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Occupational Therapy’s Role in Sleep

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Sleep is essential for well-being and critical for maintaining homeostasis and participating in activities of daily living. Occupational therapists have long acknowledged the influence of sleep on occupational performance. The Occupational Therapy Practice Framework: Domain & Process (2nd ed.; American Occupational Therapy Association, 2008) includes rest and sleep as an area of occupation addressed by occupational therapy.

Sleep insufficiency, defined as not obtaining restorative sleep, is a public health crisis in the United States (Centers for Disease Control & Prevention, 2008) with resulting negative economic consequences due to lower productivity, increased absenteeism, decreased job performance, increased health care utilization, and potential injury. There are more than 80 defined sleep disorders, each of which results in distress or daytime difficulties in daily life tasks, or home, employment, or community life—problems that occupational therapy practitioners uniquely address. Referral to a physician for further evaluation or medical intervention is indicated for clients reporting unresolved, chronic, or potentially serious sleep problems. Persistent sleep disturbances that disrupt the daily functioning of other members of the household (e.g., sundowning in adults with Alzheimer’s disease) should also be referred to the medical team. Occupational therapists work with individuals following diagnosis to create behavioral or environmental changes that facilitate daytime performance and participation.

Role of Occupational Therapy
Occupational therapists use knowledge of sleep physiology, sleep disorders, and evidence-based sleep promotion practices to evaluate and address the functional ramifications of sleep insufficiency or sleep disorders on occupational performance and participation. Sleep problems are framed from the perspective of health maintenance and health promotion and are addressed with all clients.

Therapists working with families of children with an autism spectrum disorder or another developmental disorder explore the impact of sleep deprivation on the family unit and the child’s and caregivers’ ability to function effectively during the day. They aid families to systematically trial changes in bedtime routines, habits, and patterns. Cognitive or behavioral therapy interventions, or sensory integration strategies to address sensory avoiding or sensory seeking behaviors (e.g., a picture poster for bedtime routines, stickers or consistent praise for sleeping through the night, loose or tight pajamas, lightweight or weighted blankets) are addressed. Managing the physical environment and enhancing observation skills help parents anticipate reactions to changes in clothing, toys, or family schedules. Calming activities and routines that do not burden the family and can be consistently carried out may facilitate sleep.

Therapists working in long-term-care settings for older adults develop individual sleep routines, adjust lighting in residential settings to clearly demarcate day and night, reduce staff noise, train staff to use recommended equipment for bed positioning, maintain turning schedules for individuals who are immobile, and advocate for clients’ needs for privacy. Daytime activity programs, including exercise, foster socialization and facilitate arousal, engagement, and decreased involuntary daytime napping, thus improving sleep latency and maintenance. Occupational therapy practitioners address nocturnal toileting safety, bedding management, and clothing preferences for sleep. Environmental elements, such as sufficient blankets for warmth, sound machines to add white noise, and blackout curtains or eye masks may enhance quality of sleep.

Therapists working in wellness and prevention practices can facilitate sleep health by increasing physical activity in clients and well populations across the lifespan, and addressing smoking cessation, substance use, and obesity management, which have been linked to sleep disturbances (Strine & Chapman, 2005).

Assessment
Occupational therapists evaluate clients in areas that contribute to sleep dysfunction, including difficulties in sleep preparation and sleep participation; sleep latency (how long it takes to fall asleep, typically less than 30 minutes for someone without a sleep disorder), sleep duration (the number of hours of sleep, which varies by age), sleep maintenance (the ability to stay asleep), or daytime sleepiness; the impact of work, school, and life events, such as shift work or caregiving responsibilities; the influence of pain and fatigue; disturbances in balance, vision, strength, skin integrity, and sensory systems; psycho-emotional status, including depression, anxiety, and stress; the impact of caffeine, nicotine, drugs or alcohol, smoking, or medication (e.g., prescriptions or over-the-counter sleep aids); and the impact of the environment (e.g., those in acute care hospitals and long-term-care facilities report higher rates of sleep disturbance).

Intervention
Occupational therapy interventions focus on promoting optimal sleep performance. These interventions include

  • Educating clients and caregivers on sleep terminology, misconceptions, and expectations
  • Preventing secondary conditions that may precipitate diminished sleep quality (e.g., decreased range of motion, depression, or anxiety)
  • Encouraging smoking cessation, reduced caffeine intake, a balanced diet, adequate exercise, etc.
  • Establishing predictable routines, including regular times for waking and sleeping
  • Managing pain and fatigue
  • Addressing activities of daily living, particularly for bed mobility and toileting
  • Establishing individualized sleep hygiene routines (e.g., habits and patterns to facilitate restorative sleep)
  • Teaching cognitive-behavioral and cognitive restructuring techniques, such as leaving the bedroom if awake and returning only when sleepy, or exploring self-talk statements regarding sleep patterns
  • Increasing coping skills, stress management, and time management
  • Addressing sensory processing disorders and teaching self-management or caregiver management
  • Modifying the environment, including noise, light, temperature, bedding, and technology use while in bed
  • Introducing complementary mind–body techniques, including progressive muscle relaxation, guided imagery, autogenic training, tai chi, yoga, meditation, and biofeedback
  • Advocating on a state or national level for laws that protect workers from excessive work schedules that threaten their health or public safety

Conclusion
Restful and adequate sleep provides the foundation for optimal occupational performance, participation, and engagement in daily life, a concept that is historically consistent with the development of occupational therapy. Attention to the impact of sleep is incorporated into the repertoire of occupational therapists and addressed across the lifespan. Prevention and intervention strategies to address individual, family, and population-based sleep needs lie within the scope of practice for occupational therapy and represent another way in which the profession approaches clients from a holistic perspective to help them live life to its fullest.

References
American Occupational Therapy Association (2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625–683. doi:10.5014/ajot.62.6.625

Centers for Disease Control and Prevention. (2008). Perceived insufficient rest or sleep—four states, 2006. Mortality and Morbidity Weekly Report, 57, 200–203. Retrieved February 8, 2012, from http://www.cdc.gov/mmwr/PDF/wk/mm5708.pdf

Strine, T. W., & Chapman, D. P. (2005). Associations of frequent sleep insufficiency with health-related quality of life and health behaviors. Sleep Medicine, 6, 23–27. doi: 10.1016/j.sleep.2004.06.003

Developed by Meryl Marger Picard, MSW, OTR, for the American Occupational Therapy Association. Copyright © 2012 by the American Occupational Therapy Association. This material may be copied and distributed for personal or educational uses without written consent. For all other uses, contact copyright@aota.org.