Managing sleep and fatigue after brain injury

Thank you very much. Thanks to Sam for helping to organize today, and it is nice to see so many of you here. We do not have long, so I will do a very quick whistle-stop tour of sleep, what it is, how it works, where it can go wrong, and what we see happening in people coming forward with more complex presentations, such as after they have sustained a significant injury.

Even the best sleepers in the world have a bad night from time to time. The impact of sleep disturbance in the short term tends to be psychological, as we struggle with mood and performance. When sleep problems persist for decades, it is a real shame because we have effective treatment strategies, such as Cognitive Behavioral Therapy for Insomnia (CBTI). This is what NICE guidelines recommend, and it is effective for 70% of people who engage with it.

The eight-hour sleep requirement is a myth. People vary in their needs; some feel fine on six and a half to seven hours, while others need eight and a half to nine. You must find the right amount of sleep for you consistently. This depends on age, as younger people require more sleep due to the intensity of their learning. For children, it is vital to ensure they get age-appropriate sleep, or they will struggle and become irritable.

When we are awake, we are sampling life. When we are asleep, we are processing what we sampled. We cycle between two types of sleep: REM (Rapid Eye Movement) and non-REM sleep. In healthy sleep, we drop into a long period of deep non-REM sleep first. Think of your brain as a busy office where every thought generates a piece of paper. We make thousands of decisions daily. Deep non-REM sleep is where we tidy up the office. Our hippocampus is essential for memory consolidation and is most active during this deep sleep phase, deciding what to keep and what to trash. Anything that knocks you out of this deep sleep, such as caffeine or stress, will make you feel worse the next day.

REM sleep is associated with emotional reprocessing and the limbic system, particularly the amygdala. This is why dreams can be weird, violent, or unusual; it is a safe space for emotional venting. It is also important to embrace the "forgettery," as it is healthy for us to let go of unnecessary information. As we get older, our sleep becomes lighter and more easily disturbed. Additionally, age-related weakening of the bladder often leads to night awakenings. A simple fix is to stop drinking fluids in the two hours before bed.

When someone has a significant brain injury, the injury impacts sleep, and poor sleep impacts the ability to rehabilitate. We see additional problems like fatigue, mood disturbances, pain, and side effects from medications. We use actigraphs, which are devices worn on the wrist, to measure sleep and activity levels. This helps us see when someone's routine is chaotic or if they are being pushed too hard. We can then tailor interventions—like shifting therapy sessions to the afternoon—to help the person regain their quality of life.

For children, we often use positive reinforcement to manage sleep disturbances. For adults, we focus on CBTI and lifestyle adjustments. We emphasize removing blue screen devices two hours before bed, as they suppress melatonin production. While drugs are an option, we prefer non-drug, behavioral treatments first. The goal is to get the person well-rested so they are energized to engage in their rehabilitation. Improving sleep is a powerful way to bond with a client and speed up their recovery trajectory.