By Annette M. Boyle
ARLINGTON, VA – Up to 93% of servicemembers who sustain mild traumatic brain injuries (mTBIs) or concussions experience insomnia and more than a third develop obstructive sleep apnea. Sleep disturbances also can exacerbate other symptoms such as pain and irritability as well as impair cognition and social functioning.
Given the frequency and consequences of sleep disruption, many patients and providers look to medications to provide quick and effective relief — but according to new recommendations, they need to try other solutions first.
“Helping veterans sleep is the No. 1 thing we can do to improve outcomes following mild traumatic brain injury. Sleep disruption interferes with the neural remodeling needed to recover from brain injury and may extend post-injury recovery by impeding the restorative processes that occur during sleep,” said Therese West, DNP, of the Defense and Veterans Brain Injury Center (DVBIC) Clinical Affairs and Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE).
For those looking for a fast fix, though, she had bad news. “Medications interfere with brain remodeling needed for healing from mild traumatic brain injury.”
New recommendations recently released by DVBIC and DCoE provide specific cautions about commonly prescribed sleep medications. They note that nonbenzodiazepine sedative-hypnotics may interfere with cortical plasticity and that their use for more than 30 days may lead to tolerance or dependence. The Food and Drug Administration cut the recommended dosages of this class of sleep medications in 2013 and revised them again at the beginning of this year to reflect concerns about their extended half-lives and impairment of morning functioning, particularly in women. The recommendations also note that benzodiazepines are contraindicated in post-mTBI insomnia as their use may “impede neuronal recovery and negatively impact cognitive function following TBI.”
Instead, DVBIC and DCoE advise use of non-pharmacological treatments such as stimulus control, environmental modifications, cognitive behavioral therapies (CBT) and sleep hygiene as firstline treatments for insomnia.
In addition to the recommendations, DVBIC and the DCoE recently released a suite of products for providers to improve the assessment and management of common sleep disorders, including detailed clinical recommendations, provider education presentation and a pocket-sized clinical support tool with an algorithm to assist in evaluation and initial management. Related materials are designed to increase patient awareness of the consequences of impaired sleep and self-care techniques for getting a better night’s sleep.
While many of the 247,904 servicemembers who suffered mTBIs from 2000 through the first quarter of 2014 recovered fully within several weeks, some continue to be plagued by sleep disturbances and other symptoms, according to the material. Often difficulty sleeping goes undiagnosed — sometimes with tragic consequences. As a result, the DVBIC and DCoE recommend screening every patient with mTBI for sleep disturbance.
The initial screening is very straightforward, simply asking: “Are you experiencing frequent difficulty falling or staying asleep, excessive daytime sleepiness or unusual events during sleep?”
“That one simple question can generate a lot of information. Cognitive problems, memory issues, headaches and other health concerns could be related to sleep disturbance,” West noted. Patients and providers are often not aware that headaches and other complaints are related to not sleeping well, she said, so identifying sleep disturbances can be critical to successfully resolving those issues. Other common physical complaints that may not be immediately associated with inadequate sleep include dizziness, vision problems, nausea and vomiting, balance issues and even transient neurological abnormalities. In addition, patients with sleep disturbances may suffer from problems with memory or difficulty concentrating, emotional lability, irritability, anxiety and depression.
A more detailed assessment explores the type of sleep difficulty such as trouble initiating or maintaining sleep, nonrestorative sleep, nightmares or snoring, as well as predisposing or perpetuating factors such as shiftwork, alcohol use, stress, stimulant use and pre-existing behavioral health issues.
The DVBIC urges primary care providers to look for red flags in patients with concussions who suffer from sleep issues. Providers should make a priority referral to a sleep medicine specialist for patients whose occupations make sleepiness on the job a hazard to themselves or others, such as drivers, heavy-equipment operators and medical staff. Patients with behavioral or emotional symptoms and severe sleep disturbance should also be promptly evaluated for any risk of danger to themselves or others and immediately referred to an emergency department or psychiatrist for suicidal tendencies or other troubling concerns. Those with PTSD and nightmare disorder should also receive prompt referrals to behavioral health specialists. Other patients should receive education on good sleep hygiene and complete the insomnia severity index evaluation available online at myhealth.va.gov.
Most sleep disturbances in veterans and servicemembers can be characterized as short-term or chronic insomnia, circadian rhythm sleep-wake disturbance or obstructive sleep apnea. The DVBIC/DCoE materials include a pocket card for each condition that outlines the procedures for assessment and treatment recommendations.
“Most individuals can be helped with simple steps associated with cognitive behavioral therapy,” West said. “Providers should assure patients that most individuals get better and educate them on sleep hygiene and stimulus control.” She recommended removing electronics from bedrooms, stopping caffeine consumption six hours before bedtime, getting regular exercise, maintaining a dark and quiet sleep environment, obtaining exposure to natural light (or artificial blue light, when needed) every morning and establishing consistent times for going to sleep and waking up. Progressive muscle relaxation also helps many patients.
Virtually everyone who suffers a combat-related mTBI suffers from sleep disturbance, according to the clinical recommendations, and creating the ideal environment for quality sleep poses particular challenges in deployment settings. West noted that many servicemembers have developed “ingenious ways to block light and sound, such as adding cloth around external walls to act as a buffer.” DVBIC also offers a kit that includes sleep masks and ear plugs for deployed servicemembers with trouble sleeping after a concussion.
Providers are urged to follow up with patients with sleep disturbances weekly until the problem resolves. “Start slow; give patients one or two interventions at a time to implement,” said West. “You may find the thing that’s keeping them awake or find that they may not be able to implement changes on their own.”
If the stimulus control and sleep hygiene recommendations fail to improve sleep after one to two weeks, providers might consider pharmacological assistance. “Most providers know in practice and in theory that medications are not the right answer for most patients,” West told U.S. Medicine. “The recommendations are based on research and serve to remind them of best practices. While there will be exceptions and provider judgment can supersede the recommendations, yes, they are designed to change provider behavior.”