Sleep Disturbance
Sleep Disturbance
Sleep Disturbance
2, July 2023
http://mnj.ub.ac.id/
DOI: 10.21776/ub.mnj.2023.009.02.13
eISSN: 2442-5001 pISSN: 2407-6724
Accredited by DIKTI Decree No: 21/E/KPT/2018
Correspondence: [email protected]
1Department of Neurology, Faculty of Medicine, Universitas Udayana, Sanglah Hospital, Bali, Indonesia.
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Hypersomnia
Hypersomnia, often known as excessive daytime sleepiness
Figure 1. TBI and Sleep disturbance (private property). (EDD), is a sleep disorder characterized by recurrent bouts
Traumatic brain injury is most often caused by coup– of excessive daytime sleepiness or involuntary sleepiness at
countercoup, which frequently happens towards the base of unexpected times. Drowsiness during sedentary activity is
the skull in regions with bony prominences, frequently what distinguishes hypersomnia from tiredness, which is
injured the inferior frontal regions, anterior temporal and, as more typically seen while exerting physical effort. TBI
well as the base of forebrain. Due to the fact that the basal patients tend to underestimate their symptoms of daytime
forebrain is involved in sleep initiation, damage to this area sleepiness in the same way as they underestimate their
may result in insomnia symptoms.10 As a result, sleep symptoms of insomnia. A decrease of hypocretin-1 levels in
disruption is common following TBI, as the sleep-wake CNS might be a cause. In the initial days after TBI,
cycle related to some areas in the brain, including the hypocretin-1 levels in the CSF were found to be low in 25 of
brainstem, basal forebrain, frontal-subcortical system and 27 individuals.13,14
hypothalamus. MSLT has showed that almost half of individuals with severe
Table 1. Acute and Chronic Sleep Disturbances After TBI11 TBI exhibit pathological sleepiness with latency periods of
Time Diagnosis at least 10 minutes. The pathogenesis of posttraumatic
Insomnia hypersomnia is most likely connected to direct injury to the
Insomnia related to post traumatic mood tuberomammillary histaminergic wakefulness neurons,
disturbance which drop by around 40% after a severe traumatic brain
Acute
Insomnia related to post traumatic headache injury.15
disorder
Hypersomnia
In order to properly diagnose hypersomnia, objective sleep
Insomnia tests must be done to demonstrate the presence of
Circadian rhythm disorder pathological sleepiness throughout the night. The test is
Chronic Obstructive sleep apnea referred to as the multiple sleep latency test (MSLT).
Narcolepsy Treatment for this disorder may include the use of stimulant
Chronic traumatic encephalopathy medications such as modafinil, methylphenidate, or
Some of the frequent sleep disorders that occur with TBI amphetamines.12
include insomnia, hypersomnia, sleep-wake cycle
irregularities, and parasomnia. Sleep disturbance may arise Circadian Rhythm Disorder
as a distinct characteristic or as a sign of various mental,
medical, or neurological disorders. It is possible for TBI Disturbances of the circadian rhythm after a traumatic brain
patients to suffer a wide range of sleep disruptions at various injury are sometimes confused for insomnia. TBI-induced
times after the injury.It is possible for TBI patients to suffer hypothalamic and suprachiasmatic nucleus damage is
a wide range of sleep disruptions at various times after the thought to be the primary cause of circadian rhythm
injury (Table 1). disruption. In addition, the normal 24-hour cycle of
biological cycles, such as body temperature and melatonin
release is disrupted.9
Circadian sleep disorder include abnormal sleep-wake cycles most prevalent complaint from patients was a headache.
and, more typically, delayed sleep phase syndrome. It is Between baseline and final visit, patients receiving 250 mg
indeed crucial to know the difference between insomnia and armodafinil, the R-enantiomer of modafinil, saw a
circadian rhythm disorder since the two conditions need substantial reduction in sleep latency compared to
different approaches to therapy. When individuals with this placebo.18,19
disease are able to fall asleep, both the length and pattern of Melatonin
their sleep are normal.1 It is preferable to use melatonin or
The pineal gland produces melatonin, a hormone that
strong light treatment rather than prescribing hypnotics. 9
regulates sleep and wake cycles. Melatonin levels are lower
There are two common abnormalities in the circadian rhythm in individuals with TBI compared to their healthy
of sleep that might be unnoticed following a traumatic brain counterparts, suggesting that TBI interferes with the
injury: delayed sleep phase syndrome and irregular sleep- melatonin pathway, according to previous study.20
wake rhythm. As a result, insomnia may be misdiagnosed Melatonin has also been shown to lessen symptoms of
when a patient complains of difficulties getting to sleep, anxiety and tiredness in individuals, as well as boost their
staying asleep, and problems waking up at their typical perceptions of their own vitality and cognitive abilities.21
time.16
Melatonin is a serotonin metabolite. Melatonin synthesis is
enhanced in the dark, whereas its secretion is suppressed in
Treatment the light. It is critical for maintaining the biological rhythm
It is critical to establish a diagnosis. Other comorbid of the body and for coordinating the sleep-wake cycle with
psychological and medical illnesses must be recognized and the surroundings. The suprachiasmatic nucleus, which
treated since they may be contributing to or increasing the regulates circadian rhythm, contains several melatonin
sleep disturbance. Pharmacological therapies are used in receptors, indicating the hormone's importance in
conjunction with a variety of nonpharmacological methods, maintaining the body's internal clock.1
including sleep hygiene practices, phototherapy, The MT1 and MT2 receptors in suprachiasmatic nucleus, are
chronotherapy, and psychotherapy. activated by the melatonin agonist (Ramelteon). T he Food
and Drug Administration has authorized Ramelteon to
be used in the treatment of insomnia characterized by
Pharmacological problems in falling asleep.5 Ramelteon works by altering
Benzodiazepine Sedative-Hypnotics sleep mechanisms in suprachiasmatic nucleus.1
GABA (gamma-aminobutyric acid) receptor activation by
benzodiazepines results in improved sleep, which has been Non-pharmacological
shown to be both subjective and objectively
effective. Theoretically, benzodiazepines might hinder Sleep Hygiene and Behavioural Therapy
neuronal recovery in patients with brain damage, thus they Noise and disruptions, particularly in a hospital, should be
should be administered with care. Lorazepam (0.5–2.0 mg), taken into consideration. To enable patients to sleep through
temazepam (7.5–30 mg), and clonazepam (0.25–2.0 mg) are the night, it is critical that the number of blood draws and the
among the benzodiazepines routinely used at bedtimes as timing of vital sign checks be kept to a minimum. Educating
hypnotics. The most common use is to treat short-term patients about proper sleeping habits is critical while they are
insomnia or temporary insomnia. As a general rule, rehabilitating at home. Keeping a sleep diary and
benzodiazepines should not be administered for more than establishing a daily regimen might be helpful. Late afternoon
three or four days, however this may not always be possible is the ideal time to avoid caffeinated beverages, such as tea,
in clinical practice.1 coffee, and soda. When it comes to nighttime routines, it's
Nonbenzodiazepine Sedative-Hypnotics best to avoid using television, tablets, or smartphones in the
bedroom. If you've been awake for more than 20 minutes, it's
Since nonbenzodiazepines operate only on the type 1 time to get out of bed and do something calming like
benzodiazepine receptor complex, they have a lower risk of listening to music or reading a book. Restriction of the
producing cognitive adverse effects. Additionally, they have amount of time spent in bed is a key component of sleep
short half-lifes and are less prone to produce sleepiness restriction treatment. The goal of this treatment is to enhance
throughout the day. Nausea anxiety, and dysphoric the desire to sleep, improve the quality of sleep, and reduce
responses are all common adverse effects; anterograde the amount of time spent awake throughout the night. 18
amnesia and rebound insomnia have also been
recorded. Zaleplon (5–10 mg at bedtime) and Zolpidem (5– CBT for insomnia (CBTi) is regarded as the first-line
10 mg at bedtime) are both nonbenzodiazepines that are treatment for insomnia management.22 Aims at changing
often used to treat temporary insomnia.1 sleep-related beliefs and attitudes by identifying and
correcting their root causes. It has been shown using
Modafinil and Armodafinil objective sleep measurements such as actigraphy and
The American Academy of Sleep Medicine (AASM) polysomnography that it enhances total sleep duration and
suggests these two medications for the treatment of lowers sleep–onset latency, and that it is superior to
hypersomnia related to traumatic brain injury.17 Taking 100- pharmacological treatment.1
200 mg/day of modafinil in the morning has been shown to Light therapy
be both safe and effective for improving sleepiness. Only
half of the recommended dose should be given to patients Stimulant and antidepressant effects have both been found in
with liver disease because there is risk of liver toxicity.18 The the utilization of certain wavelengths of ocular light
exposure. Neuroendocrine, neurobehavioral, and circadian
responses have been shown to be stimulated by this therapy. 9. Zhou Y, Greenwald BD. Update on insomnia after mild
Non-image forming photoreceptors apart from rods and traumatic brain injury. Brain Sci; 2018. 8(12):223.
cones influence the brain's response to light. DOI: 10.3390/brainsci8120223
Studies have shown that exposure to blue or blue-enriched 10. Viola-Saltzman M, Watson NF. Traumatic brain injury
light improves alertness and mood the most. As a and sleep disorders. Neurol Clin; 2012. 30(4):1299–
consequence, sleep quality may be improved by increasing 312. DOI: 10.1016/j.ncl.2012.08.008
sleep duration and lowering nocturnal awakenings.23 11. Zuzuárregui JRP, Bickart K, Kutscher SJ. A review of
sleep disturbances following traumatic brain injury.
Treatment with blue light 45 minutes/day for four weeks
Sleep Sci Pract; 2018. 2(1):1–8. DOI: 10.1186/s41606-
resulted in decreased daytime sleepiness and fatigue, with a
018-0020-4
return to baseline after treatment cessation.24
12. Paredes I, Navarro B, Lagares A. Sleep disorders in
traumatic brain injury. Neurocir Engl Ed; 2021.
Conclusion 32(4):178–87. DOI: 10.1016/j.neucie.2020.12.001
13. Watson NF, Dikmen S, Machamer J, Doherty M,
Insomnia, hypersomnia, sleep-wake cycle irregularities, and
Temkin N. Hypersomnia following traumatic brain
parasomnia are a few of the most common sleep disorders
injury. J Clin Sleep Med; 2007. 3(4):363–8.
associated with TBI. Sleep disturbances may manifest as a
DOI: 10.5664/jcsm.26857
unique trait or as a symptom of various mental, medical, or
14. Billiard M, Podesta C. Recurrent hypersomnia
neurological conditions. Patients with TBI may experience a
following traumatic brain injury. Sleep Med; 2013.
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14(5):462–5. DOI: 10.1016/j.sleep.2013.01.009
injury.
15. Valko PO, Gavrilov YV, Yamamoto M, Finn K, Reddy
H, Haybaeck J, et al. Damage to histaminergic
Acknowledgement tuberomammillary neurons and other hypothalamic
None. neurons with traumatic brain injury. Ann Neurol; 2015.
77(1):177–82. DOI: 10.1002/ana.24298
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Conflict of Interest Circadian rhythm sleep disorders following mild
None. traumatic brain injury. Neurology; 2007. 68(14):1136–
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17. Maski K, Trotti LM, Kotagal S, Robert Auger R,
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