Posts Tagged Insomnia

[WEB SITE] The Evaluation and Management of Fatigue – Medscape

What Is Fatigue?

The Annals of Internal Medicine recently published two systematic reviews on the diagnosis and treatment of the chronic fatigue syndrome (CFS).[1,2] The reviews use the term “myalgic encephalomyelitis/chronic fatigue syndrome” (ME/CFS) to define this condition, and as the accompanying editorial points out,[3] an expert panel convened by the Institute of Medicine (IOM) recently found that ME/CFS is a disease with a physiologic basis.[4] It is not a purely psychological problem.

As a sleep physician, I am often asked to evaluate patients with a complaint of fatigue—which raises the question, how does a physician differentiate ME/CFS from other common causes of fatigue? Regardless of etiology, how do we manage fatigue?

Any discussion of fatigue must begin by defining the term. Max Hirshkowitz, PhD, a professor and renowned sleep researcher at Baylor College of Medicine, provided a complete definition that will serve as a reference for the remainder of this review.[5] He stressed the following points:

  1. Fatigue is perceived as a sense of tiredness, exhaustion, or lack of energy.
  2. Fatigue that is nonpathologic will improve with rest.
  3. Fatigue can be provoked by exceeding capacity in terms of time-on-task or stress load.
  4. Stress load can be altered by external (environmental) or internal (genetic predisposition, medical or behavioral illness) factors.
  5. Sleep duration, quality, and timing are significant mediators of the manifestations of fatigue.

In a global sense, then, fatigue occurs when circumstances require some combination of physical and cognitive work that exceeds the capacity of the individual. The point at which this will occur varies by genetics, training, and sleep.

Diagnostic Challenges

There is value in characterizing the patient’s fatigue complaint. Sleep physicians attempt to do this for a living, and it’s a messy business at best. Some will use the term “fatigue” to describe sleepiness, whereas others will not. It is often equated with a central perception, including “lack of energy,” “no motivation,” “difficulty concentrating,” or a perceived deficit in some other aspect of executive function.

Still other patients are using the term “fatigue” to mean exercise intolerance or the inability to push through a difficult workday. Oftentimes, the patient comes to physician attention owing to poor performance in a particular setting—such as on the job, in the classroom, or on the playing field. Clarifying the circumstances under which the perception of fatigue becomes a problem is critical to identifying the cause and designing the mitigation strategy.[5,6]

An appropriate review of the possible contributors to fatigue is also important. Because sleep plays such a pivotal role, a proper sleep history is mandatory. Any discussion of sleep disorders should start with a review of total sleep time. Current data show that cognitive, behavioral, and metabolic changes consistently occur with chronic sleep restriction to less than 6 hours per night.[7-9]

Continue —> The Evaluation and Management of Fatigue

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[WEB SITE] Could High-Powered Infrared Light Help Reverse TBI Damage?

Published on August 27, 2015

NILTaaA possible treatment for traumatic brain injury (TBI) could be the use of a specific high-powered, near-infrared light (NIR), a new study suggests.

The study was published recently in the journal Neuropsychiatric Disease and Treatment, according to a media release from the Neuro-Laser Foundation.

Study co-authors Theodore Henderson, MD, PhD from the Neuro-Laser Foundation and Dr Larry Morries and Paolo Cassano of Massachusetts General suggest that a specific high-powered, near infrared light (NIR) can possibly re-energize damaged brain cells after penetrating the skin and skull, per the release.

In their study, which occurred from 2011 to 2013, the research team administered 10 transcranial applications of high-power NIR over the course of 2 months to 10 study participants who were diagnosed with chronic mild-to-moderate TBI. Using a Class IV laser and pulsed light, each treatment took less than 60 minutes, the release explains.

Continue —> Could High-Powered Infrared Light Help Reverse TBI Damage? – Physical Therapy Products

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[WEB SITE] Sleep and Traumatic Brain Injury

Every year about 1.7 million Americans sustain a Traumatic Brain Injury (TBI). 80 to 90 percent of these are considered mild, with the majority classified as concussions. In fact, the annual incidence of sports-related concussion alone has been estimated at over one million a year. In football, it is estimated that 10 percent of college and 20 percent of high school players sustain concussions.

We also see a high incidence of traumatic brain injury associated with falls, motor vehicle accidents, and in our returning veterans. In fact, in a survey of 2,525 Army infantry soldiers returning from Iraq, 15% reported injuries consistent with traumatic brain injury.

What do all of these people have in common? They have a very high incidence of sleep disorders, with as many as 70% complaining of insomnia, excessive daytime sleepiness, or severely fragmented sleep. These sleep disorders are usually noted in the first few weeks and may persist for years. As a result, they contribute to moodiness, cognitive dysfunction such as memory impairment, and lack of sustained attention.

What is most interesting is the very high incidence of sleep apnea that is found in these individuals. In several studies, the proportion of persons with TBI who are found to have sleep apnea is 30 to 50 percent. In all of these studies, patients with TBI and sleep apnea performed much worse when it came to mood and memory. They were also much more likely to be excessively sleepy and/or fatigued during the day.

Unfortunately, sleep disorders are frequently overlooked or discounted after TBI. I have had numerous patients over the years whose sleep problems began with a frequently forgotten concussion. One particular case was that of a 27-year-old man who had sustained a concussion when playing college football. Afterwards, he had had trouble with fatigue and moodiness and had complained of disrupted sleep. His new girlfriend noted that he snored and urged him to come see me. We tested him and found that he had sleep apnea. Several months later, after treatment, he was no longer fatigued and irritable and he was sleeping through the night.

The point here is that TBI in America is at an all time high, with an estimated 3.5 million suffering from chronic symptoms such as fatigue, sleepiness, cognitive dysfunction, moodiness, and anxiety. In many of these individuals, an underlying sleep disorder may be the cause. Given the very high incidence of sleep complaints, people with TBI should be thoroughly evaluated for underlying sleep disorders.

via Sleep and Traumatic Brain InjuryDr. Robert S. Rosenberg | Dr. Robert S. Rosenberg.

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[WEB SITE] Do I Have Exploding Head Syndrome?

Fyodor Dostoevsky kept a record of his seizures in a notebook. There were 102. Today some people with epilepsy do the same on Pinboards. Those less candid among the epileptic Pinterest community post empowering quotes: “Don’t flatter yourself. I wasn’t staring at you. I have petite mal seizures.”

The petite mal is a seizure not often diagnosed until it has been happening for quite a while. It involves no convulsions, only a person staring off, as if lost in thought. The spells often last just a few seconds. A child who has petite mal seizures might be dismissed as inattentive. Under that mistaken presumption, he might be given Adderall, when the real problem is a seizure disorder.

Sometimes Dostoevsky did convulse in a more Hollywood seizure fashion, even foaming at the mouth. He also slipped into outwardly subtler “ecstatic” seizures, which rendered him blissful. Actually, that’s extreme understatement. “I would feel the most complete harmony in myself and in the whole world,” he once said of the episodes, “and this feeling was so strong and sweet that for a few seconds of such bliss I would give 10 or more years of my life, even my whole life perhaps.”

Those auras most likely originated in the temporal lobe of his brain, where biochemical lapses can cause bursts of terror or euphoria that run the gamut from fleeting to life-altering. Oliver Sacks told in this magazine the story of a bus driver who, in the midst of a temporal-lobe seizure, collected fares while telling passengers how pleased he was to be in heaven.

Continue –>  Do I Have Exploding Head Syndrome? — The Atlantic.

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[WEB SITE] Moving Beyond “Hand Waving”: Why Do People Sleep a Lot After a Traumatic Brain Injury?

March 27, 2015 | Neuropsychiatry, Trauma And Violence

By Barbara Schildkrout, MD

Your patient is recovering from a traumatic brain injury (TBI). He asks you, “Doc, why do I need so much extra sleep? And, what makes me so sleepy during the day?”

If you’re like me, you’ve told patients like this individual that it takes time for the brain to heal. You’ve explained that even a mild concussion can disrupt neural fibers and that mental activity may be more effortful following such an injury.

Perhaps there is some truth to all of that. But probably it is mostly “hand waving.”

I just read about what is more likely to be the actual explanation for those post-TBI symptoms. The Annals of Neurology1 published research showing that in severe TBI, there is substantial loss to specific types of neurons in the hypothalamus—namely neurons that are part of networks involved in promoting wakefulness or in regulating sleep.

The potential explanatory power of these findings is impressive. Although this research was conducted in cases of fatal brain trauma, nonetheless it provides insights that will help scientific investigators and clinicians think more specifically about disruptions in sleep and wakefulness following any traumatic brain injury.

TBI and sleepiness

TBIs are a major public health concern, affecting close to 2.5 million individuals each year in the US, according to the CDC statistics for 2010.2 Whether the TBI is mild or severe, at least 25% of patients experience some disturbance in sleep and/or level of daytime arousal following the injury. Symptoms in this arena may substantially affect recovery and contribute to disability.

Every psychiatrist has encountered patients who have had TBIs—from mild concussions as a consequence of collisions on the soccer field or falls on icy steps to devastating brain injuries after motor vehicle accidents or barroom fights. These post-TBI patients frequently experience excessive daytime sleepiness in the face of what used to be sufficient sleep time. They also commonly exhibit pleiosomnia—the need for more than the usual amount of sleep in a 24-hour period. Less frequently, patients have disturbed nighttime sleep—insomnia.

Effective approaches are needed to help patients with these post-TBI difficulties. The design of new treatment strategies depends on developing a better understanding of the mechanisms that underlie these post-TBI problems with arousal and sleep.

New research

In the January 2015 issue of Annals of Neurology, Valko and colleagues1 report on recent studies that followed up on research they published in 2009.3 Together, the two articles make several important points.

They draw attention to the fact that hypothalamic injury is common in TBI. The authors point out that the posterior nucleus (containing histaminergic neurons) of the hypothalamus is most affected. They hypothesize that this is a consequence of shearing forces at the junction of the hypothalamus and the midbrain during head trauma. The authors identify a substantial loss of histaminergic neurons in the tuberomammillary nucleus of the posterior hypothalamus; these neurons are part of a major arousal-promoting system.

Continue –>  Moving Beyond “Hand Waving”: Why Do People Sleep a Lot After a Traumatic Brain Injury? | Psychiatric Times.

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[WEB SITE] Sleep And Traumatic Brain Injury – MSKTC

How common are sleep problems following a TBI?

Many people who have brain injuries suffer from sleep disturbances. Not sleeping well can increase or worsen depression, anxiety, fatigue, irritability, and one’s sense of well-being. It can also lead to poor work performance and traffic or workplace accidents. A review of sleep disorder studies and surveys suggest that sleep disorders are three times more common in TBI patients than in the general population and that nearly 60% of people with TBI experience long-term difficulties with sleep. Women were more likely to be affected than men. Sleep problems are more likely to develop as the person ages.

What are types of sleep problems?

Sleep disturbances have been found in people with all severities of brain injuries from mild to severe. Sleep is a complex process that involves many parts of the brain. For this reason, and depending on the location and extent of injury, many different kinds of sleep disturbances can occur after brain injury.

Common sleep disorders include:

  • Insomnia: Difficulty with falling asleep or staying asleep; or sleep that does not make you feel rested. Insomnia can worsen other problems resulting from brain injury, including behavioral and cognitive (thinking) difficulties. Insomnia makes it harder to learn new things. Insomnia is typically worse directly after injury and often improves as time passes.
  • Excessive Daytime Sleepiness: Extreme drowsiness.
  • Delayed Sleep Phase Syndrome: Mixed-up sleep patterns.
  • Narcolepsy: Falling asleep suddenly and uncontrollably during the day.

Common sleep syndromes include:

  • Restless Leg Syndrome (RLS): Urge to move the legs because they feel uncomfortable, especially at night or when lying down.
  • Bruxism: Grinding or clenching teeth.
  • Sleep Apnea: Brief pauses in breathing during sleep, resulting in reduced oxygen flow to the brain and causing loud snoring and frequent awakening.
  • Periodic limb movement disorder (PLMD): Involuntary movement of legs and arms during sleep.
  • Sleepwalking: Walking or performing other activities while sleeping and not being aware of it.

Continue –> Sleep And Traumatic Brain Injury.

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[WEB SITE] Sleep And Traumatic Brain Injury

How common are sleep problems following a TBI?

Many people who have brain injuries suffer from sleep disturbances. Not sleeping well can increase or worsen depression, anxiety, fatigue, irritability, and one’s sense of well-being. It can also lead to poor work performance and traffic or workplace accidents. A review of sleep disorder studies and surveys suggest that sleep disorders are three times more common in TBI patients than in the general population and that nearly 60% of people with TBI experience long-term difficulties with sleep. Women were more likely to be affected than men. Sleep problems are more likely to develop as the person ages.

What are types of sleep problems?

Sleep disturbances have been found in people with all severities of brain injuries from mild to severe. Sleep is a complex process that involves many parts of the brain. For this reason, and depending on the location and extent of injury, many different kinds of sleep disturbances can occur after brain injury.

Common sleep disorders include:

  • Insomnia: Difficulty with falling asleep or staying asleep; or sleep that does not make you feel rested. Insomnia can worsen other problems resulting from brain injury, including behavioral and cognitive (thinking) difficulties. Insomnia makes it harder to learn new things. Insomnia is typically worse directly after injury and often improves as time passes.
  • Excessive Daytime Sleepiness: Extreme drowsiness.
  • Delayed Sleep Phase Syndrome: Mixed-up sleep patterns.
  • Narcolepsy: Falling asleep suddenly and uncontrollably during the day.

more –> Sleep And Traumatic Brain Injury.

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