Sleep, sleep problems
and sleep treatment:
future directions for occupational therapists
Sophie Faulkner
Occupational Therapist / care co-ordinator (GMMH)
Clinical Doctoral Research Fellow (HEE / NIHR)
Why might we neglect sleep?
Occupation is our focus
What is an occupation?
-
Occupation involves an element of intentionality?
Sleep is an unconscious state
Falling asleep is not exactly an intentional process
Maybe sleep is not an occupation, but going to bed is!
Limited coverage in textbooks (Green 2008)
although this is improving (Faulkner unpublished)
Limited coverage on pre-registration programmes
?although this may be improving?
Overview
1. Background - why sleep is important, why for Occupational Therapists (OTs)
2. Normal sleep
- Circadian rhythm and sleep pressure (the 2 process model)
- The sleep cycle
- Normal variations
3. Sleep problems
- Insomnia (and treatment)
- Circadian rhythm sleep disorders (and treatment)
- Sleep apnoea (and treatment)
- Parasomnias and other sleep phenomena
4. Assessment of sleep
- Initial interview questions
- Self-report measures
- Objective measurement
5. More about interventions
Questions
1. Background:
Impact of poor sleep
Physical health:
• Reduced immunity and healing (Kahan et al 2010)
• Increased cardio-metabolic disease risk (Knutson 2010)
(potential mechanisms: affecting glucose metabolism, altered
appetite regulation)
• Poorer ‘health related behaviours’ e.g. smoking, drinking,
exercise, unhealthy eating (Strine & Chapman 2005)
Impact of poor sleep
Cognitive functioning:
• Impacts memory consolidation and learning (Walmsley &
Stickgold 2011)
• Affects ‘emotional processing’ of memories (Van der Helm &
Walker 2009)
• Increased risk taking behaviour (Womack et al 2013)
! Poor decision making after poor quality or insufficient sleep !
• Affects vocational and social engagement (Faulkner & Bee,
2017)
Sleep is gaining increasing attention
from OTs
Included in the AOTA
practice Framework (AOTA
2008)
First book on OT and sleep
published (Green & Brown
2015)
Increasingly - trials of
interventions delivered by
OTs to improve sleep (e.g.
Leland et al 2016, Eakman et
al 2017)
This month - nine OTs at SLEEP 2017
Boston!
What OT can bring
Holistic approach to address biopsychosocial factors affecting sleep.
Interactions within complex systems.
Relevant core OT skills:
Personalisation and client centredness
Assessing and modifying routines
Environmental assessment
Activity analysis
Grading
2. Normal sleep
The two process model
Sleep pressure & circadian rhythm (Borbely 1982)
Circadian rhythms
Suprachiasmatic nucleus – internal clock in the brain
Set by light
- blue toned light
- brighter light
- timing dependent
Rajaratnam & Arendt 2001
Circadian rhythms
Poorer performance at circadian ‘nadir’
(low point)
Rajaratnam & Arendt 2001
The sleep cycle
Sleep cycle over a whole night
Individual differences
Long sleepers VS short sleepers
9.5hrs - 5.5hrs
Evidence to suggest short sleepers sleep structure is more “efficient”
for getting enough slow wave sleep (Van Dongen et al 2005)
It is the right amount if you go to bed when sleepy and get up feeling
refreshed… (Ferrara and De Gennaro 2001)
Excessive sleep may carry health risks and can impact quality of life
(Cappuccio et al 2010, Ohayon et al 2013)
Individual differences
Morning type VS evening type
Larks VS owls
Largely genetically determined, habituation can impact. (Van Dongen et
al 2005)
3. Sleep problems
Insomnia
Very common (Roth 2007)
Acute in reaction to stress
Can become self sustaining
and chronic
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•
•
•
Initial insomnia / sleep onset insomnia
Sleep maintenance insomnia (waking throughout, or early waking)
Unrefreshing sleep (?)
Paradoxical insomnia
“I haven’t slept a wink all night!”
Insomnia – psychobiological model
Stressful life events
“Sleep effort”
Anxiety or frustration at
inability to sleep.
Worry about daytime
consequences.
(Perlis et al 2011)
Physiological and
psychological
arousal
Inhibits the normal circadian and
homeostatic processes
Resolves when the
stressful event is over
Insomnia – stimulus control model
In good sleepers:
bedtime
bedtime routine
getting into bed
increased sleepiness
falling asleep
In insomnia:
bedtime
bedtime routine
getting into bed
(Perlis et al 2011)
stress, anxiety
working, watching TV,
checking emails,
rumination
Treatment of Insomnia
Addressing sleep disrupting beliefs / sleep education:
• “I should be able to go straight to sleep” – no, it is normal for it to
take 10-30 minutes. <5 min means you were sleep deprived!
• “I shouldn’t be waking up in the night” – briefly waking during the
sleep cycle is normal and its important not to get stressed about it.
• “I need my 8 hours” – for some people this is not true, some may
need only 6 or 7 hours.
Treatment of Insomnia
“Sleep hygiene”
-
what is included in this varies a lot
Often used as a control condition in studies of sleep interventions
•
•
•
•
•
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Reduce caffeine and nicotine near bedtime
Avoid naps
Avoid non-sleep activities in bed
Keep a regular sleep schedule
Keep the bedroom quiet and dark
Turn the clock away from the bed
! Overlap with some components of … >>>
Treatment of Insomnia
Cognitive Behavioural Therapy for Insomnia (CBT-i)
Stimulus control
Only sleep (and sex) in bed
15 min rule
Regular sleep schedule
No naps
Only go to bed when sleepy
Sleep restriction therapy
Relaxation
Cognitive strategies
Challenging unhelpful beliefs
Thought stopping
Rehearsal and planning
Excellent evidence in insomnia
without co-morbidity (Kyle and
Espie 2009)
Very good evidence in
insomnia co-morbid with
physical and mental health
conditions (Taylor & Pruiksma
2014, Wu et al 2015)
Treatment of Insomnia
Cognitive Behavioural Therapy for Insomnia (CBT-i)
Emerging evidence for CBT-i delivered by OTs
Green A*, Hicks J, Weekes R, Wilson S (2005) A cognitive-behavioural group
intervention for people with chronic insomnia: an initial evaluation. British Journal of
Occupational Therapy 68(11), 518-522
Berger L.* (2016) Evaluation of the efficacy of a new insomnia service providing
cognitive behavioural therapy for insomnia. J Thorac Dis;8(2):AB011.
Eakman, A. M.*, Rolle, N. R*., & Henry, K. L. (2017) Occupational therapist delivered
cognitive behavioral therapy for insomnia to post-9/11 veterans in college: A wait list
control trial pilot study. SLEEP, 40 (suppl_1):A140-141.
Eakman, A. M.*, Schmid, A.*, Henry, K. L., Rolle, N. R.*, Schelly, C.*, Grupe, C. E.*, &
Burns, J. (2017) Restoring Effective Sleep Tranquility (REST): A feasibility and pilot
study. British Journal of Occupational Therapy. Early Online
*indicates author is an OT
Circadian Rhythm Sleep Disorders
Age related associations
Common in neurological and
psychiatric disorders (Jagganath
2013)
Treatment:
• Light (in research - light boxes)
• Sleep schedule
• Prescription of melatonin
(Wulff et al 2009)
Sleep disordered breathing
Obstructive sleep apnoea: Closing / narrowing of the airway >
Temporary obstruction of airflow (at least 10 seconds) > brief
awakening / partial awakening
(credit to Heather Engleman 2010 for diagram)
Sleep disordered breathing
Risk factors:
Obesity
Snoring
Middle age or older
Face / neck / nose / tongue abnormalities
Hypothyroidism
Signs:
loud snoring
observed pauses in breathing
waking to urinate often
disturbed sleep (may be aware of this)
daytime sleepiness
Increased risk of:
High blood pressure
Stroke
Heart disease
Depression
Traffic accidents
Treatment of sleep disordered
breathing
Lifestyle changes
Lose weight
Sleep on side
Reduce use of alcohol or sedating medications
Improve sleep hygiene
Continuous Positive Airway
Pressure (CPAP)
Oral appliances
Surgery
Parasomnias and other sleep
phenomena
Sleep walking
during deep sleep / Non-REM sleep
usually no memory
most common in children
Restless legs syndrome
Periodic limb movement disorder
Bruxism (teeth grinding)
Night terrors
during deep sleep / Non-REM sleep
common in PTSD
common in children
REM sleep behaviour disorder
during REM sleep
more common in older people
can be a precursor of Parkinsons
Narcolepsy (with or without
cataplexy)
Sleep Paralysis
4. Assessment of sleep
Initial interview questions:
1. What time do you go to bed, and what time do you usually fall asleep?
2. What time do you usually wake up? (do you use an alarm?)
3. Do you feel refreshed when you wake up?
4. How long does it take you to fully wake up?
5. Are these sleep timings your choice or would you prefer that they were different?
6. Are you sleepy in the daytime? (distinction between fatigue and sleepiness,
sleepiness = likely to fall asleep)
7. Do you sleep right through the night? (what wakes you up?)
8. Whereabouts do you sleep? (we can assume people sleep in their bedroom,
however this is often not the case.)
9. When did the problem start?
10. What else was going on around that time? (traumatic events? Life changes?)
11. Snoring? Moving around? Bed partner/ housemate report?
Self report measures
Pittzburg Sleep Quality Index (PSQI) (Buysse et al 1989)
PROMIS Sleep Disturbance Instruments (Buysse et al 2012)
Occupational Profile of Sleep (Pierce 2011)
Sleep Disruptive Beliefs and Attitudes Scale (Morin et al 2007)
Functional Outcomes of Sleepiness Questionnaire (Chasens, Ratcliffe, &
Weaver, 2009)
STOP BANG questionnaire (Chung et al 2008)
•
Screen for sleep apnoea
See sleepOT.org/assessments
Sleep diaries
American Academy of Sleep Medicine (AASM)
Objective measurement of sleep
Polysomnography (PSG)
• sleep structure / sleep stages
• diagnosis of sleep apnoea and parasomnias
Actigraphy
• circadian rhythm
• rest activity pattern
• (used for research)
Commercial devices for tracking activity and sleep
5. More about interventions
Mindfulness
Evidence for mindfulness to improve sleep is increasingly promising, more
research is needed (Garland et al 2016)
Relaxation techniques are often a component of CBT-I
Passive body warming
Hot shower / bath / drink / heat pack / sit somewhere hot
Cooling occurs in bed, enhances body temperature rhythm amplitude
Can improve sleep maintenance and depth (Liao et al 2002)
Part of a relaxing bedtime routine
Daytime activity to improve sleep
Level of exercise and activity
• Increasing exercise / physical activity (any type, nearly any time) (Kredlow
et al 2015)
• Increasing non-physical activity appears to help too (Leland 2016, Green
2015)
• Addressing daytime activity makes it easier to adhere to sleep schedule
recommendations (Troxel 2012)
Pattern of activities and environmental exposures
• Improving regularity of routines, activities, mealtimes, social cues (Green
2015)
• Increasing light exposure in the daytime and reducing artificial light
exposure in the evening (Skeldon et al 2017)
OT strategies to improve sleep
Environmental assessment
• Optimising the environment for sleep
• Temperature, noise, light, physical comfort (Green & Nakopoulou 2015)
• Adaptations and layout to allow easy and painless bedtime routine
Activity analysis and sleep treatment
• Alerting or sleep promoting? Stimulating, exciting, frightening, painful,
exposure to new information, goal driven? – for that individual
• Involve exposure to light?
• Scheduling activities differently to promote better sleep
Questions?
www.sleepOT.org
@sleepOT_global
@sleepOTsophie