Sleep hygiene involves promoting good sleep habits. One problem with sleep hygiene that I find is that I find it ineffective to give a patient a list of do’s and don’ts without explaining the biological and/or behavioral effect. That is why in The Sleep Diet I have the chapter “Sleep Hygiene is Crap”. Sleep Hygiene is important, but as a treatment alone is ineffective. In my practice I have had great success with sleep hygiene, but it is because I take the time to educate basic sleep science.
I will list some information on sleep hygiene, and then go back and explain they why.
Sleep Hygiene List:
– Regularize sleep / wake schedule
– Avoid stimulants and stimulating behavior
– Establish relaxing bedtime routine
– Provide conducive sleep environment
– Reduce or eliminate caffeine
– Limit daytime naps
– Obtain regular exercise
– Avoid clock watching
Now for the why’s:
– Regularize sleep / wake schedule – Failure to do this may result in circadian disruption that is not compatible with sleep onset.
– Avoid stimulants and stimulating behavior – Such medical or psychological stimulation may directly cause insomnia.
– Establish relaxing bedtime routine – It helps in Pavolovian association of sleep.
– Provide conducive sleep environment – Environmental influences can cause alerting and stimulation that promotes wake.
– Reduce or eliminate caffeine – Caffeine inhibits the accumulation of adenosine which we need for sleep drive.
– Limit daytime naps – The early part of sleep is the SWS (Slow-Wave Sleep), and if a nap is too long or to late then you will not have the homeostatic drive for sleep.
– Obtain regular exercise – I want to say because if you don’t you will die. However the energy expenditure and positive effects on metabolism do improve sleep drive at night. The one caution is that exercise too late at night increases one’s core body temperature and is less compatible with sleep onset.
– Avoid clock watching – Nothing positive nor productive will come out knowing how late you have been up. One will develop Psychophysiological insomnia. But also think a little more, to look at the clock your eyes need to be open. To register what time it is you need to think. To think you need to change your brain rate to a more wake rhythm.
Poor sleep hygiene is defined as: Daily living activities that are inconsistent with the maintenance of good quality sleep and full daytime alertness.
Poor Sleep Hygiene is cause of insomnia in 5-10% of patients with insomnia, whereas it is a contributing factor in approximately 30% of pts with insomnia as a perpetuating factor.
Categories of Sleep Hygiene:
Practices that produce increased arousal: Working in bed.
Practices that lead to increased wake: Caffeine close to bedtime, timing and intensity of light.
Practices that are inconsistent with the principles of sleep organization: Schedule variability, excessive napping.
Inadequate Sleep Hygiene practices:
– Improper sleep scheduling: Frequent daytime napping, Variable betimes, Variable wake times, Excessive amounts of TIB (Time In Bed)
– Routine use of substances in period preceding bedtime: Alcohol, caffeine, nicotine
– Engagement in mentally, physically, or emotionally activating activities close to bedtime.
– Frequent use of bed for “wake” activities: TV, reading, studying, snacking, thinking, planning, worrying
– Failure to maintain a comfortable sleep environment
Poor Sleep Hygiene Details
– Daytime naps lasting two or more hours.
– Variable bedtimes
– Variable wake times from day to day
– Exercise to point of sweating within 1 hour of going to bed
– Staying in bed when awake two or three times per week
– Activities that may wake you up before bedtime: TV, video games, internet, cleaning.
– Going to bed feeling stressed, angry, upset, nervous, anxious
– Having anxiety about poor sleep or anxiety about being sleepy next day
– Using bed for activities other then sleep or sex
– Sleeping on a perceived uncomfortable bed
– Sleeping in a perceived uncomfortable room: Too bright, stuffy, too hot, too cold, noisy.
– Conducting important work prior to bedtime: Bills, schedule, studying
– Thinking, plan, or worry in bed.
Some Sleep Hygiene Practices in Insomnia
Most common: smoking, alcohol, compensatory sleep including napping or extended time in bed while awake. It is advised to independently target these factors first.
Low dose caffeine intake before bed has been shown to have problems on PSG (Polysomnogram) with sleep onset.
Assessment of sleep Hygiene
LEARNS: Light, Environment, Activity, Routine, Napping, Substances
Environment: Temp and noise
Activity: Exercise or worry.
Substances: Caffeine, nicotine, alcohol.
AASM (American Academy of Sleep Medicine) Practice Parameters
Poor Sleep Hygiene is unlikely to be a primary cause of insomnia. It may contribute to insomnia therefore Sleep Hygiene education is a necessary but not sufficient treatment approach.
There is evidence that Sleep Hygiene alone as a sole treatment modality is ineffective. Sleep Hygiene treatment is generally a quick, single session, educational strategy.
Treatment Approaches:
Rule vs. Treatment Approach
A provider should customize specific patient behavior rather than simply general advice. Specific populations commonly express particular Poor Sleep Hygiene behaviors. Use of knowledge of principles of sleep science and circadian physiology should be educated to patients.
Mindell et al. SLEEP 2009
Specific populations at risk that most benefit from Sleep Hygiene: Elderly, shift workers, children, travelers.
Treatment: Light
Use light to stabilize sleep wake behavior. Use light to shift sleep wake behavior when necessary. Light administered too early to late evening will produce a phase delay. Light in early morning around 4-5 A.M. will cause advancement of circadian phase.
Treatment: Environment
Temperature: Sleep at thermal comfort zone 54◦-75◦F Optimal 66◦F. Cold and heat extremes reduce REM, SWS, and increase arousals. Heat is most disruptive in elderly.
Dark: Consider eye masks, blackout shades.
Quiet: 40 decibels or as high as 70 decibels can disrupt sleep. Point of reference: Faint whisper in a quiet library is approximately 30dB. Moderate rainfall is 50dB. Typical conversation or dishwasher is approximately 60dB. Average alarm clock is approximately 70dB. Loud kitchen blender is approximately 80dB. Hand drill, lawn mower, snow blower is approximately 100dB. Maximum output of most MP3 players is 110dB. Jet plane taking off is 120dB and firearms are approximately 140dB.
Note: Snoring may fall as loud as 60-90dB.
Remove pets and TV from bedroom. Consider ear plugs, TV timer, white noise headphones.
Treatment: Sleep surface
Newer mattress (<10 years old), pillows (yearly). Reduce allergens.
Treatment: Activity: No vigorous exercise within 5 hours of bedtime or after 6 P.M. Exercise in early evening advances circadian rhythms. There is a perceived increase sleep drive at times from exercise, of which this is because of the drop in body temperature after its raised body temp due to the exercise.
Warm bath prior to bed has been found to be helpful.
Use bedroom for sleep and sex only. Keep computer and TV out of bedroom. Do not work in bed. Avoid cognitive activity near bedtime. Consider scheduling a “worry time” during the day.
Note: I personally disagree with the recommendation of no late exercise. There is an epidemic of obesity and unanimously exercise is encouraged. Though it is ideal to try shift the exercise time to earlier, I fear that discouraging late exercise many times leads to no exercise. I believe an effort should be made lower your core temperature with potentially a cooler shower and cooler clothing after exercising. Protein consumption can induce sleepiness, and protein consumption after exercise is good for repair of muscle and can potentially help with sleep. I have no study to back this up, only personal experience.
Cognitive Activity
Clock watching. Excessive worry or mind racing. Consider scheduling worry time in daytime, with an itemized list. Remove the clock from the bedroom or turn it around.
Note: Sleep experts have advised to schedule a worry time, for about 15-30 minutes. Really? If someone is so rigid to where they can schedule a time to worry, then time and energy would be better spent with a therapist. I personally believe that the last thing a person with worries needs to do is worry about when they are going to worry. I can just see the individual worrying right before their worry time, and then they will worry about worrying when it is not there worry time. They also advise that you make an itemized list of your worries. Seriously! Good luck worrying about not losing that list. I think it would be more productive to sing Don’t Worry Be Happy then it would be to chose scheduling a Worry Time instead of seeing a therapist. Many sleep psychologist say that in their experience doing such a worry list is helpful. My response to that is that it is because they are a psychologist and they are providing therapy to there clients. In the absence of a licensed therapist I find this to be controversial advice.
Routine:
One of the most important outcomes of emphasizing Sleep Hygiene is to be able to develop a consistent bedtime sleep routine. Note that I didn’t say night routine because of two factors (1) I view insomnia and sleep science as a 24 hour disorder, and (2) there are a number of shift workers or caretakers that do not have the luxury of being able to have specific night routines for themselves.
Regularize bedtime and wake time. Keep similar sleep-wake schedule for weekdays and weekends. Develop a bedtime ritual an hour before bedtime, dim lights an hour before bedtime, reading outside of bed, shack, bath. Avoid brain activating activities prior to sleep. Avoid sleeping in on weekends, which happens to be a common response in depression. People with insomnia feel at times it is important to catch up on sleep, though that is logical in thought the downward consequence of sleeping in later is decreased sleep drive at desired sleep time. Rather through concept of SRT (Sleep Restriction Therapy) we use that sleep deprive to help us get to sleep at a more desired time. Address other stressors, consider relaxation techniques.
Naps
Limit daytime naps to 1 hour or less. Limit naps to 3x per week or less.
Note: If napping is more then this, consider evaluation for primary hypersomnia.
Substances:
No caffeine after 4pm (consider noon) or within 6 hours of bedtime. Note, there is high variability in metabolism and response.
Note: A Venti coffee at Starbucks can have 600mg of caffeine whereas average home brewed coffee has approximately 100 mg in a serving.
Do not use alcohol for sleep. No alcohol within 5 hours of bedtime. Alcohol does cause sedation to get to sleep, however tolerance develops and the escalation to the desired sedation effect increases over time. Then, the larger the dose, the more symptoms of withdrawal that one has later and this leads to sleep fragmentation and Hyperarousal.
Limit smoking within an hour before bedtime. Consider tobacco as a “relative addiction”. One goes all night without it and they don’t wake up dead. Smoking within 5 minutes of sleep onset has been shown to significantly contribute to poor sleep.
Sleep Hygiene in Elderly
Most aspects of Sleep Hygiene are equivalent in older Good vs. Poor sleepers. In nursing homes there is significant noise. Naps lasting more than 1 hour, each hour of napping was associated with 10% less sleep on that night. The circadian component may need specific treatment.
In terms of sleep timing and circadian changes that occur in older adults much of the disturbances in the elderly population can be attributed to changes within the circadian system with age. This includes a reduced circadian amplitude, earlier clock hour for circadian melatonin phase, awakening at an earlier circadian time closer to the melatonin midpoint. This leads to both an advanced sleep onset time and wake-time than desired. This also contributes to increased night arousals, however that has multiple other medical and hormonal factors that occur with age.
Sleep Hygiene in Children:
Much of this is related to a lack of bedtime routine.
From newborn to 10 years of age: A late bedtime and having a parent present while the child falls asleep were the biggest predictors of poor sleep patterns. Children without a consistent bedtime routine obtained significantly less sleep. Mindell et al. Sleep Medicine 2009
Bedtime Routine: Toddlers
Routine consisted of: Bath, massage, quiet activities such as cuddling or singing lullaby.
Participants in the routine group showed improved sleep latency, sleep continuity, mood, and improved parental perception of bedtime ease.
Shift Workers
Shift workers are changing their sleep pattern to daytime sleep. Due the circadian influence, there may be some Sleepiness during the night shift, even in the absence of daytime insomnia.
Napping has positive effects in shift workers. Inappropriate use of substances such as caffeine and nicotine are a major contributing factor in Poor Sleep Hygiene in this population. Eating close to bedtime also contributes to poor sleep. It should also be noted there is an increase in OSA incidence in circadian shift workers.
Few shift workers completely shift their circadian drive to there new shifted sleep-wake rhythm. This produces shortened and fragmented sleep. In contrast to elderly, napping is helpful.
“Anchor Sleep” – Four hour period of sleep just after the night shift. Then a later 3-4 hour nap period at the patient convenience has been shown to improve sleepiness in shift workers.
