Sleep and Acquired Brain Injuries

1. Sleep and Acquired Brain Injuries John Garcia, MD Director, Gillette Sleep Health Diplomate, American Board of Sleep Medicine Diplomate, American Board of Pediatrics

3. Ground rules: Interruptions are requested. (A good question could expand all our minds� Otherwise we could end up like Homer) Without them this is just another talk you attended. With them it becomes YOUR talk tailored to your needs by your questions.

4. Why should you care about improving sleep? Sleep disturbances can: compromise the rehabilitation process impair the ability to return to school/work. exacerbate other symptoms such as pain, cognitive deficits fatigue irritability. Ouellet MC, Savard J, Morin CM. Insomnia following traumatic brain injury: a review. Neurorehabili Neural Repair 2004;18:187-98

5. Why you should care about improving sleep�Sleep improves learning Patients with frontal lobe lesions were asked to do a motor task known as serial reaction time test (SRTT). Patients with better sleep did significantly better than their peers Conclusion: improving sleep in patients with frontal lobe injury improves motor learning. Gomez et al.Clin Neurol Neurosurg. 2008 Mar;110(3):245-52. Epub 2007 Dec 21.

6. Why you should care about improving sleep� Sleep disorders impair learning in patients with acquired brain injuries. 135 adults in rehabilitation centers were surveyed for sleep arousals and sleep disorders. 47% reported arousals or disturbance in sleep patterns Sleep disorders were associated with poorer functioning CONCLUSIONS: Long-term outcome from severe brain injury can be compromised by enduring sleep disorders. Treatment should be based on judicious use of medication (beyond hypnotic drugs) and greater emphasis on non-pharmacological management. Brain Inj. 2006 Mar;20(3):327-32

7. TBI and sleep disorder Abnormal sleep studies were found in nearly half of adults more than 3 months after TBI 23% (n=40/87) with OSA 11% (n=10/87) with posttraumatic hypersomnia 6% (n=5/87) with narcolepsy 25% with insomnia Catriotta et al, Journal of Clinical Sleep Medicine Vol 3, No.4, 2007

8. TBI and OSA 45% of adults more than 3 months after TBI presenting with sleep complaints are obese (BMI> 30 kg/m2) and reported significant weight gain after their injury. Speculations on cause Hypothalamic injury; the hypothalamus is home to both sleep and the brain�s nutrition satiation center Inactivity secondary to neurologic impairment 23% of patients in this study went on to be diagnosed with obstructive sleep apnea. Journal of Clinical Sleep Medicine Vol 3, No.4, 2007

9. Etiology of sleepiness post TBI Increased rates (23%) of obstructive sleep apnea in TBI patients. Abnormal upper airway tone and increased weight conspire to collapse the upper airway. Collapse can occur anywhere between the nasal turbinates and the thoracic inlet.

10. Scope of the Problem Primary snoring Upper Airway Resistance Syndrome (UARS) Sleep fragmentation without oxygen desaturation Severe obstructive sleep apnea (OSA) Children may have oxygen desaturation to the teens and as many as 100 episodes of sleep fragmentation per hour.

11. Suggested Clinical tool: The OSA Questionnaire(this is not rocket science) Does your child snore nightly? Does s/he have intermittent pauses, snorts, or gasps? Does she have disturbed or restless sleep? Is your child more sleepy than other children his/her age? Does s/he have behavioral problems? Does s/he have failure to thrive? Does s/he have any history of cor pulmonale, pulmonary hypertension or right heart failure? Practice Guideline: Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome. Pediatrics 109; 4April 2002, pp 704-712

12. How to measure a sleep disorder and its effects Polysomnogram Usually done in the hospital Get a lot of data Expensive Gold standard for diagnosis of obstructive sleep apnea (OSA)

13. All ready for a good night�s sleep!

14. Diagnosis of Sleep Apnea

15. Evaluation of Sleep Related Symptoms Nasoendosopy Can be performed in waking and artificially induced sleeping states under light general anesthesia Advantage Real time Guide surgical decisions This is the only known picture of a child smiling while enduring a nasendoscopy

16. Interventions: surgical The following is a non-exhaustive list of examples of surgical interventions indicated for some cases: Tonsillectomy Adenoidectomy Lingual tonsil removal Nasal stenting Septoplasty turbinate reductions tongue reduction mandibular advancement

17. Interventions: surgical May be complex Close post-operative inpatient monitoring prevent airway compromise from edema, secretions, bleeding, Respiratory drive suppression from meds. This is something the Gillette team does well.

18. Interventions: non-surgical Trial of nasal steroids in treatment of primary snoring without OSA Rapid maxillary expansion (orthodontic treatment) for children with OSA and crossbite. Non-invasive ventilatory support with CPAP or BiPAP

19. Interventions: positive airway pressure CPAP (Continuous Positive Airway Pressure): A continuous puff of air stents the upper airway open. BPAP (Bilevel Positive Airway Pressure) operates in a similar way but provides a lesser pressure on expiration.

20. Getting kids to wear CPAP Desensitization Here is a little girl teaching her doll how to tolerate the continuous positive airway pressure (CPAP) mask

21. Getting kids to wear CPAP Now she and her doll are ready for bed. We make it part of the bedtime routine along with putting on pajamas and brushing teeth.

22. Getting kids to wear CPAP Success is wearing the CPAP mask for any length of time while asleep. Children are rewarded for success. We use a compliance download monitor that is part of the CPAP machine to measure the number of hours per night a child wears CPAP.

23. Child life, psychology and sleep lab collaboration Child life, psychology and the sleep lab work together in difficult cases when wearing PAP is necessary. Children not tolerating mask desensitization at home will come to the hospital to try a more intensive mask desensitization procedure.

24. Complications of Undiagnosed OSA neurocognitive impairment poor learning, behavioral problems attention-deficit/hyperactivity disorder. Ali NJ, Pitson D, Stradling JR. Natural history of snoring and related behaviour problems between the ages of 4 and 7 years. Arch Dis Child. 1994;71:74-76 Weissbluth M, Davis AT, Poncher J, Reiff J. Signs of airway obstruction during sleep and behavioral, developmental, and academic problems. J Dev Behav Pediatr. 1983;4:119-121 Chervin RD, Dillon JE, Bassetti C, Ganoczy DA, Pituch KJ. Symptoms of sleep disorders, inattention, and hyperactivity in children. Sleep. 1997;20:1185-1192 Goldstein NA, Post C, Rosenfeld RM, Campbell TF. Impact of tonsillectomy and adenoidectomy on child behavior. Arch Otolaryngol Head Neck Surg. 2000;126:494-498

25. Severe Complications of Undiagnosed OSA Pulmonary hypertension Untreated pulmonary hypertension may lead to: Systemic hypertension Right Heart Failure

26. Treating OSA improves quality of life Children with CP and treated OSA showed an 18% improvement in quality of life. Hsaio KH, Nixon GM. The effect of treatment of obstructive sleep apnea on quality of life in children with cerebral palsy. Research in Developmental Disabilities (2007) doi 10.1016/j.ridd.207.01.003

27. TBI and hypersomnia Patients >3 months after TBI complaining of a sleep problems: 11% were diagnosed with posttraumatic hypersomnia (PTH) 6% were diagnosed with narcolepsy. Catriotta et al, Journal of Clinical Sleep Medicine Vol 3, No.4, 2007

28. Sleepiness 1 mo. & 1yr after injury One month after TBI 55% (p<.02) were sleepy by self report compared to 41% of trauma without TBI and 3% of trauma free controls. One year after injury 27% of TBI patients were still sleepy. BUT! 90% of the most severe TBI subgroup could not take make a self-report at 1 month and half could not do so at 1 year after injury. Watson N et al. Hypersomnia following traumatic Brain Injury. Journal of Clinical Sleep Medicine. Vol. 3, No.4, 2007

29. Basic neuroanatomy of sleep Hypocretin-orexin is an alerting neurotransmitter made in the lateral hypothalamus. It is broadly distributed both to the cortex and to the brainstem. It is easy to see how something so broadly distributed could be disrupted by injury.

30. Suggested tool:The 24-hour history Start at dinner time. A non-threatening tool is to ask, �what happens next?� (Known as the parent-cued interview; don�t leave home without it.) Spontaneously get bedtime routine, frequency, character and duration of arousals. wake time and routine is it spontaneous or �aided� by the parent.

31. The 24-hour history Is daytime behavior consistent with excessive daytime sleepiness? (�are you falling asleep in school or �resting your head on your desk�) Naps: Timing Duration Many children give up naps at 5 years but this is primarily a culturally based phenomenon. new onset naps are a red flag.

32. Suggested tool: the sleep log available online: http://www.gillettechildrens.net/FileUpload/Library/0122-005_Sleep%20Log.pdf

34. Take the history and the diagnosis will magically appear I pledge that if you take a 24-hour sleep history the diagnosis will be obvious more than half the time. If it is not obvious please do something they do not teach you to do in school: pick up the phone and call me: pager 612-580-1377

35. How to measure a sleep disorder and its effects: the sleep logavailable online: http://www.gillettechildrens.net/FileUpload/Library/0122-005_Sleep%20Log.pdf

36. Etiology of sleepiness post TBI Injury to the posterolateral hypothalamus may decrease the levels of the excitatory hypothalamic neuropeptide hypocretin-1 (orexin). This same neuropeptide is deficient in narcolepsy. Hypocretin found to be deficient in 95% of patients with acute moderate to severe TBI Neurology 2005;65;147-9

37. Hypersomnia: Diagnosis The diagnosis of hypersomnia as a separate entity from fatigue is best made with a multiple sleep latency test (MSLT). Fatigue=temporary loss of strength and energy Hypersomnia is defined as the ability to fall asleep. Fatigued people may talk about their state as sleepy but cannot fall asleep given the opportunity

38. How to measure daytime sleepiness Multiple sleep latency test Patient is offered 5 opportunities to nap spaced 2 hours apart thoughout the day. Offered after an overnight polysomnogram. Mean sleep latency less than 15 minutes is considered consistent with objective hypersomnolence in children.[1] [1] Hoban TF and Chervin R. Semin Pediatr Neurol. 2001 Dec;8(4):216-28

39. How to measure a sleep disorder and its effects Actigraphy A wrist-watch size motion sensor Downloads onto a computer Computer algorithm correlates inactivity and sleep. Worn for 2-3 weeks decreases night to night variability problem of the polysomogram.

40. Data from an actigraph

41. Hypersomnia:treatment Stimulant medications are generally very effective. Methylphenidate Amphetamine salts Side effects: Headache, stomach ache, appetite suppression, tics. Non-stimulants Modafinil Concerns: makes hormonal birth control less reliably effective, Stevens Johnson Syndrome.

42. Hypersomnia: case 10 year old with �cognitive blunting� in therapies Consultation with sleep medicine was requested. There was some suspicion of both obstructive sleep apnea and hypersomnia

43. Hypersomnia: case On polysomnogram The tracheostomy was capped and she had minimal sleep disordered breathing providing sufficient assurance the the tracheostomy could be removed safely. But wait�She had sleep onset REM. This is seen in patients with narcolepsy It was discovered that a nutritional supplement the family was providing had caffeine in it.

44. Sleep onset REM? This is a normal sleep histogram The horizontal blue lines represent wake The horizontal dark lines represent non-REM sleep REM sleep generally occurs in the later part of the night. Seeing it in the first hour is abnormal.

45. Hypersomnia: case She returned for a multiple sleep latency test Mean sleep latency was less than 10 minutes on average. ( Remember in children, a multiple sleep latency test less than 15 minutes is considered abnormal) [1] Stimulant medication provided a significant advantage over caffeine. Family was very pleased with overall care provided. [1] Hoban TF and Chervin R. Semin Pediatr Neurol. 2001 Dec;8(4):216-28

46. Insomnia in patients with TBI None of the 60 patients had sleep related symptoms prior to the TBI. Insomnia was present in 33%. Half had sleep onset insomnia These had heightened scores on the anxiety scale: PTSD The remainder had sleep maintenance insomnia Due to post-traumatic mood disorder Summary: insomnia is always a symptom. Treat the diagnosis. Journal of Clinical Sleep Medicine, Vol. 3, No.4, 2007

47. � After acute care by intensivists and surgeons is done the long term success is determined by a multidisciplinary team that includes sleep medicine.

48. For more information Gillette Children�s Specialty Healthcare Sleep Health Clinic www.gillettechildrens.org Ph# 651-726-2899 American Academy of Sleep Medicine (www.aasmnet.org) American Association of Sleep Technologists (www.aastweb.org) sleepeducation.com