Sleep hygiene

Recommend and optimize appropriate sleep hygiene and nonpharmacologic therapies for the management and prevention of sleep disorders. 

Management includes identifying the cause of insomnia, education on sleep hygiene, stress management, monitoring for mood symptoms, and elimination of unnecessary pharmacotherapy. 

Transient and short-term insomnia should be treated with good sleep hygiene and careful use of sedative-hypnotics if necessary. 

Behavioral and educational interventions that may help include shortterm cognitive behavioral therapy, relaxation therapy, stimulus control therapy, cognitive therapy, sleep restriction, paradoxical intention, and sleep hygiene education (Table 72-3). 

Good sleep hygiene, as well as two or more brief daytime naps daily (as little as 15 minutes), should be encouraged. 

Sleep disturbances are common in the elderly. These disturbances are often secondary to medical illness and/or medication use (Martin et al. 2000). Illnesses could be anxiety disorders or any illness that may disturb sleep due to pain or nocturia. Medications that may cause sleep disturbances are e.g. beta-blockers, corticosteroids and SSRIs. If the sleep disturbance is secondary the treatment should be focused on the underlying cause. If there is no such cause the sleep disturbance is said to be primary. First-line treatment should then be improvement of sleep hygiene (Box 4.1). 

Sometimes bad sleep habits develop during the period of stress. This is termed poor sleep hygiene and it may consist of taking daytime naps, drinking a nightcap, or engaging in other behaviors that ultimately interfere with quality nighttime sleep. When such bad sleep habits persist after the initial stress has passed, then a vicious cycle of anxious anticipation and ever-poorer sleep may arise. 

Acute Phase Treatment. Hypnotic medications are useful for short-term treatment of insomnia, but they should always be accompanied by behavioral and psychoeducational treatments, including a review of good sleep hygiene practices. It may also include more aggressive measures such as relaxation training, sleep restriction therapy, and stimulus control therapy. 

Whichever sedative-hypnotic agent is selected, the following guidelines can help ensure a safe and effective treatment. Use the minimal therapeutic dose at first to decrease possible hangover effects. Consider using the medication on an as-needed basis if the insomnia is intermittent, and after 2-4 weeks attempt a trial off medication to see if it is still required. Many individuals with chronic insomnia will relapse after a 14-28 day trial of treatment, but this time frame also affords an opportunity to implement sleep hygiene improvements. 

Though this book focuses on pharmacotherapy, we would be remiss if there was not some mention of sleep hygiene. The goal of sleep hygiene is to provide an environment that is maximally conducive to the onset and sustaining of sleep for the desired time period in bed. General principles include ... 

Sleep problems can cause considerable difficulty in and of themselves and can also exacerbate and be exacerbated by other psychiatric and behavioral problems in individuals with MR. The Expert Consensus Panel (Rush and Frances, 2000) recommended sleep hygiene... 

Appropriate sleep hygiene techniques should always be considered and, when possible, used in lieu of pharmacotherapy. When medication is given, such nonpharmacological approaches may significantly decrease the amount and duration of drug exposure. Sleep therapies include the following ... 

Sleep hygiene education emphasizes alterations in lifestyle, such as the following ... 

Good sleep hygiene and what constitutes normal sleep... 

Bedtime Routine and Sleep Hygiene. Sleep-Deprivation.com. Available online at http //www.sleep-deprivation.com/html/sleep-basics.php3. 

Transient insomnia lasts less than 3 d and usually is caused by a brief environmental or situational stressor. It may respond to attention to sleep hygiene rules. If hypnotics are prescribed, they should be used at the lowest dose and for only 2 to 3 nights. 

The question of causality can only be fully resolved with controlled studies that randomly control sleep duration. For short sleep, controlled trials of longterm prescription of hypnotics or long-term use of sleep hygiene, etc., may help us understand the causal role of sleep. Similarly, for those with long sleep, controlled restriction of sleep or time-in-bed may help clarify the causal pathways. 

Holbrook MI, White MH, Hutt MJ. Increasing awareness of sleep hygiene in rotating shift workers arming law-enforcement officers against impaired performance. Percept Mot Skills 1994 79 520-522. 

Zarcone VP. Sleep hygiene. In Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine, 3rd ed. Philadelphia Saunders, 2000 657-651. 

Friedman L, Benson, K, Noda A, Zarcone V, Wicks DA, O Connell K, Brooks JO III, Bliwise DL, Yesavage, JA. An actigraphic comparison of sleep restriction and sleep hygiene treatments for insomnia in older adults. J Geriatr Psychiatry Neurol 2000 13 17-27. 

Hoch CC, Reynolds III CF, Buysse DJ, Monk TH, Nowell P, Begley AE, Flail F, Dew MA. Protecting sleep quality in later life a pilot study of bed restriction and sleep hygiene. J Gerontol 2001 56B P52-P59. 

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