Sleep Disorders and Fatigue Issues following TBI - Presented by OTR/L, CBIST Brooke Murtaugh, OTD
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Sleep Disorders and Fatigue
Issues following TBI
Presented by
Brooke Murtaugh, OTD,
OTR/L, CBIST
Brain Injury Program
Manager
Madonna Rehabilitation
Hospitals
Objectives • OBJECTIVES • State the nature and prevalence of sleep disorders and fatigue issues following TBI • Describe at least five causes of sleep disorders and fatigue issues following TBI • State 4 non-pharmacological and pharmacological treatment options for treatment of sleep disorders and fatigues issues following TBI
Sleep • As necessary as food, water and light. • Crucial to the development and maturation of the brain. • Sleep is a restorative function of the brain. • Sleep regulates immune function, endocrine function. • Promotes neuroplasticity and brain healing. • Normal sleep occurs in organized patterns.
Sleep and TBI
• Studies show individuals in comatose state have
disorganized sleep patterns.
• Well organized sleep-wake cycle is a positive
prognosticator for increased clinical outcome after
TBI.
• Arnaldi, D. (2016).
• Insomnia is a key variable of perceived disability.
• Mollayeva, T. (2015).
• Sleep disturbances can persist for years post injury.
• Sleep disturbances are more prevalent in those with
MTBI.
Sleep and TBI
• Most Common Sleep Disorders Post TBI:
– Insomnia
– Sleep-related breathing disorders
• Obstructive sleep apnea
• Central apnea
– Narcolepsy
• Rare
– Post-Traumatic Hypersomnia
• Increased duration of sleep
– Circadian Rhythm Sleep Disorders
• Disorganized sleep-wake patterns
Insomnia • Factors contributing to insomnia – Neuropathological process – Medications – Pain – Psychological Factors – Environmental Factors – Life habits
Sleep and Acute Rehabilitation
• Large numbers of admitted patients have
sleep disorders:
– 2015 ACRM Study indicates 67% of acute rehab
patients with BI met diagnostic criteria for a
sleep disorder
– Recent study of 205 consecutive admissions to
Acute TBI Rehab unit found 66% had a specific
clinical diagnosis (Nakase-Richardson et al 2015)
• Circadian Rhythm Disorder (>47%)
• Sleep Apnea (33%)
Sleep Study Findings
(Ponsford et al, 2013; Shekelton et al, 2010)
• 80% of TBI survivors report subjective sleep changes
– Poorer sleep quality
– Increased daytime sleepiness
– Longer sleep onset and more naps
• TBI patients reported higher levels of pain, depression and anxiety which
were associated with some of the changes reported
• Reports of sleep changes are correlated with reduced REM and increased
slow wave sleep even after controlling for the impact of anxiety and
depression
• TBI patients have lower levels of melatonin in the evening which is
associated with reduced REM
• Elevated psychological distress, particularly depression was associated
with reduced sleep quality
Sleep Disorders • Mathias (2012) Review of Sleep and TBI • 12x risk of obstructive sleep apnea following TBI • 2/5 had sleep apnea on inpatient admission • Trazodone doesn’t help sleep apnea • Circadian rhythm disorder is the most common problem • Studies have show a direct relationship between FIM Cognition score and CPAP compliance
Sleep Disorders • Cognitive deficits will appear worse when sleep disorder is present. • Daytime sleepiness is associated with reduced cognitive functioning. • Experience increased anxiety, depression and fatigue with sleep/wake cycle disturbance. • Increased overall pain and chronic headaches.
TBI and Sleep Disturbance
Associated with Worse Outcomes
• Patients with sleep disturbance had
– Slower reaction time
– Poor delayed recall scores
– Executive Dysfunction
– Longer Duration of PTA
– Longer Lengths of Stay
– Decrease in vigliance
• Daytime somnolence can result in lack of participation and possible early
discharge
• Confused patients are awake at night
• Increases likelihood of physical restraints
• More agitation
• Use of chemical restraints which may slow recoverySleep Disorders
• Depression and Anxiety
– Common after TBI
– Vicious cycle
• Depression and anxiety can cause insomnia and sleep
disorders, and sleep disorders can increase depression
and anxiety. Hard to know which comes first.What about kids?
• Sleep-wake disturbances are common after
traumatic brain injury in school aged children
regardless of the severity of injury.
• Fatigue issues are common after TBI in school
aged children.
– Fatigue is one of the most frequent post-
concussive symptoms, and can be persistent.
• There has been no structured study to date of
preschool children with TBI.Sleep is IMPORTANT! • Sleep links to participation in rehabilitation. • Sleep links to acute cognitive recovery. • Sleep links to productivity at one year. • Sleep improvement precedes resolution of other confusion symptoms. • Early improvement in sleep is associated with earlier resolution of PTA. • Strong evidence that sleep promotes brain repair.
Inpatient Rehab:
What can we do?
• Raise awareness of the importance of sleep for our patients.
• Staff, physicians, family awareness
• Monitor patient sleep cycles
– Actigraphy
– Nurse Sleep Logs
– Sound/Light Monitors
– PSG/Sleep studies
• Limit night time noise on the unit
• Limit night time vitals and cares
• Limit night time audio/visual stimulation from personal electronics
• Use light darkening shades, dimmed lights at bedside
• Use bright lights in the morning, use of light boxes
• Limit daytime sleep periods
• No Caffeine
• Schedule toileting before sleepTreatment of Sleep Disorders • Prescription drugs are a short term fix. • Even in short term, not very effective. • Conduct an objective sleep assessment. – Self report is not always accurate • Management of pain. • Treat mood disturbance. • Cognitive-behavioral therapy. – Target mal-adaptive sleep behaviors
CBT
• Limited studies on efficacy of CBT to treat
sleep disorders post TBI.
• Conclusive evidence that CBT does positively
impact insomnia secondary to depression and
anxiety, thus positively impacting depression
and anxiety symptoms.
– Ashworth, 2015Fatigue and TBI
Sleep and Fatigue as a Long-term Issue
Fatigue and TBI • Most common symptom and can be long- standing after TBI. • Difficulty to treat, wide range of symptoms and descriptions of fatigue and every person experiences fatigue differently. • Frequently referred to as Post-Traumatic Fatigue (PTF) or pathological fatigue.
Fatigue and TBI
• Hypothesis
– Fatigue is the product of poor neuronal
processing, impaired by a combination of primary,
secondary and tertiary effects, decreasing the
effectiveness of coordinated cognitive out put.
• Henri, 2013What is Fatigue? • A universal symptom, also present in healthy individuals. • Defining fatigue is difficult as it is a subjective and multidimensional construct. • “the failure to initiate and/or sustain attentional tasks and physical activities requiring self- motivation…” – (Chauduri & Behan, 2000). • Distinction between physiological and psychological resources.
Fatigue and TBI
• Pathological Fatigue
– “A state that refers to a weariness unrelated to a
previous exertion level, and not ameliorated by
rest.”Fatigue Pathophysiology • TBI can impact the areas of the brain responsible for our arousal. – Reticular activating system – Medulla – Pons – Basal Ganglia • Can lead to decreased initiation, motivation and decreased activation of arousal centers.
The Problem: Fatigue and TBI • Numerous studies examining outcomes following mild, moderate and severe TBI have found fatigue to be a common and persistent problem, reported between 21-72% of patients. • (Borgaro et al, 2005; Bushnik et al, 2007,2008; Kempf et al, 2010; Ponsford et al, 2000; Olver et al, 1996; Ponsford et al, 2012, Henrie, 2013)
Physiological Fatigue • Physiologically, fatigue is defined as functional organ failure, generally caused by excessive injury consumption. • Depletion of essential substrates of physiological functioning (e.g. hormones, neurotransmitters) and/or a diminished ability to contract muscles.
Physiological Fatigue: Central vs.
Peripheral Fatigue
• Central Fatigue: Arises from impairment
within the CNS (e.g. hypothalamus, reticular
formation) or impaired transmission between
the CNS and PNS
• Peripheral Fatigue: Results from malfunction
of the peripheral nervous system, such as
impaired neuromuscular transmission at the
motor end plate, not related to the CNSPsychological Fatigue • A state of weariness related to reduced motivation, prolonged mental activity, or boredom that occurs in situations such as chronic stress, anxiety or depression.” (Lee et al., 1991, p. 291) • A high proportion of TBI patients develop depression and anxiety.
Predictors of Fatigue
• Psychiatric symptoms
• Sleep disturbances
• Post-traumatic amnesia
• Loss of consciousness
• Schiehser, 2016Factors Impacting Fatigue • Systematic Review demonstrated consistent factors contributing to fatigue post TBI: – Earlier fatigue severity – Genetic disposition – History of mental health issue – Medical disability – Marital status (widowed, divorced, separated) – Litigation – Depression
Measurement of Fatigue • Numerous measures developed • No single valid and reliable measure exists • Many fatigue scales are specific to a particular illness (e.g. cancer) • Existing scales address differing aspects of fatigue—it’s characteristics, it’s consequences and the associated subjective feelings
Measurement of Fatigue • Aaronson et al (1999) recommend assessment of: • Subjective quantification of fatigue levels • Subjective distress because of fatigue • Subjective assessment of the impact of fatigue on activities of daily living • Correlates of fatigue with other associated factors (e.g. sleep and depression) • Biological parameters
First Ponsford Study – Mild-Severe TBI – Ages 16-67, living in the community, no prior TBI, neurological or psychiatric illness – Average time since injury ranged from 21-1153 days – 139 TBI, 77 normals, similar in demographics – TBI individuals experience greater subjective fatigue which impacts on their daily lifestyle – Used the causes of fatigue questionnaire and found that everything was more fatiguing for patients with TBI except watching TV and taking a shower – Found that injury severity and age were not predictive of fatigue – Time since injury did predict fatigue severity with some scores increasing over time – Higher levels of anxiety and depression were highly significant predictors of fatigue but don’t know which is causal
First Ponsford Study (continued) – Later studies have shown that feeling fatigued made people feel more depressed and anxious. – No significant association between taking any medication and Fatigue Severity Scores. – No significant association between the presence/absence of orthopedic injuries and scores on the fatigue scales. – TBI patients showed significantly higher pain severity ratings and pain severity and fatigue ratings are moderately associated. – Fatigue levels did not decrease over time and in some areas they increased.
Second Ponsford Study
• Investigation of the impact of subjective fatigue on cognitive performance
• Attention
– Higher levels of subjective fatigue were associated with slowed information
processing and poorer performances on tasks with higher working memory or
dual task demands
• Vigilance
– Higher ratings of subjective fatigue associated with slower and more errors on
performance
– Sustaining performance on measures of vigilance were associated with:
• Increases in blood pressure greater than controls
• The Impact—A Bad Cycle
– Greater increases in blood pressure resulted in greater subjective fatigue
– Greater errors on Vigilance task and increase in systolic BP was associated with
higher levels of anxiety and depression
– Greater need for mental effort may increase systemic stress including both
physical and psychological stressImplications • TBI patients need to have the attentional demands of their daily activities modified. • TBI patients can potentially benefit from management of mood disturbances which will further impact attention difficulties.
Implications
• Fatigue and impact on employment:
– Study by Palm, 2017 found that those with fatigue
post TBI had a reduced employment status.
– Higher level of rated mental fatigue correlated
with lower employment status.
– Employment status was not dependent upon age
or TBI severeity.
– Higher rating of depression and anxiety also
correlated with lower employment status.Distinguishing Fatigue from
Sleep Disorders
• Excessive daytime sleepiness is
different from fatigue.
• Excessive daytime sleepiness is
defined as drowsiness, feeling
the need to nap when they want
to be awake, after insufficient
sleep or sleep disruption
• In practice, patients may not be
able to differentiate sleepiness
from fatigue but as the clinician it
will help if you can.
• Excessive daytime sleepiness is
usually from sleep apnea or
circadian rhythm disorder.Organic Basis of Fatigue? • In TBI patients, fatigue was predictive of depression and sleepiness however, depression and sleepiness did not predict fatigue. • Results support the view of fatigue after TBI as “primary fatigue”-that is a consequence of the structural brain injury rather than a secondary consequence of depression or daytime sleepiness – Schoenberger et al (2014)
Is there an organic basis for fatigue?
• Schonberger, M. JHTR 29(5) 427-431.
– Primary fatigue is not just a consequence of
depression.
Lower visible brain stem volume.
Neuroendocrine abnormalities including lower
growth hormone levels
2005 Study Orexin in TBI (Hypocretin)
-95% of patients with mod-severe TBI had low
levels of Orexin
Hypothalamic injury?Other Possible Causes of Fatigue Neuroendocrine abnormalities including lower growth hormone levels (Bushnik et al, 2007; Englander et al, 2010) 2005 Study Orexin in TBI (Hypocretin) -95% of patients with mod-severe TBI had low levels of Orexin Baumann et al (2007) make a case for lower CSF Hypocretin-1 caused by loss of hypocretin neurons causing excessive daytime sleepiness. Found fewer hypocretin neurons in the brains of 4 deceased TBI cases postulating the role of hypothalamic injury in fatigue
Fatigue Management • Need to assess contributors/ differential diagnosis. Rule out any other medical issues. – Attention issues – Medications – Pain levels – Mood concerns
Fatigue Management
• Work on regulation of lifestyle
– Decrease work hours?
– Modify pace/demands of work
• Energy Conservation
• Prioritize activities
– Decrease distraction/need for multi-tasking
– Allow time to rest
– Address psychological issues, cognitive behavioral
therapy
– Modify cognitive demands of tasks.Fatigue Management
• Dietary Lifestyle
– Weight reduction
– Foods to boost energy
• Sleep Hygiene
• Energy Conservation Strategies
• Community participation
• Physical Activity-Walking
» Kolakowsky-Hayner, 2016Fatigue Management
• Physical conditioning programs can decrease
fatigue (Sullivan, Richer & Laurent, 1990;
Wolman, Cormail, Fulcher & Greenwood, 1994;
Jankowski & Sullivan, 1990)
• Pharmacological Interventions
• Modafinil-2 Randomized Controlled Trials
– Helps with daytime sleepiness but not helping with subjective
fatigue
• Sleep Hygiene Techniques
• Avoiding naps if this interferes with nighttime sleep
• Adhering to a regular schedule
• Avoid time spent in bed awake
• Outlet and Morin (2007) CBT for insomniaFatigue Management
• Light Therapy for Fatigue and Daytime Sleepiness
– 2014, Sinclair et al, Neurorehabilitation and Neural
Repair, 28(4), 303-313.
– 30 persons with TBI
– RCT utilizing 4 week treatment phase of morning use (45 minutes per
day)
– Showing promise
– Blue Light is the most effective, yellow light and placebo not helpful
– Projects on the back of the retina
– Releases melanopsin to the suprachiasmatic nucleaus
– Increases arousal
– Blue light therapy following TBI helps with subjective fatigue and
daytime sleepiness
– Trend towards increase in psychomotor vigilance-lots of individual
variability
– Study is ongoing, soon to analyze larger sample sizeSummary—Sleep and Fatigue
shouldn’t be ignored
• There is considerable evidence that sleep disorders are highly
prevalent following brain injury both in the acute stages and long-
term.
• Sleep issues impact our patient’s outcomes.
• Patients with brain injury also suffer from fatigue that is separate and
distinct from sleep issues.
• Fatigue appears to be a direct result of the brain injury and cannot be
explained as a secondary effect of mood disorders, medications or
pain but can be exacerbated by those factors.
• Treatment of both issues is multifaceted but should be addressed as
part of our rehabilitation program.Thank You!
Questions?
bmurtaugh@madonna.orgReferences
• Ashworth, DK., et al. (2015). A randomized controlled trial of cognitive
behavioral therapy for insomnia: an effective treatment for comorbid
insomnia and depression. Journal of Counseling Psychology; 62(2): 115-
123.
• Arnaldi, D., Terzaghi, M., et al. (2016). The prognostic value of sleep
patterns in disorders of consciousness in the sub-acute phase. Clinical
Neurophysiology, 127; 1445-1451.
• Gagner, C., Landry-Roy, C., Laine, F., & Beauchamp, M.H. (2015). Sleep-
wake disturbances and fatigue after Pediatric Traumatic Brain Injury: A
Systematic Review of the Literature. Journal of Neurotrauma, 32: 1-14.
• Gardani, M., Morfiri, E., Thomson, A., et al. (2015). Evaluation of sleep
disorders in patients with severe traumatic brain injury during
rehabilitation. Archives of Physical Medicine and Rehabilitation, e-pub
ahead of print.
• Henri, M, Elovic, E. (2013). Fatigue: Assessment and Treatment. In Brain
Injury Medicine. Zasler (Eds). DemosMedical, New York, NY.References
• Kolakowsky-Hayner, s., et. Al. (2016). A randomized control trial of walking
to ameliorate brain injury fatigue: a NIDRR TBI model system centre-based
study. Neuropsychological Rehabilitation; 13: 1-17.
• Mathias , J.L. & Alvaro, P.K. (2012). Prevalence of sleep disturbances,
disorderrs, and problems following traumatic brain injury: A meta-
analysis. Sleep Medicine (13); 898-905.
• Mollayeva, T., Pratt, B., & Mollayeva, S. et al. (2015). The relationship
between insomnia and disability in workers with mild traumatic brain
injury/concussion. Sleep Medicine; 1-10.
• Mollayeva, T., et al. (2014). A systematic review of fatigue in patients with
traumatic brain injury: the course, predictors and consequences.
Neuroscience and Behavioral Reviews. 47:684-716.
• Nakase-Richardson, R., (2015). Brain Injury Sleep Wake Cycle Disorders.
Presentation at the Brain Injury Summit, Vail, CO.References
• Ouellet, M., Beaulieu-Bonneau, S., & Morin, C.M. (2015). Sleep-wake disturbances
after traumatic brain injury. Lancet Neurol, 14; 746-757.
• Ouellet, M., Beaulieu-Bonneau, S., & Morin, C. (2013). Sleep-wake disturbances. In
Brain Injury Medicine. N.Zasler (Eds). 707-725.
• Palm, S., Ronnback, L, & Johansoon, B. (2017). Long-term mental fatigue after
traumatic brain injury and impact on employment status. Journal of Rehabilitation
Medicine; 49; 228-233.
• Ponsford, J., (2015). Post-traumatic fatigue; Creating an evidence base for
efficacious treatments. Presentation at the Brain Injury Summit, Vail, CO.
• Schiehser, D., et. Al. (2016). Predictors of cognitive and physical fatigue in post-
acute mild-moderate traumatic brain injury. Neuropsychological Rehabilitation; 18:
1-16.You can also read
