Study: Children can experience disturbed sleep after traumatic brain injury

A study indicates that children's sleep can be disturbed following a traumatic brain injury.

Children who sustain traumatic brain injury (TBI) are more likely to experience greater daytime sleepiness, sleep disturbances, and poorer overall sleep quality, and to have impaired emotional, physical, and social functioning, when compared with children without TBI, a small study suggests.

"For clinicians treating children with TBI, it's worth asking children or their parents about their sleep," principal investigator Kimberly Allen, PhD, RN, from the Center for Narcolepsy, Sleep and Health Research, Department of Women Children and Family Health Science, University of Illinois-Chicago, noted in an interview withMedscape Medical News.

She presented the study at SLEEP 2015: the Annual Meeting of the Associated Professional Sleep Societies.

Research Gaps

Pediatric TBI is common. Each year in the United States over 500,000 children are admitted to the hospital with a TBI. The short- and long-term consequences can include motor and sensory impairments; cognitive, emotional, and psychosocial impairments; and sleep problems, although sleep is less well studied, Dr Allen said.

She and her colleagues assessed the sleep of 15 children with TBI (3 with mild TBI, 5 with moderate TBI, 6 with severe TBI, and 1 with unknown TBI severity) compared with that of 15 healthy children, matched on age, race, and maternal education level. The children were about 11 years of age on average. Those with TBI were an average of 594 days post-injury (range, 26 to 1076 days).

As hypothesized, compared with healthy children, children with TBI demonstrated statistically significant increases in daytime sleepiness on the modified Epworth Sleepiness Scale (P = .03), poorer sleep quality on the Child Sleep Wake Scale (P = .001), and poorer functional status on the Pediatric Quality of Life Inventory (P < .001). Overall, the effect sizes were "high and clinically relevant," the researchers note in their poster.

"Sleep is something physicians need to ask about in children with TBI," Dr Allen said.

She noted that "in most studies of pediatric TBI and sleep, sleep has been a secondary aim, not a primary aim," and they haven't used standardized sleep measures.

"This study," Dr Allen said, "provides a first glance at what children with TBI look like in terms of sleep compared to their peers that are healthy, typically developing children. We need more research in this area."

It should be noted, she added, that most children with TBI were hospitalized for more than 1 week and required rehabilitation, which may play a role in why they experienced daytime sleepiness, poorer sleep quality, and poorer functional status.

"Important" Study

Reached by email for comment, Suresh Kotagal, MD, consultant in neurology, pediatrics and sleep medicine, Mayo Clinic, Rochester, Minnesota, said, "The results are important as they address an important gap in pediatric sleep medicine, i.e., hypersomnia, that develops after head injury."

Dr Kotagal, who wasn't involved in the study, said there are likely "multiple factors underlying excessive daytime sleepiness after head injury. To start with, one has to consider variables prior to trauma that can impact sleep such as hyperactivity and anxiety. The head injury itself could also lead to central neurotransmitter imbalance or hypocretin deficiency that predispose to drowsiness. Medications utilized in head injured children such as antiepileptic drugs and antispasticity agents like baclofen can also contribute to drowsiness."

"Pediatric physical medicine and rehabilitation programs need to pay more attention to post-traumatic hypersomnia as an important treatable symptom that influences cognitive function and the overall quality of life," Dr Kotagal told Medscape Medical News.

Shalini Paruthi, MD, fellow of the American Academy of Sleep Medicine and director of the Pediatric Sleep and Research Center at SSM Cardinal Glennon Children's Medical Center, St. Louis, Missouri, toldMedscape Medical News that sleep in children with TBI "hasn't been studied enough, so it's great to have this pilot data. Being able to recognize that sleep problems might be part of the TBI effects is very important."

"As part of comprehensive care for our kids who have traumatic brain injuries, we should also be thinking about their sleep. Better sleep may have an impact on healing. We don't know that yet, but it's possible," added Dr Paruthi, who wasn't involved in the study.

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Study: Link between insomnia and stroke

A recent study indicates that those suffering from insomnia have a greater risk of stroke than those who do not have insomnia.

Insomniacs face a much higher risk of stroke than restful sleepers, according to a recent study.

The study, published in the peer-reviewed scientific journal Stroke, an American Heart Association (AHA) publication, sought to link cardiovascular health with sleep-related health.

Past research has shown that not getting enough sleep can lead to a significant number of health problems, including elevated stress levels, symptoms of Alzheimer's disease, and even widespread pain conditions such as fibromyalgia.

Now, researchers from Taiwan's Chia Nan University of Pharmacy and Science, and the Department of Medical Research at Chi-Mei Medical Center, have tied insomnia - a condition of chronic sleep deprivation - to an elevated risk of stroke.

To determine this, the researchers analyzed the medical records of more than 21,000 insomniacs in Taiwan, China. The medical data on these patients was observed for a four-year period, allowing the researchers to conclusively differentiate the intensity of each insomniacs' condition.

The participants were identified as having either chronic or persistent insomnia - disturbed sleep lasting for more than a month; relapse insomnia - return of insomnia symptoms after being free of the condition for more than 6 months; or remission insomnia - becoming non-insomniatic at any point during the study.

These groups were then compared to the medical histories of over 60,000 people who did not have insomnia.

Looking at hospital records, the researchers were able to determine that the patients with insomnia had a 54 percent increased risk of stroke than the non-insomniacs. Even more alarming, insomniacs who were diagnosed with the sleeping disorder when they were young-adults between 18 and 35 years old were a whopping eight times more likely to be hospitalized for stroke, compared to non-insomniacs.

Predictably, the risk of stroke was also found to be greatest in those who suffered from chronic or persistent insomnia or had diabetes.

According to the researchers, although they did not determine a cause-and-effect relationship with this study, past research has suggested that the stress disturbed sleep can have on your heart can cause inflammation, increased blood pressure, and even impaired glucose levels.

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What causes sleep issues for Parkinson's patients?

This article discusses the link between Parkinson's disease and sleep issues, and what may cause sleep issues for people with Parkinson's disease.

Up to 70% of Parkinson’s disease (PD) patients experience sleep problems that negatively impact their quality of life. Some patients have disturbed sleep/wake patterns such as difficulty falling asleep or staying asleep, while other patients may be subject to sudden and involuntary daytime sleep “attacks.” In the extreme, PD patients may exhibit REM-sleep behavior disorder (RBD), characterized by vivid, violent dreams or dream re-enactment, even before motor symptoms appear. A review in the Journal of Parkinson’s Disease discusses the underlying causes of sleep problems in PD, as well as medications, disease pathology, and comorbidities, and describes the most appropriate diagnostic tools and treatment options.

Sleep problems in PD patients can have wide-ranging adverse effects and can worsen in later stages of the disease. Sleepiness socially isolates patients and excessive sleepiness can put patients at risk of falls or injury, and can mean patients must give up driving. Sleepiness can impair cognition and concentration, exacerbate depression, and interfere with employment. Wakefulness at night impairs daytime wakefulness and may also cause mood instabilities and can exhaust caregivers.

“Diagnosis and effective treatment and management of these problems are essential for improving the quality of life and reducing institutionalization of these patients,” says lead author Wiebke Schrempf, MD, Technische Universität Dresden, Faculty of Medicine Carl Gustav Carus, Department of Neurology, Division of Neurodegenerative Diseases, Dresden, Germany.

Dr. Schrempf and colleagues describe some of the complexities associated with treating sleep problems in PD patients, such as the worsening of sleep problems by dopaminergic medications used to treat motor symptoms. Lower doses of levodopa or dopamine agonists are able to improve sleep quality partly by reducing motor symptoms such as nighttime hypokinesia (decreased body movement), dyskinesia (abnormal voluntary movements), or tremor (involuntary shaking), which interfere with normal sleep. However, the same medications may also cause excessive daytime sleepiness. The report describes how changing medication, dose, duration of treatment, or timing of administration can improve outcomes.

The presence of other conditions common in PD patients such as depression, dementia, hallucinations, and psychosis may interfere with sleep. Unfortunately, some antidepressants can also impair sleep.

Sleep problems may also be harbingers of future neurodegenerative disease. Patients with RBD exhibit intermittent loss of normal muscle relaxation during REM sleep and engage in dream enactment behavior during which they may shout, laugh, or exhibit movements like kicking and boxing. “RBD seems to be a good clinical predictor of emerging neurodegenerative diseases with a high specificity and low sensitivity, whereas other early clinical features of PD, such as olfactory dysfunction and constipation, are less specific,” says Dr. Schrempf. “These early clues may help identify PD patients before motor symptoms appear, when disease-modifying therapies may be most beneficial.”

PD is the second most common neurodegenerative disorder in the United States, affecting approximately one million Americans and five million people worldwide. Its prevalence is projected to double by 2030. The most characteristic symptoms are movement-related, such as involuntary shaking and muscle stiffness. Non-motor symptoms, such as worsening depression, cognition, and anxiety, olfactory dysfunction, and sleep disturbances, can appear prior to the onset of motor symptoms.

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Kids who are bullied can have nightmares years later

A study looked into kids who were bullied and found they have nightmares and night terrors years after being bullied.

New research suggests that kids who are bullied when they're younger may be more likely to suffer from nightmares and night terrors a few years later.

However, bullies themselves don't appear to face any higher risk of disturbed sleep.

"They sleep solidly," said study author Dieter Wolke, a professor of developmental psychology and individual differences at the University of Warwick in England. "That is clearly different than what most people think. They are not disturbed thugs, but calculated manipulators."

The study has weaknesses. Its design doesn't allow researchers to compare the percentages of children -- bullied or not-bullied -- who have bad dreams. And researchers can't be certain that being bullied at a younger age directly causes nightmares a few years later. It's possible that some other factor is responsible.

Still, "there is a clear association" between being bullied and having nightmares and night terrors, the researchers found.

What's a night terror? It's when a child gets "stuck" between stages of sleep and may scream and thrash around. "They're nearly impossible to wake and won't remember the episode the next morning," Wolke said.

For the study, the researchers examined surveys of over 6,400 children in the United Kingdom. The children answered questions about bullying at ages 8 and 10, and about sleep problems at age 12.

Overall, 24 percent of the kids had nightmares and 9 percent had night terrors. Even after the investigators adjusted the statistics in the study so they wouldn't be thrown off by high or low numbers of children who had issues such as psychiatric problems, those who'd been bullied when they were younger were still more likely to have these kinds of sleep problems at age 12.

Not all kids who have nightmares or other sleep problems are being bullied. However, among those who do, the level of extra risk of bullying is "moderate," Wolke said.

Could the nightmares be the problem that contributes to bullying by, say, causing kids to be more anxious and seen as vulnerable? Wolke said the study findings don't suggest that possibility.

Robert Faris, an associate professor of sociology at the University of California, Davis, said the study appears to be valid and fits in with previous research that has linked bullying to stress, anxiety and depression. "It does seem likely that anxiety would play a role in nightmares," he said.

What to do? "It is important for pediatricians and doctors to be aware of this relationship," study author Wolke said, and ask about bullying when kids have sleep problems. "Identifying and helping children who are being bullied would eliminate potential mental health problems in the future," he said.

But Faris pointed out that many victims of bullying -- perhaps more than half -- don't feel comfortable telling their parents about what's going on, often because they feel their parents can't do anything about it.

That may indeed be the case, he said. Still, this study suggests that parents of kids who have chronic nightmares should be aware that this behavior may be a sign that their child is being bullied, Faris said.

What if a parent doesn't think their child will open up? "Don't ask directly about whether they're being bullied, but engage in some more subtle conversations instead," Faris suggested. "And pay attention to what's going on with their interactions with friends."

The findings are to be presented Saturday at the annual meeting of the Pediatric Academic Societies in Vancouver. Research presented at meetings should be viewed as preliminary until published in a peer-reviewed journal.

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