Sleep Hygiene

Question 1

What is sleep hygiene?

Answer 1

Simple recommendations that may influence the length and quality of sleep by modification of behaviors, habits, and environmental conditions.

Question 2

What is the influence of improved sleep hygiene on sleep?

Answer 2

In most patients, it improves sleep.

Question 3

What effect does improved sleep hygiene have on the use of sleep medications?

Answer 3

In most patients, the use of sleep medications decreases wiht improved sleep hygiene.

Question 4

How do outcomes from improved sleep hygiene compare to pharmacological interventions for improved sleep?

Answer 4

Healthier sleep without tolerance, dependence, or other adverse reactions to medications.
Better quality of sleep when compared to pharmacological therapy

Question 5

What are the components of sleep hygiene?

Answer 5

Behavior
Environment
Diet
Exercise

Question 6

What is the behavioral recommendation regarding sleep schedule?

Answer 6

Regular sleep schedule: go to bed and get up at the same time every day, regardless of the day of the week.
If you can’t control your schedule, you MUST control one thing: the wake up time. Make it the same every day, no matter whether it’s holiday, vacation, etc.

Question 7

What are the physiologic reasons that a regular schedule are so important in sleep hygiene?

Answer 7

Irregular schedule will offset/disrupt the circadian rhythm.

Sleep deprivation or abrupt nighttime awakenings trigger release of cortisol which increases wakefulness.

Question 8

What is the behavioral recommendation regarding pre-sleep routine?

Answer 8

Have a relaxing pre-sleep routine to prepare mind and body for sleep

Question 9

What are the scientific principles for a relaxing pre-sleep routine?

Answer 9

Resolve worries before bedtime because stress induces release of corticotropin releasing hormone (CRH) which stimulates ACTH which induces adrenals to release cortisol and other stress hormones.
High levels of cortisol and ACTH increase wakefulness and inhibit slow wave sleep

Question 10

What is the behavioral recommendation regarding activities in the bedroom?

Answer 10

Ensure that the bedroom is reserved only for sleep or intimacy. Only go to bed when drowsy. No TV, eating, or reading in bed.

Question 11

What are the scientific principles behind the bedroom activity recommendations?

Answer 11

Conditioning response to identify the bed and bedroom with sleep and not a place for other activities.

Question 12

What is the behavioral recommendation regarding trying to fall asleep at bedtime?

Answer 12

Limit the time you spend awake in bed. If awake for 15-20 minutes, get up and leave the bedroom. Engage in a quiet activity until drowsy.

Question 13

What is the scientific principle behind the recommendation to not lie awake in bed?

Answer 13

Paradoxical intention: the longer one tries to fall asleep, the further away it gets.

Question 14

What is the behavioral recommendation regarding naps?

Answer 14

Avoid long naps. Naps should not be longer than an hour and should be scheduled in the early part of the day (mid-morning to early afternoon).
Power naps are okay. Only nap if necessary to retain alertness, 30 minutes maximum; avoid napping 6-8 hours prior to sleep.

Question 15

What are the scientific principles behind avoiding long naps?

Answer 15

Long naps get a person into N3 sleep. Because you have already used some of your quartile of N3 sleep, it will be more difficult to get into N3 sleep during the night.
Long naps also disrupt the circadian rhythm.

Question 16

What are the environmental sleep hygiene rules?

Answer 16

Have a dark bedroom
Set cool temperature (uncomfortably warm room disrupts sleep)
Avoid loud noises (earplugs or white noise machines are good)
Have a bedroom free of allergens

Question 17

What is the dietary recommendation with regards to caffeine?

Answer 17

Avoid caffeine 6-8 hours before sleep. No more than 1-2 cups of coffee per day.

Question 18

What are the scientific principles behind the recommendation to avoid caffeine close to bedtime?

Answer 18

Caffeine antagonizes (blocks receptors of) adenosine (which promotes sleep). Adenosine blocks release of choline (excitatory neurotransmitter which maintains wakefulness).
Caffeine delays sleep.

Question 19

What is the dietary recommendation regarding alcohol?

Answer 19

Avoid alcohol 3-5 hours before sleep. Alcohol help sleep onset but the sleep is fragmented and poor quality.

Question 20

What is the scientific principle behind the recommendation to avoid alcohol 3-5 hours before sleep?

Answer 20

EtOH is a CNS depressant. Lowers muscle tone of upper airway. Higher incidence of apneas. Repeated arousals fragment sleep and increase sleepiness the next day.
EtOH also increases incidence of myoclonus. These brief limb contractions can cause frequent arousals and fragment sleep.

Question 21

What is the dietary guideline regarding nicotine?

Answer 21

Avoid nicotine prior to sleep. Wakefulness is increased and withdrawal can cause sleep disruptions.

Question 22

What is the scientific principle behind the nicotine guideline?

Answer 22

Nicotine stimulates serotoninergic neurons in the dorsal raphe nucleus, which initiates sleep onset.
Normally, these fibers fire rapidly during wake, slow during slow wave and nearly cease during REM.
Nicotine causes them to continue firing at a higher than normal rate causing REM and slow wave sleep to reduce.

Question 23

What is the recommendation regarding meals close to bedtime?

Answer 23

Eat a light carbohydrate snack close to bedtime because hunger can disrupt sleep. Avoid large meals, sugars, and caffeine prior to sleep.

Question 24

What are the recommendations about exercise?

Answer 24

Exercise regularly.

Avoid strenuous exercise 3-5 hours before sleep.

Question 25

What is the scientific basis for the guideline to exercise regularly?

Answer 25

Regular exercise promotes a sleep/wake cycle.
Exercise stimulates the immediate release of epinephrine (causes a sense of happiness and excitement). Time is essential in allowing the epi levels to drop in order to decrease wakefulness.

Question 26

What is the basis for no strenuous exercise 3-5 hours before sleep?

Answer 26

Strenuous exercise raises body temperature. During sleep, body temperature drops.
About four hours after exercise, there is a drop in body temperature.

Question 27

What is the recommendation regarding a clock in the bedroom?

Answer 27

Avoid having an illuminated clock where you can see it in the bedroom.

Question 28

Why does sleep hygiene therapy fail?

Answer 28

Sleep hygiene has limitations that must be addressed first (insomnia, traumatic events that are associated with sleep, medical sleep disorders)
Inability to comply with rules set by physician

Question 29

What two major issues are we addressing with sleep hygiene?

Answer 29

Homeostatic drive (sleep load): avoid naps, spend just enough time in bed to sleep, regular exercise, hot bath before bedtime
Circadian drive: regular sleep/wake schedule, avoid bright light at nocturnal awakenings, exposure to sunlight in the morning