Identifying and Addressing Sleep-Wake Disturbances Post-TBI


Sleep disturbances can exacerbate TBI symptoms. Here’s how to address them.


Dragana Gordic/AdobeStock

Traumatic brain injuries (TBI) are a leading cause of death and disability.1 In many cases, those who survive their TBI appear to make a complete physical recovery while being left with subtle, “invisible” disabilities that are likely to severely impact daily functioning. Such disabilities include learning/memory, problem solving and executive functioning deficits, difficulties with psychosocial interactions, as well as emotional/behavioral issues. Secondary disabilities may be additionally impacted by one of the most common and persistent sequelae post-TBI, sleep-wake disturbances (SWD).2 Sleep is known to be an essential component of daily living, impacting a wide range of functioning from cognition and emotional well-being to immune system and endocrine function, as well as general health.3-5 Sleep disturbances can serve to exacerbate TBI symptoms and reduce functional outcome potential, as cognitive and affective processes are already likely impacted by the TBI itself.


TBIs are highly variable, as are the SWDs that accompany them. SWDs are generally multiple and multifaceted, impacting both objective sleep characteristics as well as subjective sleep quality. Common sleep-related complaints post-TBI consist of insomnia, difficulty maintaining sleep, poor sleep efficiency/frequent awakenings, and excessive daytime sleepiness.6 These complaints are corroborated by objective data from polysomnographies (PSG).7-10 In addition, sleep-related breathing disorders such as obstructive sleep apnea have been identified in up to 70% of patients with TBI—a prevalence 12 times higher than in the general population.11 Ultimately, SWDs may vary based on injury chronicity and severity; however, they present in even mild cases, are often observed acutely and may persist for years after the injury.12-18

Factors Influencing SWDs

Disturbances in sleep may be a primary result of damage to the sleep-wake circuitry of the brain or a secondary consequence of TBI-related comorbidities, including depression, pain, and anxiety, as well as pharmacological treatments.13 Patients with TBI self-report high levels of depression and anxiety, as well as poor sleep quality.7,9,13 Increased levels of depression and anxiety are likely to contribute to SWDs after an injury, as similar subjective and objective sleep disturbances are also common in patients with depression and no reported history of brain trauma.19 Additionally, many drugs commonly prescribed to patients with TBI have adverse effects of excessive sleepiness, insomnia, depression and/or anxiety. Considered together, these factors are likely to have a significant effect on quality of life for TBI survivors.

As mentioned previously, SWDs may appear at any point in the recovery continuum; thus, it is important to monitor for sleep disturbances across time. For example, fatigue and posttraumatic hypersomnia have been observed up to 3 years post trauma.16 Though SWDs have been identified in a wide range of injury severities, some studies have identified a worsening of sleep-related complaints, as well as an increase in sleep-time requirements with more severe injuries.20 Additionally, normal aging is associated with an increase in SWDs in the general population.21 Given the effects of age on sleep, it is likely that aging will exacerbate TBI-associated SWDs. Other important considerations are body mass index (BMI) and the patient’s sex. These variables can provide valuable information on the likelihood of SWDs, particularly sleep apnea, as increased BMI and the male sex have shown a positive correlation with the presence of sleep apnea, though this may be underdiagnosed in women due to differing symptoms.22-24 

Outcome Impact

Disruptions in the normal sleep-wake cycle are likely to have a negative impact on the rehabilitative process. In general, patients with TBI show deficits in executive functions, including attention, verbal fluency, planning skills, etc. These deficits may be further impacted by SWDs and depression.25-28 In fact, deficits across a wide array of cognitive areas have been reported to be greater in patients with TBI and concurrent sleep disorders.29,30 The frontoparietal regions of the brain that control these functions are particularly vulnerable to injury; the networks in these areas are also disproportionately affected by disruptions in sleep.25,28 In addition, sleep has been identified as a requirement for the consolidation of hippocampal dependent memory and motor-skill learning.31-34 It has been proposed, however, that sleep-dependent memory and learning rely heavily on proper organization of the sleep cycle, which is frequently disrupted post-TBI.31,35

Sleep is also known to contribute to emotional and psychological well-being. For example, excessive daytime sleepiness, as a consequence of apnea, has been found to impact mood and judgment.30 Likewise, trauma-induced SWDs have been shown to increase negative behavior and increase the likelihood of patients staying in bed during sessions.12 In addition to deficits in rehabilitation performance and cognition, SWDs have been linked to longer rehabilitative stays.36 Overall, disturbances in sleep will ultimately influence the ability of patients to reach their full rehabilitative outcome potential. 

Assessment and Treatment of SWDs

Considering the potential consequences of SWDs and the correlation with brain injury, care should be taken to properly screen, diagnose, and treat these disturbances in an attempt to improve patient outcomes.37 Screening may include a combination of clinical interviews, sleep diaries, and self-reported questionnaires. During a clinical interview, baseline information is gathered to assess potential changes in sleep patterns and factors that may be influencing sleep (comorbid factors such as pain, anxiety, depression; use of prescription and nonprescription medications; use of illicit drugs; and general symptoms of SWDs (ie, snoring, nightmares, limb movements, etc)).

Sleep diaries may be a useful self-monitoring tool for documenting the nature, frequency, and severity of any disturbances in sleep. Several subjective questionnaires may also be administered, including the commonly used Epworth Sleepiness Scale and the Pittsburgh Sleep Quality Index.38 Objective measures of SWDs, specifically full, overnight PSGs, should be used whenever possible, as it gives the most accurate representation of brain, muscle, and respiratory activity. Actigraphy may be used as a more feasible measure, as it is inexpensive, easy to use, and allows for multi-night monitoring; however, the data is limited, and the reliability and accuracy has not yet been fully validated in regards to brain injury.39

Once any SWDs are identified, treatment depends largely on the type of disturbance. By utilizing a combination of the aforementioned screening/diagnostic techniques, one may better identify the root-cause of the disturbance, thereby allowing for more appropriate treatment. Treatment for sleep apnea primarily includes the use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure machines, which treat apnea by increasing air pressure in the throat to keep the airway from collapsing while a person sleeps. Prescription medication may also be used; for example, dopamine agonists to treat restless leg syndrome or periodic limb movement disorder; benzodiazepines, anticonvulsants, or orexin receptor antagonists for insomnia; stimulants for hypersomnia, etc.

Ideally, medications should be used short-term and paired with good sleep hygiene and other behavioral treatments (ie, relaxation training, cognitive therapy, etc). Other interventions that may be utilized include forms of light therapy and counseling. Exposure to red light and near infrared light may improve sleep for patients with TBI, as this type of light therapy has been shown to reduce sleepiness and improve mood in healthy adults.40-42 Counseling will also provide a beneficial support system for patients with TBI who are experiencing disruptions in sleep, especially if depression/anxiety are thought to be the basis of the SWDs.

Proper treatment often requires a mixture of treatment paradigms. Regardless of the type of intervention, feasibility may be limited when dealing with the brain-injured population, largely due to issues of tolerance and adherence to treatment. Adherence to CPAP use, medications, and light therapy should be closely monitored.

Dr Howell is a senior neuroscientist at the Centre for Neuro Skills. She is a specialist in brain injury rehabilitation, neurodegenerative disease, and clinical research.


1. Traumatic brain injury & concussion. Centers for Disease Control and Prevention. December 15, 2022. Accessed February 23, 2023.

2. Wickwire EM, Williams SG, Roth T, et al. Sleep, sleep disorders, and mild traumatic brain injury. What we know and what we need to know: findings from a national working group. Neurotherapeutics. 2016;13(2):403-417.

3. Alhola P, Polo-Kantola P. Sleep deprivation: impact on cognitive performance. Neuropsychiatr Dis Treat. 2007;3(5):553-567.

4. Irwin MR. Why sleep is important for health: a psychoneuroimmunology perspective. Annu Rev Psychol. 2015;66:143-172.

5. Thompson KI, Chau M, Lorenzetti MS, et al. Acute sleep deprivation disrupts emotion, cognition, inflammation, and cortisol in young healthy adults. Front Behav Neurosci. 2022;16:945661.

6. Mathias JL, Alvaro PK. Prevalence of sleep disturbances, disorders, and problems after traumatic brain injury: a meta-analysis. Sleep Med. 2012(7);13:898-905.

7. Shekleton JA, Parcell DL, Redman JR, et al. Sleep disturbance and melatonin levels following traumatic brain injury. Neurology. 2010;74(21):1732-1738.

8. Modarres MH, Kuzma NN, Kretzmer T, et al. EEG slow waves in traumatic brain injury: convergent findings in mouse and men. Neurobiol Sleep Circadian Rhythms. 2016;2:59-70.

9. Parcell DL, Ponsford JL, Rajaratnam SMW, Redman JR. Self-reported changes to nighttime sleep after traumatic brain injury. Arch Phys Med Rehabil. 2006;87(2):278-285.

10. Parcell DL, Ponsford JL, Redman JR, Rajaratnam SMW. Poor sleep quality and changes in objectively recorded sleep after traumatic brain injury: a preliminary study. Arch Phys Med Rehabil. 2008;89(5):843-850.

11. Wolfe LF, Sahni AS, Attarian H. Sleep disorders in traumatic brain injury. NeuroRehabilitation. 2018;43(3):257-266.

12. Gardani M, Morfiri E, Thomson A, et al. Evaluation of sleep disorders in patients with severe traumatic brain injury during rehabilitation. Arch Phys Med Rehabil. 2015;96(9):1691-1697.

13. Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after traumatic brain injury. Lancet Neurol. 2015;14(7):746-757.

14. Baumann CR, Werth E, Stocker R, et al. Sleep-wake disturbances 6 months after traumatic brain injury: a prospective study. Brain. 2007;130(Pt 7):1873-1883.

15. Verma A, Anand V, Verma NP. Sleep disorders in chronic traumatic brain injury. J Clin Sleep Med. 2007;3(4):357-362.

16. Kempf J, Werth E, Kaiser PR, et al. Sleep-wake disturbances 3 years after traumatic brain injury. J Neurol Neurosurg Psychiatry. 2010;81(12):1402-1405.

17. Imbach LL, Bucjele F, Valko PO, et al. Sleep-wake disorders persist 18 months after traumatic brain injury but remain underrecognized. Neurol. 2016;86(21):1945-1949.

18. Chen PY, Tsai PS, Chen NH, et al. Trajectories of sleep and its predictors in the first year following traumatic brain injury. J Head Trauma Rehabil. 2015;30(4):E50-55.

19. Rotenberg VS, Indursky P, Kayumov L, et al. The relationship between subjective sleep estimation and objective sleep variables in depressed patients. Int J Psychophysiol. 2000;37(3):291-297.

20. Ponsford JL, Parcell DL, Sinclair KL, et al. Changes in sleep patterns following traumatic brain injury: a controlled study. Neurorehabil Neural Repair. 2013;27(7):613-621.

21. Ancoli-Israel S, Alessi C. Sleep and aging. Am J Geriatr Psychiatry. 2005;13(5):341-343.

22. Young T, Peppard PE, Taheri S. Excess weight and sleep-disordered breathing. J Appl Physiol (1985). 2005;99(4):1592-1599.

23. Redline S, Kump K, Tishler PV, et al. Gender differences in sleep disordered breathing in a community-based sample. Am J Respir Crit Care Med. 1994;149(3 Pt 1):722-726.

24. Jordan AS, McEvoy D. Gender differences in sleep apnea: epidemiology, clinical presentation and pathogenic mechanisms. Sleep Med Rev. 2003;7(5):377-389.

25. Jones K, Harrison Y. Frontal lobe function, sleep loss and fragmented sleep. Sleep Med Rev. 2001;5(6):463-475.

26. Cicerone K, Levin H, Malec J, et al. Cognitive rehabilitation interventions for executive function: moving from bench to bedside in patients with traumatic brain injury. J Cogn Neurosci. 2006;18(7):1212-1222. 

27. Bloomfield IL, Espie CA. Do sleep difficulties exacerbate deficits in sustained attention following traumatic brain injury? J Int Neuropsychol Soc. 2010;16(1):17-25.

28. Sinclair KL, Ponsford JL, Rajaratnam SMW, Anderson C. Sustained attention following traumatic brain injury: use of the psychomotor vigilance task. J Clin Exp Neuropsychol. 2013;35(2):210-224.

29. Mahmood O, Rapport LJ, Hanks RA, Fichtenberg NL. Neuropsychological performance and sleep disturbance following traumatic brain injury. J Head Trauma Rehabil. 2004;19(5):378-390.

30. Wilde MC, Castriotta RJ, Lai JM, et al. Cognitive impairments in patients with traumatic brain injury and obstructive sleep apnea. Arch Phys Med Rehabil. 2007;88(10):1284-1288.

31. Diekelmann S, Born J. The memory function of sleep. Nat Rev Neurosci. 2010;11(2):114-126.

32. Walker MP, Brakefield T, Morgan A, et al. Practice with sleep makes perfect: sleep-dependent motor skill learning. Neuron. 2002;35(1):205-211.

33. Walker MP, Stickgold R, Alsop D, et al. Sleep-dependent motor memory plasticity in the human brain. Neuroscience. 2005;133(4):911-917.

34. Marshall L, Born J. The contribution of sleep to hippocampus-dependent memory consolidation. Trends Cogn Sci. 2007;11(10):442-450.

35. Sonni A, Spencer RMC. Sleep protects memories from interference in older adults. Neurobiol Aging. 2015;36(7):2272-2281.

36. Makley MJ, English JB, Drubach DA, et al. Prevalence of sleep disturbance in closed head injury patients in a rehabilitation unit. Neurorehabil Neural Repair. 2008;22(4):341-347.

37. Wiseman-Hakes C, Murray B, Moineddin R, et al. Evaluating the impact of treatment for sleep/wake disorders on recovery of cognition and communication in adults with chronic TBI. Brain Inj. 2013;27(12):1364-1376.

38. Johns MW. A new method for measuring daytime sleepiness: the Epworth sleepiness scale. Sleep. 1991;14(6):540-545.

39. Kamper JE, Garofano J, Schwartz DJ, et al. Concordance of actigraphy with polysomnography in traumatic brain injury neurorehabilitation admissions. J Head Trauma Rehabil. 2016;31(2):117-125.

40. Ponsford JL, Ziino C, Parcell DL, et al. Fatigue and sleep disturbance following traumatic brain injury—their nature, causes, and potential treatments. J Head Trauma Rehabil. 2012;27(3):224-233.

41. Naeser MA, Saltmarche A, Krengel MH, et al. Improved cognitive function after transcranial, light-emitting diode treatments in chronic, traumatic brain injury: two case reports. Photomed Laser Surg. 2011;29(5):351-358.

42. Morries LD, Cassano P, Henderson TA. Treatments for traumatic brain injury with emphasis on transcranial near-infrared laser phototherapy. Neuropsychiatr Dis Treat. 2015;11:2159-2175.

Related Videos
atomic bomb
atomic fallout
stop violence
stopping stigma
© 2024 MJH Life Sciences

All rights reserved.