TOOL 7.1: Prolonged Post-concussion Sleep Disturbances Algorithm

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TOOL 7.1: Prolonged Post-concussion Sleep Disturbance Algorithm

Medical follow-up

(Sleep disturbance >1-4 weeks)

  • Screen for medical conditions, current medication use, comorbid psychopathology, and risk factors for sleep disturbances (Sidebar 1)
  • Reinforce the importance of sleep hygiene and physical and cognitive activity
  • Assess return to school and return to sport status
  • Consider treating with cognitive behavioural therapy (CBT) or refer to interdisciplinary concussion team if symptoms last longer than 4 weeks (or sooner as needed/using clinical judgment)

Sleep disturbances persist > 6 weeks post-concussion and interventions at 4-weeks have been unsuccessful

Cognitive behavioural therapy or referral to healthcare professionals/interdisciplinary concussion team 

  1. Cognitive behaviour therapy (CBT): treatment of choice
  2. Daily supplements: magnesium, melatonin, and zinc
  3. If CBT is not available: monitor behavioural interventions weekly, consider referral to an interdisciplinary concussion clinic or occupational therapist

 Refer to a sleep  specialist for consultation Particularly if sleep hygiene  can’t be optimized and  poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist   who has experience with  mTBI and polysomnography.

Pharmacological treatment

Consider prescribing medication on a short-term basis if sleep has not improved > 6 weeks postinjury. Ensure that medications do not result in dependency and that patient has minimal adverse effects. The aim is to establish a more routine sleep pattern. (Sidebar 2)

Refer to a sleep specialist for consultation Particularly if sleep hygiene can’t be optimized and poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist who has experience with mTBI and polysomnography.

Refer to a sleep specialist for consultation Particularly if sleep hygiene can’t be optimized and poor sleep quality is impacting ability to return to school or ability to recondition. Ideal specialist: a specialist who has experience with mTBI and polysomnography.

SIDEBAR 1

Factors that may influence the child/adolescent’s sleep/wake cycle

>Medical conditions

  • Endocrine dysfunction
  • Metabolic dysfunction
  • Obesity
  • Enlarged tonsils
  • Obstruction
  • Sleep-related breathing disorders
  • Early morning headaches

>Current medication use

Verify if patient’s prescribed or non-prescribed medications impact sleep: 

  • Inadequate medication •Dosage
  • Timing of administration
  • Screen for stimulants

>Comorbid psychopathology 

  • Mood and anxiety disorders
  • Post-traumatic stress disorder (PTSD)
  • Query nightmares and/or night terrors

>Unhealthy habits

  • Lack of exercise
  • Variable sleep-wake schedule
  • Excessive napping
  • Excessive time spent in bed
  • Exercising close to bedtime
  • Screen time
  • Use of nicotine, caffeine, energy drinks, processed foods, processed sugars, alcohol and drugs

SIDEBAR 2

Potential medication options – short-term basis only 

  • Trazodone 12.5 mg
  • Amitriptyline 5.0 – 10.0 mg