Getting a good assessment of the extent and nature of the person’s sleep problem is key to finding the right interventions. This section covers:
- Informal assessment of sleep – what to ask, how to ask, when to ask.
- Assessment of sleep through patient self report measures – including sleep diaries, screening tools, and outcome measures for practice or research use.
- Assessment of sleep through objective measurement – polysomnography (in the sleep lab or at home), actigraphy (Actiwatches), and other forms of observational assessment of sleep.
Informal assessment of sleep
It is important to ask people, and/or their caregivers, how they are sleeping as sleep difficulties are frequently not reported (and instead considered as always been that way, part of the disability, just to be expected, or not a priority for the family). Practitioners should include sleep screening questions in their assessments, as in so settings sleep problems are very prevalent.
It often fits well in an initial interview to ask about sleep alongside other questions about daily routine; for instance some standard MOHO assessments ask about a typical weekday and a typical weekend day and questions about sleep can fit well there.
Basic sleep screening questions may include:
- Do you feel you get enough sleep (quantity)?
- Do you feel refreshed after a night of sleep (quality)?
- Do you sleep at regular times that fit with your preferred daily schedule (timing)?
Answers to these question or observations from carers may lead to a more formal sleep assessment.
It can also be helpful to ask:
- What time do you go to bed, and what time do you usually fall asleep.
- What time do you usually wake up?
- (especially if the times are unusually late or early) Are these timings your choice or would you prefer that they were different?
- Do you sleep right through the night?
- Whereabouts do you sleep? (we can assume people sleep in their bedsroom, however this is often not the case.)
- Are you sleepy in the daytime?
If there are indications that this might be a problem, such as sleepiness in the daytime, snoring, or being overweight, it may be relevant to ask some questions related to sleep apnoea / sleep disordered breathing.
Your own observations during assessments of function might also highlight issues around the person’s sleep pattern, or if they are excessively sleep or fatigued, and your assessment of their home (including their sleeping environment) might prove informative.
If you are working in a hospital environment, nursing observation charts (for example hourly observations conducted on mental health wards) can be a useful source of information about a person’s overall rest-activity pattern. Although bear in mind that when they are observed to be sleeping, they may be in bed trying to sleep but not asleep.
Choosing a screening tool, self-report assessment or outcome measure:
There are various screening tools used in research and in practice, which can indicate whether a person has a sleep problem. Some also give other relevant and useful information about the type of problem and sometimes about possible causes. Other tools are more suited to measuring outcomes (i.e. detecting change after an intervention). Your choice of tool should depend on what you need to measure, whether it is for research or for clinical practice, and how long your patient or participant will have to fill in the tool.
Sleep diaries are widely used in research and in practice settings and involve the person recording their own sleep, and sometimes other factors which might impact on their sleep. What information is recorded in a sleep diary depends on its purpose, some ask for information just about bedtime, how long it took to fall asleep, and waking time, others ask more about how the person felt, some ask about alcohol or caffeine consumption, and activities the person did earlier that day or straight before bed.
Whether you are using a sleep diary in a research project or for clinical practice may influence what is most appropriate. There are a lot of choices of sleep diary available and these are just some:
This review article includes three printable examples of sleep diaries, with instructions for use: Carney, C. E., Buysse, D. J., Ancoli-Israel, S., Edinger, J. D., Krystal, A. D., Lichstein, K. L., & Morin, C. M. (2012). The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep, 35(2), 287-302
This sleep diary is straightforward to complete, it is hosted as part of the e-learning for the rest project (improving quality in sleep treatment in primary care): Rest Project – sleep diary
Sleep dysfunction assessments, screenings and outcome measures
Pittsburg Sleep Quality Index (PSQI): The most widely cited sleep screening tool is the Pittsburg Sleep Quality Index (PSQI). Although please note that this is not as good at detecting problems with irregularly timed sleep, and some forms of sleep related daytime dysfunction, and it does not detect excessive sleep (hypersomnia).
PROMIS Sleep Disturbance Instruments: The PROMIS Sleep Disturbance Instruments are outcome measures developed through a thorough research process including a literature review and qualitative research with people with sleep problems to decide on the items, and can act as a general ‘thermometer’ to measure level of impairment, and wont identify causes of problems. A guide to the sleep related assessments can be downloaded here.
The assessments themselves can be searched here (for ‘domain’ select ‘sleep’).
There are many other domains included in the PROMIS (disease specific and general wellbeing), here is more information about PROMIS.
Occupational Profile of Sleep: An initial interview format to gather information about a sleep problem, from Doris Pierce‘s chapter “Rest and Sleep” in “Occupational therapy in mental health : a vision for participation”. Download the occupational profile of sleep here. View a preview of the book here.
Sleep disorder screening questionnaire: Although we can’t find any evidence that this has been validated, it is quite a helpful checklist.
NHS Choices Sleep Assessment Screening: A self assessment tool provided by the NHS, in association with Sleepio (online CBT for insomnia provider) (UK)
National Sleep Foundation (USA): Assessment Toolkit for Primary Care
Functional Outcomes of Sleepiness Questionnaire: (Chasens, Ratcliffe, & Weaver, 2009) Whilst developed as an outcome measure this can also provide some useful questions to find out in what respects a sleep problem is affecting your client.
Holland Sleep Disorders Questionnaire: (Kerkhof et al., 2013) recently developed as a screening tool to help to identify sleep disorders in relation to more specific domains of insomnia, parasomnias, circadian rhythm sleep disorder, hypersomnia, restless legs syndrome/periodic leg movement disorder, and sleep disordered breathing. (awaiting link)
Measuring sleep impact
As well as measuring sleep problems, it can be important to measure the impact of sleep problems.
The Glasgow Sleep Impact Scale is particularly client centred in its measurement of outcomes, as scoring is based on the completer’s own top three priorities, which they are asked to select, regarding the impact of their sleep problem:
The PROMIS sleep related impairment short form also measures the impact of sleep problems and may be quicker to complete requiring less decision making by the patient / participant. Scoring manual here.
Literature on sleep measurement:
Here is a systematic review about patient reported outcome measures regarding sleep:
And here is a review about some of the issues affecting self-reported sleep measures: Buysse, Daniel J., Lan Yu, Douglas E. Moul, Anne Germain, Angela Stover, Nathan E. Dodds, Kelly L. Johnston, Melissa A. Shablesky-Cade, and Paul A. Pilkonis. “Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments.” Sleep 33, no. 6 (2010): 781-792.
Measures for particular sleep conditions and populations
The Insomnia Severity Index is also popular as a very short insomnia screening.
Nightmare Effects Survey and Nightmare Frequency Questionnaire (see pages 328 and 331)
The STOP BANG questionnaire: A popular sleep apnoea screening questionnaire.
The National Healthy Sleep Awareness Project (USA) hosts resources for healthcare professionals and includes a very short screening tool for sleep apnoea on this page: sleepeducation.org – resources for health care professionals. If you use this with your patients we’d like you to reassure them that waking up once per night to urinate is not too unusual or a cause for concern in itself. Waking up several times per night to urinate could be more of an indicator that something might be wrong, or waking up once per night to urinate, alongside other indicators and symptoms.
BEARS paediatric sleep screening tool (standardized and psychometrically tested)
- Does the child snore lightly or loudly at night?
- Does the child exhibit excessive daytime sleepiness?
- Does the child have difficulty falling asleep at night?
- Does the child roll, kick, or move around frequently in sleep?
- Does the child wake up frequently in the night?
- Is the child difficult to awaken in the morning?
- Does the child gasp, choke, or snort in sleep?
- Does the child stop breathing during sleep?
- Does the child get enough sleep at night compared with peers of the same age?
- Does the child have a difficult temperament (irritable or easily frustrated)?
Children’s Sleep Habits Questionnaire (Owens, Spirito, & McGuinn, 2000) is a formal and validated questionnaire can also be used such as for preschool and school age children.
Autism / Autistic Spectrum Disorders:
The Autism Network: (Malow et al., 2012; Malow, Adkins, McGrew, Wang, Goldman, Fawkes, & Burnette, 2012) suggests screening for insomnia in children on the autism spectrum by asking five questions:
- Does your child fall asleep within 20 minutes after going to bed?
- Does your child fall asleep in the parent or sibling’s bed?
- Does your child sleep too little?
- Does your child awaken once during the night?
- Do you consider these a problem?
Sleep habits for young children with ASD (Reference: A Sleep Habits Questionnaire for Children with Autism Spectrum Disorders, Beth A Malow, Crystal Crowe, Jennette Henderson, Susan G McGrew, Lily Wang, Yanna Song and Wendy L Stone, J Child Neurol, 2009; 24; 19;DOI 10.1177/0883073808321044)
Measuring sleepiness or fatigue
Epworth Sleepiness Scale – (measures daytime sleepiness, through self-reported likelihood of falling asleep in various situations). This scale asks people to rate their usual chances of dozing off or falling asleep in eight different situations or activities that most people engage in as part of their daily lives, although not necessarily every day. A score of 0-4 indicates satisfactory daytime functioning; 5-9 indicates daytime tiredness or lack of energy and score of over 10 as excessive daytime sleepiness with a possible underlying medical condition.
A pictorial format of the Epworth Sleepiness Scale has been developed for adults with intellectual disability (Ghiassi, Murphy, Cummin, & Partridge, 2011)
Flinders Fatigue Scale (measures levels of fatigue, which can be distinct from sleepiness)
Measures of factors which can impact on sleep
As well as screening for or assessing a sleep problem some self-report questionnaires can help identify contributing factors:
Glencoe Regional Health Services Occupational Therapy Dept. sleep hygiene check list (developed in house) – http://grhsonline.org/wp-content/uploads/2011/08/Form-760-0909T-Basic-Sleep-Hygiene-Guidelines.pdf
Bedroom Environment Screening Tool (developed by OTs and used in occupational therapy research) – see pages 16 to 19 (http://cbotlabs.wix.com/cbbes-workbook)
Beliefs about sleep:
The Dysfunctional Beliefs About Sleep (DBAS) questionnaire (measures the level of potentially unhelpful sleep related beliefs, usually used in insomnia).
Objective measurement of sleep
PSG and video in sleep laboratories
Polysomnography (PSG), often referred to as a sleep study, it is used to study sleep and diagnose sleep disorders. A PSG is able to monitor body functions such as brain activity (EEG), eye movements (EOG), muscle activation (EMG), positioning, oxygen saturation, heart rate and breathing. The sleep study is worn during sleep either in a laboratory setting or in the person’s home. For someone being assessed for sleep apnoea, a home sleep study will often be adequate. Somebody suspected of having nocturnal seizures or sleep walking however, is more likely to require laboratory study where video cameras can also capture activity.
Although PSG is the gold standard for the evaluation of sleep, it is often timely and costly to administer, disrupts sleep in the person being assessed, and provides no data on daytime activity/napping. Actigraphy is the measurement of activity through the use of a small device known as an actigraph or actiwatch. This is often worn on the wrist and measures activity (and often light exposure) typically over a period of a few weeks. Although actigraphy cannot provide data on the stage of sleep someone is in, it measures activity/movement and applies a complex algorithm to infer sleep or wakefulness.
Commercially available activity monitoring devices
There are now lots of devices that measure movement, and many claim to measure sleep quality. These include devices worn on the wrist and apps installed on mobile phones. The reliability of such devices is an area currently being researched. It is very unlikely that any of these can measure sleep stages as some claim to, however some may be useful for tracking changes in daily rhythms and activity levels. If you have helpful information or are doing research on these devices please contact us as Sophie is interested to hear from you.