1. Sleep Problems in Traumatic Brain Injury Eilis Boudreau M.D., Ph.D.

2. Talk Overview Case Brain structures involved Sleep problems and acute TBI Chronic sleep problems associated with TBI Treatments Key Points

3. Case Mr. M. is a 50 yr-old gentleman with a history of severe traumatic brain injury 10 years ago. Immediately after the injury he complained of daytime tiredness which improved over the first year after the injury (but his daytime level of energy never returned to his pre-injury baseline). Over the past two years he has become increasingly tired, sleeping up to 16 hours per day.

4. Studies of Sleep and TBI (human)

5. Possible Brain Structures Involved Brain stem Basal forebrain Hypothalamus

6. Possible Markers/Etiologies Hypothalamic-pituitary insufficiency (Belmont and co-workers, 2006) Significantly lower levels of hypocretin in CSF (Baumann and co-workers, 2007) Disruption of normal patterns of melatonin secretion (Paparrigopoulos et al., 2006)

7. Early Reports of TBI and Sleepiness First reports 1941 by Gill in Lancet: head trauma and narcolepsy Guilleminault and co-workers (1983) at Stanford reported on a series of 20 individuals with TBI and sleep complaints

8. Sleep Complaints Common # SubjectsPrevalence TBI Severity/ Acute vs Chronic Authors 8746%All/chronicCastriotta et al., 2007 5141 mo. 55% 1 yr. 27% All/acute & chronic Watson et al., 2007

9. Wide Range of Sleep Disorders Diagnosis Prevalence (general pop.) TBI Severity/ Acute vs Chronic Authors Insomnia30%All/acute & chronic Fichenberg, 2000 29.4% (9%)All/chronic Ouellet, 2006 OSA30%All/chronic Verma, 2007 23% (4-20%)All/chronic Castriotta, 2007 CRSD36%Mild/?Ayalon, 2007

10. Wide Range of Sleep Disorders DiagnosisPrevalence (general pop.) TBI Severity/ Acute vs Chronic Authors Parasomnias25%; 13% with RBD All/chronicVerma, 2007 Narcolepsy6% (0.5%)All/chronicCastriotta, 2007 PTH11%All/chronicCastriotta, 2007 PLMS7%All/chronicCastriotta, 2007

11. Insomnia Has Widespread Effects (Ouellet and co-workers, 2006)

12. Arousal Problems Adversely Impact Rehabilitation (Worthington and co-workers, 2006)

14. Other Issues Complicate Sleep Problems Pain -> 2-fold increase in insomnia complaints (Beetar et al., 1996) Neuropsychological function being more intact  greater sleep dysfunction (Mahmood et al., 2004) Older individuals and women more likely to have sleep problems (Clinchot et al., 1998)

15. Case Revisited Additional history obtained from his wife Increased snoring, witnessed apneas 30 lb weight gain AM headaches Sleep-onset insomnia

16. Diagnosis Screening in a sleep clinic Diagnostic polysomnography as indicated

17. Treatments Little data on response to treatments Direct treatments to underlying sleep issue –CPAP for sleep disordered breathing –Light and melatonin for circadian rhythm disorders –Aggressively treat co-morbidities (eg. pain, depression)

18. Key Points Many sleep complaints have an identifiable underlying cause Treatments are available