Ep. 222: Traumatic Brain Injury and Sleep Disorders

00:00:00: Welcome to EANcast, your weekly source for education research and updates from the European Academy of Neurology.

00:00:15: Hello!

00:00:15: And welcome to EENcast Weekly Neurology.

00:00:21: My name is Mariusz Szyminski.

00:00:22: I'm a neurologist from Poland and also specialist in emergency medicine.

00:00:31: I used to work in the field of sleep medicine, so it explains slightly about this episode.

00:00:45: In this month we have a topic on neurotraumatology and with these episodes will talk about relations between sleep disorders and traumatic brain injury.

00:00:58: I have the honor to have with me here David Schreyer, our guest who is Swiss neurologist and neuroscientist focusing on sleep disorders.

00:01:10: And on disorders of consciousness.

00:01:12: actually working in Boston right?

00:01:15: Yes that's where

00:01:18: i am now!

00:01:19: I'm very happy you accepted my invitation.

00:01:28: the sleep disorders and traumatic brain injury.

00:01:32: So welcome, thank you for joining this podcast!

00:01:38: We will talk about Sleep & Traumatic Brain Injury because it may be not so obvious that there are quite many links between these two areas of neurology.

00:01:54: We all know on one side that traumatic brain injury is a severe epidemiological problem, especially as it touches young productive men and women making them disabled with some chronic problems.

00:02:09: On the other hand we now what sleep disorders are also a civilization problem.

00:02:21: Arias are not so frequently joined together.

00:02:24: Meanwhile, we may assume that there is a link between... I would like to split our talk into two parts.

00:02:33: first will be rather about sleep disorders as risk factor

00:02:39: for

00:02:40: traumatic brain injuries.

00:02:42: So getting into that Aria David how do you think can person with sleep problems be at higher risk of being injured or experiencing brain injury.

00:03:00: First, thank you very much Marius for having me it's an honor and pleasure And Thank You For The Question on the interesting topic which I agree is somewhat not often talked about in this combination.

00:03:15: so they're different sleep-related injuries that potentially can result in traumatic brain injury.

00:03:20: They're at the forefront, I believe are motor vehicle accidents their falls they're occupational injuries.

00:03:28: there also sports and recreational injuries but they're also parasomnia related trauma for example.

00:03:35: something is maybe more rare And motor vehicle accident and falls likely most relevant for traumatic brain.

00:03:46: The etiology of falls, especially if sleep-related is often not well documented.

00:03:52: So we don't really have good evidence on that.

00:03:55: a lot of the things were going to talk about today.

00:03:57: I believe We don't Really Have Very Good Evidence from From The Injuries i've Mentioned The Strongest Evidence We Potentially Or Probably Have For Motor Vehicle Accidents.

00:04:08: That's Also Probably Why I Want To Focus A Bit More On These Today And for motor vehicle accidents, but in principle also the other injuries I've mentioned except maybe those that are sleep-related sensors to like parasomnia related trauma.

00:04:24: There're three main etiologies In my view and worst case they all present at same time.

00:04:31: The first one is sleepiness so biological underlying drive to sleep falling asleep on a wheel.

00:04:38: then there's fatigue.

00:04:40: There are some discussions sometimes about it, what is the difference between sleepiness fatigue?

00:04:44: Is this same or not?

00:04:46: from a neurologist's perspective I believe that there is.

00:04:49: A different so kind of sleepiness more than as i said underlying drive to sleep while fatigues more time on task decrement which we know also form let say modern neuromuscular aside for peripheral fatigue.

00:05:02: but the same can apply too central or mental fatigue and fatigue in also reduced Vigilance can result in this.

00:05:10: maybe loss of concentration, inattention increased reaction time etc.

00:05:16: And then we also have medication related etiology.

00:05:20: so there could be especially in patients receiving for example some of these sed drugs such as Sopidem which are non-biopensodyzepine medications that they're still mainly acting on GABA receptors.

00:05:33: They really create a sedating effect and the hangover the next morning after intake, the day before.

00:05:41: And there are obviously other adverse effects of CNS active drugs with hypnotic effect and these can also be additionally modulated by the circadian rhythm.

00:05:54: How do you feel?

00:05:57: Do believe that we've got epidemiological data showing directly that insomnia just well... The most popular sleep disorder can be a risk factor for traumatic brain injury.

00:06:12: So, for insomnia... A lot of the evidence we have is kind of like indirect or inferring from one study to another while direct link between these is often not necessarily well studied.

00:06:28: I mean in some general.

00:06:29: so you know the prevalence around maybe ten-to twenty percent also according to recent meta-analysis depends also more on different regional differences and assessment methods.

00:06:41: And one in maybe twenty patients with insomnia experience at least won motor vehicle accidents over the period of a year, But the direct link of how many then also result in traumatic brain injury and subsequent consequences, like this direct link is not very well studied.

00:07:10: So it's a great area for neurology but also public health in terms of increasing the risk.

00:07:19: as you said motor vehicles disasters or accidents are the same with plane traffic I truly believe still unrecognized issue, especially in terms... But we know that those people work in a shift paradigm during the night.

00:07:38: So where circadian rhythm is also distorted which may add some extra risk to being sleepy or disoriented during the day.

00:07:49: so ...I truly believe although i agree.

00:07:54: direct epidemiological large study showing exactly what people with insomnia do suffer more frequently from car accidents.

00:08:05: We know that patients in Insomnia visit generally emergency departments, more frequently than normal sleepers.

00:08:14: and on the other pole of sleep problems we have patients who need to sleep more especially during the day.

00:08:25: The hypersuminal lenses of central origin with narcolepsy being number one, how do you feel about this population?

00:08:34: How they are at risk from being a victim of traumatic brain

00:08:39: injury?".

00:08:41: Yeah, as you pointed out already like we mainly talk about narcolepsy.

00:08:44: Like type one, type two maybe also theopathic hypersonia.

00:08:47: That's also where we do have some evidence.

00:08:50: there are other centers disorders of hypersonal and for example the Kline-Eleven syndrome Which is just too rare to be able to say anything about it But they're multiple studies Also showing that the risk for motor vehicle accidents in narcolepsy and the opathic hypersomnia higher compared to healthy controls.

00:09:06: Interestingly though There was also evidence suggests The risk for accidents in this patient population is highest at the beginning of disease.

00:09:17: But when treated, let's say five years according to a study from I believe twenty fifteen it does not differ that much anymore and also based on personal conversations with patients or narcolepsy therefore also at the beginning of the disease or on set where in first few years, I imagined it almost to be like a reset of internal calibration and subjective perception of sleepiness.

00:09:54: They've told me that they may feel overwhelmed with the sleepiness suddenly as this progresses.

00:10:04: And how do you feel, as a neurologist and sleep specialist about the idea of restriction in terms driving license for patients diagnosed with narcolepsy to protect them from brain injuries due to car accidents?

00:10:21: Would be fair or rather unfair those people.

00:10:25: So that's a very good

00:10:27: kind of personal question.

00:10:28: I know

00:10:29: yeah, it's very It's a great big question also Very i would say sometimes controversial questions.

00:10:34: Yeah so i mean if we think about the risk and if you think About those are what is for which part?

00:10:42: Of The population has to highest risk For these accidents then they will be healthy young men right.

00:10:48: so generally speaking They have A much higher Risk for Accidents.

00:10:52: But we don't just say, well healthy young male cannot drive anymore because of that reason.

00:11:00: We also have this habitual sleep deprivation which is very prevalent in the population and significantly increases risk for motor vehicle accidents.

00:11:11: And once subjectively perceiving sleepiness one can not really predict when they fall asleep.

00:11:20: So it is generally speaking not safe to drive anymore, and then the best strategy is stop driving because performance impairments may also be similar to alcohol above legal limits.

00:11:31: To switch driver if possible... And there's no other choice to pull over and drink caffeinated beverages napped for fifteen-to twenty minutes afterwards!

00:11:39: And so with respect that we know these measures are among most effective therefore I would say risk taking behavior eventually maybe more relevant than the severity of sleepiness.

00:11:51: So as long as this perception is working, and I believe still in patients with narcolepsy they may perceive that there might be somewhat sleepiness And maybe some just want to continue driving while they should not.

00:12:08: i think it's a risk-taking behaviour.

00:12:10: essentially that is relevant.

00:12:13: we tend to use tests to quantify the degree of sleepiness, which may not always be fair because if someone is very sleepy but stops to drive immediately it might have a single accident while somebody else just pushes through and even let's say healthy long-drive truck driver.

00:12:34: And then has an accident at risk for this person who had an accident that was higher.

00:12:40: so I think we should also take that into account.

00:12:45: And it's interesting, you said about the taking risk behaviors.

00:12:51: I have such well... It is not my impression kind of fact that being sleepy or not sleeping enough also acts negatively on our prefrontal cortex and our awareness off.

00:13:05: our disadvantages are criticism.

00:13:08: so we may also assume still another field for research But that patients who are chronically underslept may be less critical towards themselves and toward their potential as a, let's say drivers.

00:13:24: So what?

00:13:24: they also increase the risk of them getting into some risky situation?

00:13:29: And taking unnecessary risks while being driver.

00:13:33: another issue to study in the field of neurotraumatology and some knowledge.

00:13:39: do you feel like it is reasonable?

00:13:42: Yeah, I completely agree.

00:13:44: There have been these studies also with sleep deprivation or sleep restriction and gambling tasks that exactly show like the increased risk taking.

00:13:54: And so that's something that is often not in my view insufficiently considered.

00:13:59: there Is too much of a focus to quantify sleepiness?

00:14:03: What degree of sleepiness isn't less Like how prone to risk-taking someone?

00:14:09: Yeah,

00:14:12: and taking all that into consideration.

00:14:15: And in terms of public health maybe it would be reasonable at first scientific mode to recruit patients who underwent the car collision or car accident... ...and ask them to participate in a sleep examination with maybe polysomnography may be MSLT.

00:14:38: So maybe we would find in this population, people with undiagnosed sleep problems then what will be something to promote it within the public health.

00:14:50: To make that kind of a sleep assessment as due after having car accident?

00:14:56: What would you promote?

00:14:57: development of sleep medicine?

00:15:00: certainly

00:15:01: Yeah, that would be super interesting.

00:15:03: One of the challenges there is often to To be able to access and get that data like who had an accident.

00:15:09: And then also that That it's not rare that police officers on scene for example They do not necessarily... It's difficult to test for sleepiness right?

00:15:19: It's not like alcohol and therefore it's also Often under-recognized.

00:15:23: so we don't really have always good statistics with respect to that.

00:15:27: There are a few studies but generally speaking Yes, unfortunately.

00:15:32: And how about as you mentioned a couple of times, parasomnia-related brain injury or injury in general?

00:15:39: For instance there is... Well I believe it's the myth that sleepwalkers, somnambulic patients are at higher risk of being injured.

00:15:50: What are the epidemiological data on those fields?

00:15:53: do know?

00:15:55: To my knowledge There is very few data on this.

00:15:59: to be honest, because like also if an injury happens.

00:16:03: If an accident happens you then retrospectively reconstruct that it was somewhat parasomnia related is very difficult and there's also under-recognized.

00:16:14: interestingly though I remember a patient where... That woke up in their car being somewhere And It seems like if the story is really true we were discussing back then who basically was sleepwalking, taking the car keys and driving somewhere.

00:16:34: And just woke up and luckily nothing happened.

00:16:39: but there are few cases to my knowledge that it's very... There is not good evidence.

00:16:47: Yeah, rather this history which I also know from my shifts at the emergency departments of a patient who woke after having a car accident More frequently they were patients with insomnia and Z-drug stakers, which really may lead to such uncontrolled sleep awakening half awakening.

00:17:10: And then acting as some non-bullying and causing traffic problems for instance or experiencing some head trauma.

00:17:20: so it's... another.

00:17:22: you mentioned the pharmacotherapy of insomnia as one of risk factors.

00:17:26: that didn't do.

00:17:28: Yeah,

00:17:29: and what I would add maybe is well we haven't talked about sleep apnea.

00:17:34: so there's also like very prevalent in population general right?

00:17:40: Maybe around fifteen to thirty percent depending on where are.

00:17:44: And I would generally say awareness is significantly improved, but it's still underdiagnosed.

00:17:49: So there are a lot of people out here who do not know that they have sleep apnea and the risk for motor vehicle accidents may be two to three times higher than in general population.

00:18:00: But we also know... That's why recognition is important.

00:18:05: Most often treatment with CPAP can significantly reduce this risk by maybe two-thirds.

00:18:13: And maybe one thing there to add is that we just know the hypopnea index not necessarily correlates always with a degree of sleepiness and the risk.

00:18:24: therefore, yes.

00:18:25: Yeah but it's another important population especially in terms of epidemiology or sleep apnea.

00:18:29: how frequent this... But then if bad things happens and patient undergoes traumatic brain injury What are the most common, according to your knowledge and experience sleep disorders after TBI?

00:18:45: Yes.

00:18:45: The consequences of TBI on sleeping wakefulness.

00:18:49: they widely vary.

00:18:50: it depends on the location of injuries their recovery whether we're talking also about acute chronic stage comorbidities in treatment.

00:19:00: generally speaking there is this bilateral relationship between traumatic brain injury.

00:19:06: On the one hand, we just discussed how sleep-wake disorders may increase risk for traumatic brain injury.

00:19:12: And preexisting sleep disorder can also worsen due to traumatic brain injuries and consequently impact recovery.

00:19:18: On the other hands, traumatic brain injury can affect and disrupt sleep wake regulation.

00:19:24: It only makes sense that then degree of sleep disturbance and sleep preservation is also prognostically relevant especially at acute stage of traumatic brain where intact sleep and presence of spindles, for example is associated with a better prognosis than if spindles are not present.

00:19:44: Now in tact wakefulness, sleep-and-sleep-wake rhythm they do not only reflect this preservation of the relevant anatomical structures in circuitry but there also essential to recovery.

00:19:58: so wakefulness on one hand and consciousness it's obviously important for communication with loved ones, but also the responsible healthcare team participation in therapies from any other vital functions and survival.

00:20:11: Sleep is central to the reduction of the homeostatic sleep pressure that accumulates during the awake period.

00:20:18: therefore also like neuroplasticity ,the waist clearance mental health especially after a trauma right?

00:20:26: And numerous other vital with respect when we often just talk about sleep and wakefulness, sometimes forget-about is that every cell in our body hormones or vital functions are subject to a circadian rhythm.

00:20:41: This master clock synchronizes all these clocks in the brain more specifically the suprachiasmatic nucleus.

00:20:48: an injury can also have profound impacts on the circadian rhythms of the whole body.

00:20:59: Can we think of any form of theoretical intervention in traumatic brain injury patients towards Reconstruction versus cardiac rhythm regardless whether it's a daytime sleepiness after TBI or insomnia.

00:21:14: After TBI, do you know any clinical trials aiming at this?

00:21:21: Yeah so I mean maybe first also to keep in mind is that A lot of the if we especially talk about more let's say the chronic condition and the mild TBI, there are seventeen to maybe eighty percent off those people that recover very well.

00:21:41: And it is may be like twenty two thirty percent but then have some sustained symptoms insomnia obviously being the most prevalent one.

00:21:50: basically the evidence we have is that therapies or largely the same as for insomnia and sleep-wake disorders, if they have other symptoms than traditional insomnia treatment.

00:22:03: So that means like first time treatments cognitive behavioral therapy.

00:22:07: there may be also melatonin or four As you mentioned for circadian disorders And depending on how How they are shifted?

00:22:16: That this can be used.

00:22:17: although the evidence overall I would say is not very strong.

00:22:26: I think it is important to keep in mind that the etiology of traumatic brain injury may sometimes be a bit more different and maybe also just change over time with recovery as well.

00:22:40: It's not straightforward, this classic sleep wake disorders.

00:22:45: but we have to look probably on a more personalized medicine which complicates large trials.

00:22:56: Yeah, in fact we don't have any simple rules or guidelines.

00:23:01: If a patient after traumatic brain injury is insomniac give him benzo or melatonin and our wonderful pill... We do not have any wonderful pills indeed!

00:23:14: Absolutely it's another area where the personalized medicine is necessary with selecting proper therapeutic intervention pretty much relies on doctors' experience and patient's readiness to take the therapy.

00:23:32: Okay, David... Well!

00:23:35: The topic of brain injury resulting sleep problems is really large And we can get into more details I hope that someday in future.

00:23:48: But thank you for sharing with me your experience and reflections on that topic.

00:23:57: It was a great talk for me, it's been a great pleasure to have this conversation about traumatic brain injury related sleep disorders.

00:24:05: Thank you very much for the recording.

00:24:08: I hope we will meet soon.

00:24:10: Goodbye everybody!

00:24:12: For taking home message please remember That it is not so obvious what sleep problems can be A risk factor for traumatic brain injury, but indeed it is.

00:24:24: We must consider this as a risk factor

00:24:27: of

00:24:28: being injured.

00:24:29: and also sleep disorders are not so obvious as the consequence of traumatic brain injuries that really patients after DBI suffer from sleep disorders.

00:24:41: It's worth asking them about how they sleep?

00:24:44: And do we need any medical help in the field of sleep disorders?

00:24:49: Thank you very much, David and hope to see soon.

00:24:52: Goodbye!

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