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Thursday, December 12, 2013
Insomnia and Brain Injury
What are some techniques to deal with insomnia from brain trauma?
Sleep disturbances are very common following traumatic brain injury (TBI) and many of these patients will suffer from insomnia. A recent study found that 25% of TBI patients will have insomnia that can occur either at the start of the night (sleep onset insomnia) or in the middle of the night (sleep maintenance insomnia). How best to treat insomnia following TBI depends on a number of factors and I will attempt to address some of these.
Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia are extremely important to ensure appropriate treatment. Factors affecting one's ability to fall asleep at the start of the night are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breath well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body's biologic rhythms are out of synchrony or delayed).
The problem of maintaining sleep, or staying asleep once you fall asleep, has other underlying causes such as; depression, substance abuse (especially alcohol use, that can result in withdraw in the middle of the night), certain medications, pain, medical conditions that cause frequent urination throughout the night, heartburn, breathing disturbances in sleep, leg jerks in sleep and circadian rhythm disturbances (when the biologic rhythms are advanced earlier in the night). Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as "idiopathic insomnia" or insomnia for which a cause can not be found. In the case of TBI patients, certain factors such as pain, depression, anxiety, medications, and even the nature of the brain injury itself could all play a role in the insomnia.
As you can see, insomnia is a complex problem that requires a detailed evaluation to help sort out important underlying factors that may need to be addressed. A full history should be obtained to try to pinpoint any specific causes of the insomnia as therapy is most effective when targeted at the underlying cause. Many cases of chronic insomnia can be managed without the use of sleep-inducing medications.
Often times, behavioral therapy can be very effective for patients whose insomnia is the result of a poor sleep environment, poor sleep habits or psychological conditions. Some of the techniques used for behavioral treatment of insomnia (usually labeled as "cognitive behavioral therapy") include sleep hygiene education, stimulus control therapy, and sleep restriction. A recent study looked at using these techniques in TBI patients with insomnia found them to be highly successful at improving sleep. Even more impressive was that these improvements were maintained for months after the therapy had been started. In addition, the patients noted less symptoms of general and physical fatigue.
In some cases, drug therapy is required to manage insomnia, though caution should be exercised with long-term use of some medications. Certain sleep agents, such as benzodiazepines, are often accompanied by daytime sleepiness, fatigue and problems with tolerance (or losing effectiveness over time). These effects may be seen less with some of the newer sleep-inducing medications such as zolpidem (Ambien), zaleplon (Sonata), or eszopiclone (Lunesta), though chronic long-term use of these agents has not been well-studied.
Melatonin, a naturally occurring sleep-inducing substance, has been found to be variably effective for treating insomnia. It may play a role in treating some individuals who have insomnia and are lacking normal melatonin secretion, but this does not appear to be common. It is probably most effective in treating those who have problems related to their underlying biologic or circadian rhythms, as melatonin will help to regulate these. Usually a dose of 1 mg at bedtime is adequate. Users of melatonin should be aware that this drug is not regulated by the FDA.
Recently, a new melatonin-like substance, ramelteon (Rozerem), was approved for the treatment of insomnia. This medication appears to be fairly well-tolerated and is the first uncontrolled medication approved by the FDA for the treatment of insomnia. Use of any and all medications in TBI patients needs to monitored closely as the chance for an abnormal response could be more likely than in the general population.
You should discuss the insomnia issue with your primary care physician or rehabilitation specialist, though I suspect you may require the help of specialist in insomnia. Referral to a Sleep Specialist is often needed. A Sleep Specialist will take a detailed history and perform a physical examination. Based on this information, they will determine if further testing is needed or if a treatment strategy can be initiated.
To learn more about insomnia or other sleep disorders, please visit the American Academy of Sleep Medicine. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you.
Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University