Fatigue & Sleep Disorders

Date Published: August 29, 2020

Sleep Disorders

Overview

Definition

Sleep disorders are one of the most common and persistent sequelae of ABI. Patients in both the acute and chronic phases of rehabilitation, regardless of injury severity, may present with insomnia, excessive daytime sleepiness, an increased need for sleep, or sleep fragmentation. 19 The most common sleep disorder is insomnia.

Insomnia

  • Dissatisfaction with the quality or quantity of sleep.

Sleep-related breathing disorders

  • Altered respiration during sleep.

Narcolepsy

  • Rare disorder characterized by recurrent unplanned daytime sleep episodes.

Parasomnias

  • Abnormal movements, behaviours, emotions, perceptions and dream that occur while falling sleep, sleeping, between sleep stages or during arousal from sleep.

Post-traumatic hypersomnia

  • Hypersomnia because of medical condition (TBI) when other primary sleep disorders have been ruled out.

Circadian-rhythm sleep disorders

  • Mismatch between one’s sleep-wake rhythm and the 24-hour environment.

Prevalence

Sleep disorders are estimated to occur in 30-70% of individuals following an ABI.

  • Insomnia – 30-50%
  • Sleep apnea – 23-36%
  • Post-traumatic hypersomnia – 20-28%
  • Parasomnias – 25%
  • Restless legs syndrome – 13-17%
  • Narcolepsy – 3-5%
  • Circadian rhythm sleep-wake disorders – unknown

19,20

Etiology

  • Poor sleep hygiene
  • Psychological issues (i.e. anxiety and depression)
  • Pain
  • Obstructive sleep apnea
  • Medication side effects
  • Lifestyle issues

Risk Factors

  • Severity of Brain Injury
  • Older age
  • Sex – women insomnia; men – sleep apnea and circadium rhythm disorders
  • Obesity and/or premorbid history of obstructive sleep apnea
  • Premorbid history of sleep disorders
  • Premorbid history of anxiety and depression

Clinical Features

Insomnia

  • Subjective complaints of difficulty initiating sleep, maintaining sleep (frequent awakenings or difficulty returning to sleep), early morning awakenings (with insufficient sleep duration) and/or nonrestorative sleep.

Sleep-related breathing disorders

  • Daytime sleepiness, snoring which may be interrupted by apneas (observed gasping during sleep), slow or absent breathing, frequent awakenings to restart breathing, restless and nonrestorative sleep, and/or morning headaches.

Narcolepsy

  • Tetrad of classic symptoms: daytime sleepiness, cataplexy (i.e., episodic loss of muscle function), hypnagogic hallucinations (i.e., dream-like experiences while falling asleep, dozing or awakening) and sleep paralysis (i.e., transitory, inability to talk or move upon awakening).

Post-traumatic hypersomnia

  • Excessive daytime sleepiness, increased sleep duration.

Circadian rhythm sleep disorders

  • Sleep disturbances when trying to conform with conventional times (inability to fall asleep or remain asleep); normal sleep quality and duration when choosing the preferred schedule. 21

Assessment

INESSS-ONF Clinical Practice Guideline Recommendations

All individuals who have sustained a traumatic brain injury should be assessed for fatigue and sleep disorders and offered appropriate treatment. 7

History

  • Premorbid sleep history
  • Review of sleep hygiene
  • Review of physical activity
  • Review of medications
  • Examination for risk of sleep apnea (i.e. weight gain, history of snoring)

Physical Exam

  • Inspect throat/oral cavity for obstructions (sleep apnea)
  • Body habitus (i.e. obese)

Screening

A variety of self-reported questionnaires exist to evaluate various aspects of sleep disorders following ABI. Scores obtained from these questionnaires are not a substitute for assessment and do not provide a diagnosis; however, they can identify persons at risk of sleep disorders and/or track the effects of interventions.

Sleep Quality

  • Pittsburgh Sleep Quality Index 22
  • Insomnia severity index 23

Circadian preferences

  • Morningness-eveningness questionnaire 24
  • Sleep timing questionnaire 25

Daytime Sleepiness

  • Epworth sleepiness scale 14
  • Stanford sleepiness scale 26

Sleep Apnea

  • STOP-BANG 27
  • Berlin questionnaire 28

Questionnaire

PurposeScore Interpretation
Pittsburgh Sleep Quality Index22Measures quality and patterns of sleep within seven domains>5 Poor sleep quality
Insomnia severity index23Screening for insomnia

0-7 No insomnia

8-14 Mild

15-21 Moderate

22-28 Severe
Morningness-eveningness questionnaire24Preference for morning or evening tendencies

>59 Morning type

42-58 Intermediate

<41 Evening type
Sleep timing questionnaire25Assessment of habitual sleep timingNo score.
Epworth sleepiness scale14Measures general level of daytime sleepiness≥10 excessive daytime sleepiness
Stanford sleepiness scale 26 Alternative to Epworth, measures daytime sleepiness≥4 excessive daytime sleepiness
STOP-BANG27Screening for obstructive sleep apnea (Snoring, Tired, Observed apneas, high blood Pressure, Body mass index, Age, Neck size, male Gender)

0-2 Low risk

3-4 Intermediate risk

5-8 High risk
Berlin questionnaire 28Screening for obstructive sleep apnea≥2 positive categories indicates high likelihood of sleep disordered breathing

Diagnostic Testing

Assessment MethodDescription
Sleep Diary
  • Self-monitor nature, severity, and frequency of sleep difficulties
  • Several days of monitoring is necessary to gather clinically relevant information
Self-Reported Questionnaires
  • Assess nature and severity of symptoms
  • Insomnia: Insomnia Severity Index or Pittsburgh Sleep Quality Index
  • Excessive daytime sleepiness: Epworth Sleepiness Scale
  • Circadian rhythms: Morning-Eveningness Questionnaire or Sleep Timing Questionnaire
  • Sleep apnea: STOP-Bang, Berlin Questionnaire
Polysomnography
  • Gold standard to diagnose obstructive sleep apnea, limb movement disorders and narcolepsy
  • Combination of EEG, electro-oculography (measures eye movements) and electromyography (measures limb movements)

Multiple Sleep Latency Test

And Maintenance of Wakefulness Test
  • Objective measures of daytime sleepiness performed in a specialized setting
Actigraphy
  • Wristwatch-like device worn over extended period of time to measure motor activity, heart rate, and sleep-wake schedule

Laboratory Investigations

Serology or imaging are rarely helpful in the diagnosis of sleep disorders.

Diagnosis

Sleep disorders resulting from an ABI should be diagnosed with a comprehensive evaluation to rule out comorbid medical conditions, psychiatric disturbances or environmental factors. Findings from the clinical history should guide the physical exam and use of problem-focused laboratory (if necessary) and/or diagnostic testing (as indicated above) or referral to a sleep specialist.

INESSS-ONF Clinical Practice Guideline Recommendations

Clinicians should consider the possibility of sleep disorders related to traumatic brain injury as a cause of cognitive and other behavioural changes. 7

Diagnostic Criteria

DisorderDiagnostic Criteria
Insomnia

Significant distress or impairment ≥3 nights per week for ≥3 months; not attributable to a comorbidity, substance abuse, or medication effect.

Hypersomnolence

A main sleep period ≥9 hours that is non-restorative; difficulty in feeling fully awake on abrupt awakening; significant distress or impairment, frequency of ≥3 times per week for ≥3 months.

Narcolepsy

≥3 times per week for >3 months; cataplexy, orexin deficiency.

Breathing-related sleep disorders

Nighttime breathing disturbances and negative daytime consequences (e.g., fatigue); for obstructive sleep apnea, this is often defined as ≥15 obstructions per hour of sleep.

Circadian rhythm sleep-wake disordersA persistent misalignment of the circadian system; excessive sleepiness or insomnia, clinically significant distress or impairment.
Restless legs syndrome

Symptoms persisting for ≥ 3 months and occurring ≥3 nights per week; disturbed night-time sleep and daytime sleepiness.

ParasomniaVaries with different parasomnias (see DSM-5).

Differential Diagnosis

DisorderDifferential Diagnosis
Insomnia

Medications (e.g., psychostimulants, corticosteroids, anticonvulsants, antidepressants), pain, psychological or medical comorbidities, environmental factors or life habits, other sleep disorders (e.g., sleep apnea), neuroendocrine disorders (e.g., growth hormone deficiency, hyperthyroidism).

Hypersomnolence

Medications (e.g., CNS depressants, opioids or other pain medications, anticonvulsants, anti-emetics, antihistamines, antidepressants, anxiolytics, beta-blockers, anti-spasticity medications, muscle relaxants), psychological or medical comorbidities, substances (e.g., cannabis, alcohol), age-related increased need for sleep (e.g., adolescents), other sleep disorders (e.g., sleep apnea), neuroendocrine disorders (e.g., hypothyroidism).

Narcolepsy

Insufficient sleep syndrome (chronic sleep deprivation), medications (see above), other sleep disorders (e.g., sleep apnea, hypersomnia, Kleine-Levin syndrome).

Breathing-related sleep disorders

Breathing-related sleep disorder is an umbrella term that encompasses central sleep apnea, obstructive sleep apnea, obesity hypoventilation syndrome, and sleep-related hypoventilation.

Circadian rhythm sleep-wake disorders

Environmental influences on circadian rhythm (e.g., shift work, inappropriate sleep environment, residing at extremely high or low latitudes), medications (e.g., CNS depressants or stimulants), substances (e.g., amphetamines, cannabis, alcohol), age-related increased/decreased need for sleep (e.g., adolescents, elderly), other sleep disorders (e.g., sleep apnea).

Restless legs syndrome

Medications (antihistamines, dopamine antagonists such as anti-emetics or antipsychotics, lithium, antidepressants such as SSRIs and TCAs), substances (caffeine), akathisia, peripheral vascular disease


Secondary causes of restless legs syndrome include iron deficiency, pregnancy, chronic kidney disease, and peripheral neuropathy.

Complications

  • Fatigue
  • Reduction in physical endurance
  • Decreased memory retention
  • Reduction in attention and learning
  • Irritability
  • Worsening anxiety and depression

Management

Sleep DisorderNon-Pharmacological InterventionsPharmacological Interventions
Insomnia

CBT**

TBI education

Sleep hygiene**

Acupuncture

Regular exercise**

Avoid caffeine, other CNS stimulants

Melatonin**

Melatonin agonists

Trazodone**

Benzodiazepines&

Nonbenzodiazepine receptor agonists&

Tricyclic antidepressants

Other sedative antidepressants

Orexin blockers

Re-evaluate contributory medications
Sleep-related breathing disorders

Non-invasive positive pressure ventilation (NIPPV, such as CPAP or BiPAP)

TBI education

Sleep position (lateral decubitus)

Weight loss (if overweight)

Avoid alcohol, other CNS depressants

Oxygen therapy

Surgery for upper airway obstruction

Morning modafinil (100 to 400 mg) and armodafinil (150 to 250 mg) are approved for obstructive sleep apnea and excessive daytime sleepiness in patients who also use CPAP

Re-evaluate contributory medications

Consider referral to sleep specialist
NarcolepsyTBI education

Stimulants

Consider referral to sleep specialist
Hypersomnia

TBI education

Caffeine and power naps

Methylphenidate**

Modafinil and armodafinil

Amantadine

Re-evaluate contributory medications
Circadian rhythm sleep-wake disorders

TBI education

Sleep hygiene

Light therapy		Melatonin**
Restless legs syndrome

Iron supplementation (if iron deficient)

Avoid caffeine, nicotine, alcohol

Exercise program (if peripheral vascular disease)

Dopamine agonists (pramipexole) Levodopa/carbidopa

Gabapentin

Re-evaluate contributory medications
ParasomniaSleep hygiene

Dopamine agonists

Sedative-hypnotics

**indicates recommended by ONF Guidelines; &indicates ONF Guidelines recommend against use

Non-pharmacological Interventions

INESSS-ONF Clinical Practice Guideline Recommendations

Non-pharmacological interventions should be considered in the treatment of fatigue and sleep disorders for individuals with traumatic brain injury. Interventions may include: cognitive behaviour therapy (CBT) [for insomnia], light therapy, regular exercise, energy conservation strategies and sleep hygiene.7

Sleep Hygiene

Sleep hygiene involves education about behavioural patterns and environmental factors that disrupt sleep.

Sleep Hygiene Recommendations

Relaxation Strategies

Very limited evidence exists examining the use of relaxation strategies for sleep disturbances following an ABI.

Cognitive Behavioural Therapy

The goal of CBT is to modify behavioral factors that perpetuate insomnia, for example, sleep habits and dysfunctional beliefs about sleep. CBT for insomnia has five main components: stimulus control, sleep restriction, cognitive therapy, sleep hygiene education and fatigue management. For more information please refer to the ERABI Clinical Handbook.

Respiratory Therapy

In the general population, obstructive sleep apnea is often managed with alcohol avoidance, non-invasive positive pressure ventilation therapy (e.g., CPAP), proper sleep positioning (lateral decubitus, avoidance of supine position), dental or nasal appliances, and weight loss. The effectiveness of these interventions has not been reported for patients with ABI specifically.

Acupuncture

Few studies have examined the benefits of acupuncture in a population with ABI and generally it is not effective.

Light Therapy

The goal of light therapy is to shift waking or bedtimes towards a more desirable sleep-wake schedule. Typically, light therapy involves a person being exposed to a short wavelength light (430-475 nm; blue wavelength light) upon awakening.

InterventionEffectLevel of Evidence
Sleep Hygiene**

UC

N/A

Although used clinically, sleep hygiene practices have not been studied in a population with moderate to severe ABI.

Relaxation Strategies+1b
Warm footbath in the evening may
improve wake after sleep onset and
sleep onset latency but not sleep efficiency or sleep time.

ERABI Evidence Table

Cognitive Behavioural Therapy for Insomnia**+1b
May reduce fatigue and insomnia.

ERABI Evidence Table

Respiratory TherapyUCN/A
Although used clinically, CPAP for sleep apnea has not been studied in a population with moderate to severe ABI.
Acupuncture

-


2
May not improve insomnia compared to instructions on good sleep habits.

ERABI Evidence Table

Light Therapy*C1b

Blue light therapy, but not yellow light therapy, may be effective in reducing fatigue and daytime sleepiness.

ERABI Evidence Table

**Indicates recommended by ONF Guidelines; &indicates ONF Guidelines recommend against use

Pharmacological Interventions

MedicationMedication TypeComments

Melatonin**

Hormone excreted by pineal gland.

Highly recommended due to modest improvement in sleep with excellent side effect profile.
Ramelteon Melatonin agonistHighly recommended due to modest improvement in sleep with excellent side effect profile.
Temazepam&

Benzodiazepine

Short term use only. Concerns about interfering with recovery, cognitive side effects and physical dependency.
Zolpidem ( (Zopiclone in Canada), EszopicloneAtypical GABA agonistSimilar to Benzodiazepines although negative impacts are less severe.
Zaleplon&PyrazolopyrimidineSimilar to Benzodiazepines although negative impacts are less severe.

Amitriptyline and Nortriptyline

Doxepin 		Tricyclic AntidepressantsAnticholinergic side effects, esp. with Amitriptyline including persistent morning drowsiness.
Trazadone**Triazolopyridine derivativeAntidepressant most often used as sleeping medication.
Mirtazapine
Tetracyclic AntidepressantAntidepressant that exhibits both noradrenergic and serotonergic activity.
DiphenhydramineAntihistamineAnticholinergic side effects including cognitive impairment and not recommended.
Methylphenidate**StimulantRecommended for hypersomnia and narcolepsy.
ModafinilStimulantUsed to treat sleepiness due to narcolepsy, shift work sleep disorder, or obstructive sleep apnea.

**Indicates recommended by ONF Guidelines; &indicates ONF Guidelines recommend against use

For full list including dosing see Table 15 in the ERABI Clinical Handbook.

InterventionEffectLevel of Evidence
Melatonin**+
-		1b
Effective in improving sleep quality, sleep efficiency, and fatigue.
1b
Not effective for sleep onset latency or daytime sleepiness.

ERABI Evidence Table

Methylphenidate**C3
May not have adverse effects on the sleep-wake cycle.

ERABI Evidence Table

Modafinil+1a
Effective short-term in treating excessive daytime sleepiness.

ERABI Evidence Table

**Indicates recommended by ONF Guidelines; &indicates ONF Guidelines recommend against use

Surgical Interventions

Surgical management of obstructive sleep apnea is usually only offered for individuals who do not find CPAP therapy effective after at least 3 months. 6

Resources

INESSS-ONF Clinical Practice Guidelines

ERABI Module

ERABI Clinical Guidebook

ONF Guidelines for Concussion/Mild Traumatic Brain Injury & Persistent Symptoms

MD-CALC

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