New Guidelines on Concussion and Sleep Disturbance

According to the DoD, 300,707 U.S. service members were diagnosed with a traumatic brain injury (TBI) between 2000 and the first quarter of 2014. Of those, 82% had mild TBI (mTBI), also known as a concussion. Usually, a patient recovers from concussion relatively quickly—in days to weeks. But some patients, especially those with preexisting and concomitant conditions, have persistent symptoms that interfere with daily life. The most common of these symptoms are sleep disturbances, usually insomnia, which is a critical issue, given that sleep is so important to the brain’s—and the rest of the body’s—ability to heal. Poor sleep also exacerbates other symptoms, such as pain and irritability, has a negative impact on cognition, and may partially mediate the development of posttraumatic stress disorder or depression.

The Defense and Veterans Brain Injury Center (DVBIC) has released a new clinical recommendation and support tools to help clinicians identify and treat post-TBI sleep disturbances. The suite includes Management of Sleep Disturbances Following Concussion/Mild Traumatic Brain Injury: Guidance for Primary Care Management in Deployed and Non-Deployed Settings, a companion clinical support tool, and a fact sheet for patients. The clinical recommendation (CR) and companion tool are based on a review of current literature and expert contributions from the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury, in collaboration with clinical subject matter experts.

The CR strongly advises that all patients with concussion be screened for a sleep disorder. The key question to ask during the patient interview is “Are you experiencing frequent difficulty in falling or staying asleep, excessive daytime sleepiness, or unusual events during sleep?”

The DVBIC Clinical Affairs Officer PHS Capt. Cynthia Spells says “the initial step in the diagnosis of a sleep disorder includes a focused sleep assessment.” The clinical interview should include the “3 Ps”: predisposing, precipitating, and perpetuating factors. Predisposing factors include excessive weight, older age, and medications. Precipitating factors include concussion, deployment, and acute stress. Perpetuating factors include excessive use of caffeine or other stimulants, time zone changes, and familial stress. Noting that comorbid conditions are common with sleep disorders, the CR notes an anxiety disorder postinjury is a more significant predictor of sleep disruption than is pain, other comorbid conditions, or the adverse effects of medication.

A guide for primary care providers (PCPs) in addition to giving an overview of the suite and how to use the components provides insight into the research and science behind managing TBI-related sleep disturbances. The clinical support tool is an algorithm for PCPs to use in assessing sleep disturbances, a step-by-step process to determine the level of care required. The tool is offered as a pocket-sized reference card and can be downloaded. (Health care providers can also take a self-guided course in identifying and treating mTBI at http://www.brainlinemilitary.org.)

According to the CR, nonpharmacologic measures are the first-line treatment for post-TBI sleep problems. These include teaching patients good sleep hygiene and stimulus control; that is, doing as much as possible to physically and environmentally promote sleep. (See App Corner) The patient fact sheet gives tips on getting a healthy night’ s sleep, such as avoiding naps, avoiding alcohol close to bedtime, and getting exposure to natural light as much as possible.

The CR and other components are available at https://dvbic.dcoe.mil/resources/management-sleep-disturbances.