Staff Perspective: The Importance of Screening for Sleep Disorders in Patients with a History of Traumatic Brain Injury
Since 2000 over 449,000 service members have had at least one documented TBI, of which approximately 82% are mild (Traumatic Brain Injury Center of Excellence, 2021). These injuries occur as part of mission-related activities while in-theater or during training exercises or as part of recreational activities. Many patients report experiencing headaches, memory and concentration issues, changes in mood, and increased irritability, depression, anxiety, and sleep problems (Mayo Clinic Staff, 2021). For many service members who sustain a mild TBI (commonly referred to as a concussion), we see a return to full duty in 10 to 14 days (Traumatic Brain Injury Center of Excellence, 2021). However, patients may continue to experience symptoms related to their TBI after this point.
As we think about TBI, it’s important to consider the more common co-occurring symptoms. One that we see particularly often is sleep problems (Armed Forces Health Surveillance Center, 2013), which can occur rapidly after a TBI (Ouellet et al., 2006). In fact, sleep problems are so common after a TBI, it has been suggested that the increased occurrence of mild TBIs in service members may in part be responsible for the increases in insomnia among military patients (Bryan, 2013). Although the ranges of comorbidity vary within the literature, one study of service members with a combat-related TBI found an incredibly high rate of sleep complaints (approximately 97%), with insomnia and obstructive sleep apnea (OSA) being diagnosed at the greatest rate (Collen et al., 2012). Interestingly, patients with a blunt TBI (e.g., head injuries resulting from a fall, assault, or motor vehicle accident) were more likely to have OSA whereas patients with a blast TBI (e.g., head injuries resulting from an improvised explosive device or breaching charge) were more likely to have greater insomnia symptoms. Importantly, the risk and severity of a comorbid sleep diagnosis may increase with additional TBIs, even after controlling for depression, PTSD, and TBI severity.
Notably, sleep issues appear particularly high in patients with a mild TBI and may include insomnia, OSA, circadian rhythm disorders, hypersomnolence or excessive sleepiness, and fatigue, among others (Stavitsky Gilbert et al., 2015). Although it is not quite clear why we see more reports of sleep disruptions in patients with mild TBI, there are a few theories (Orff et al., 2009; Ouellet et al., 2006):
- It may be the result of different types of injuries.
- Brain function may be more permanently changed in more severe traumas.
- There may be differences in recovery patterns or treatments.
- Patients with more severe injuries may consider other symptoms to be more critical or problematic and are thus less concerned about or aware of their sleep problems.
Although it is as of yet unclear why we see more sleep problems in patients with a mild TBI, it is nevertheless important to screen and treat any co-occurring sleep problems in all TBI patients.
Clinical Implications
When we think about some of the more common concerns a patient may report after a TBI, we see a lot of overlap with the consequences of sleep disturbances, such as problems with concentration and memory, changes in mood or irritability, feeling more tired or sleepy, and a lack of energy. Unfortunately, despite many patients reporting their sleep problems decrease their functioning, well-being, and quality of life, these symptoms often go untreated (Ouellet et al., 2006). Additionally, sleep problems may exacerbate TBI-related symptoms and can hinder recovery and treatment (Stavitsky Gilbert et al., 2015), thus targeting these symptoms may benefit recovery and improve outcomes (Wiseman-Hakes et al., 2013).
When working with patients with a history of TBI, it is important to always screen for sleep problems. Incorporating sleep-related questions into your intake is a great addition to any intake procedure, but it may be particularly important for patients with a history of TBI. I recommend asking your patients if they are experiencing any problems falling asleep, staying asleep, or waking early; if they have bad dreams or nightmares; if they snore loudly; or if they are experiencing any other symptoms that they think may be interfering with their sleep. In addition to discussing their sleep as part of your intake, it can be beneficial to include specific screeners to help identify sleep disorders. The two most frequent sleep diagnoses in patients with TBI are OSA and insomnia, so the STOP-BANG Questionnaire, a screener for OSA, and the Insomnia Severity Index and can be very useful during treatment planning.
There are a few considerations I would like to highlight when working with a patient with a comorbid sleep disorder:
- If your patient screens high on the STOP-BANG or you suspect OSA, a referral to a neurologist or primary care provider for evaluation and a sleep study may be warranted.
- Avoid long-term use of sleep medications because the side effects can add additional strain on a patient’s alertness and cognition (Larson & Zollman, 2010).
- For patients with clinically significant symptoms of insomnia, consider adding Cognitive Behavioral Therapy for Insomnia (CBT-I) or Brief Behavioral Treatment for Insomnia to your treatment plan. Although the research is currently limited, there is evidence to suggest CBT-I may improve sleep symptoms including sleep efficiency, sleep quality, and general insomnia symptoms as well as comorbid symptoms such as anxiety, depression, fatigue, and pain (Ludwig et al., 2020).
For providers who work with patients with TBIs, these considerations can be helpful to improve recovery and patient outcomes.
Interested in receiving training in CBT-I from the Center for Deployment Psychology? Please visit https://deploymentpsych.org/training.
Check out some of CDP’s previous blogs recognizing TBI Awareness Month:
Guest Perspective: Understanding and Treating Traumatic Brain Injury
Traumatic Brain Injury Awareness Month
Military Children and Traumatic Brain Injury - Books to Help Parents
Military Spouses and Traumatic Brain Injury – Exploring the Stories of Affected Partners and Resources for Caregivers
Listening to the Stories of Service Members and Veterans with Traumatic Brain Injury
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Armed Forces Health Surveillance Center. (2013). Incident diagnoses of common symptoms ("sequelae") following traumatic brain injury, active component, U.S. Armed Forces, 2000-2012. Msmr, 20(6), 9-13.
Bryan, C. J. (2013). Repetitive Traumatic Brain Injury (or Concussion) Increases Severity of Sleep Disturbance among Deployed Military Personnel. Sleep, 36(6), 941-946. https://doi.org/10.5665/sleep.2730
Collen, J., Orr, N., Lettieri, C. J., Carter, K., & Holley, A. B. (2012). Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest, 142(3), 622-630. https://doi.org/10.1378/chest.11-1603
Larson, E. B., & Zollman, F. S. (2010). The Effect of Sleep Medications on Cognitive Recovery From Traumatic Brain Injury. The Journal of Head Trauma Rehabilitation, 25(1). https://journals.lww.com/headtraumarehab/Fulltext/2010/01000/The_Effect_of_Sleep_Medications_on_Cognitive.8.aspx
Ludwig, R., Vaduvathiriyan, P., & Siengsukon, C. (2020). Does cognitive-behavioural therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping review. Brain Inj, 34(12), 1569-1578. https://doi.org/10.1080/02699052.2020.1831070
Mayo Clinic Staff. (2021, February 4, 2021). Traumatic Brain Injury. https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557
Orff, H. J., Ayalon, L., & Drummond, S. P. A. (2009). Traumatic Brain Injury and Sleep Disturbance: A Review of Current Research. The Journal of Head Trauma Rehabilitation, 24(3). https://journals.lww.com/headtraumarehab/Fulltext/2009/05000/Traumatic_Brain_Injury_and_Sleep_Disturbance__A.2.aspx
Ouellet, M.-C., Beaulieu-Bonneau, S., & Morin, C. M. (2006). Insomnia in Patients With Traumatic Brain Injury: Frequency, Characteristics, and Risk Factors. The Journal of Head Trauma Rehabilitation, 21(3), 199-212. https://journals.lww.com/headtraumarehab/Fulltext/2006/05000/Insomnia_in_Patients_With_Traumatic_Brain_Injury_.1.aspx
Stavitsky Gilbert, K., Kark, S. M., Gehrman, P., & Bogdanova, Y. (2015). Sleep disturbances, TBI and PTSD: Implications for treatment and recovery. Clinical Psychology Review, 40, 195-212. https://doi.org/https://doi.org/10.1016/j.cpr.2015.05.008
Traumatic Brain Injury Center of Excellence. (2021). DoD Worldwide Numbers. https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers
Wiseman-Hakes, C., Murray, B., Moineddin, R., Rochon, E., Cullen, N., Gargaro, J., & Colantonio, A. (2013). Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain Injury, 27(12), 1364-1376. https://doi.org/10.3109/02699052.2013.823663
Since 2000 over 449,000 service members have had at least one documented TBI, of which approximately 82% are mild (Traumatic Brain Injury Center of Excellence, 2021). These injuries occur as part of mission-related activities while in-theater or during training exercises or as part of recreational activities. Many patients report experiencing headaches, memory and concentration issues, changes in mood, and increased irritability, depression, anxiety, and sleep problems (Mayo Clinic Staff, 2021). For many service members who sustain a mild TBI (commonly referred to as a concussion), we see a return to full duty in 10 to 14 days (Traumatic Brain Injury Center of Excellence, 2021). However, patients may continue to experience symptoms related to their TBI after this point.
As we think about TBI, it’s important to consider the more common co-occurring symptoms. One that we see particularly often is sleep problems (Armed Forces Health Surveillance Center, 2013), which can occur rapidly after a TBI (Ouellet et al., 2006). In fact, sleep problems are so common after a TBI, it has been suggested that the increased occurrence of mild TBIs in service members may in part be responsible for the increases in insomnia among military patients (Bryan, 2013). Although the ranges of comorbidity vary within the literature, one study of service members with a combat-related TBI found an incredibly high rate of sleep complaints (approximately 97%), with insomnia and obstructive sleep apnea (OSA) being diagnosed at the greatest rate (Collen et al., 2012). Interestingly, patients with a blunt TBI (e.g., head injuries resulting from a fall, assault, or motor vehicle accident) were more likely to have OSA whereas patients with a blast TBI (e.g., head injuries resulting from an improvised explosive device or breaching charge) were more likely to have greater insomnia symptoms. Importantly, the risk and severity of a comorbid sleep diagnosis may increase with additional TBIs, even after controlling for depression, PTSD, and TBI severity.
Notably, sleep issues appear particularly high in patients with a mild TBI and may include insomnia, OSA, circadian rhythm disorders, hypersomnolence or excessive sleepiness, and fatigue, among others (Stavitsky Gilbert et al., 2015). Although it is not quite clear why we see more reports of sleep disruptions in patients with mild TBI, there are a few theories (Orff et al., 2009; Ouellet et al., 2006):
- It may be the result of different types of injuries.
- Brain function may be more permanently changed in more severe traumas.
- There may be differences in recovery patterns or treatments.
- Patients with more severe injuries may consider other symptoms to be more critical or problematic and are thus less concerned about or aware of their sleep problems.
Although it is as of yet unclear why we see more sleep problems in patients with a mild TBI, it is nevertheless important to screen and treat any co-occurring sleep problems in all TBI patients.
Clinical Implications
When we think about some of the more common concerns a patient may report after a TBI, we see a lot of overlap with the consequences of sleep disturbances, such as problems with concentration and memory, changes in mood or irritability, feeling more tired or sleepy, and a lack of energy. Unfortunately, despite many patients reporting their sleep problems decrease their functioning, well-being, and quality of life, these symptoms often go untreated (Ouellet et al., 2006). Additionally, sleep problems may exacerbate TBI-related symptoms and can hinder recovery and treatment (Stavitsky Gilbert et al., 2015), thus targeting these symptoms may benefit recovery and improve outcomes (Wiseman-Hakes et al., 2013).
When working with patients with a history of TBI, it is important to always screen for sleep problems. Incorporating sleep-related questions into your intake is a great addition to any intake procedure, but it may be particularly important for patients with a history of TBI. I recommend asking your patients if they are experiencing any problems falling asleep, staying asleep, or waking early; if they have bad dreams or nightmares; if they snore loudly; or if they are experiencing any other symptoms that they think may be interfering with their sleep. In addition to discussing their sleep as part of your intake, it can be beneficial to include specific screeners to help identify sleep disorders. The two most frequent sleep diagnoses in patients with TBI are OSA and insomnia, so the STOP-BANG Questionnaire, a screener for OSA, and the Insomnia Severity Index and can be very useful during treatment planning.
There are a few considerations I would like to highlight when working with a patient with a comorbid sleep disorder:
- If your patient screens high on the STOP-BANG or you suspect OSA, a referral to a neurologist or primary care provider for evaluation and a sleep study may be warranted.
- Avoid long-term use of sleep medications because the side effects can add additional strain on a patient’s alertness and cognition (Larson & Zollman, 2010).
- For patients with clinically significant symptoms of insomnia, consider adding Cognitive Behavioral Therapy for Insomnia (CBT-I) or Brief Behavioral Treatment for Insomnia to your treatment plan. Although the research is currently limited, there is evidence to suggest CBT-I may improve sleep symptoms including sleep efficiency, sleep quality, and general insomnia symptoms as well as comorbid symptoms such as anxiety, depression, fatigue, and pain (Ludwig et al., 2020).
For providers who work with patients with TBIs, these considerations can be helpful to improve recovery and patient outcomes.
Interested in receiving training in CBT-I from the Center for Deployment Psychology? Please visit https://deploymentpsych.org/training.
Check out some of CDP’s previous blogs recognizing TBI Awareness Month:
Guest Perspective: Understanding and Treating Traumatic Brain Injury
Traumatic Brain Injury Awareness Month
Military Children and Traumatic Brain Injury - Books to Help Parents
Military Spouses and Traumatic Brain Injury – Exploring the Stories of Affected Partners and Resources for Caregivers
Listening to the Stories of Service Members and Veterans with Traumatic Brain Injury
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Maegan Paxton Willing is a Postdoctoral Fellow at the Center for Deployment Psychology (CDP) at the Uniformed Services University of the Health Sciences in Bethesda, Maryland.
References
Armed Forces Health Surveillance Center. (2013). Incident diagnoses of common symptoms ("sequelae") following traumatic brain injury, active component, U.S. Armed Forces, 2000-2012. Msmr, 20(6), 9-13.
Bryan, C. J. (2013). Repetitive Traumatic Brain Injury (or Concussion) Increases Severity of Sleep Disturbance among Deployed Military Personnel. Sleep, 36(6), 941-946. https://doi.org/10.5665/sleep.2730
Collen, J., Orr, N., Lettieri, C. J., Carter, K., & Holley, A. B. (2012). Sleep disturbances among soldiers with combat-related traumatic brain injury. Chest, 142(3), 622-630. https://doi.org/10.1378/chest.11-1603
Larson, E. B., & Zollman, F. S. (2010). The Effect of Sleep Medications on Cognitive Recovery From Traumatic Brain Injury. The Journal of Head Trauma Rehabilitation, 25(1). https://journals.lww.com/headtraumarehab/Fulltext/2010/01000/The_Effect_of_Sleep_Medications_on_Cognitive.8.aspx
Ludwig, R., Vaduvathiriyan, P., & Siengsukon, C. (2020). Does cognitive-behavioural therapy improve sleep outcomes in individuals with traumatic brain injury: a scoping review. Brain Inj, 34(12), 1569-1578. https://doi.org/10.1080/02699052.2020.1831070
Mayo Clinic Staff. (2021, February 4, 2021). Traumatic Brain Injury. https://www.mayoclinic.org/diseases-conditions/traumatic-brain-injury/symptoms-causes/syc-20378557
Orff, H. J., Ayalon, L., & Drummond, S. P. A. (2009). Traumatic Brain Injury and Sleep Disturbance: A Review of Current Research. The Journal of Head Trauma Rehabilitation, 24(3). https://journals.lww.com/headtraumarehab/Fulltext/2009/05000/Traumatic_Brain_Injury_and_Sleep_Disturbance__A.2.aspx
Ouellet, M.-C., Beaulieu-Bonneau, S., & Morin, C. M. (2006). Insomnia in Patients With Traumatic Brain Injury: Frequency, Characteristics, and Risk Factors. The Journal of Head Trauma Rehabilitation, 21(3), 199-212. https://journals.lww.com/headtraumarehab/Fulltext/2006/05000/Insomnia_in_Patients_With_Traumatic_Brain_Injury_.1.aspx
Stavitsky Gilbert, K., Kark, S. M., Gehrman, P., & Bogdanova, Y. (2015). Sleep disturbances, TBI and PTSD: Implications for treatment and recovery. Clinical Psychology Review, 40, 195-212. https://doi.org/https://doi.org/10.1016/j.cpr.2015.05.008
Traumatic Brain Injury Center of Excellence. (2021). DoD Worldwide Numbers. https://www.health.mil/Military-Health-Topics/Centers-of-Excellence/Traumatic-Brain-Injury-Center-of-Excellence/DOD-TBI-Worldwide-Numbers
Wiseman-Hakes, C., Murray, B., Moineddin, R., Rochon, E., Cullen, N., Gargaro, J., & Colantonio, A. (2013). Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain Injury, 27(12), 1364-1376. https://doi.org/10.3109/02699052.2013.823663