Trajectories of Insomnia in Adults After Traumatic Brain Injury

Emerson M Wickwire,C Dirk Keene,Michael Mccrea,Jacob Collen,Scott G Williams,Nancy Temkin,Neeraj Badjatia,J Kent Werner,Michael T Smith,Ramon Diaz-Arrastia,Ross Zafonte,Lindsay D Nelson,Shankar P Gopinath ,Vincent F Capaldi,Andrew D Krystal,David M Schnyer,Laura B Ngwenya ,Geoffrey T Manley,David O Okonkwo ,Raquel C Gardner,Randall E Merchant ,Rao P Gullapalli ,Xiaoying Sun,Frederick K Korley ,Joseph T Giacino,Esther L Yuh ,Claudia S Robertson ,Jennifer S Albrecht,Sabrina R Taylor ,Ashlee B Mckeon,Ann‐Christine Duhaime ,Amy J Markowitz,John K Yue ,Pratik Mukherjee,Sonia Jain

doi:10.1001/jamanetworkopen.2021.45310

Abstract

Insomnia is common after traumatic brain injury (TBI) and contributes to morbidity and long-term sequelae. To identify unique trajectories of insomnia in the 12 months after TBI. In this prospective cohort study, latent class mixed models (LCMMs) were used to model insomnia trajectories over time and to classify participants into distinct profile groups. Data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a longitudinal, multisite, observational study, were uploaded to the Federal Interagency Traumatic Brain Injury Repository (FITBIR) database. Participants were enrolled at 1 of 18 participating level I trauma centers and enrolled within 24 hours of TBI injury. Additional data were obtained directly from the TRACK-TBI investigators that will be uploaded to FITBIR in the future. Data were collected from February 26, 2014, to August 8, 2018, and analyzed from July 1, 2020, to November 15, 2021. Traumatic brain injury. Insomnia Severity Index assessed serially at 2 weeks and 3, 6, and 12 months thereafter. The final sample included 2022 participants (1377 [68.1%] men; mean [SD] age, 40.1 [17.2] years) from the FITBIR database and the TRACK-TBI study. The data were best fit by a 5-class LCMM. Of these participants, 1245 (61.6%) reported persistent mild insomnia symptoms (class 1); 627 (31.0%) initially reported mild insomnia symptoms that resolved over time (class 2); 91 (4.5%) reported persistent severe insomnia symptoms (class 3); 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months (class 4); and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months (class 5). In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex (odds ratio [OR], 1.65 [95% CI, 1.02-2.66]), Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1. These results suggest important heterogeneity in the course of insomnia after TBI in adults. More work is needed to identify outcomes associated with these insomnia trajectory class subgroups and to identify optimal subgroup-specific treatment approaches.

Highlights

Traumatic brain injury (TBI) represents a major public health burden by any standard
1245 (61.6%) reported persistent mild insomnia symptoms; 627 (31.0%) initially reported mild insomnia symptoms that resolved over time; 91 (4.5%) reported persistent severe insomnia symptoms; 44 (2.2%) initially reported severe insomnia symptoms that resolved by 12 months; and 15 (0.7%) initially reported no insomnia symptoms but had severe symptoms by 12 months
In a multinomial logistic regression model, several factors significantly associated with insomnia trajectory class membership were identified, including female sex, Black race (OR, 2.36 [95% CI, 1.39-4.01]), history of psychiatric illness (OR, 2.21 [95% CI, 1.35-3.60]), and findings consistent with intracranial injury on computed tomography (OR, 0.36 [95% CI, 0.20-0.65]) when comparing class 3 with class 1

Summary

Introduction

Traumatic brain injury (TBI) represents a major public health burden by any standard. Each year in the US alone, at least 2.5 million adults seek medical care for TBI.[1] Traumatic brain injury incurs substantial health-related and economic costs, including increased risk of fatigue, depression, posttraumatic stress disorder, chronic pain, impaired cognition, diminished quality of life, and other adverse outcomes.[2,3,4,5,6] Insomnia, which is defined as difficulty initiating or maintaining sleep with associated daytime impairment, is among the most common complaints after TBI. Meta-analytic findings suggest an insomnia prevalence rate of 29% among adults with a history of TBI of any severity.[7] This rate is approximately twice the prevalence of insomnia among adults in the general population

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Discussion

Conclusion