PRACTICAL HINTS AND TIPS FOR FACILITATING IMPROVED SLEEP HYGIENE

Dr Bronwen BonfieldPrincipal Clinical PsychologistCommunity Neurological Rehabilitation Service Buckinghamshire

Aims of the Session To explore MS & Sleep

To understand the patterns of sleep.

To explore factors that affect our sleep.

To share experiences of working with clients with sleep difficulties.

To discuss hints and tips on how to support clients and their families who are experiencing sleep difficulties.

MS and Sleep

MS Trust – 26th April 2016. How common is daytime sleepiness in people with MS?Popp RF, Fierleck AK, Knuttel H et al. •

Poor sleep and sleep disorders are more frequent in people with MS than the general population.

• Daytime sleepiness (less frequent than fatigue) but was associated with disrupted sleep and poor sleep quality.

• Data suggests that this is under diagnosed and undertreated in people with MS.

• Sleepiness can be indication of another condition, there may be several factors affecting their sleep pattern and if recognised treatment could improve day to day life and fatigue.

Understanding Sleep

What does “a good nights sleep” mean?

• Hours we sleep?

• Undisturbed sleep?

• Does it depend upon what type of sleep we have – REM? Non REM?

• Sleep is pattern based

Hours we sleep

• No formula for the correct number of hours – depends upon many factors :

Each individual – we are all different

Age – life span differences - babies, teenagers, 30’s and above.

Level of activity - – retired v young family & working

Types of sleep

• Sleep is not one entity – there are different types and levels of sleep

• REM – rapid eye movement sleep where most dreams are experienced

• Non-REM sleep is divided into four areas:

Drowsiness & REM

Sleep Stage 2

Deeper sleep 3

Deep sleep 4

Most individuals will go up and down this staircase throughout the night.

Individuals will actually wake several times during the night

Older adults with have lighter, more broken sleep, easily disturbed but should be refreshing

Deep Sleep:

- Restores the body

- Builds up energy resource for the day

- Maintains health - stimulating growth and development, repairing muscles and tissues, and boosting your immune system.

Sleep is Pattern BasedWhatever our current sleep pattern is – your body will try and maintain this.

We make associations throughout everyday life:

Have you ever eaten a large meal, felt entirely satisfied, gone to see a film, entered the lobby of the cinema and wanted a box of popcorn and a drink, or sweets, even though you knew you were not in the least hungry! Through years of experience of having food or drink on most of the occasions that you went to the cinema, the lobby has become a strong cue for you to want popcorn, sweets or a drink.

Example 2: Feeling alarmed when the phone rings in the middle of the night, though you don't experience any anxiety when the phone rings during the day.

Therefore sleep patterns are also influenced by association. Positive associations bed = sleep, Unhelpful associations bed = time to think, read, worry but not sleep.

What are the main difficulties with sleeping?

• Taking a long time to fall asleep

• Having a disrupted night sleep – waking often

• Waking earlier than usual

• Over sleeping – sleeping for too long

• Poor quality of sleep – non refreshing sleep

What can cause these difficulties with sleeping?

Stress & Anxiety

Work

Health - symptoms

Family & children

Low mood/depression

Bereavement Moving House

Relationships

Daily Hassles

Sleep Difficulties – Who does it affect?

The effects of sleep difficulties can affect family, friends, carers, any system in which the client operates.

What challenges have you experienced linked to clients with sleep difficulties?

What our clients say

Irritable

Exhausted

Frustrated

Worsening symptoms

No capacity to complete

tasks

Can’t remember

Can’t think straight

Assessing for Sleep Difficulties

• Understand the client – find out about them before & what changes they are experiencing – and what their relatives are observing.

• Ask whether the client feels refreshed upon waking? Physical

Environment

Symptoms

BehaviourFeelings

Thinking

How to assess?

Questions to ask?

Is your bed comfortable? What is the temperature of the bedroom? How noisy is the room? Is there too much light to sleep?

Physical Environment

How to assess?

Questions to ask?

Are symptoms waking the client e.g. toileting, pain, cramps/spasms

Symptoms

How to assess?

Questions to ask?

What is their current pattern? Avoid over stimulation before bed – e.g. physical

activity/exercise, rushing to get chores done Are you waking yourself up or winding down activities Do you have a bedtime routine Work patterns – shift workers

Behaviour

How to assess?

Questions to ask:

Do you feel worried when you get ready for bed? Do you wake during the night and feel panicky? Have you lost interest and enjoyment in things? Does it feel like your mind is whirring when your head

hits the pillow or when you wake?

Feelings

How to assess?

Questions to ask?

Do you find yourself worrying about not being able to sleep?

Do you find yourself saying “I should be sleeping … I need my sleep…. I will feel dreadful tomorrow if I don’t sleep tonight”

Thinking

QuestionnairesEpworth Sleepiness Scale• Brief 8 item scale where client rates on a 0 – 3 point

scale (0 = would never doze, 3 = high chance of dozing)

• Results in a score ranging from normal, borderline and abnormal.

Pitsburgh Sleep Quality Index• More detailed information required from the client

relating to usual sleep habits for the past month. • Identifies some of the factors that disrupt sleep • Scores look at:

• Duration of sleep• Sleep disturbance• Sleep latency (falling off to sleep) • Day Dysfunction due to sleepiness• Sleep efficiency• Overall sleep quality• Needs meds to sleep• Total

Hospital Anxiety and Depression Scale (HADS)

Can support us in clinical decision making regarding referring onto specialist services

What strategies have you tried?

Hints and Tips for Supporting Clients with Sleep Difficulties

PHYSICAL ENVIRONMENT

• Establish an association with the bedroom and sleeping – try not to use the bedroom for activities in the day

• Ensure the temperature is comfortable

• Blackout blinds can be helpful

• Turn off the light straight away

SYMPTOMS

• Advise the client to discuss with relevant team member, MS Specialist Nurse or GP, continence service

Hints and Tips for Supporting Clients with Sleep Difficulties

BEHAVIOUR

• Avoid day time naps or limit to no more than half an hour. Rule of thumb if you wake from daytime nap and are refreshed and ready to participate in activities and it doesn’t interfere with your sleep routine at night – you probably need it.

• Try to keep generally active mentally and physically during the day

• Exercise: avoid exercise near bedtime as it may wake you up.

• Diet: snacks before bedtime should be light and fluid intake limited.

• Stimulants: e.g. cigarettes and caffeine containing substances (coffee, tea) should be avoided or reduced 4 – 6 hours before bed time.

• Alcohol : regular use as a hypnotic should be avoided, have a milky drink instead.

Hints and Tips for Supporting Clients with Sleep Difficulties

BEHAVIOUR

Establish a routine• Go to bed at the same time at night • Get up at the same time (set an alarm) • Establish a routine before bed – prepares the body for

sleep.

Hints and Tips for Supporting Clients with Sleep Difficulties

THOUGHTS & FEELINGS• Use self talk to diffuse frustration of not sleeping –

“resting in bed is good for me”, “I feel comfy and warm”

• Don’t try too hard to sleep - allow it to come naturally

• Use visualisation strategies – picture a favourite place and describe it in detail to yourself e.g favourite holiday.

• Try not to clock watch - fuels a cycle of frustration

• Before going to bed write down your list of worries, prioritise them and then make an action plan. Use fact or thought.

• If you wake in the night due to worries – acknowledge that you have a plan that you can pick up in the morning.

Hints and Tips for Supporting Clients with Sleep Difficulties

THOUGHTS & FEELINGS cont…..

• Have a notepad by the bed – if you wake in the night and your mind starts whirring – write the thoughts down and close the notepad.

• Relaxation strategies

• Before going to bed either write or acknowledge three things that have gone better than expected or are a positive. This should help redress the balance of drawing unhelpful reflections on the day.

Implementing Strategies

Remember:

Use strategies consistently It takes time to change a sleep

pattern Include partners/spouse in the

planning/change of routine

Referring On……

It is important to gain specialised assessment and support if the clients’ difficulties are:

• Significantly affecting their participation in daily activities

• Causing the client and/or their families distress• Their difficulties put them in a vulnerable and or

risk position

Who to refer to: GP for initial discussion Community Neurological Rehabilitation

Service Local IAPT Services can have sleep

management programmes

Thank you for Listening

Any Questions?