SSRI activity but is more
sedating than other SSRI’s.
 May increase REM sleep, anticholinergic side
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Trazodone has SSRI activity but is more
sedating than other SSRI’s.
 May increase REM sleep, anticholinergic side
effects
 Hang over in the AM
 Higher doses than 100mg or more can result
in modest cognitive impairment
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Tricyclics
 Decreased REM sleep
 Anticholinergic side effect ( dry mouth,
urinary retention
 Lower seizure threshold
 Cardiac arrhythmias
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Anticonvulsants
Should generally be avoided
Cause daytime sedation
* May be used for agitated behavior
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Antipsychotics
Haldol, Zyprexa, Risperdal, Seroquel
Increased total sleep time
Increased REM percent
Improve sleep continuity
Increase daytime somnolence
Would try other medications first
OK for use especially in the critical care
setting.
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Antihistamines
Anticholinergic side effects
May impact memory and new learning
May cause hangover
May cause paradoxical effect
May increase Blood pressure
Should be used with caution in the elderly
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Hospital units: repositioning, personal
hygiene, lab tests, and frequent nursing
monitoring.
Constant lighting. May disorient a patient’s
sense of day versus night.
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Go to bed when drowsiness present
If wakefulness occurs during the night get up
and read or watch television until drowsy.
Have a regular sleep routine.
Attempt to avoid stress.
Avoid anything that tends to excite just
before attempting sleep. ( horror movies,
news, alcohol, caffeine, nicotine, strenuous
exercise.
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Sexual activity may relax men, but it does not
relax women.
Try a warm bath prior to bed to relax tense
muscles.
Avoid afternoon naps EXCEPT if you are a
night shift worker or elderly
Sleep in a cool environment.
Use the bedroom for sleep and sex only.
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Warm milk.
Don’t watch the clock.
Eat a light snack before bed if hungry.
Consult with an MD before taking over the
counter sleep aid or herbs.
Cognitive behavioral therapy. (Insomnia)
Light Therapy in the AM. ( Hypersomnia)
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Mild TBI
Short loss of consciousness ( < 30 minutes)
and or
Post traumatic amnesia ( PTA, < 24 hours)
GCS between 13 and 15.
Sleep complaints usually present in the first
few days and weeks after injury
 Of 443 patients studied with Mild TBI, 13.3%
of the patients reported sleep complaints 10
days post injury.
 Sleep complaints increased to 33.5% at 6
weeks.
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Patients with sleep complaints at 10 days
post injury were 2.9 times more likely to
experience sleep difficulties at 6 weeks post
injury.
More likely to suffer from irritability,
depressive symptoms, and headaches at both
10 days and 6 weeks post injury, suggesting
the acute sleep complaints predict
psychological and somatic symptoms
amongst individuals with mild TBI. (Caput et
al. 2013)
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Value neuropsychological testing and input
BDI score
Consider sleep aid medication
Assess for contributing factors- headache,
pain when choosing medication
Consider referral to psychology (PTSD,
anxiety, depression)
Cognitive behavioral therapy
??Questions????