Sleep hygiene is the controlling of "all behavioural and environmental factors that precede sleep and may interfere with sleep".[1] It is the practice of following guidelines in an attempt to ensure more restful, effective sleep. Good sleep hygiene can promote daytime alertness, help to treat or avoid specific kinds of sleep disorders,[2][3] and prevent the negative consequences of sleep deprivation.
Specific sleep hygiene recommendations have become more established and refined over time, but there is variable research support across recommendations. The benefits of practicing sleep hygiene recommendations vary by individual and some special populations have unique additional considerations. Consultation with sleep professionals can facilitate personal application of sleep hygiene recommendations.
History
The term sleep hygiene was coined in 1977 by psychologist Peter Hauri, who published a list of behaviors intended to promote improved sleep.[4] Similar concepts are credited to Paolo Mantegazza,[5] who published a related original book in 1864 and to Michael Perlis who wrote an article in the British Medical Journal in 1894.[4] The 1991 publication of the International Classification of Sleep Disorders introduced the diagnostic category Inadequate Sleep Hygiene.[6] Over recent decades, specific sleep hygiene recommendations have been revised and expanded as the medical field has made advancements. For example, while avoiding sleeping pills may have been appropriate in the 1970s, there are now non-habit-forming sleep aids.[4]
Assessment
Trouble sleeping and daytime sleepiness can be indications of poor sleep hygiene or sleep habits. The International Classification of Sleep Disorders-Revised (ICSD-R) says: "The importance of assessing the contribution of inadequate sleep hygiene in maintaining a preexisting sleep disturbance cannot be overemphasized."[2] In the ICSD-R, the diagnosis inadequate sleep hygiene is classified as an extrinsic sleep disorder, code 307.41-1. To qualify for the diagnosis of inadequate sleep hygiene, an individual must first meet criteria for insomnia, and then exhibit one of the following behaviors:[2]
- napping twice or more per week
- having a variable sleep-wake schedule
- spending excessive time in bed
- exercising shortly before bedtime
- engaging in activities that induce intense emotion shortly before bedtime
- frequently using bed for non-sleep-related activities
- using an uncomfortable bed for sleeping
- creating a bedroom environment that is not conducive to sleep (e.g. too hot or cold)
- engaging in activities that require high concentration shortly before bedtime
- recurrent intense thinking once in bed (e.g. planning or reminiscing)
Practice of sleep hygiene and knowledge of sleep hygiene practices can be assessed with the Sleep Hygiene Index,[7] Sleep Hygiene Awareness and Practice Scale,[8] Sleep Hygiene Practice Scale,[9] or Sleep Hygiene Self-Test.[unreliable medical source?][10] For younger individuals, sleep hygiene can be assessed by the Adolescent Sleep Hygiene Scale or the Children’s Sleep Hygiene Scale.[11]
Recommendations
Clinicians choose among recommendations for improving sleep quality for each individual and counselling is presented as a form of patient education.[4][6]
Sleep schedule
One set of recommendations relate to the timing of sleep. As most adults need 7–9 hours of sleep each night,[6] a top recommendation is allowing enough time for sleep. Clinicians will more frequently advise that these hours of sleep are obtained at night instead of through napping, because while naps can be helpful after sleep deprivation, under normal conditions naps may be detrimental to nighttime sleep.[6] Negative effects of napping on sleep and performance have been found to depend on duration and timing, with shorter midday naps being the least disruptive.[4] Modifying a sleep schedule to involve regular sleep-wake times and a minimum of seven hours of sleep has been associated with improved well-being and alertness during the day. There is also focus on the importance of awakening around the same time every morning and generally having a regular sleep schedule.[12]
Activities
Exercise is an activity that can facilitate or inhibit sleep quality; people who exercise experience better quality of sleep than those that do not,[13] although exercising too late in the day can be activating and delay falling asleep.[4] Increasing exposure to bright and natural light during the daytime and avoiding bright light in the hours before bedtime helps promote a normal sleep-wake schedule by aligning a person's circadian rhythm with nature's daily light-dark cycle.[14]
Activities that reduce physiological arousal and cognitive activity promote falling asleep, so engaging in relaxing activities before bedtime is recommended.[12] Conversely, continuing important work activities or planning shortly before bedtime or once in bed has been shown to delay falling asleep.[6] Similarly, good sleep hygiene involves minimizing time spent thinking about worries or anything emotionally upsetting shortly before bedtime.[6] Trying purposefully to fall asleep has been found to induce frustration and further prevent falling asleep,[4] so in these situations a person may be advised to get out of bed and try something else for a brief amount of time.[6]
Generally, for people experiencing difficulties with sleep, spending less time in bed results in deeper and more continuous sleep,[4] therefore clinicians will frequently recommend eliminating use of the bed for any activities except sleep (or sex).[citation needed]
Foods and substances
A number of foods and substances have been found to disturb sleep, due to stimulant effects or disruptive digestive demands. Avoiding nicotine, caffeine (including coffee, energy drinks, soft drinks, tea, chocolate, and some pain relievers), and other stimulants in the hours before bedtime is recommended by most sleep hygiene specialists,[15][16] as these substances activate neurobiological systems that maintain wakefulness.[17] Alcohol near bedtime is frequently discouraged by clinicians, because, although alcohol can induce sleepiness initially, the arousal caused by metabolizing alcohol can disrupt and significantly fragment sleep.[12] Both consumption of a large meal just before bedtime, requiring effort to metabolize it all, and hunger have been associated with disrupted sleep;[4] clinicians may recommend eating a light snack before bedtime. Lastly, limiting intake of liquids before bedtime can prevent interrupted sleep due to necessary bathroom breaks.[4]
Sleep environment
Arranging a sleep environment that is quiet, very dark, and cool is recommended. Noises, light, and uncomfortable temperatures have been shown to disrupt continuous sleep.[14][18] Other recommendations that are frequently made, though less studied, include selecting comfortable mattresses, bedding, and pillows,[4] and eliminating a visible bedroom clock, to prevent focusing on time passing when trying to fall asleep.[4]
Research
No two sleep hygiene studies use identical sets of sleep hygiene recommendations.[6] There is an imbalance in the popularity of sleep hygiene recommendations in proportion to the amount of evidence supporting the recommendations.[12] The strength of research support for each recommendation varies; some of the more robustly researched and supported recommendations include the effects of noisy sleep environments, alcohol consumption in the hours before sleep, cognitive demand of pre-bedtime activities, and purposeful attempts to focus on falling asleep.[4] There is a lack of evidence for the effects of certain sleep hygiene recommendations, including the under-established effects of comfortable mattresses, visible bedroom clocks, making a worry list, and limiting liquids.[4] Other recommendations may have a greater research evidence base, but have more complicated findings, such as the effects of napping or exercise. The effects of napping, for example, seem to depend on the length and timing of napping, in conjunction with how much cumulative sleep an individual has had in recent nights, but effects are still variable.[12]
Most research on sleep hygiene principles has been conducted in clinical settings, and there is a need for more research on non-clinical populations.[12]
There is support showing positive sleep outcomes for individuals that use several sleep hygiene recommendations together.[4] Because of this, it is suggested that sleep hygiene recommendations are not to be absolutely and blindly followed as rules, but rather explored with each person to determine best recommendations for the individual.[4][6]
In special populations
Sleep hygiene is a central component of treatment for insomnia.[19] Sleep hygiene recommendations has been shown to reduce or eliminate the symptoms of insomnia. Specific sleep disorders may require additional treatment approaches. Continuing difficulties with sleep may require additional assistance from healthcare providers.[20]
College students have been identified as being at risk of engaging in poor sleep hygiene and also of being unaware of how the resulting sleep deprivation affects them.[21] In general, because of irregular weekly schedules and the campus environment, college students are more likely to have variable sleep-wake schedules across the week, take naps, drink caffeine and/or alcohol near bedtime, and sleep in disruptive sleeping environments.[21] Because of this, it is important to have sleep hygiene education on college campuses.[21]
Similarly, shift workers have difficulty maintaining a healthy sleep-wake schedule due to irregular job hours.[22] Shift workers need to be strategic about napping and drinking caffeine, as these practices may be necessary for work productivity and safety, but should be timed carefully. Because shift workers may need to sleep while other individuals are awake, additional sleeping environment changes should include reducing disturbances by turning off phones and posting signs on bedroom doors to inform others when they are sleeping.[22]
Due to symptoms of low mood and energy, individuals with depression may be likely to have behaviors that are counter to good sleep hygiene, such as taking naps during the day, consuming alcohol near bedtime, and consuming large amounts of caffeine during the day.[23] In addition to sleep hygiene education, bright light therapy is a particularly useful treatment approach for individuals with depression. Not only can bright light therapy help establish a more normal sleep-wake schedule, but it also has been shown to be effective for treating depression directly, especially when related to seasonal affective disorder.[24]
Individuals with any type of breathing difficulties – due to asthma or allergies – may need to make special changes to their bedroom environment. Difficulties with breathing while sleeping reduce ability to stay asleep and to get restful sleep;[unreliable medical source?][25][26] it is therefore important to consider how to reduce allergy or asthma triggers. This might include purchasing hypoallergenic bedding, not allowing pets in the bedroom, using de-humidifiers, and especially avoiding exercise in the hours before bedtime.
Individuals who experience chronic or situational physical pain have to be particularly careful about consumption of medications and substances.[full citation needed][27] Many pain-relieving substances – ibuprofen, intense pain killers, alcohol – have chemical effects that can induce either sleepiness or wakefulness, and therefore individuals managing pain should consider the timing of these medications.[citation needed]
See also
References
- ^ van der Heijden, KB; Smits, MG; Gunning, WB (March 2006). "Sleep hygiene and actigraphically evaluated sleep characteristics in children with ADHD and chronic sleep onset insomnia". Journal of Sleep Research. 15 (1). European Sleep Research Society: 55–62. PMID 16490003.
- ^ a b c The International Classification of Sleep Disorders, Revised 2001. p. 74.
- ^ Benca, Ruth M (March 2005). "Diagnosis and treatment of chronic insomnia: a review". Psychiatr Serv. 56 (3): 332–43. doi:10.1176/appi.ps.56.3.332. PMID 15746509.
- ^ a b c d e f g h i j k l m n o p Hauri., P. (2011). Sleep/wake lifestyle modifications: Sleep hygiene. In Barkoukis TR, Matheson JK, Ferber R, Doghramji K, eds. Therapy in Sleep Medicine. Elsevier Saunders, Philadelphia, PA. pg 151-160
- ^ Gigli, Gian Luigi; Valente, Mariarosaria (30 June 2012). "Should the definition of "sleep hygiene" be antedated of a century? A historical note based on an old book by Paolo Mantegazza, rediscovered". Neurological Sciences. 34 (5): 755–760. doi:10.1007/s10072-012-1140-8. PMID 22752854.
- ^ a b c d e f g h i Stepanski, Edward J; Wyatt, James K (June 2003). "Use of sleep hygiene in the treatment of insomnia". Sleep Medicine Reviews. 7 (3): 215–225. doi:10.1053/smrv.2001.0246. PMID 12927121.
- ^ Mastin, D. F., Bryson, J., & Corwyn, R. (2006). Assessment of sleep hygiene using the Sleep Hygiene Index. Journal of behavioral medicine, 29(3), 223-227. PMID 16557353.
- ^ Lacks, P., & Rotert, M. (1986). Knowledge and practice of sleep hygiene techniques in insomniacs and good sleepers. Behaviour research and therapy, 24(3), 365-368. PMID 3729908.
- ^ Yang CM, Lin SC, Hsu SC, Cheng CP. Maladaptive sleep hygiene practices in good sleepers and patients with insomnia. J Health Psychol 2010;15:147–55. PMID 20064894
- ^ [unreliable medical source?] Blake DD, Gomez MH: A scale for assessing sleep hygiene: Preliminary data. Psychol Rep 1998, 83:1175-1178. PMID 10079712
- ^ Lewandowski AS, Toliver-Sokol M, Palermo TM (2011). "Evidence-based review of subjective pediatric sleep measures". J Pediatr Psychol. 36 (7): 780–93. doi:10.1093/jpepsy/jsq119. PMC 3146754. PMID 21227912.
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ignored (help)CS1 maint: multiple names: authors list (link) - ^ a b c d e f Irish, Leah A.; Kline, Christopher E.; Gunn, Heather E.; Buysse, Daniel J.; Hall, Martica H. (October 2014). "The role of sleep hygiene in promoting public health: A review of empirical evidence". Sleep Medicine Reviews. doi:10.1016/j.smrv.2014.10.001. PMID 25454674.
- ^ Driver, Helen S.; Taylor, Sheila R. (August 2000). "Exercise and sleep". Sleep Medicine Reviews. 4 (4): 387–402. doi:10.1053/smrv.2000.0110. PMID 12531177.
- ^ a b Czeisler, C. A.; Gooley, J. J. (January 2007). "Sleep and Circadian Rhythms in Humans". Cold Spring Harbor Symposia on Quantitative Biology. 72 (1): 579–597. doi:10.1101/sqb.2007.72.064.
- ^ Sin, Celia WM; Ho, Jacqueline SC; Chung, Joanne WY (January 2009). "Systematic review on the effectiveness of caffeine abstinence on the quality of sleep". Journal of Clinical Nursing. 18 (1): 13–21. doi:10.1111/j.1365-2702.2008.02375.x. PMID 19120728.
- ^ Jaehne, Andreas; Loessl, Barbara; Bárkai, Zsuzsanna; Riemann, Dieter; Hornyak, Magdolna (October 2009). "Effects of nicotine on sleep during consumption, withdrawal and replacement therapy". Sleep Medicine Reviews. 13 (5): 363–377. doi:10.1016/j.smrv.2008.12.003. PMID 19345124.
- ^ Boutrel B, Koob GF (2004). "What keeps us awake: the neuropharmacology of stimulants and wakefulness-promoting medications". Sleep. 27 (6): 1181–94. PMID 15532213.
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ignored (help) - ^ Xie H, Kang J, Mills GH (2009). "Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units". Crit Care. 13 (2): 208. doi:10.1186/cc7154. PMC 2689451. PMID 19344486.
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: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link) - ^ [unreliable medical source?] Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW (2004). "Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison". Arch. Intern. Med. 164 (17): 1888–96. doi:10.1001/archinte.164.17.1888. PMID 15451764.
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ignored (help)CS1 maint: multiple names: authors list (link)}} - ^ Running on Empty: Fatigue and Healthcare Professionals: The Consequences of Inadequate Sleep. NIOSH: Workplace Safety and Health, August 2, 2012
- ^ a b c [unreliable medical source?] Brown, Franklin C.; Buboltz, Walter C.; Soper, Barlow (January 2002). "Relationship of Sleep Hygiene Awareness, Sleep Hygiene Practices, and Sleep Quality in University Students". Behavioral Medicine. 28 (1): 33–38. doi:10.1080/08964280209596396. PMID 12244643.
- ^ a b Åkerstedt, T. (1998). Shift work and disturbed sleep/wakefulness. Sleep Medicine Reviews, 2(2), 117-128.
- ^ [unreliable medical source?] Doghramji, K. (2003). Treatment strategies for sleep disturbance in patients with depression. Journal of Clinical Psychiatry, 64, 24-29. PMID 14658932.
- ^ [unreliable medical source?] Loving RT, Kripke DF, Shuchter SR. Bright light augments antidepressant effects of medication and wake therapy. “Depress Anxiety” 2002;16:1–3. PMID 12203667.
- ^ [unreliable medical source?] Léger, D., Annesi-Maesano, I., Carat, F., Rugina, M., Chanal, I., Pribil, C., ... & Bousquet, J. (2006). Allergic rhinitis and its consequences on quality of sleep: an unexplored area. Archives of internal medicine, 166(16), 1744-1748. PMID 16983053
- ^ [unreliable medical source?] Vir, R., Bhagat, R., & Shah, A. (1997). Sleep disturbances in clinically stable young asthmatic adults. Annals of Allergy, Asthma & Immunology, 79(3), 251-255. PMID 9305233
- ^ Lavigne, G. (2003). Sleep and Pain. “sleepmatters”
External links
- Healthy Sleep
- University of Maryland Medicine Sleep Hygiene
- How to Get Kids to Sleep More – New York Magazine article by Ashley Merryman
- Australian fact sheet on sleep hygiene, PDF
- Sleep Hygiene Tips from the National Sleep Foundation