Sleep Disturbance During Post-Traumatic Amnesia and Early Recovery After Traumatic Brain Injury

Following moderate to severe traumatic brain injury (TBI), sleep disturbance commonly emerges during the confused post-traumatic amnesia (PTA) recovery stage. However, the evaluation of early sleep disturbance during PTA, its recovery trajectory, and influencing factors is limited. This study aimed to evaluate sleep outcomes in patients experiencing PTA using ambulatory gold-standard polysomnography (PSG) overnight and salivary endogenous melatonin assessment at two timepoints (a hormone which influences the sleep-wake cycle). The relationships between PSG-derived sleep-wake parameters and PTA symptoms (i.e., agitation and cognitive disturbance) were also evaluated. In a patient subset, PSG was repeated after PTA had resolved to assess the trajectory of sleep disturbance. Participants in PTA were recruited from Epworth HealthCare's inpatient TBI Rehabilitation Unit. Trained nurses administered overnight PSG at the patient bedside using the Compumedics Somté portable PSG device (Compumedics Ltd, Australia). Two weeks after PTA had resolved, PSG was repeated. On a separate evening, two saliva specimens were collected (at 24:00 and 06:00 hours) for melatonin testing. Routine daily hospital measures (i.e., Agitated Behavior Scale and Westmead PTA Scale) were also collected. Twenty-nine patients were monitored with PSG (mean: 41.6 days post-TBI; standard deviation SD: 28.3). Patients mean sleep duration was reduced (5.6 hours, SD: 1.2), and was fragmented with frequent awakenings (mean: 27.7, SD: 15.0). Deep, slow-wave restorative sleep was reduced, or completely absent (37.9% of patients). The use of PSG did not appear to exacerbate patient agitation or cognitive disturbance. Mean melatonin levels at both timepoints were commonly outside of normal reference ranges. After PTA resolved, patients (n=11) displayed significantly longer mean sleep time (5.3 hours PTA; 6.5 out PTA, difference between means: 1.2, p=.005). However, disturbances to other sleep-wake parameters (e.g., increased awakenings, wake time and sleep latency) persisted after PTA resolved. This is the first study to evaluate sleep disturbance in a patient cohort as they progressed through the early TBI recovery phases. There is a clear need for tailored assessment of sleep disturbance during PTA, which currently does not form part of routine hospital assessment, to suggest new treatment paradigms, enhance patient recovery and reduce its long-term impacts.