Sleep as an Occupational Need

Evolution of Sleep as an Occupational Domain

Adolf Meyer was the first in the occupational therapy field to recognize the vital role of sleep. In “The Philosophy of Occupational Therapy,” he proposed that rest and sleep were necessary and of equal importance to work and play in maintaining health and well-being (Meyer, 1922). The American Occupational Therapy Association (AOTA) originally classified sleep as an activity of daily living. In 2008, rest and sleep were reclassified as an occupational domain in the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008). This shift in focus acknowledged the significant effect rest and sleep can have on participation (Gentry & Loveland, 2013).

Given the unclear, and sometimes controversial, delineation between the definitions of occupation and activity, agreement with this reclassification may be difficult for some. The World Federation of Occupational Therapists (2012) defined occupations as “the everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life” (para. 2). AOTA’s reclassification of sleep seems justified given the temporal context of sleep as well as the restorative properties of sleep required to function and derive meaning and pleasure from living.

Sleep Dysfunction: Impact and Prevalence

Poor sleep is the most frequent complaint after pain in people with chronic illness (Ancoli-Israel, 2006). The Centers for Disease Control and Prevention (2015) has recognized insufficient sleep as a public health epidemic. It is estimated that 50–70 million U.S. adults have a sleep or wakefulness disorder (Institute of Medicine, 2006) such as sleep apnea, pain syndromes, parasomnias, and insomnia. Sleep helps regulate the body’s physiological functioning and substantially affects health, participation, and engagement (Brown, 2008; O’Donoghue & McKay, 2012). Therefore, it is not surprising that sleep can influence employment status, social interactions, and daily functioning in general. When sleep is insufficient, brain functions, mood, and healing processes often are compromised (Institute of Medicine, 2006) and deficits in attention and working memory result (Durmer & Dinges, 2005). Inadequate sleep has been linked to heart disease, stroke, cancer, depression, diabetes, and obesity, as well as increased risk for mortality (Institute of Medicine, 2006).

Occupational therapy practitioners are well positioned to understand how illness, the environment, habits, routines, and psychosocial factors affect sleep, yet sleep is underrecognized by many practitioners (Green, 2008). Current research and reports focus primarily on sleep in children with developmental disorders and older adults (AOTA, 2017; Leland, Marcione, Schepens Niemiec, Kelkar, & Fogelberg, 2014; O’Connell & Vannan, 2008; Reynolds, Lane, & Thacker, 2012). In adults with neurological impairment, the impact sleep may have on rehabilitation processes, therapeutic outcomes, activities of daily living, and meaningful occupations is less frequently addressed.

Consideration of Sleep: Critical in Neurological Populations

Among populations with neurological impairment such as people with spinal cord injury, traumatic brain injury, stroke, multiple sclerosis, Parkinson’s disease, and dementia, sleeping difficulty and daytime sleepiness are common (Ouellet & Beaulieu-Bonneau, 2010). A person with spinal cord injury participating in one of our recent research studies indicated that sleep and fatigue were the main factors influencing her participation in meaningful activities. She reported that her rehabilitation progress depended on the amount of sleep and rest she experienced. Unfortunately, this person’s sleep-related problems, like those of many others with neurological impairment, remained undiagnosed and untreated. Sleeping difficulties in the population of persons with neurological impairment are often viewed as secondary problems, with poorly understood etiologies and limited treatments (Ouellet & Beaulieu-Bonneau, 2010).

Although health professionals may consider poor sleep to be a secondary concern, it likely exacerbates the impairments from primary diagnoses and plays a critical role in daily functioning. Diagnosis of sleep-related conditions is not within occupational therapy’s scope of practice, but our profession is in a position to assess sleep and its impact on participation and satisfaction. Gansor and Ganjikia (2015) investigated the current status of addressing the occupation of sleep in occupational therapy. Although they found that sleep was addressed in multiple stages of the occupational therapy process, practitioners reported relying on nonstandardized assessments and still considered sleep to be an activity of daily living rather than an area of occupation. Without standardized assessments and a focus on addressing occupations, it is difficult to establish baseline levels of impairment, document progress, and justify medical reimbursement.

Sleep-Related Assessments and Interventions

No known standardized occupational therapy assessments are specific to sleep. Tools that do exist include qualitative assessments that can be used to identify the client’s impression of sleep quality, sleep habits and routines, number and type of disruptions, and participation. The Functional Outcomes of Sleep Questionnaire (Weaver et al., 1997) examines the repercussions of daytime sleepiness on instrumental activities of daily living, and sleep diaries, logs, and interviews provide insight into sleep patterns. Such assessments may be useful in identifying sleep-related problems and establishing intervention approaches. However, because these assessments are not standardized they do not allow practitioners to quantify either the degree of sleeping difficulty and sleep quality or the changes that may occur in sleep behavior.

Standardized sleep instruments used in other disciplines can be adopted until instruments specific to occupational therapy practice are developed. The Daily Cognitive Communication and Sleep Profile (Wiseman-Hakes, Victor, Brandys, & Murray, 2011) provides information on sleep disturbances related to cognition, communication, and mood. Actigraphy measures the number and duration of nighttime disturbances, and questionnaires such as the Epworth Sleepiness Scale (Johns, 1991), the Fatigue Severity Scale (Krupp, LaRocca, Muir-Nash, & Steinberg, 1989), and the Pittsburgh Sleep Quality Index (Buysse, Reynolds, Monk, Berman, & Kupfer, 1989) can quantify sleepiness, fatigue, and sleep quality.

Once a sleeping difficulty has been identified using one of these assessments, it is appropriate to consider therapeutic approaches. The development of assessments that could measure the functional impact of sleep on life participation and daily activities, however, would aid occupational therapy practitioners in targeting therapeutic approaches and documenting associated outcomes.

One intervention used in occupational therapy to address the consequences of poor sleep in people with neurological impairment is energy conservation. Pacing strategies, rest breaks, and schedules based on peak energy levels have been reported to be beneficial for people with multiple sclerosis (Matuska, Mathiowetz, & Finlayson, 2007; Vanage, Gilbertson, & Mathiowetz, 2003) and Parkinson’s disease (Sturkenboom et al., 2011). Although this strategy may be beneficial for severe fatigue, it does not directly address the occupation of sleep; instead, it is a compensatory strategy that limits life participation. In an effort to improve sleep and enhance engagement, occupational therapy practitioners should consider other interventions for clients with neurological impairment.

Common interventions for people with primary sleep disorders include cognitive–behavioral therapy (CBT), physical activity interventions, multicomponent interventions, and modification of the sleep environment (Leland et al., 2014). These interventions may improve sleep across neurological populations and can be incorporated into occupational therapy practice. CBT can promote awareness of factors influencing sleep (e.g., stress, pain, diet, apnea) and teach methods to manage or modify these factors. Moreover, goals and schedules promoting physical activity and exercise can be developed in collaboration with the client. Multicomponent interventions combining multiple sleep intervention strategies, such as CBT and physical activity, may also be used.

Interventional evidence for sleep is limited, but growing, across multiple neurological diagnoses. CBT has been shown to alleviate sleep disturbances (Ouellet & Morin, 2004), increase sleep efficiency, and reduce symptoms of general and physical fatigue (Ouellet & Morin, 2007) for insomnia associated with traumatic brain injury and to reduce fatigue in people with multiple sclerosis (van Kessel et al., 2008). In people with neurological impairment, trends associating physical exercise with reduced apathy and depression and greater positive affect have been found (Abrantes et al., 2012). Nascimento et al. (2014) reported that deficits in instrumental activities of daily living and sleep disturbances were reduced in people with Parkinson’s or Alzheimer’s disease with regular multimodal physical exercise. Physical activity also effectively reduced sleep-related periodic leg movements in people with spinal cord injury (De Mello, Silva, Esteves, & Tufik, 2002).

Other strategies range from providing adaptive equipment to modifying the environment. For example, sleep apnea may be reduced with sleep positioning alone or in combination with use of a continuous positive airway pressure device. A quiet and dark sleep environment using earplugs and a sleep mask may offer a strategy to improve sleep in people with traumatic brain injury or posttraumatic stress disorder (Hu, Jiang, Zeng, Chen, & Zhang, 2010).

Minimal clinical effort is required to integrate and incorporate assessments and interventions such as those outlined in this section. We propose that sleep should be routinely assessed with standardized measures, addressed with intervention, and reassessed as part of standard practice for clients with neurological impairment.

Recommendations to Improve Occupational Therapy’s Role in Sleep

We propose the following recommendations to advance occupational therapy’s role in sleep. First, knowledge and skills related to sleep should be integrated into educational curricula. Learning objectives should incorporate an understanding of

These same objectives should be presented at professional development events to increase knowledge and application to practice.

In addition to educating those within our profession, we must also advocate for awareness outside of occupational therapy. We should strive to make other health disciplines aware of the consequences of inadequate sleep and occupational therapy’s role. Occupational therapy practitioners can work toward this goal through education and networking with other health professionals. Occupational therapy practitioners practice a holistic approach and should work toward understanding all aspects of a client’s diagnosis and care. We should not hesitate to initiate dialogue with other members of the client’s health care team, promoting interdisciplinary relations and providing a platform to discuss sleep with other disciplines.

It will be critical to expand the evidence base for existing occupational therapy interventions and focus efforts on identifying novel ways to improve sleep and reduce fatigue. We should investigate the effect of sleep on activities of daily living, engagement, and participation. Ways in which patients can modify their sleep environment may provide an avenue for investigation. Efforts to educate hospital staff about the detrimental effects that night care may have on patients’ sleep quality and health could be effective (Cmiel, Karr, Gasser, Oliphant, & Neveau, 2004). As interventions are identified, it also will be necessary to develop and validate standardized instruments applicable to occupational therapy practice.

Conclusion

The influence sleep has on general health and well-being necessitates addressing it in client populations throughout the lifespan. Occupational therapy practitioners and their clinics and departments can take a variety of steps to enhance awareness of the importance of sleep and incorporate sleep-related considerations into practice. As we move forward, it will be important to prioritize research efforts targeting sleep assessments that meet our clinical needs and to establish an evidence base for treatment interventions aimed at fostering the rehabilitation process, enhancing participation, and improving life quality and satisfaction for our clients.