Colin Snow
Sleep is critical for stroke recovery, but it is common for survivors to experience fatigue and excessive sleepiness during the early stages of their recovery journey. This phenomenon is known as excessive daytime sleepiness (EDS) or hypersomnia, and it can impact daily activities and delay recovery. While sleep is essential, excessive sleep after a stroke may indicate more serious underlying issues.
| Characteristics | Values |
|---|---|
| Prevalence | 18-72% of stroke survivors experience excessive daytime sleepiness |
| Onset | The incidence of hypersomnia increases in the first month after a stroke |
| Duration | EDS usually decreases after a few weeks, but can last for over six months in 30% of cases |
| Causes | Sleep-related breathing disorders, Reversed Robin Hood Syndrome, Depression, Medication, Behavioural, Lesions in the posterior hypothalamus and mesencephalon, Direct lesion in the Reticular formation |
| Symptoms | Constant fatigue, Slowed cognition or speech, Excessive napping, Slow response time, Difficulty concentrating |
| Treatment | Stimulants, Regular sleep schedule, Avoiding caffeine and alcohol, Exercise, Cognitive-behavioural therapy, Continuous positive airway pressure treatment, Addressing underlying causes |
What You'll Learn
Excessive daytime sleepiness (EDS) or hypersomnia
Excessive daytime sleepiness (EDS), also known as hypersomnia, is a common condition following a stroke, affecting 18% to 72% of stroke survivors. EDS is characterised by prolonged daytime napping and nighttime sleep, with individuals often feeling compelled to sleep during the day despite getting a full night's rest. While sleep is crucial for recovery, excessive sleep can indicate more serious underlying issues.
Causes of EDS
EDS can be caused by various factors, including sleep-related breathing disorders, neurological changes, and mental health issues.
- Sleep-related breathing disorders, such as obstructive sleep apnea, are common in stroke survivors and can lead to interrupted sleep and excessive daytime sleepiness. Obstructive sleep apnea is caused by abnormal breathing patterns and can increase the risk of a second stroke.
- Neurological changes in the brain, such as lesions in the posterior hypothalamus and mesencephalon, can cause excessive sleepiness. This includes the Reversed Robin Hood Syndrome, where the brain redirects blood flow from damaged areas to healthy ones, leading to excessive sleep.
- Mental health issues, such as depression, are common after a stroke and can cause fatigue and drowsiness, resulting in excessive daytime sleep.
Symptoms of EDS
The primary symptom of EDS is constant fatigue throughout the day. Individuals may nap frequently and experience slowed cognition or speech. EDS can interfere with daily activities, rehabilitation, and recovery.
Treatment of EDS
Treating EDS effectively is crucial to improving quality of life and promoting recovery. Here are some recommended approaches:
- Addressing underlying conditions: Identifying and treating conditions such as sleep apnea or depression can help reduce excessive sleepiness. Continuous positive airway pressure (CPAP) machines or dental appliances can be used to treat sleep apnea, while psychotherapy or support groups can address mental health issues.
- Pharmacological treatments: Stimulant medications, such as modafinil, amphetamines, or Ritalin, can be prescribed to increase alertness and reduce daytime sleepiness. However, it is important to review medications with a doctor, as some may cause drowsiness as a side effect.
- Improving sleep hygiene: Establishing good sleep habits, such as maintaining a consistent sleep schedule, limiting technology use before bed, and creating a peaceful sleeping environment, can optimise nighttime sleep and reduce daytime drowsiness.
- Healthy lifestyle changes: Adopting a healthy diet, regular exercise, and consuming smaller, nutrient-dense meals can increase energy levels and reduce daytime sleepiness. Caffeinated drinks, consumed in moderation and under medical advice, can also help reduce drowsiness.
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Sleep-related breathing disorders
Sleep apnea can cause the sufferer to wake up frequently throughout the night, though they may not remember doing so. It can also cause unusual breathing patterns, such as Cheyne-Stokes breathing, which involves fast breathing that gets deeper, then shallower, until breathing stops altogether. Other symptoms include night sweats, feeling restless at night, and waking up feeling short of breath or like you're choking.
Sleep apnea can have serious consequences if left untreated. The constant interruptions to the sleep cycle can lead to extreme daytime drowsiness, impacting a person's quality of life. It can also put stress on the heart, potentially causing heart damage and heart failure.
Treatments for sleep apnea include conservative (non-medical) treatments, such as weight loss, changes in sleeping position, and nasal sprays. Positive airway pressure and adaptive ventilation devices can also be used to increase the air pressure in the airway, keeping it open during sleep. Oral appliances, such as mouthpieces, can also be used to prevent the tongue from blocking the airway. In some cases, surgery may be required to widen the airway.
If you suspect you may have sleep apnea, it's important to consult a healthcare professional. They can recommend tests, such as an overnight sleep study or a home sleep apnea test, to confirm the diagnosis and determine the severity of the condition.
In addition to sleep apnea, other sleep-related breathing disorders can occur following a stroke. These may include abnormal breathing patterns, such as loud snoring, choking, and gasping sounds during sleep. These issues can impact the quality of sleep and contribute to excessive daytime sleepiness.
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Sleep-wake cycle disorders
These sleep-wake cycle disorders can be treated in a variety of ways. Bright light therapy, typically administered in the morning for about 30 minutes, can help reset the body's natural sleep-wake cycle. Melatonin, a hormone that acts as a sedative, can also be taken at night to induce sleep. It's important to note that sleep-wake cycle disorders are usually not permanent, and there are ways to manage and improve sleep quality.
Additionally, there are some general tips for managing sleep problems that can be applied. These include maintaining a dark, comfortable bedroom, reducing nighttime noises, increasing physical activity during the day, exposing oneself to light during the day, and following a regular sleep schedule. It is also recommended to avoid certain foods and drinks that can disrupt sleep, such as caffeine and heavy meals close to bedtime.
Excessive daytime sleepiness (EDS) or hypersomnia is another condition that can occur after a stroke, causing fatigue and prolonged daytime napping. This can be a sign of more serious underlying issues and can impact an individual's rehabilitation and recovery process. Addressing the underlying causes of EDS, such as sleep apnea, depression, or medication side effects, is crucial for effective treatment.
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Insomnia
Treatment
There are several treatment options for insomnia in stroke patients:
- Cognitive-behavioural therapy (CBT): This can be effective in managing chronic insomnia and may be applied to patients who need long-term management. However, it may not show apparent long-term physical and mental benefits.
- Pharmacological therapy: Antidepressants such as mianserin may improve insomnia after a stroke. Zolpidem, which has relatively fewer effects on cognition and muscle tension, might also be beneficial. However, benzodiazepines are not recommended as they can aggravate breathing-related sleep disorders and induce the reappearance of motor deficits.
- Acupuncture: Acupuncture at specific acupoints has been found to be a promising method for treating insomnia after a stroke.
Prevention and Management
To prevent and manage insomnia, it is important to maintain a sleep-friendly environment and routine:
- Keep your bedroom dark, quiet, and at a comfortable temperature.
- Avoid noise and light disturbances.
- Establish a regular sleep schedule by going to bed and waking up at the same time each day.
- Engage in a relaxing bedtime routine, such as taking a warm bath, listening to calm music, or reading a book.
- Limit caffeine, heavy meals, and alcoholic drinks close to bedtime, as these can disrupt sleep.
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Reversed Robin Hood Syndrome
Excessive daytime sleepiness (EDS) is a common issue for people recovering from a stroke. While sleep is critical for recovery, too much sleep could indicate underlying issues. One such issue is Reversed Robin Hood Syndrome, a condition in which the brain favours sleep above other processes, resulting in excessive sleeping. This could be the brain's way of compensating for the damage caused by the stroke.
The Reversed Robin Hood Syndrome is characterised by the "steal phenomenon", which is detected by transcranial Doppler (TCD) monitoring as transient, spontaneous, or vasodilatory stimuli-induced velocity reductions in affected arteries at the time of velocity increase in normal vessels. In other words, blood flow is "stolen" from the ischemic (affected) brain to the non-affected brain. This is associated with desaturation of oxygen, which, along with the natural blood pressure dip observed in sleep, could create the "perfect storm" to further damage brain tissues with poor hemodynamic reserve.
In a study of six patients with acute ischemic stroke, all patients exhibited the steal phenomenon and recurrent neurological worsening. Three of the five patients who received non-invasive ventilatory correction for snoring/sleep apnea showed no further velocity or NIHSS score changes. This suggests that non-invasive ventilatory correction may be a viable treatment for Reversed Robin Hood Syndrome.
In summary, Reversed Robin Hood Syndrome is a condition that can occur after a stroke, in which the brain prioritises sleep, leading to excessive sleeping. This syndrome has been linked to blood flow being diverted away from the affected areas of the brain, which could be detrimental to recovery. However, non-invasive ventilatory correction may be a potential treatment option.
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Frequently asked questions
Excessive daytime sleepiness (EDS) is a common condition following a stroke, with an estimated 18-72% of stroke survivors experiencing it. While sleep is critical for recovery, excessive sleep could indicate more serious underlying issues.
There are several factors that can cause excessive sleepiness after a stroke:
- Sleep-related breathing disorders, such as sleep apnea, which is caused by abnormal breathing patterns and can increase the risk of a second stroke.
- Sleep-wake cycle disorders, where the sleep-wake schedule is no longer affected by sunlight or the darkness of night, making it difficult to fall asleep at night and wake up in the morning.
- Fatigue due to the physical and emotional changes after a stroke, as well as the rehabilitation process, can result in increased sleep.
- Depression, which is a common issue among stroke patients, can lead to excessive sleep.
- Reversed Robin Hood Syndrome, where the brain favours sleep above other processes, resulting in excessive sleeping to compensate for the damage caused by the stroke.
Excessive daytime sleepiness usually decreases after a few weeks. However, in about 30% of stroke survivors, EDS can last for over six months and may interfere with rehabilitation and recovery.
There are several treatment options for excessive sleepiness after a stroke:
- Addressing underlying conditions, such as sleep apnea, with the use of a Continuous Positive Airway Pressure (CPAP) machine to improve sleep quality and reduce daytime drowsiness.
- Seeking psychological care for emotional changes, depression, or other mental health conditions that may be contributing to excessive sleepiness.
- Reviewing medications with a doctor, as drowsiness is a common side effect, and there are stimulant medications available to treat excessive sleepiness.
- Improving sleep hygiene by maintaining a consistent sleep schedule, limiting technology use before bed, creating a peaceful sleeping environment, and practising breathing exercises or relaxation techniques.
