Sleep-Wake Patterns in Brain Injury Patients in an Acute Inpatient Rehabilitation Hospital Setting

Primary Objective: To determine staffdocumented sleep/wake patterns of hospitalized brain injury patients. Research Design: Cohort study. Methods and Procedures: Data on 17 patients were recorded hourly for a twoweek period by staff as to the wakefulness of patients. In addition, demographic data and FIM scores were obtained. Main Outcomes and Results: Seventeen patients experienced interrupted sleep 71% of the night. This was true of 66% of the patients with traumatic brain injury and 92% of those with anoxic brain injury. One hundred percent of the women had a sleep disturbance as compared with 64% of the men. Patients who were at least 60 years of age had interrupted sleep 90% of the time as compared to those who were less than 25 Seventy-three percent of the hospitalized patients with brain injury complained of sleeping problems.7 Of those, 82% reported problems initiating and maintaining sleep. Fifty-two percent of the outpatients reported sleep problems; most of these cases of sleep disturbance involved excessive somnolence. Complaints were unrelated to age and length of coma, but were more prevalent in females. This study also found that patients with untreated sleep disturbances demonstrated poorer vocational outcome, more behavioral problems, more cognitive and communicative dysfunction, and greater incidence of anxiety and depression. It is important to note that this study did not verify patients’ subjective loss of sleep with objective measures such as staff monitoring. Another study by Clinchot and colleagues evaluated sleep disturbances in 86 brain injury patients 1 to 3 years after hospitalization.8 Fifty percent of the patients noted difficulty sleeping, 65% woke too early, 25% slept more than usual and 45% experienced problems falling asleep. Eighty percent of the patients with sleep problems also reported fatigue. They found that the more severe the brain injury, the less likely that the subject would report sleep disturbances. Their data suggests that sleep problems occurred at a higher incidence in female patients, the elderly, and those with a history of alcohol abuse. However, all of these data were subjective. Investigators who have looked at objective sleep patterns in brain injury have focused on electroencephalograph (EEG) monitoring. Various studies have characterized altered sleep architecture in brain injury patients, including decreased slow wave sleep, decreased REM sleep, and incomplete or absent vertex sharp waves and sleep spindles.9-11 One study noted that abnormal sleep patterns decreased as the time since injury increased.12 These authors also found that REM sleep increased as cognition improved. However, none of these studies correlated patients’ EEG patterns with subjective or objective sleep-wake cycles. To our knowledge, there is no study that measures staff documented sleepwake patterns of hospitalized brain injury patients. Therefore, we sought to objectively assess the sleep patterns of brain injury inpatients and compare the patterns of sleep with injury etiology (traumatic brain injury vs anoxia), functional impairment (FIM scores), cognitive impairment (Ranchos Los Amigos score, cognitive FIM), time since injury, medication effect (methylphenidate), age, and gender. METHODS Patients were selected from the acquired brain injury (ABI) program at a freestanding rehabilitation hospital in the USA. Patients were included if they had a diagnosis of acquired brain injury and were between the ages of 18 and 85. Staff, including nurses, physical therapists, occupational therapists, and speech language pathologists, collected data once per hour concerning the wakefulness of their patients. Data were collected at the therapy gym or the patient’s hospital room. At each hour, staff recorded whether the patient appeared to be awake or asleep. Patients with eyes closed and regular breathing were considered sleeping. Staff designated 1 of 5 sleep-wake categories for each patient: peaceful sleep (PS), restless sleep (RS), awake-calm (AC), awake-agitated (AA) and awake-drowsy (AD). For data analysis, all responses of PS and RS were considered sleep and other responses (AC, AA, AD) were considered awake. Data were recorded 24 hours of the day and for a 2-week evaluation period. Vol. 4, No. 2, 2004 • The Journal of Applied Research 240 A chart review was performed on all patients subject to data collection. Their charts were reviewed for gender, age, diagnosis, time since injury, significant past medical history, medications, Rancho Los Amigos (RLA) scores, cognitive FIM scores, and overall FIM scores. The 24-hour period of data collection was arbitrarily separated into sleep and wake intervals. The time of normal sleep was designated from 10 PM to 6 AM. Appropriate wakefulness was designated from 8 AM to 6 PM. The data collected outside of these intervals were not included in the analysis. Data were reviewed for all patients who were inpatients during the 2-week study interval. This included patients who were present from 3 to 15 days of the study period. The percentage of nights the patient was found awake during the period of designated sleep time was calculated for each individual. Additionally, sleep patterns were compared for injury etiology (anoxia vs traumatic brain injury), age (less than 25 vs greater than 60), gender, and time since injury (less than 3 months vs greater than 3 months). We also compared the sleep patterns of patients with low functioning level (RLA score of 2 or 3) and high functioning level (RLA score of 7 or 8). Also, the sleep patterns of patients with the 5 lowest FIM and cognitive FIM scores were compared to those with the 5 highest FIM, and cognitive FIM scores, respectively.