Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

Taking the Burden Out of in Persons With Dementia and Their Caregivers

Kimberly Lloyd, OTD, OTR/L 4. Describe how occupational therapy can intervene to improve Rocky Mountain University of Health Professions, Provo, UT the occupation of sleep with persons with dementia and their Associate Professor, Idaho State University, Pocatello, ID caregivers

Ellen Hudgins, OTD, OTR/L, ITOT INTRODUCTION Rocky Mountain University of Health Professions, Provo, UT Quality of life for persons with dementia (PWD) and their care- givers depends partly on sleep quality. Sleep is a core occupa- Kristin Biggins, OTD, OTR/L, CHT, CLT, PYT tion as defined in the Occupational Therapy Practice Framework: Rocky Mountain University of Health Professions, Provo, UT Domain and Process, 3rd Edition (Framework; American Occupa- tional Therapy Association [AOTA], 2014, 2017a). The Centers This article was developed in collaboration with AOTA’s Productive Aging for Control and Prevention (2018) reported that 31.6% Special Interest Special Interest Section. of adults in the United States do not get a sufficient amount of sleep. PWD have more difficulty with sleep quality than their ABSTRACT age-matched peers (Peter-Derex et al., 2015). The Alzheimer’s Decreased sleep quality of persons with dementia (PWD) is Association in the United States reported that the prevalence of common, affecting not only the person diagnosed but also the dementia and Alzheimer’s disease (AD) is placing a burden on caregivers, and it can contribute to placement of these individ- the government and health care system as well as individuals and uals in assisted living facilities. Sleep seems to be a forgotten their caregivers. This population has more home health visits occupation, yet it is a core occupation essential to the health and skilled nursing home stays per year than others without the and well-being of all populations. Conservative or non-pharma- disease (Alzheimer’s Association, 2019). Sleep difficulties in PWD cological interventions (NPIs) are often overlooked as viable are the primary reason for early institutionalization (Gibson et solutions, and sleep in PWD is typically treated with tranquiliz- al., 2014). ing drugs. Yet pharmacological treatments can increase confu- This article aims to inform occupational therapy practitioners sion and increase the risk of falls. The intent of this article is about the effect sleep disturbances have on PWD and their care- to provide a summary of NPIs available for PWD and provide givers, and provides current evidence supporting NPIs. It is also occupational therapy practitioners with additional treatment intended to inform occupational therapy practice regarding the options for this population. current research supporting NPIs for sleep and how they may be incorporated into occupational therapy treatment planning for OBJECTIVES community-dwelling PWD and their caregivers. After reading this article, you should be able to: AOTA’s (2017b) Vision 2025 states that occupational therapy 1. Articulate the importance of addressing sleep in persons with services should be evidence based and cost effective. Occupational dementia and their caregivers therapy practitioners can address the sleep issues of this population 2. Identify the effect of sleep quality disruptions in not only the using current evidence on NPIs. Evidence-based treatment for person with dementia but also their caregivers sleep disturbances may improve quality of life and increase the time 3. Discuss current evidence regarding non-pharmacological spent aging in place for those with dementia. Aging at home (i.e., interventions for sleep in persons with dementia and their delaying institutionalization) is not only preferred but also more caregivers cost effective for payment sources (Alzheimer’s Association, 2019). Median nursing home costs for PWD in 2019 ranged from $89,000

ARTICLE CODE CEA0320 | MARCH 2020 CE-1CE-1 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682). to $100,000; mean assisted living costs were $48,000; and home Epidemiological studies have found that up to 45% of PWD care and adult day cares ranged from $72 to $132 per day, similar have sleep disturbances (Peter-Derex et al., 2015). Symptoms to the cost for assisted living facilities. of poor sleep quality among PWD include daytime irritabil- Caregivers are the primary determinant of when PDW are ity, decreased and motivation, and poor cognitive placed in a nursing or supervised facility (Gehrman et al., performance (Cipriani et al., 2015). Particularly in those with 2018). Occupational therapy practitioners often determine AD and other types of dementia, sleep disturbances have been when a PWD needs higher level of assistance and may assess the correlated with impaired , decreased ability for new need for long-term care. Moreover, the occupational therapist learning, , and nighttime agitation (Peter-Derex et may assess caregiver burnout when treating such clients. With al., 2015). Gibson and colleagues (2014) reported that sleep dis- increased knowledge of the importance of sleep in PWD and turbances are the most difficult behavior associated with PWD, their caregivers and information on NPIs, occupational therapy and that sleep difficulties are the primary reason for deciding to practitioners can potentially help delay institutionalization and place a loved one in an institution or facility. These symptoms support aging in place. affect not only the PWD but also the caregiver and the relation- ship between the two. SLEEP AND OCCUPATIONAL THERAPY Sleep is a core occupation addressed by occupational therapy Caregiver Impact of Sleep Disturbances Among PWD professionals, as outlined in the Framework (AOTA, 2014). Sleep Symptoms in PWD progress in severity over time, and family is a restorative occupation that allows one to recover and move caregivers are the custodians navigating these challenging forward each day. Sleep is a complex phenomenon generated symptoms as well as the consequences of sleep disturbances. and modulated by the , brainstem, and thalamus Chiu and colleagues (2014) found through a cross-sectional (Cipriani et al., 2015). Occupational therapy is in an informed study of family caregivers of PWD that two thirds of 180 couples position to address sleep with clients. When looking at sleep, experienced some form of sleep disturbance themselves. The one must take into consideration the person’s roles, habits, authors suggest common symptoms for the caregivers include routines, disease, health, and wellness. Poor sleep quality is and fatigue. This cross-sectional study found a strong defined by the National Sleep Foundation (n.d.) as decreased positive correlation between caregivers’ distress and sleep dis- sleep latency (when falling asleep takes more than 30 minutes), turbance (r = 0.20-0.29, p<0.01). Sleep disturbance and distress waking more than one time during the night, and staying awake related to neuropsychiatric symptoms among PWD was exem- more than 20 minutes after a nighttime awakening. plified by hallucinations, agitation, depression, and . This Impaired sleep can directly affect daytime occupations, study was conducted in Taiwan, which may affect its generaliz- such as driving, social interactions, work, and leisure (Small- ability to other geographical areas (Chiu et al., 2014). field & Molitor, 2018). According to Tester and Foss (2018), Providing care for PWD can be difficult for family members occupational therapy practitioners often overlook sleep issues and health care professionals. Caring for PWD on a daily basis with clients, particularly those with neurological conditions. is already difficult; adding medical professionals’ recommen- Impaired sleep contributes to an increased need for medical ser- dations can further complicate the caregiver’s role and respon- vices, affects quality of life, and contributes to earlier morbidity sibilities. One reason for caregivers’ discontent is health care (Capezuti et al., 2018). People tend to seek over-the-counter workers prescribing interventions and additional tasks without remedies, alcohol, or other substances rather than seek medical considering the caregivers’ health, well-being, quality of life, and advice when experiencing sleep disturbances (Ho & Siu, 2018). sleep (Jurgens et al., 2012). Health care professionals as a matter of course should Dementia and Sleep address disruptions in sleep of PWD and their caregivers. Shim Dementia is a debilitating neurocognitive disorder that occurs and colleagues (2012) found through a qualitative study of 21 most frequently in older adults and diminishes a person’s ability spousal caregivers of PWD that the of the caregiving to function in everyday life (Cipriani et al., 2015). Sleep serves experience profoundly affected how caregivers received edu- as a restorative function and plays a critical role in cognitive cation. Caregiver of their experiences were either functioning. According to the National Sleep Foundation negative or positive based on three factors: (1) current relation- (n.d.), frequent sleep disturbances are characteristic of AD ship dynamics, (2) their ability to find meaning in the process, and senile dementia. In addition to classic symptoms of AD— and (3) the amount of compassion or they had toward including progressive deterioration of intellect, memory, and their spouse. Caregivers who perceived caregiving as a positive language—sleep patterns also worsen with disease progression experience received and implemented education and strategies, (Peter-Derex et al., 2015). Disruptions to the sleep/wake cycle and were able to share strategies to help improve the process are related to the breakdown of brain structures and neurotrans- and help other caregivers find meaning in it as well. Conversely, mitters, resulting in behavioral and psychosocial changes. educational efforts by health care workers did not help when The most commonly reported of these symptoms are apathy, caregiving perceived their experiences negatively. depression, and agitation (Chiu et al., 2014; Gibson et al., 2014; Shim and colleagues (2012) in a study that allowed partici- Zauszniewski et al., 2018). pants to tell stories and bring life to their experiences revealed

CE-2 ARTICLE CODE CEA0320 | MARCH 2020 Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

three groups of participants: the negative group, the ambiva- they may not be prepared to learn strategies to assist themselves lent group, and the positive group. The negative group reported or PWD in improving sleep. Other reported barriers to execut- similar relationship characteristics of the past and present, ing sleep health promotion recommendations were lack of time, including abuse, mistrust, or hurt, which influenced their view resources, and motivation (Simpson & Carter, 2013). of caregiving. The nature of the relationship made it difficult Simpson and Carter (2013) reported three main themes for caregivers to identify or relate negative behaviors to the when exploring the causes of poor sleep among caregivers disease process. The ambivalent group described their past of PWD. First, caregivers’ sleep fluctuated in response to the relationship with the PWD as mostly positive and their current condition of the PWD—if the sleep pattern of the PWD was relationship as conflicted. The positive group had positive views disturbed, the caregiver’s sleep was negatively affected. Sec- of their current and past relationship with their spouse and ond, caregivers reported that the sleep patterns of the PWD found meaning in the caregiving process. This group was able varied greatly day to day and certainly changed over time as to focus on what they had now and not on what they once had. the disease progressed. Caregivers reported vigilance at night They were able to accept that their partners were unable to as being disruptive, making for light sleep, as they felt the need reciprocate and did not expect anything in return for being the to be up often to assess for safety and the bathroom needs of primary caregiver. the PWD. The last theme identified that affected sleep quality Caregiving of any type can be taxing, and resilience is an for caregivers was concern about the present and the future. important quality for the care provider. In a qualitative study These concerns consisted of planning for the next day based on by Donnellan and colleagues (2015), the authors identified the behavior of the PWD that day, and worrying about housing factors that contribute to increased resiliency with caregivers and financial concerns, what the future would bring, and how of spouses with dementia. They concluded that prominent higher levels of care would be provided over time. themes—including positivity, knowledge, expertise of dementia, Simpson and Carter (2013) further reported that caregiv- and shared experiences—contribute to resiliency. The authors ers often medical professionals did not address or found the following individual psychological assets beneficial even inquire about their sleep quality or quantity. This led the to the caregiving process: maintenance of self-identity, humor, caregivers to believe their sleep was not a priority. In addition, and a desire to learn as a caregiver. The authors also identified caregivers could recite healthy strategies to improve sleep but health and social resources as extremely important. had not been successful in or able to implement them into Gehrman and colleagues (2018) completed a randomized their busy daily lives. It is imperative to include the perceptions control trial (RCT) with 10 caregivers in an active treatment and experiences of the caregiver in addition to the PWD when group and 12 caregivers in a control group. The study demon- addressing sleep or any other type of intervention. strated that it is feasible to train caregivers to make changes to Lastly, Simpson and Carter (2013) emphasized the impor- sleep hygiene programs for PWD; however, providing written tance of assessing caregivers’ sleep and assessing it often, materials is not sufficient. The training must include rationale, especially as the PWD’s conditions evolve. Caregivers’ beliefs specific suggestions, and assistance setting up a sleep hygiene and values must be considered when prescribing sleep inter- program. In addition, caregivers need assistance solving prob- ventions and providing education on the potential side effects lems that arise with adhering to a sleep hygiene program. of pharmacological sleep aids. This study, as with many of the The results of the RCT also demonstrated that sleep dis- others covered in this review, reminds practitioners that the turbance symptoms in care recipients with dementia predict caregiver must be included in interventions for the PWD (Chiu caregiver burden. Caregiver burden was significantly associated et al., 2014; Gehrman et al., 2018; Gibson et al., 2014; Simpson with nocturnal awakenings, nocturnal wandering, snoring, and & Carter, 2013; Zauszniewski et al., 2018). daytime sleepiness more than 1 hour daily, all with p<0.002 Chiu and colleagues (2014) identified that decreased sleep (Gehrman et al., 2018). Caregiver burden may lead to poor in caregivers of PWD is associated with caregiver depression health outcomes for the caregiver; furthermore, it was reported and interferes with daily life. Minimizing for caregivers of that sleep disturbances were a substantial factor contributing to PWD can increase quality of life and ultimately result in better the decision to move the person to a nursing home (Gehrman et care for PWD within the home. Occupational therapy practi- al., 2018). tioners should use a family-centered approach when treating Occupational therapy practitioners may assist caregivers of this client population, as successful treatment relies on includ- PWD with their own and offer suggestions ing the caregiver portion of this dyad. for managing their lack of sleep (Simpson & Carter, 2013). Practitioners must value and attempt to understand the lived Treating Sleep Disturbances in PWD experience of the caregivers’ sleep quality and routines. When One frequently used method to combat sleep disturbances in occupational therapy practitioners are working on interventions PWD is using sleep (Smallfield & Molitor, 2018). with caregivers regarding sleep, they must be sensitive to how The 1999–2010 National Ambulatory Medical Care Survey the caregivers are perceiving health promotion recommen- found that older adults are significantly more likely than dations at that time. If the caregivers are not in good health, younger adults to have a formal sleep diagnosis and prescribed having difficulty sleeping, or are overwhelmed by their role, sleep medication (Ford et al., 2014). Although this may cause

ARTICLE CODE CEA0320 | MARCH 2020 ARTICLE CODE CEA0320 | MARCH 2020 CE-3CE-3 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682). improvements for some, using sleep medication often increases to anti-psychotic drugs; however, further research is needed, as daytime sleepiness, increases the risk for falls, and decreases the terms NPIs (i.e., activities with staff contact) and activities cognitive function in older adults (Smallfield & Molitor, 2018). (i.e., without staff contact) often were used interchangeably in One can see the coupling effect on reduced cognitive the documentation. This was a limitation of the study; however, function when PWD are taking sleep medication. Ideally, NPIs implementing increased activities during the day does contrib- would be considered the first-line treatment approach in PWD, ute to occupational balance, which is recommended in other including occupational therapy intervention (Backhouse et studies looking to improve the sleep of PWD and their caregiv- al., 2016; Capezuti et al., 2018; Ho & Siu, 2018; Smallfield & ers. In 2016, Backhouse and colleagues identified barriers to Molitor, 2018). implementing activities and NPIs, including difficulty incorpo- Blytt and colleagues (2018) identified management rating them into daily care routines, administering the required as having a positive effect on the sleep quality of PWD. In training, and providing ongoing guidance for staff, along with their quantitative evaluation of data collected from 47 nursing the need for increased funding for activity programs. homes for 106 clients, adequate pain management improved A systematic review by Smallfield and Molitor (2018) used sleep efficiency, sleep onset latency, and early morning the U.S. Preventative Task Force guideline for the number of awakenings. Pain management often includes pharmaceutical studies included in their review and to rate the strength of the agents; however, there are also non-pharmacological options evidence. The authors reported that there was a high level of that can be part of the occupational therapy intervention, such evidence to support occupational therapy interventions for as progressive muscle relaxation, application of heat and cold sleep with older adults living in the community. This systematic modalities, and massage (Blytt et al., 2018). The following review is part of the Occupational Therapy Practice Guidelines for section highlights other NPIs that may be used with PWD and Productive Aging for Community Dwelling Older Adults (AOTA, their caregivers. 2019). Three effective modes of treatment included one to one, one NPIs for Sleep in Persons With Dementia to many, and group discussion. The interventions with rigorous NPIs for sleep are alternatives to medication. A systematic evidence included relaxation training, physical , medi- review in 2018 by Capezuti and colleagues included 42 studies, tation, sleep-related goal setting, sleep hygiene education, sleep 25 of which were RCTs. The included articles focused on NPIs journals, cognitive therapy, and group sessions. to improve sleep in long-term settings. Although not specifically Ho and Siu (2018) completed a systematic review to work focusing on sleep dysfunction with dementia, more than half of toward establishing a framework for occupational therapy to the participants (52%) included subjects with dementia. Sev- use in sleep management. The framework includes the per- eral categories emerged from the data, including clinical care son, environment, and subjective choice of occupations. The practices, mind–body practices, social and physical , reported interventions for sleep are mapped onto those three complementary health practices, environmental considerations, areas. After review of the 11 final articles, the authors suggested and multicomponent interventions. minimizing the effect of bodily function as it relates to sleep Capezuti and colleagues (2018) reported that NPIs for sleep promotion, promoting an environment that is conducive to issues is on the rise; however, there is currently low-quality sleep, and restructuring daytime activities to promote occupa- research to support this strategy. The authors recognized that tional balance. The interventions recorded that were effective even with the need for more research, there is little to no risk included using assistive devices/equipment, such as music, noise for using the different approaches highlighted in their review. machines, weighted blankets, and eye masks. Additionally, cog- Eleven of the reviewed articles included complementary health nitive behavioral therapy to address a person’s negative practices that highlighted touch therapies, such as acupuncture surrounding sleep could considerably improve sleep issues. or massage. Thirteen articles included mind–body practices, Ho and Siu (2018) noted that sleep management does not including cognitive behavioral therapy and relaxation tech- only involve sleep but also daytime activities and function. The niques. Sleep hygiene techniques were typically included in lifestyle intervention they discuss came from one large-scale multicomponent interventions. Four studies included physical RCT that was designed to improve sleep with community-dwell- activity with positive results. Promoting an environment condu- ing adults. This form of intervention involves finding the right cive to sleep was reported in three RCTs and three pre-post sin- balance of activity one engages in during the day, because gle group design studies. The seven studies reviewed included too little or too much activity can affect one’s sleep quality. multicomponent interventions, environmental considerations, The intervention included promoting occupational balance, sleep hygiene, and physical activity. educating PWD and caregivers about sleep hygiene and habits, Backhouse and colleagues (2016) conducted four ethno- rescheduling daytime activities as needed, setting goals, sharing graphic case studies regarding NPIs associated with dementia experiences, and embracing role changes throughout life. The behaviors in skilled nursing facilities. The authors discovered results included increased daytime engagement; increased social that including NPIs and activities (e.g., arts and crafts) in activities; and positive changes in sleep behaviors, including regular daily routines in care homes could increase sleep quality decreased nightmares, reduced daytime napping, and increased and quality of life. NPIs could potentially become alternatives quantity of sleep.

CE-4 ARTICLE CODE CEA0320 | MARCH 2020 Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

OCCUPATIONAL THERAPY APPROACHES TO SLEEP WITH PWD AND • Sleep-related goal setting and sleep journals can help CAREGIVERS people identify factors that positively and negatively affect The Do-Live-Well Framework originating with Macey Cho sleep (Ho & Siu, 2018; Smallfield & Molitor, 2018). focuses on how what we do every day matters and is essential • Sleep hygiene education and habits can include establishing to one’s health and well-being (Moll et al., 2015). The Do-Live- a consistent bedtime and bedtime routine each night, and Well Framework encourages activating the senses, the mind, the participating in structured activities that promote good body, social connections, and experiences of joy, while identify- habits (Capezuti et al., 2018; Ho & Siu, 2018; Smallfield et ing various potential outcomes (Moll et al., 2015). The health al., 2018). and well-being outcomes—including physical, mental, social, • Group problem-solving sessions give people the opportunity emotional, and spiritual—come from our activity patterns. to hear from others in the same situation providing support, Examples of healthy activity patterns include engaging in mean- and also to learn strategies from one another and provide ingful activities, having routines, having choices, and striving for each other with feedback (Smallfield & Molitor, 2018). occupational balance in our lives. • Promoting environments conducive to sleep includes decreas- In another article, by Leland and colleagues (2016), a similar ing auditory and visual input as the evening progresses, up theme emerged. The authors suggested that people need more until bedtime (Capezuti et al., 2018; Ho & Siu, 2018). “doing” and physical activity during the day to stimulate the • Occupational balance can be addressed by increasing and into sleep mode. People need regularity, restructuring daytime activities, consistently engaging in and occupational therapy practitioners are in a position to iden- ADLs and IADLs with as much independence as possible, tify contributing factors of sleep disturbances and help establish and priming the body for sleep mode (Capezuti et al., new routines and habits as necessary to facilitate improved 2018; Ho & Siu, 2018). sleep quality. • Adaptive equipment, including music, noise machines, An occupational therapy model that could be implemented weighted blankets, and eye masks can provide relaxation in treating sleep with this population is the Kawa Model. The for sleep (Ho & Siu, 2018). Kawa Model was designed to support harmony of all elements in • Lifestyle intervention helps clients strive for healthy behav- life, minimize factors that cause disruption, and create optimal iors and balance their activities (Ho & Siu, 2018). functioning for individuals (Iwama et al., 2009). The nature • Cognitive behavioral therapy, including identifying and of the model is client centered and culturally sensitive and changing negative thoughts regarding sleep issues, can involves creating balance and promoting well-being. This model reduce worry to enhance sleep (Capezuti et al., 2018; Ho & takes into consideration that people and cultures view rehabili- Siu, 2018; Smallfield & Molitor, 2018). tation differently and conforms to individual needs. The Kawa Model encourages occupational therapy practi- IMPLICATIONS FOR OCCUPATIONAL THERAPY tioners to look at life metaphorically as a river. Occupational Occupational therapy practitioners are well prepared to address therapy practitioners should be sensitive to the obstacles that the area of sleep by adapting activities, modifying the environment, change our life course and assist clients in figuring out how to get and providing education about personal and environmental factors around these obstacles to move forward (Wada, 2011). This model to improve the quality of sleep for PWD and their caregivers. provides a holistic way to view occupational dysfunction of sleep. Implications for occupational therapy practice include: When sleep is disturbed or disrupted, it affects all other areas of • Education and advocacy are expected behaviors for occupa- our lives. Occupational therapy strives for balance in occupation, tional therapy practitioners and key approaches to promot- and in some cases, optional paths to ensure success of flow. ing improved sleep quality in persons with dementia and their caregivers (AOTA, 2015). OCCUPATIONAL THERAPY INTERVENTIONS • Dementia’s effect on sleep results in difficulty (agitation, The Kawa Model supports the following summary of occupa- depressing, hallucinations, decreased quality of life) for tional therapy interventions to improve sleep quality for PWD PWD and their family caregivers (Chiu et al., 2014; Simp- and their caregivers: son & Carter, 2013). • Pain management can help PWD, who often have difficulty • The decreased sleep quality among PWD affects caregivers’ identifying what is upsetting them or causing physical sleep quality and potentially their quality of life. discomfort (Blytt et al., 2018). • The poor sleep quality of PWD is one of the major factors • Mind–body practices, including relaxation training and for early placement in assisted care (Gehrman et al., 2018; meditation, can help mitigate difficulties with sleep by Gibson et al., 2014; Porter et al., 2015). calming the senses (Capezuiti et al., 2017; Ho & Siu, • Occupational therapy can promote aging in place for this 2018). population using client- and family-centered care. • Social and physical stimulation, including physical exercise • Occupational therapy must continue to strive for cost-ef- and increasing daytime activity, can contribute to priming fective and evidence-based practice with PWD and their the central nervous system for sleep mode (Capezuti et al., caregivers to fulfill AOTA’s Vision 2025 (AOTA, 2017b) 2018). within this population.

ARTICLE CODE CEA0320 | MARCH 2020 ARTICLE CODE CEA0320 | MARCH 2020 CE-5CE-5 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682).

• Occupational therapy practitioners and researchers need to Chiu, Y.-C., Lee, Y.-N., Wang, P.-C., Chang, T.-H., Li, C.-L., Hsu, W.-C., & Lee, S.-H. (2014). Family caregivers’ sleep disturbance and its associations with gather data one case study at a time and through research multilevel stressors when caring for patients with dementia. Aging & Men- projects to increase evidence-based practice for sleep with tal Health, 18, 92–101. https://doi.org/10.1080/13607863.2013.837141 this population. Cipriani, G., Lucetti, C., Danti, S., & Nuti, A. (2015). Sleep disturbances and • P eople tend to seek over-the-counter medication, alcohol, dementia. Psychogeriatrics, 15, 65–74. https://doi.org/10.1111/psyg.12069 or other substances instead of obtaining medical advice Donnellan, W. J., Bennett, K. M., & Sousby, L. K. (2015). What are the factors when experiencing sleep disturbances (Ho & Siu, 2018). that facilitate or hinder resilience in older spousal dementia carers? A quali- tative study. Ageing & Mental Health, 19, 932–939. • A dditional research is needed for knowledge translation Ford, E. S., Wheaton, A. G., Cunningham, T. J., Giles, W. H., Chapman, D. P., & regarding sleep deprivation in PWD and NPIs. Croft, J. B. (2014). Trends in outpatient visits for , , and prescriptions for sleep among U.S. adults: Findings from the CONCLUSION National Ambulatory Medical Care survey 1999–2010. Sleep, 37, 1283– The occupational therapy profession has a responsibility to 1293. https://doi.org/10.5665/sleep.3914 provide evidence-based practice and knowledge translation, and Gehrman, P., Gooneratne, N. S., Brewster, G. S., Richards, K. C., & Karlawish, J. (2018). Impact of Alzheimer disease patients’ sleep disturbances on their to consider differences in populations and cultures to provide caregivers. Geriatric Nursing, 39, 60–65. https://doi.org/10.1016/j.gerin- the best treatment possible. This includes prioritizing improved urse.2017.06.003 sleep quality with the population of PWD and their caregivers. Gibson, R. H., Gander, P. H., & Jones, L. M. (2014). the sleep problems A holistic approach when treating this population may increase of people with dementia and their family caregivers. Dementia, 13, 350–365. the quality of life for PWD and their caregivers and potentially Ho, E. C. M., & Siu, A. M. H. (2018). Occupational therapy practice in sleep management: A review of conceptual models and research evidence. delay institutionalization. Occupational Therapy International, Article ID 8637498. https://doi. It is necessary to explore alternative NPIs to contribute to org/10.1155/2018/8637498 occupational therapy literature and evidence-based practice in Iwama, M. K., Thomson, N. A., & Macdonald, R. M. (2009). The Kawa Model: treating PWD, and to preserve cognitive function and reduce the The power of culturally responsive occupational therapy. Disability and risk of falls with this client population. The findings will inform Rehabilitation, 31, 1125–1135. the profession and help occupational therapy practitioners Jurgens, F. J., Clissett, P., Gladman, J. R. F., & Harwood, R. H. (2012). Why are family carers of people with dementia dissatisfied with general hospital care? understand the critical needs associated with sleep deprivation A qualitative study. BMC Geriatrics, 12, Article Number 57. Retrieved from for PWD and their caregivers. http://www.biomedcentral.com/1471-2318/12/57 Leland, N. E., Fogleberg, D., Sleight, A., Mallinson, T., Vigen, C., Blanchard, J., … Clark, F. (2016). Napping and nighttime sleep: Findings from an REFERENCES occupation-based intervention. American Journal of Occupational Therapy, 70, 7004270010p1–7004270010p7. https://doi.org/10.5014/ajot.2016.017657 Alzheimer’s Association. (2019). Fact and figures. Retrieved from https://www. alz.org/alzheimers-dementia/facts-figures Moll, S. E., Gewurtz, R. E., Krupa, T. M., Law, M. C., Larivière, N., & Levasseur, M. (2015). “Do-Live-Well”: A Canadian framework for promoting occupa- American Occupational Therapy Association. (2014). Occupational therapy tion, health, and well-being. Canadian Journal of Occupational Therapy, 82, practice framework: Domain and process (3rd ed.). American Journal of 9–23. https://doi.org/10.1177/0008417414545981 Occupational Therapy, 68(Suppl. 1), S1–S48. https://doi.org/10.5014/ ajot.2014.682006 National Sleep Foundation. (n.d.). Dementia and sleep. Retrieved from https:// www.sleepfoundation.org/sleep-disorders-problems/dementia-and-sleep American Occupational Therapy Association. (2015). Occupational therapy code of ethics. American Journal of Occupational Therapy, 69(Suppl. 3), Peter-Derex, L., Yammine, P., Bastuji, H., & Croisile, B. (2015). Sleep and Alz- 6913410030p1–6913410030p8. https://doi.org/10.5014/ajot.2015.696S03 heimer’s disease. Sleep Medicine Reviews, 19, 29–38. American Occupational Therapy Association. (2017a). Occupational therapy’s Porter, V. R., Buxton, W. G., & Avidan, A. Y. (2015). Sleep, , and demen- role in sleep [fact sheet]. Retrieved from https://www.aota.org/About-Occu- tia. Current Reports, 17, 97. https://doi.org/10.1007/s11920-015-0631-8 pational-Therapy/Professionals/HW/Sleep.aspx Shim, B., Barroso, J., & Davis, L. L. (2012). A comparative qualitative analysis of American Occupational Therapy Association. (2017b). Vision 2025. Amer- stories of spousal caregivers of people with dementia: Negative, ambiva- ican Journal of Occupational Therapy, 71, 7103420010p1. https://doi. lent, and positive experiences. International Journal of Nursing Studies, 49, org/10.5014/ajot.2017.713002 220–229. American Occupational Therapy Association. (2019). Occupational therapy Simpson, C., & Carter, P. (2013). Dementia caregivers’ lived experience of sleep. practice guidelines for productive aging for community-dwelling older Clinical Nurse Specialist, 27, 298–306. adults. Bethesda, MD: AOTA Press. Smallfield, S., & Molitor, W. L. (2018). Occupational therapy interventions Backhouse, T., Killett, A., Penhale, B., & Gray, R. (2016). The use of non-pharma- addressing sleep for community-dwelling older adults: A systematic review. cological interventions for dementia behaviours in care homes: Findings from American Journal of Occupational Therapy, 72, 7204190030p1–7204190030p9. four in-depth, ethonographic case studies. Age and Ageing, 45, 856–863. https://doi.org/10.5014/ajot.2018.031211 Blytt, K. M., Bjorvatn, B., Husebo, B., & Flo, E. (2018). Effects of pain treatment Tester, N. J., & Foss, J. J. (2018). Sleep as an occupational need. American Journal on sleep in nursing home patients with dementia and depression: A multi- of Occupational Therapy, 72, 7201347010p1–7201347010p4. https://doi. center placebo-controlled randomized clinical trial. International Journal of org/10.5014/ajot.2018.020651 Geriatric Psychiatry, 33, 663–670. Wada, M. (2011). Strengthening the Kawa Model: Japanese perspectives on per- Capezuti, E., Zadeh, R. S., Woody, N., Basara, A., & Krieger, A. C. (2018). An son, occupation, and environment. Canadian Journal of Occupational Therapy, integrative review of nonpharmacological interventions to improve sleep 78, 230–236. among adults with advanced serious illness. Journal of Palliative Medicine, Zauszniewski, J. A., Lekhak, N., & Musil, C. M. (2018). Caregiver reactions to , 700–717. 21 https://doi.org/10.1089/jpm.2017.0152 dementia symptoms: Effects on coping repertoire and mental health. Issues Centers for Disease Control and Prevention. (2018). Sleep health. Retrieved in Mental Health Nursing, 39, 382–387. https://doi.org/10.1080/01612840.20 from https://www.cdc.gov/nchs/fastats/sleep-health.htm 18.1424974

CE-6 ARTICLE CODE CEA0320 | MARCH 2020 Continuing Education Article Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details.

3. An occupational therapist (OT) is working with a geriatric client who is experiencing poor sleep. The OT should describe the con- How to Apply for tributing factors for sleep to the client’s caregivers with which Continuing Education Credit of the following statements? A. Sleep is influenced by specific structures of the brain A. To get pricing information and to register to take the exam online for the (amygdala, cerebellum, and thalamus). article Taking the Burden Out of Sleep in Dementia, go to http://store.aota.org, B. Successful sleep entails falling asleep within 30 minutes, or call toll-free 800-729-2682. staying asleep, having limited nighttime awakenings, and B. Once registered and payment received, you will receive instant email sleeping a sufficient duration. confirmation. C. Sleep may not be tied to other co-morbid conditions, C. Answer the questions to the final exam found on pages CE-7 & CE-8 such as dementia. by March 31, 2022 D. Sleep habits and routines may not play a significant role D. On successful completion of the exam (a score of 75% or more), you will in improving sleep quality in adults. immediately receive your printable certificate. 4. An OT is evaluating an adult client recently diagnosed with Alzheimer’s disease (AD). Per the chart review, the client is demonstrating difficulty with sleep hygiene, routines, and sleep quality during their stay in a skilled nursing facility. Which of Final Exam the following statements best reflects information important for Article Code CEA0320 the therapist to be mindful of? A. As the disease progresses, the client’s sleep patterns Taking the Burden Out of Sleep in Persons tend to remain stable at the levels before admission or With Dementia and Their Caregivers diagnosis. B. Sleep difficulties experienced by people with AD are the To receive CE credit, exam must be completed by primary reason they are placed into an institution/facility March 31, 2022 on a long-term basis. C. The symptoms of poor sleep quality typically include Learning Level: Beginner sporadic cognitive function, euphoria, and perseverating Target Audience: Occupational Therapy Practitioners speech. Content Focus: Domain: Occupation of Sleep; OT Process: Occupational D. People with AD and sleep disturbances include a very Therapy Evaluation and Interventions narrow portion of the client population—approximately 17%. 1. According to the Occupational Therapy Practice Framework: Domain and Process, 3rd Edition (Framework; AOTA, 2014), rest 5. The literature related to individuals with AD suggests an and sleep are recognized as core: increase in neuropsychiatric symptoms because of poor sleep– wake cycles. Occupational therapy practitioners should take A. Instrumental activities of daily living care to document which of the following common symptoms? B. Environmental factors A. Agitation C. Motor processing skills B. Mania D. Occupations C. Hallucinations 2. Which of the following statements regarding occupational D. Motoric tics therapy and rest and sleep describes current issues in practice? 6. The most common population that provides long-term care of A. Rest and sleep are only addressed in practice as deter- individuals with AD is: mined by a client’s funding source. B. Rest and sleep are often overlooked as a primary area A. Spouses/significant others of occupational performance by occupational therapy B. Rehabilitation professionals practitioners. C. Nurses C. Occupational therapy professionals lack the foundational D. Physicians competencies to address rest and sleep in practice. D. In most states, sleep and rest fall outside of occupational therapy’s scope of practice.

ARTICLE CODE CEA0320 | MARCH 2020 ARTICLE CODE CEA0320 | MARCH 2020 CE-7CE-7 CE Article, exam, and certificate are also available ONLINE. Continuing Education Article Register at http://www.aota.org/cea or Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-7 for details. call toll-free 877-404-AOTA (2682).

7. An OT has been implementing a plan of care for a home health 10. Occupational therapy practitioners may be asked to track client with AD. Best practice indicates that in addition to ensur- the effects of pharmacological agents used to improve sleep ing proper habits and routines to support rest and sleep in the quality in clients with AD as they directly provide services to client, the OT should mirror that focus on the in-home family the client. Which priority factor should the occupational therapy caregivers. Which of the following statements best describe the practitioner track and report to the rest of the medical team? rationale for this approach? A. The number of naps the client takes, as reported by the A. Caregivers in general spend such a significant amount of caregiver time providing physical care of clients with AD that they B. The number of night awakenings reported by the just need additional sleep themselves. caregiver B. Caregivers will experience sleep disturbances that result C. The severity of daytime sleepiness of the client and its in quality-of-life issues, including depressive symptoms effects on safety and physical fatigue. D. A decrease in the number and severity of hallucinations C. The Framework has established rest and sleep as a prima- and agitation the client experiences ry occupation. D. The cost of pharmacological supports for caregivers of 11. An OT is exploring different therapeutic options to improve individuals with AD may not be covered by third-party sleep quality among clients with AD. Which of the following funding sources. intervention practices should be implemented first? A. Collaborate with the local pharmacist on over-the-count- 8. The chronic effect of caregiving for individuals with AD is well er medications to improve sleep. documented in the literature. All the following statements are B. Implement a bowel/bladder routine for the client during true, except: waking hours. A. As caregivers experience distress they also experience C. Increase the amount of occupations/physical activity sleep disturbances. during the day while reducing extraneous stimuli before B. The primary caregivers of individuals with AD typically bed. are the same age and physical capacity as the client. D. Limit eating before bed to reduce any gastrointestinal C. Sleep disturbances and distress also contribute to halluci- reflux. nations, agitation, and anxiety in individuals with AD. D. Primary caregivers typically do not experience disrup- 12. A geriatric client in the early stages of AD is 3 days post- tions in the core occupation of rest and sleep. operative for bilateral knee replacements. The client complains of pain before, during, and after ADL training, which seems to 9. An OT is assessing clients in a skilled nursing facility. They coincide with poor sleep quality and sleepiness during the day. notice resistance among clients and their caregivers related to The most appropriate action the OT should take is: recommendations to improve sleep hygiene as a part of their A. Collaborate with the rehabilitation team (i.e., physical routines in the facility. Clients and caregivers may resist such therapist, nurse, physician) to ensure the client’s pain suggestions because: management supports their rehabilitation goals and A. The screening assessment occurred right after a meal. comfort needs. B. The client/caregiver are hard of hearing and fail to hear B. Engage the client in more physical activity outside of the key words and concepts of the discussion. prescribed therapy sessions. C. The caregiver is overwhelmed with the number of rec- C. Reduce the amount of therapy activity (e.g., psychomo- ommendations by the rehabilitation professionals. tor training) and have the client repeat the key tasks for D. The client/caregiver are tired from a long day of medical precautions for ADLs. and therapy activities. D. H ave the client use a sleep journal to track sleep latency, number of night awakenings, and sleep duration during the plan of care.

Now that you have selected your answers, you are only one step away from earning your CE credit.

Click here to earn your CE

CE-8 ARTICLE CODE CEA0320 | MARCH 2020