Sleep Disturbances and Fatigue in TBI Survivors: Causes, Consequences, and Management

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Traumatic brain injury (TBI) is a major public health issue and is estimated to occur in more than 10 million people across the globe. However, the immediate effect of TBI is treated most of the time; the subsequent effects can be as crippling as the initial injury. Of these, sleep disturbances and fatigue have been indicated to be some of the most prevalent and long-term effects of TBI. Such problems not only decrease patients’ quality of existence but also prevent recovery, deteriorating the cognitive condition, mood, and even the physical health of the patient. Appreciating the risk factors and effects of sleep disturbances and fatigue in TBI patients and subsequent management approaches is vital for the improvement of patient’s quality of life and the promotion of enhanced rehabilitation.

Understanding Sleep Disturbances in TBI Survivors

Insomnia and other sleep-related complaints are common in TBI patients, with literature suggesting that up to 72% of the patients develop at least one sleep-wake disorder in the initial six months after injury. These disturbances can appear in various guises, such as insomnia or EDS, hypersomnia, or clock-wrecking disorders of the circadian cycle. The root causes of the above-mentioned sleep disorders are therefore complex and may include physiologic or neurologic, as well as psychological factors.

Among the several pathological changes occurring in TBI patients, alteration of circadian rhythm remains one of the most common physiological contributors to sleep disorders. During a particular phase of a brain injury, the pathways regulating sleep-wake cycles may be affected, and this causes sleep disorders. This disruption is usually accompanied by a decrease in the synthesis of melatonin, a hormone that is very vital in controlling the sleep and wake cycles. It has been established that patients with TBI secrete less melatonin during the evening, which is associated with reduced sleep efficiency and increased wake time after sleep onset.

Neural factors are also highly implicated in sleep alterations and disturbances after TBI. The injury can result in changes in the neurological processes, such as those regulating sleep profiles. For example, some individuals with TBI are indicated to have more slow-wave sleep, which is a restorative phase of sleep. This appears advantageous, but actually, an overload of slow-wave sleep is damaging as it affects the sleep rhythm, putting the person in a state of poor sleep quality and fatigue during the day.

Other non-sleep disorders causing sleep fragility in TBI victims are anxiety and depression. The physical pain that results from the injury, together with the difficulties arising from the process of healing, puts stress on the heart, and stress, in turn, influences the ability to fall and remain asleep. Also, some changes attributed to TBI may involve the physical and cognitively challenged state that may contribute to hopelessness and frustration that results in sleep disorders.

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The Effects of Disrupted and Fatiguing Sleep

The impact of sleep disturbance and fatigue following TBI is multilateral, as it puts a touch on virtually all aspects of life in clients and patients. Cognitive function is one of the areas that is most affected by poor sleep. Thus, sleep is crucial for the processes of consolidation of memories and learning, as well as the cognitive processes in general. When sleep is disrupted, these processes are for a while inactivated, which results in poor attention, poor concentration, and poor memory. Adjustment of the circadian rhythm can be disruptive for TBI survivors in general; if the patient already has some cognitive deficits because of the injury, the loss of normal sleep pattern can aggravate these problems and jeopardize the rehabilitation process since every task will be more difficult.

Self-perceived emotional status is still another facet of health that is negatively influenced by sleep disorders. It could be noted that sleep affects mood regulation in individuals, and thus, unstable sleep may result in increased levels of irritability, anxiety, and depression. Mood disorders The effects of TBI on sleep significantly worsen mood disorders in TBI survivors, as these patients are at a higher risk of developing mood disorders; mood disorders, on their part, worsen sleep and thus perpetuate the cycle.

Sleep disturbance and fatigue also affect physical health a lot. Lack of sleep has negative effects on health, such as the immunomodulating results leading to enhanced vulnerability to infections and increased regular cardiovascular diseases. Inherent to an already taxed body system resulting from the TBI, these health risks affect the lives of the TBI survivors severely. Also, fatigue makes people less energetic, and energy is vital in the overall health of an individual and recovery.

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Management Strategies for Sleep Disturbances and Fatigue

Since sleep disturbances and fatigue affect TBI survivors greatly, appropriate management should be introduced to enhance the quality of life. Managements usually employ both behavior and drugs as well as therapeutic methods about the specific circumstances of the concerned patient.

Behavioral Interventions

Cognitive-behavioral approaches to treat sleep problems are usually employed as initial steps of treatment for sequelae of TBI. Such interventions entail controlling what is ingested before going to sleep before the formation of a regular sleep schedule. Some of the strategies include having a specific time to go to bed and wake up, having a comfortable bed and pillow, and avoiding foods that contain caffeine and other substances like cigarettes. Before bedtime, patients are advised to take up hobbies such as reading or taking a warm bath to inform the body that it’s time for rest.

Besides recommending changes in sleep hygiene, cognitive behavioral therapy (CBT) can be useful in the treatment of the psychological causes of the problem. CBT for insomnia (CBT-I) is an organized plan that assists the patient in altering such patterns of thinking and behavior that hinder sleep. It is useful when the TBI survivor suffers from an anxiety- or depression-related sleep problem.

Pharmacological Interventions

In cases where behavioral interventions cannot be used as a sole strategy, then the use of pharmacological treatments may be employed. The treatment of sleep disturbances in TBI survivors through drug administration should be done carefully because drugs can harm the patient or have a negative interaction with other drugs that the patient might be on.

Melatonin is perhaps one of the most disputably used pharmacological interventions for sleep disturbances among TBI survivors. Melatonin plays a role in controlling sleep and wakefulness, and its supplementation may increase the quality of sleep and decrease the period of wakefulness in those patients who have low levels of melatonin because of their injury. However, care must be taken to administer melatonin at the right time and in the correct doses to reduce such side effects as excessive dozing during the day.

On some occasions, they are given prescription sleep medicines, including benzodiazepines and non-benzodiazepine sleeping tablets. These medications should only be taken under the supervision of the doctor since they are drugs of abuse and dependency if administered for an extended period. Furthermore, some TBI survivors are on antidepressants and/or antianxiety medications due to underlying psychological causes of sleep disturbances.

Therapeutic Interventions

Besides behavioral and pharmacological treatments, potential interventions for SSW may include neurofeedback and light therapy. Biofeedback is a broader technique in which the patient gets to know about the changes in their physiological activity and thereby attempts to modify these comments deliberately. Neurofeedback is a specific type of biofeedback that focuses on the brain activity of the patient, where the patient learns about his/her brain activity and, in the process, tries to control this activity deliberately. This therapy has also been useful in enhancing the TBI survivor’s sleep and diminished anxiety and depression traits.

Bright light, which is adjusted in time of the day, can also be used to control circadian rhythms, hence improving one’s wake-sleep cycle. This therapy is beneficial for patients with some sleep disorders, including those with circadian dysfunctions or excessive daytime sleepiness. Light therapy has to be taken as per the doctor’s prescription so that it can be used safely and to its optimum benefit.

Multidisciplinary Approach

There is comprehension of using a biopsychosocial model to cater to sleep issues and fatigue in TBI survivors. The treatment approach used in such cases is the multidisciplinary approach, where the neurologist, the psychologist, the physical therapist, and the sleep specialist will have to sit down and come up with a treatment plan for the patient. This calls for constant review of the treatment plan and the person’s response to the interventions to deal with new issues that may develop along the course of the recovery period.

Conclusion

Insomnia and tiredness are major problems for persons with TBI and have an impact on their quality of life in the aspects of mental, physical, and social. The management of these problems requires knowledge of how these symptoms originate and are initiated from a physiological, neurological, and psychological standpoint. Currently, there are medical and non-medical options, both behavioral, pharmacological, and therapeutic approaches, for the survivors of TBI to enhance sleep quality, reduce fatigue, and enhance their quality of life, under the guidance of a multidisciplinary healthcare team.

References

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