In the previous post, I described some of the first areas to consider in assessing sleep problems in pain management, and discussed some simple strategies to consider. This post will complete the assessment and management approaches, and some resources you can use.
Once you have assessed sleep onset, sleep duration and quality should be assessed. That is, once someone has been able to get to sleep, how long do they remain asleep, how often do they wake, how long do they stay awake, what do they think, feel and do when they are awake. It’s helpful to ask the person to record this information, as it is for all the sleep assessment, as people are not always good at remembering what happens!
It’s at this point I often go through sleep architecture and the phases of sleep with the person. It’s normal to have periods of very deep sleep and periods of lighter sleep, and during the periods of lighter sleep it’s common for both internal and external factors to become sufficiently disturbing to bring an individual to full wakefulness. Most times this is a very brief period, but when pain is a feature it can become much longer – and it can become habitual, and maintained by poor sleep hygiene and anxiety.
As a result, it’s helpful for the person to review what is going through their minds when they wake – and for them to be advised of the way lack of distraction can make the experience of pain much more difficult to tolerate when they’ve woken during the night.
Factors known to prolong middle sleep disturbance:
- anxiety, and especially negative rumination about ‘not being able to cope the next day without enough sleep’
- attention, and difficulty distracting from pain while trying to return to sleep
- using alcohol to go off to sleep
- increasing sensory input (eg lights on, noise from TV/radio, reading stimulating material)
- using stimulants such as coffee, tea, milo, sugar
- moving around or exercising
- trying hard to go back to sleep
- remaining awake while in bed for more than 20 minutes
- having had daytime naps (reducing the overall need for sleep at night)
- some medications
- nicotine addiction
- not having skills to settle to sleep without external aids (eg needing to use a relaxation tape, typically falling asleep very quickly, not being able to relax breathing rate and muscle tension)
Each one of these potential factors can be explored and strategies employed to manage them. Most are fairly commonsense such as avoiding alcohol, coffee, leaving lights down low, using imagery or relaxation to distract and so on, but there are several that are not quite as straightforward.
Paradoxical hypnotic technique – such as trying to keep the eyelids open and saying to yourself ‘I will try to stay awake’. When the eyelids close, saying ‘I’m falling asleep now’ – this is a hypnotic self suggestion.
Relaxation techniques that do not require a recording such as breathing, counting down, progressive muscle relaxation and so on can help to distract from pain and anxiety, while providing a very low level of stimulus. If you are using a relaxation recording as part of overall pain management, it’s important that the individual learns how to do this without needing the recording once they have a solid relaxation response. If they continue to rely on a recording, it can become a habit to ‘need’ the recording, and make it difficult to use in other setting such as in bed, while driving or at work.
Positive statements such as ‘I’ll get to sleep shortly’, rolling over and saying ‘I’m dropping off now’, or ‘Even if I’m just resting I’ll be OK’ can help, as can efforts to avoid ‘watching the clock’ by, for example, turning the clock face away from the bed. These all help to reduce anxiety levels.
Some heavily addicted smokers may find using a nicotine patch at night (early in the evening) will help them avoid any withdrawal effects during the night, as some may find more than 3 hours without nicotine can be difficult to tolerate.
There are some times in a couples’ life when sleep is more difficult than others – this usually occurs with pregnancy and having children, as well as later in life with possible prostate problems. Its during these times that skills to help return quickly to sleep can be helpful for all of us! It’s useful to reflect to a couple that sleep disruption is normal, and that it’s not waking up that’s the problem, it’s remaining awake that creates difficulties. Anxiety around the thought ‘I NEED to have undisturbed sleep’ can be somewhat reduced by knowing that the brain is very good at making sure it gets enough deep sleep (Stage 4) the following night if deep sleep has been lost the previous night.
Once middle sleep disturbance has been explored, it’s time to assess terminal sleep disturbance, usually early morning waking, but also sleeping late. I ask people when they wake up, when they get up, how refreshed they feel when they get up, and how quickly they wake up.
Early morning waking can be a symptom of low mood, although sometimes it can be a feature of anxiety. Erratic bed and wake times, or napping during the day can also disrupt morning waking.
The prevalence of this problem tends to increase with age and is associated with a decreased total sleep time and excessive daytime sleepiness.
People with long term early morning awakening reach their minimum body temperature at an average time of 12:20 a.m., more than three hours earlier than a control group. Their average melatonin onset also occurs more than two hours earlier than the control group at 8:30 p.m. This results in an early average wake-up time of 4:49 a.m (Lack, et al. 2005).
Treating depression associated with early morning waking is helpful, as is sleep restriction and light therapy.
Resources:Sleepeducation.com has a large range of patient-related resources including a patient discussion forum.
Sleep restriction is a process of reducing the time spent in bed awake, while at the same time condensing the total amount of sleep in a night to a single period. There are many different ways to do this, but this description is quite clear and easy to follow.
An excellent site with a comprehensive review of cognitive behavioural therapy for insomnia is the National Sleep Foundation – worth a look, but probably mainly for patients rather than therapists.
So, I’ve reviewed some of the assessment domains and questions to ask, and some of the strategies used. If you’ve enjoyed this post, and want to get more – don’t forget you can subscribe using the RSS feed above, bookmark this site, or use Google reader to be updated. And you can comment below, or email me!