Stroke Victims: Programming Sleep Patterns For Recovery

Sleep and stroke are closely related. Sleep disorders, including sleep-disordered breathing, insomnia, hypersomnia, parasomnias, and sleep-related movement disorders, are intimately intertwined with comorbid cardiovascular conditions and increase stroke risk. Post-stroke sleep disorders also impact stroke rehabilitation, quality of life, and, if left untreated, can contribute to stroke recurrence.

After a stroke, survivors often experience fatigue and excessive sleepiness during the day, known as excessive daytime sleepiness (EDS). This can be a symptom of an underlying condition, such as sleep apnea, or a side effect of medication. EDS can negatively impact a survivor's rehabilitation and recovery, mood, relationships, and daily activities.

While sleep is crucial for promoting healthy recovery, excessive sleep after a stroke can be a sign of more serious underlying problems. Therefore, it is important to identify and address sleep disorders as part of both primary and secondary stroke prevention and treatment.

Sleep-disordered breathing

SDB can have serious consequences for stroke survivors. It can increase blood pressure and blood clotting, putting more strain on the heart. It can also lead to excessive daytime sleepiness (EDS), which can interfere with rehabilitation and recovery, as well as mood, relationships, and daily activities.

The treatment options for SDB include the use of a continuous positive airway pressure (CPAP) machine, which pumps a continuous stream of pressurised air through a mask over the mouth and/or nose. This helps to ensure adequate oxygen intake during sleep, reducing daytime drowsiness. Addressing underlying conditions, such as depression or other mental health conditions, through psychotherapy or medication, can also help to manage SDB.

In addition to CPAP therapy, there are other approaches to treat and manage SDB. One approach is to review and adjust medications, as drowsiness can be a common side effect of many drugs. Stimulant medications, such as modafinil, amphetamines, and Ritalin, can also be prescribed to treat excessive sleepiness. Improving sleep hygiene is another important component of managing SDB. This includes habits such as maintaining a consistent sleep schedule, limiting technology use before bedtime, creating a peaceful sleeping environment, and practising breathing exercises or relaxation techniques.

Overall, SDB is a common and potentially serious condition affecting stroke survivors. Effective treatments and management strategies are available, including CPAP therapy, addressing underlying conditions, adjusting medications, and improving sleep hygiene. These approaches can help reduce the impact of SDB on the lives of stroke survivors.

Circadian rhythm disturbances

The time of stroke occurrence may also correlate with prognosis and outcome, with strokes that occur during the morning tending to be more severe and associated with elevated diastolic blood pressure, increased hospital stay, and worse outcomes, including mortality, compared to strokes that occur later in the day.

Insomnia

Sleep disorders are a common occurrence after a stroke, with insomnia affecting 20-56% of stroke patients. Insomnia is defined as persistent difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity and circumstances for sleep and results in some form of daytime impairment. Insomnia can impair daytime energy levels, concentration, and memory, thus contributing to suboptimal performance during rehabilitation.

The development of insomnia may be related to the location of the stroke, with an increased prevalence in right hemispheric strokes, as well as those within the thalamus or brainstem, including the pontine tegmentum and thalamo-mensencephalic region. Strokes within the paramedian thalamus can also lead to insomnia due to an inability to generate sleep spindles due to the involvement of the thalamoreticular system. Environmental factors, such as hospitalization, unfamiliar environments, loss of uninterrupted sleep, and medication side effects, can also contribute to insomnia in stroke patients.

In addition to insomnia, other sleep disorders such as hypersomnia, sleep-disordered breathing, and parasomnias can occur after a stroke. Hypersomnia, or excessive daytime sleepiness, is characterized by an exacerbated sleep propensity with excessive daytime sleepiness, increased daytime napping, or prolonged nighttime sleep. It can impair optimal stroke rehabilitation and is often found after subcortical, upper pontine, medial ponto-medullary, and cortical strokes affecting the reticular activating system.

Sleep-disordered breathing, including obstructive sleep apnea and central sleep apnea, is suspected in approximately 50-70% of acute stroke patients. It can lead to and augment pre-existing comorbidities, such as hypertension, cardiac arrhythmia, and systemic atherosclerosis, which are typical risk factors for stroke. The presence of sleep-disordered breathing portends an overall increased risk of cerebrovascular events.

The treatment of sleep disorders, such as obstructive sleep apnea, can augment functional recovery after a stroke, improving depression, increasing activities of daily living, and enhancing attention and concentration. Therefore, the identification and management of sleep disorders should be an important component of both primary and secondary stroke prevention to reduce the morbidity and mortality associated with this devastating disease.

Sleep-disordered breathing treatment

Sleep-disordered breathing (SDB) is a condition characterised by abnormal breathing patterns that interrupt sleep. Obstructive sleep apnea (OSA) is the most common type of SDB, causing the airway to become blocked repeatedly during sleep. This can cause the heart rate to increase, blood pressure to rise, and oxygen levels in the blood to drop.

There are a variety of treatment options for SDB, including:

• Continuous positive airway pressure (CPAP) therapy: This is the gold standard treatment for SDB. It involves delivering a continuous stream of pressurised air through a mask over the mouth and/or nose to ensure adequate oxygen intake during sleep.
• Mandibular advancement devices: These oral appliance devices help to keep the airway open during sleep.
• Hypoglossal nerve stimulation: This newer therapy involves stimulating the hypoglossal nerve to improve breathing during sleep.
• Tonsillectomy and adenoidectomy (T&A): This surgical procedure is often recommended for children with enlarged tonsils and adenoids, which are common causes of SDB.
• Weight loss: Losing weight can help reduce fatty deposits around the neck and throat that can narrow the airway and contribute to SDB.
• Additional surgical procedures: In some cases, further surgery may be required to correct structural issues that contribute to SDB.

It is important to consult a doctor or specialist to determine the most appropriate treatment option for an individual's specific needs.

Post-stroke hypersomnia

The incidence of hypersomnia increases in the first month after a stroke, with between 18% and 72% of stroke survivors experiencing EDS. It usually decreases after a few weeks, but it can last for over six months in about 30% of cases. EDS can negatively impact a person's mood, relationships, and daily activities, as well as their rehabilitation and recovery.

There are several factors that can contribute to EDS after a stroke, including sleep-related breathing disorders, Reversed Robin Hood Syndrome, and depression. Obstructive sleep apnea is the most common type of sleep-related breathing disorder and can cause fragmented sleep, leading to EDS. Reversed Robin Hood Syndrome occurs when the brain redirects blood flow from damaged areas to healthy ones, which can result in excessive sleepiness. Depression is also a common mental health disorder that can develop after a stroke and cause fatigue and drowsiness.

Treating EDS after a stroke involves addressing the underlying conditions. For example, continuous positive airway pressure (CPAP) machines can be used to treat sleep apnea, and antidepressants or psychotherapy can help with depression. Stimulant medications, such as modafinil, can also be prescribed to increase alertness. However, it is important for survivors to review their current medications with their doctor, as drowsiness is a common side effect of many drugs.

In addition to treating the underlying conditions, improving sleep hygiene can also help manage EDS. This includes practices such as maintaining a consistent sleep schedule, limiting technology use before bed, creating a peaceful sleeping environment, and using breathing exercises or relaxation techniques.

Frequently asked questions