After a traumatic brain injury, 30 to 70 percent of people encounter sleep disturbances. This can cause significant issues because during sleep, the brain remains active. What the brain does as we sleep includes a variety of healing and helpful functions, such as make decisions, learn physical tasks, and form or retain memories. Sleep also allows the brain to do some major cleanup. For example, neurons shrink and create more space, allowing the brain fluid to flush out the day’s toxins.
Everyone needs sleep, but sleep becomes even more critical during the recovery process after a brain injury. Lack of quality sleep can further affect cognitive function, as well as a person’s ability to participate in activities of daily living. If a client with a traumatic brain injury (TBI) already receives treatment from their medical team for sleep issues, try helping them apply skills they practice in your sessions toward getting better sleep. If you work on executive function, for example, have your client generalize those skills by tracking their time awake and asleep.
Is it possible to teach executive-function skills to people who have brain injuries? Absolutely, says cognitive rehab clinical researcher McKay Sohlberg.
These six tips work for me when applying speech-language strategies to my clients’ sleep goals:
Build a bedtime routine.
Building a daily routine can help with attention and memory by keeping you on task and decreasing distractions or forgetfulness. To connect back to sleep goals, work with your clients to set up a bedtime routine. Research shows that going to bed and waking up at the same time can help improve sleep hygiene.
During sessions, target problem-solving by asking clients to identify a realistic time to go to bed and wake up every day. Target divergent thinking skills by having the client generate a list of things they can do in their bedtime routine—turn off electronics an hour before bed, for example, or form a relaxing habit like reading or drinking herbal tea. Target use of external memory strategies by programming an alarm to alert starting the bedtime routine each night.
Use a planner to schedule waking hours.
Perhaps your client uses an electronic or paper planner to improve attention, memory and executive functioning skills during daily activities. I use planners to address sleep goals in several ways:
- Schedule the bedtime routine in the planner.
- Use an hourly planner to help your client assess when they are most awake and alert during the day, so they can schedule more cognitively demanding tasks during that time.
- Schedule naps or rest breaks based on the activities they plan to do each day.
Track data that affects quality and quantity of sleep.
Using a daily planner can also help the client to track behaviors affecting their sleep patterns. For example, one client recorded how many times he woke up during the night. Another client recorded how much caffeine he drank. A third client who struggled with fatigue during the day used a subjective fatigue rating scale—ranging from 1 equaling very awake to 10 meaning extremely tired—to record how she felt throughout each day. This exercise revealed clear trends about what behaviors most affected her energy levels.
Manage medication.
If your client takes medication for sleep issues, one of your sessions can focus on cognitive strategies around medication management. Work with your client on ways to organize and implement a medication schedule, understand medication instructions and any foods or drinks to avoid, and setting reminders to take the medication at the right time.
Write things down.
For clients who need to improve organizational or memory functions, one strategy involves writing things down. Writing things down can also become part of the bedtime routine for those clients who experience trouble falling or staying asleep, because they worry about the things they might be forgetting.
One client I worked with would keep a notebook by her bed and “free-write” all the thoughts on her mind as part of her bedtime routine. She told me that knowing these thoughts were all on paper for her to look at and organize the next day allowed her to clear her mind and sleep better.
Meditate before bed.
There is a growing body of research on the cognitive benefits of meditation. Meditating before bed can help with physical and mental relaxation. And it’s simple. Instruct your client to just lie comfortably, close their eyes and breathe naturally. Then focus their attention on the breath and on how the body moves with each inhalation and exhalation.
One challenge in teaching clients new cognitive-linguistic strategies is generalizing them outside of structured activities during sessions. Applying these strategies to various contexts or experiences can help promote carryover. For patients who struggle with getting good sleep, showing them ways to apply the strategies they learn during your sessions to real-world application can also show them how they can carryover these strategies to other parts of their daily lives.
Emily Dubas, MS, CCC-SLP, treats patients with neurological conditions in both inpatient and outpatient rehabilitation settings at Constant Therapy and Spaulding Rehabilitation Hospital. She’s also an affiliate of ASHA Special Interest Groups 2, Neurogenic Communication Disorders, and 15, Gerontology. emily.dubas@constanttherapy.com
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