Sleep, Rest, and Occupational Therapy
Do you address sleep and rest with your clients? If not, maybe you should….
The CDC considers insufficient sleep a public health concern. Sleep and rest are included in the American Occupational Therapy Practice Framework: Domain and Process (3rd. Ed.) (AOTA, 2014; CDC, 2015).
Sleep problems can be caused by pain and meds or mental health concerns (among others). Most of our clients need more sleep and rest to help with healing.
Here are some suggestions to work on sleep and rest, with links to web content.
Assessment of Sleep and Rest
Assessment of sleep should focus on three things (Fung, Wiseman-Hakes, Stergiou-Kita, Nguyen, & Colantonio, 2013):
- Quality and quantity of sleep
- Analysis of lifestyle factors, behaviors, and environmental issues that impact sleep
- Impact of sleep on function
#1-#2. Assessment tools for quality and quantity of sleep and lifestyle factors, behaviors, and environment (NOTE: I focus on adults here):
#3. Assessment tools to assess functional outcomes of sleep deficits (#3):
- Interview and observation of the client
- The Functional Outcome of Sleep Questionnaire
Sample sleep diaries:
Treatment for sleep and rest
(Bloom, et al., 2009; Fung, Wiseman-Hakes, Stergiou-Kita, Nguyen, & Colantonio, 2013)
1. Therapist should educate client:
- Discuss how pain might impact sleep (for help with treatments for pain, read my blog) and how to monitor fatigue and energy levels.
- Help restore regular sleep and wake times (it is disruptive to the body’s natural sleep rhythm to “sleep in” on the weekends -recommendation is to “sleep in” no more than 1 hour on an “off” day).
- Teach stress management/relaxation strategies – meditation, guided imagery, progressive muscle relaxation ( many people with sleep problems start a pattern of behaviors that make sleep more difficult – rising anxiety levels when sleep does not come soon. See my other blog posts about substance use and pain for stress mgmt/relaxation techniques)
- Physical activity and occupational engagement: Remain active or engage in pleasurable occupations during the day. Keeping active during the day improves chances of falling asleep when bedtime arrives (Leland, et al., 2016).
- Understand that if it takes more than 20 minutes to fall asleep, leave the bed, do something relaxing, and return when sleepy
2. Client should learn time management techniques:
Getting adequate sleep may mean that bedtime needs to be scheduled. The National Sleep Foundation (NSF) recommends that adults achieve 7-9 hours of sleep per night (Hirschkowitz, et al., 2015). If your client is having difficulty getting the recommended amount of sleep, they might need help adjusting their schedule to get into bed on time. Find a sample worksheet for scheduling sleep here. In addition, here are some other tips:
- Assist clients in the timing and pacing of activities based on their peak energy levels. Instruct patients to use times of peak energy to finish important tasks.
- Use good sleep hygiene: Sleep hygiene is a routine that tells the brain to prepare for sleep. Tips for good sleep hygiene can be found at the National Sleep Foundation’s website. And, a great client handout on sleep hygiene can be found at the Centre for Clinical Interventions!
3. Identify and recommend changing behaviors that limit sleep:
- Caffeine: Stop caffeine intake 6-8 hours before sleep.
- Alcohol: Limit alcohol prior to bedtime.
- Technology: Turn off technology at least 1 hour prior to going to bed.
- Food: Do not eat a large meal within 1 hour of going to bed.
- Naps: Limit naps (one 15-30 minute power nap during the day is OK – more than that and it takes away from the natural sleep rhythm; do not nap after 2pm.
- Time in bed: Limit time in bed – bed should be for sleep (and sex) only!
- Physical activity: No heavy physical activity 2 hour before bed.
4. Recommend changes in the sleep environment:
- Blackout curtains
- Earplugs, eye mask
- White noise machine
- Ideal temperature is cool (window slightly open for fresh air circulation)
- Remove blankets that will cause overheating during the night
- Remove technology from the bedroom. It is not OK to put cell phones on “silent mode”. They should be turned OFF. The light emitted from the devices can be distracting, even without sound.
- No pets in bedroom or in bed
5. Cognitive behavioral (C-B) techniques (and behavioral conditioning)
- Because chronic sleep problems can be viewed as a habit that needs changing, behavioral techniques can work. C-B techniques help the client question beliefs about sleep.
- Sleep compression/restriction: Set a limit to the amount of time in bed (both a bed time and a time to wake) and only allow sleep for that time. This will be hard at first, but it helps the brain associate the bed with sleep only.
UMass Medical School has an on-line webinar for clinicians interested in insomnia using cognitive behavioral techniques – $195 for the CEUs. Click here.
Cover photo by Andrew Roberts: Image source
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 68(Suppl. 1), S1–S48. doi:10.5014/ajot.2014.682006
Bloom, H.G., Ahmed, I. , Alessi, C.A., Ancoli-Israel, S. , Buysse, D.J., Kryger, M.H., Phillips, B.A, Thorpy, M.J., Vitiello, M.V., & Zee, P.C.(2009).Evidence-Based recommendations for the assessment and management of sleep disorders in older persons. Am Geriatr Soc, 57(5), 761–789.
Centers for Disease Control (2015, September 3). Insufficient sleep is a public health concern. Retrieved from http://www.cdc.gov/features/dssleep/
Fung,C., Wiseman-Hakes, C., Stergiou-Kita, M., Nguyen, M., and Colantonio, A. (2013). Time to wake up: bridging the gap between theory and practice for sleep in occupational therapy. British Journal of Occupational Therapy, 76(8), 384-386.
Hirschkowitz, M., Whiton, K., Albert, S.M…..Hillard, A. (2015). National Sleep Foundation’s sleep time duration recommendations: methodology and results summary. Sleep Health: Journal of the National Sleep Foundation, 1 (1) , 40 – 43.
Leland, N.E., Fogelberg, D., Sleight, A., Mallinson, T., Vigen, C., Blanchard, J., Carlson, M., & Clark, F. (2016). Napping and Nighttime Sleep: Findings From an Occupation- Based Intervention. The American Journal of Occupational Therapy, 70(4), 1-7.