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Inadequate sleep hygiene is an insomnia associated with daily living activities that are inconsistent with the maintenance of sleep and daytime alertness. Not everyone who practices poor sleep hygiene develops insomnia. In patient’s suffering from chronic insomnia there is a complex interplay of internal factors and poor sleep hygiene behaviors. Diagnosis is made by history and treatment is based on education. KeywordsSleep hygiene-Napping-Caffeine-Alcohol-Drug use-Ambient noise
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Abstract
Inadequate sleep hygiene is an insomnia associated with daily living activities
that are inconsistent with the maintenance of sleep and daytime alertness. Not
everyone who practices poor sleep hygiene develops insomnia. In patient’s suf-
fering from chronic insomnia there is a complex interplay of internal factors
and poor sleep hygiene behaviors. Diagnosis is made by history and treatment
is based on education.
Keywords: Sleep hygiene, Napping, Caffeine, Alcohol, Drug use, Ambient noise
Definition
The American Academy of Sleep Medicine (previously the American Sleep
Disorders Association) classifies poor sleep hygiene-induced insomnia as one of
the 11 insomnias in the 2005 second edition of the International Classification
of Sleep Disorders [1]. Inadequate sleep hygiene is an insomnia associated with
daily living activities that are inconsistent with the maintenance of sleep and
daytime alertness. For example, intake of caffeinated beverages very close to
bedtime produces insomnia due to the stimulating properties of caffeine and so
does nicotine. Alcohol close to bedtime interferes with sleep maintenance by
causing awakenings during the major sleep period. These constitute poor sleep
hygiene. Setting aside relaxation or “down time” prior to going to bed facili-
tates sleep; therefore, it is an element of good sleep hygiene.
Grossly apparent poor sleep hygiene practices like the above and others
such as excessive time in bed, exercising before bed or major variations in
bedtime and rise-time on a daily basis are easy to spot but more subtle effects
of practices such as a single daily nap may go undetected. Clinical judgment is
needed when determining how long a nap should be and how close to bedtime
to prevent it from interfering with nighttime sleep [1] (Table 14.1).
14
Sleep Hygiene
Hrayr Attarian
From: Clinical Handbook of Insomnia, Current Clinical Neurology
Edited by: H.P. Attarian and C. Schuman, DOI 10.1007/978-1-60327-042-7_14,
© Springer Science+Business Media, LLC 2003, 2010
184 H. Attarian
Epidemiology
There are no ethnic or racial predilections identified and men and women
are affected almost equally; however, there are cultural differences [2]. Older
teenagers and young adults are one of the two groups especially affected by
poor sleep hygiene. Manni et al., studied a large group of Italian high school
students aged 17. In their cohort, 19% of girls and 11.6% of boys had persist-
ent insomnia due to poor sleep hygiene [3], this was better than their American
counterparts whom complained more of insomnia due to poor sleep hygiene
(Italians: 18%; Americans: 25%), according to a newer study [2]. The other
group that is affected by poor sleep hygiene is the elderly, especially those
dwelling in nursing homes [4]. This is due to the level of noise and ambient
light at night [5]. Although recently, a sample of community dwelling elderly
insomniacs were surveyed and other than greater amounts of napping, they did
not engage in poorer sleep hygiene behaviors than their age-matched nonin-
somniac counterparts [6]
In patient’s suffering from chronic insomnia there is a complex interplay
of internal factors and poor sleep hygiene behaviors. It is impossible to tease
out the magnitude of the roles each element plays in the development of the
insomnia. Most patients suffering from chronic and persistent insomnia have
at least some features of inadequate sleep hygiene admixed with the features of
their primary disorder. It is not known whether the sleep hygiene components
are a result, or a partial cause, of the main sleep problem. There is, however,
evidence that suggest that sleep hygiene education is at least partially effective
in patients with primary insomnia [7] even though it is not recommended as a
standalone treatment for primary insomnia [8]. In a survey conducted among
3,600 adult Japanese women to identify external factors causing insomnia, the
prevalence of insomnia was found to be 11.2% [9]. Most of the complaints
of insomnia were related to street noise at night. More recently, studies have
Table 14.1 Sleep hygiene guidelines used at University of Vermont Sleep
Center.
1. Go to bed only when sleepy
2. Use the bed only for sleeping; do not read, watch television, or eat in bed
3. If unable to sleep, get up and move to another room. Stay up until you are
definitely sleepy and then return to bed
4. Set the alarm and get up at the same time every morning, regardless of how much
you have slept through the night
5. Do not nap
6. Don’t exercise just before going to bed
7. Don’t engage in stimulating activity just before bed
8. Avoid caffeine in the afternoon
9. Don’t drink alcohol close to bedtime
10. Eliminate clocks in the bedroom
11. Before bedtime, schedule a period to review stressful events of the day
12. Focusing on quiescent tasks that occupy the mind such as reading, watching
television, or listening to music promotes relaxation and sleep
14 Sleep Hygiene 185
shown that chronic insomniacs do engage in poor sleep hygiene activities that
tend to perpetuate the problem. Among these, the most prevalent are smoking
and drinking alcohol close to bedtime as well as “sleeping in” to make up for
missed sleep during the night [10].
Etiology
As we discussed above, the main cause of poor sleep hygiene insomnia is
the set of behaviors that the patients voluntarily engage in, that produces
increased arousal or in some way disrupts normal sleep [1]. These behaviors
are normal when practiced in moderation but cause insomnia when they occur
in susceptible people or in conjunction with other factors that disrupt sleep.
Common poor sleep hygiene practices include going to bed when not feeling
sleepy, consuming moderate amounts of alcohol, caffeine, or nicotine close to
bedtime, night-to-night variability in bed- and wake-times, excessive napping
especially when done in close proximity to the major sleep period, stimulation
near bedtime (psychosocial stress, excitement, physical exercise, stimulating
mental activity, etc.) [11], poorly regulated environmental elements such as
ambient noise [9], light, or temperature [11], or disturbing household members
[12]. A study done in community dwelling Japanese women found that living
near streets with high nighttime traffic was the most important external risk
factor for developing poor sleep hygiene insomnia. Others included experi-
encing major life events, having young children under the age of 6 years and
having an irregular bedtime [9] (Table 14.2).
Pathogenesis and Pathophysiology
Not everyone who practices poor sleep hygiene develops insomnia. Persons
diagnosed with inadequate sleep hygiene insomnia have an underlying hyper-
sensitivity to changes in their sleep schedules and minute amounts of external
stimuli. They have exaggerated physiological responses to even small amounts
of stimulants (caffeine, nicotine), alcohol, exercise, excitement, or strong
environmental disruptions, such as noise, shift work and ambient light. It is
thought that these persons’ circadian control centers (suprachiasmatic nucleus)
[12] also seem to be sensitive to even minimal variations in their sleep sched-
ules or to daytime napping [1]. Others, who suffer from inadequate sleep
hygiene insomnia, because of psychological or physical illness or due to an
innate predisposition, may have a particularly low tolerance to the effects of
even infrequent sleep deprivation and, in good faith, in an attempt to remedy
Table 14.2 Amount of caffeine in common beverages.
Beverage Amount of caffeine
8 oz of brewed coffee 100–150 mg
8 oz of instant coffee 85–100 mg
8 oz of tea 65–75 mg
12 oz of cola 40–75 mg
8 oz of cocoa 50 mg
186 H. Attarian
the situation may resort to such poor sleep hygiene behaviors as extra naps or
bedtime alcohol. A combination of behaviors that are nonconducive sleep and
an innate physiological hyperarousal leads to the development of poor sleep
hygiene insomnia [13, 14].
Clinical Manifestations
The main clinical symptom of inadequate sleep hygiene is insomnia. Other
symptoms may include dysphoric mood, fatigue, irritability, occasionally
hypersomnia, and poor concentration.
The time course of poor sleep hygiene-induced sleep problems may vary
from self limiting and transient, to occasional or even frequent but intermit-
tent, or persistent. It may be the cause of insomnia or may exacerbate an
already existing one or itself may be the result of a preexisting primary or
secondary insomnia. The insomnia may be sleep onset, sleep maintenance, or
terminal resulting in early morning awakenings. In some cases it may present
as irregular sleep patterns. The activities that constitute poor sleep hygiene and
lead to poor sleep hygiene insomnia, usually, are common activities of daily
life, which produce sleep disturbances in people with an innate susceptibility.
Behaviors that are considered nonconducive to sleep include intake of caf-
feine late in the afternoon or evening, intake of alcohol at night (often in an
attempt to self-medicate) psychological stress or excitement in the evening,
obsessive clock watching while awake at night, exercise or smoking late at
night or close to bedtime, use of the bed for activities unrelated to sleep (other
than sex), variable bedtime and rise-time, going to bed when not sleepy poorly
regulated comfort measures in the bedroom such as temperature, light, noise,
uncomfortable bed, pets, family members or house mates that may engage in
behaviors that is disruptive to one’s sleep [15]. In addition to an innate suscep-
tibility, a combination of these behaviors and extrinsic factors is needed, any
one of which might be considered acceptable behavior in most people.
Case Study 1
A 46-year-old engineer comes in with the complaint of sleep maintenance
insomnia. The patient goes to bed between 10 and 11 p.m., and has no diffi-
culty initiating sleep. He awakens everyday at around 3 a.m. He, subsequently,
is unable to go to sleep for the rest of the morning. This problem has been of
about 2–3 years duration. Over-the-counter hypnotics have not helped. The
patient denies experiencing pain or worry or anxiety at night, history of snor-
ing or witnessed apneas, falling asleep unintentionally during the day or any
caffeine intake after his early morning cup of coffee. He denies any neuroveg-
etative symptoms of anxiety and depression.
Medications: Zestril, Lipitor.
Exam is normal and his Beck’s Depression Inventory score is 4 (not
depressed).
When further questioned, he reveals that he drinks on a nightly basis, over
the past several years, three glasses of wine or some other type of liquor just
before he goes to bed. He does this out of habit and denies having had problems
falling asleep prior to him engaging in this nightly alcohol consumption.
14 Sleep Hygiene 187
He is asked to reduce his alcohol intake and to drink lesser amounts earlier
in the evening.
At the next visit 6 weeks later his insomnia has resolved.
Case Study 2
A 26-year-old right-handed psychology student presents to the Sleep Medicine
Centers clinic for initial evaluation of recent onset sleep initiation insomnia.
In the past, she had only rare problems falling and staying asleep until 6–7
months ago when this problem became persistent.
Currently she goes to bed exhausted, sleepy, around 12 midnight or 1 a.m.
and is still unable to fall asleep. She lays there anywhere from half an hour
to 3–4 h tossing and turning, but does not leave the bed or the bedroom. She
usually gets up in the morning at 7 a.m. with an alarm and on weekends when
she doesn’t have to go to work she sleeps into late morning, and sometimes
till early afternoon.
During the day she takes a 45 min to h nap. She also uses her bedroom
during the day to study, to eat, to watch television, read, and sometimes works
late into the night shortly before retiring. She does not abuse caffeine and
only uses alcohol socially. She does not abuse recreational drugs and does
not smoke. She denies cataplexy, hypnagogic hallucinations, snoring, choking
spells, falling asleep unintentionally during the day or symptoms of restless
legs. The only symptom she states that she’s experienced rare periods of sleep
paralysis, maybe twice to three times in her life time.
Past medical history: ADHD.
Medications: Dexedrine. Ambien PRN.
Exam is normal and his Beck’s Depression Inventory score is 6 (not
depressed).
Differential Diagnosis
The differential diagnosis of poor sleep hygiene insomnia falls under three
main categories. The first consists of the other environmental sleep disorders,
e.g., adjustment insomnia, behavioral insomnia of childhood, behaviorally
induced insufficient sleep syndrome, high altitude periodic breathing, insom-
nia due to drug or substance, insomnia due to alcohol use, nocturnal eating or
drinking syndrome, food allergy insomnia, and toxin-induced sleep disorder
(the last three disorders no longer exist in the ICSD2) [1].
Sometimes, it is hard to differentiate individual disorders from each other
because of significant overlap among them.
The second main category consists of the primary insomnias that include
psychophysiological insomnia, childhood onset or idiopathic insomnia and
paradoxical insomnia [1]. Any of these may coexist with poor sleep hygiene
may cause it or be exacerbated by it.
The third includes insomnia due to other sleep disorders such as obstructive
sleep apnea, restless legs syndrome, periodic limb movement syndrome, and
even narcolepsy. Insomnia due to neurological, psychiatric, and other medical
causes such as due to degenerative neurological illnesses, anxiety disorders,
asthma etc. When the symptoms of the underlying disorder are prominent then
188 H. Attarian
secondary insomnias are usually suspected and diagnostic testing appropriate
to the circumstance may elucidate the underlying cause of the insomnia.
Diagnostic Workup
The diagnosis of inadequate sleep hygiene is best made through careful and
detailed history of the patient’s daily sleep-related habits [16]. These include
bedtime, rise-time, time spent in bed awake, different nonsleep-related activi-
ties that the patient does in the bed and the bedroom including watching TV,
reading etc., the timing of exercise, activities engaged in prior to bedtime and
while awake at night, amount and timing of caffeine or alcohol ingestion, and
daytime napping. In short, trying to identify any activity that is incompatible
with sleep.
A useful diagnostic tool is a detailed sleep questionnaire completed by
the patient and the bed partner [17, 18]. In 2006, Mastin et al., developed a
well-validated short questionnaire called the Sleep Hygiene Index for the bet-
ter assessment of poor sleep behaviors [19] (Table 14.3). As in most primary
insomnias, sleep diaries are an essential tool in identifying sleep problems
and charting their evolution and response to treatment. In a paper published in
1998, Blake and Gomez introduced a simple but useful questionnaire by which
to measure compliance with sleep hygiene education [20].
A thorough psychiatric and medical evaluation including a physical exam
should be done to rule out medical or psychiatric causes of the insomnia, as
is true for most insomnias. Polysomnography is only recommended if the
patient has symptoms suggestive of other primary sleep disorders or they do
not respond to behavioral modification. Below are the AASM guidelines for
the use of polysomnography in the evaluation of insomnia [21] (Table 14.4).
Table 14.3 Sleep Hygiene Index.
1. I take daytime naps lasting 2 or more hours
2. I go to bed at different times from day to day
3. I get out of bed at different times from day to day
4. I exercise to the point of sweating within 1 h of going to bed
5. I stay in bed longer than I should two or three times a week
6. I use alcohol, tobacco, or caffeine within 4 h of going to bed or after going to bed
7. I do something that may wake me up before bedtime (for example: play video
games, use the internet, or clean)
8. I go to bed feeling stressed, angry, upset, or nervous
9. I use my bed for things other than sleeping or sex (for example, watch television,
read, eat, or study)
10. I sleep on an uncomfortable bed (for example, poor mattress or pillow, too much
or not enough blankets)
11. I sleep in an uncomfortable bedroom (for example, too bright, too stuffy, too hot,
too cold, or too noisy)
12. I do important work before bedtime (for example, pay bills, schedule, or study)
13. I think, plan, or worry when I am in bed
14 Sleep Hygiene 189
Prognosis and Complications
As in most extrinsic sleep disorders, once the underlying cause is removed,
the symptoms resolve completely. The sooner treatment is started the more
complete the resolution of symptoms, the better the prognosis. If poor sleep
hygiene is allowed to continue it may lead to psychophysiological insomnia
in susceptible individuals.
Some recent publications find a high correlation between poor sleep hygiene,
especially among younger drivers, and high rates of accident [22, 23].
Prevention
Education is the cornerstone for the prevention of poor sleep hygiene insom-
nia. Almost all of us engage in poor sleep hygiene at various times in our
life. There are also a large number of external sleep disruptors such as noise,
ambient light etc., outside of one’s control. Although it is extremely important
to educate people about sleep hygiene, these rules do not strictly apply to
everyone. A short daily nap is part of the lifestyles of some cultures and does
not necessarily constitute poor sleep hygiene if it does not result in symptoms
of insomnia or sleep disturbances. Similarly a cup of coffee or a drink with
dinner or even reading in bed may not negatively impact some people’s sleep.
In some people, however, either because of their predisposition or due to the
additive effect of different factors may develop significant insomnia.
It is essential to inform people early on, at the first appearance of symptoms,
the potential sleep problems poor sleep hygiene can cause, and help identify
and stop them.
Table 14.4 Practice parameters for evaluation of chronic insomnia.
1. The health-care practitioner should screen patients for symptoms of insomnia
2. An in-depth sleep history is essential in identifying the cause of insomnia.
Additionally, a physical examination is an important element in the evaluation of
insomnia patients with medical symptoms
3. Polysomnography is not indicated for the routine evaluation of chronic insomnia.
However, symptoms of insomnia do not exclude polysomnographic evaluation in
assessing the complaint. There should be a valid indication and a clear rationale,
based upon specific elements of the history, to support use of polysomnographic
evaluation
4. Instruments which are helpful in the evaluation and differential diagnosis of insom-
nia include self-administered questionnaires, at-home sleep logs, symptom check-
lists, psychological screening tests, and bed partner interviews
5. The multiple sleep latency test (MSLT) is not routinely indicated for the evaluation
of insomnia
6. There is insufficient evidence to make recommendations about the diagnostic role
of other portable equipment
Adapted from ref. [21].
190 H. Attarian
Treatment
Like all extrinsic sleep disorders the mainstay of treatment needs to be
modification or complete removal of the external factors causing the insomnia.
Sleep hygiene must be taught and reinforced in patients suffering with this
disorder [24]. It may be overwhelming for patients to follow every single sleep
hygiene regulation at once and, if tried, could lead to noncompliance. It is best
to isolate two or three key factors individualized to the patient and ask them
to concentrate on those [16]. Other cognitive behavioral treatment modalities
may be helpful in select cases. These include relaxation therapy, biofeedback,
sleep restriction consolidation, and stimulus control [16]. Usually, sleep
hygiene education is simpler and easier to follow and as effective as the more
elaborate and difficult to follow cognitive behavioral treatment. In fact, of all
the nonpharmacological/behavioral treatments, sleep hygiene education is one
of the most effective methods and one of the easiest to follow [7].
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