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DVBIC collaboration leads to improved sleep recommendations

Airman sleeping on floor of plane A U.S. Air Force Airman sleeps inside a C-17 Globemaster III during a flight over an undisclosed location in support of Operation Freedom Sentinel, Jan. 22, 2018. (U.S. Air Force photo by Staff Sgt. Jordan Castelan)

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Sleep | Traumatic Brain Injury

Newly released guidelines from the Defense and Veterans Brain Injury Center will help health care providers manage sleep disturbances among service members and veterans diagnosed with concussion, and should provide measures that could improve the health and readiness of U.S. forces.

The expanded recommendations identify additional sleep disturbances through a streamlined process of diagnosis and management; and provide medication dosing and specialty referral recommendations, when appropriate. DVBIC is a division of the Defense Health Agency Research and Development Directorate, and is the Defense Department’s center of excellence for traumatic brain injury.

“Our recommendations are developed with the primary care provider in mind,” said Gary McKinney, DVBIC’s section chief for clinical practice and clinical recommendations. “One goal is assisting with making treatment and specialty referral decisions.”

Sleep disturbances are a widely reported symptom among service members and veterans diagnosed with concussion, also known as mild traumatic brain injury. Nearly 12 percent of service members were diagnosed with at least one sleep disorder in 2018, the latest figures available from the DoD Health of the Force. The most commonly diagnosed sleep disorders were sleep apnea and insomnia.

In October 2019, the Defense Department and the Department of Veterans Affairs released a clinical practice guideline on the management of chronic insomnia disorder and obstructive sleep apnea, which noted the high prevalence of sleep disorders in active-duty service members and veterans. In addition, a study by the VA San Diego Health Care system found more than half of the veterans seeking treatment at that VA had insomnia symptoms.

At a recent TBI symposium at the National Institutes of Health, University of Maryland School of Medicine clinical psychology professor and sleep disorder specialist Emerson Wickwire explained that conditions following a TBI such as headaches, dizziness and poor balance can be affected by sleep disturbances and “if providers knew more about sleep, it would have a huge impact on TBI care.” Wickwire served as a member of DVBIC’s expert working group that developed the clinical recommendations.

Twenty four experts in sleep medicine, neurology, psychiatry, psychology, and pharmacology participated in the working group that developed the updated clinical recommendation. Experts represented the Army, Air Force and Navy, the Uniformed Service University of the Health Sciences, the Department of Veterans Affairs, and the civilian sector including the University of Maryland. The clinical recommendations align with the DoD/VA clinical practice guideline.

Practice guidelines have multiple advantages for the practitioners. “They sort of standardize the care…so everybody, if they are following the guidelines, they are generally doing the same thing for the same sort of situation,” said Army Col. (Dr.) Brian Robertson, the chief of sleep medicine service at Walter Reed National Military Medical Center. Because those who design guidelines have both clinical experience and knowledge of the scientific literature, “a lot of that work on deciding what to do has already been done for you. That makes life a lot easier for [the] clinician. That’s the goal.”

“Medical students get a one-hour lecture on sleep for their entire medical training,” said Risa Nakase-Richardson, a neuropsychologist and scientific research director at the Tampa DVBIC-VA site. Because of that, “the CR will provide an outstanding reference tool for sleep for primary care physicians to help evaluate and make clinical decisions about managing sleep for persons with TBI.”

Known as the “Management of Sleep Disturbances Following Concussion/Mild Traumatic Brain Injury: Guidance for Primary Care Management in Deployed and Non-Deployed Settings,” the recommendations are tailored to assist practitioners managing sleep and concussion in the primary care setting. To inform appropriate clinical interventions, it includes screening questions, guidance on potentially emergent symptoms, diagnostic criteria, and recommended evaluations.

Like its 2014 predecessor, the new recommendations cover insomnia, obstructive sleep apnea, and irregular sleep-wake patterns. They also address excessive daytime sleepiness, insufficient sleep syndrome, restless legs syndrome, and other unusual events during sleep, such as nightmares and sleepwalking.

DVBIC staff have also developed a suite of patient and provider focused tools in support of these new guidelines. A fact sheet helps patients learn about healthy sleep practices and offers tips on how to limit sleep disturbances and use relaxation strategies to combat insomnia. Healthy sleep practices include limiting screen time, cutting back on caffeine and alcohol before bedtime, and making a comfortable bedroom environment where activity is limited to sleep and intimacy.

The updated recommendations are available online from the DVBIC website.

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