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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. The impact of sleep on function and participation is incorporated into the repertoire of occupational therapy practitioiners and addressed across the lifespan (American Occupational Therapy Association, 2014). 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. Referral to a physician for further evaluation or medical intervention is indicated for clients reporting unresolved, chronic, or potentially serious sleep problems (e.g., sundowning in adults with Alzheimer’s disease).
Sleep insufficiency, defined as not obtaining restorative sleep, is a public health problem (Centers for Disease Control & Prevention [CDC], 2015) that is linked to motor vehicle crashes, industrial accidents, increased health care utilization, and decreased work productivity. Sleep insufficiency is also linked to chronic diseases such as hypertension, diabetes, depression, and obesity, along with cancer, early mortality, and reduced quality of life and productivity (CDC, 2015).
Role of Occupational Therapy
Occupational therapists use knowledge of sleep physiology, sleep disorders, and evidence-based sleep promotion practices to evaluate and address the ramifications of sleep insufficiency or sleep disorders on occupational performance and participation. Sleep problems are addressed with all clients and framed from the perspective of health maintenance and health promotion. The following are examples of how occupational therapy practitioners may address sleep dysfunction among different populations and settings.
Children With Autism Spectrum Disorder
Occupational therapy practitioners 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 strategies to address sensory avoiding or sensory seeking behaviors (e.g., a picture poster depicting bedtime routines, stickers or consistent praise for sleeping through the night, loose or tight pajamas, lightweight or weighted blankets) are used. 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.
Older Adults in Long-Term Care
Practitioners working in long-term-care settings for older adults develop individualized sleep routines, adjust the lighting 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.
Practitioners working in wellness and prevention practices can facilitate sleep health by helping clients across the lifespan to incorporate physical activity into their daily routines, along with addressing mood disorders, dietary habits, substance abuse, and smoking cessation, which have been linked to sleep disturbances (Perry, Patil, & Presley-Cantrell, 2013).
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 fewer 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 misconceptions and expectations
- Addressing secondary conditions that may precipitate diminished sleep quality (e.g., pain, decreased range of motion, depression, anxiety)
- Encouraging health management behaviors such as smoking cessation, reduced caffeine intake, a balanced diet, and adequate exercise.
- Establishing predictable routines, including regular times for waking and sleeping
- Managing pain and fatigue
- Addressing performance deficits or barriers to 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 disorders and teaching self-management or caregiver management
- Modifying the environment, including noise, light, temperature, bedding, and technology use while in bed
- Advocating on a state or national level for laws that protect workers from excessive work schedules that threaten their health or public safety
Conclusion
Occupational therapy practitioners are important members of the health care team addressing sleep disorders that place clients at risk for health problems or performance deficits during daily life tasks. They often work with individuals following diagnosis to create behavioral or environmental changes that can facilitate effective sleep habits and routines, providing a foundation for effectively participating in valued activities.
References
American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006
Centers for Disease Control and Prevention. (2015). Insufficient sleep is a public health problem. Retrieved from https://www.cdc.gov/features/dssleep/
Perry, G. S., Patil, S. P., & Presley-Cantrell, L. R. (2013). Raising awareness of sleep as a healthy behavior. Preventing Chronic Disease, 10, 130081. http://dx.doi.org/10.5888/pcd10.130081
Updated by Meryl Marger Picard, PhD, MSW, OTR. Copyright © 2017 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.