Aims: 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

1. PRACTICAL HINTS AND TIPS FOR
FACILITATING IMPROVED SLEEP
HYGIENE
Dr Bronwen Bonfield
Principal Clinical Psychologist
Community Neurological Rehabilitation Service
Buckinghamshire

2. 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.

3. 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.

4. 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

5. 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

6. 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

7. 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.

8. Sleep is Pattern Based
Whatever 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.

9. 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

10. What can cause these difficulties with sleeping?
Stress & Anxiety
Work
Health - symptoms
Family & children
Low mood/depression
Bereavement
Moving House
Relationships
Daily Hassles

11. Sleep Difficulties – Who does it affect?
The effects of sleep difficulties can affect family, friends,
carers, any system in which the client operates.

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

13. What our clients say
Irritable
Exhausted
Frustrated
Worsening
symptoms
No capacity
to complete
tasks
Can’t
remember
Can’t think
straight

14. 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

15. 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

16. How to assess?
Questions to ask?
 Are symptoms waking the client e.g.
toileting, pain, cramps/spasms
Symptoms

17. 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

18. 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

19. 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

20. Questionnaires
Epworth 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

21. What strategies have you tried?

22. 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

23. 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.

24. 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.

25. 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.

26. 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.

27. Implementing Strategies
Remember:
 Use strategies consistently
 It takes time to change a sleep
pattern
 Include partners/spouse in the
planning/change of routine

28. 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

29. Thank you for Listening
Any Questions?