Sleep Hygiene

• J is a 47 year old man who presents with about 4 month difficulty falling asleep and maintaining sleep.

• Concerned about ability to maintain work performance in face of mounting daytime fatigue.

• It all started after several people in his company laid off. He started working overtime often till late.

• Postponed his 20 minute jog on treadmill to 30 mts prior to bedtime.

• He stopped sleeping at fixed times to assist with kids homework.

• Due to stress he started drinking about 500 ml of wine prior to bedtime.

• However, things got worse and to stave off fatigue, he started drinking 7 cups of coffee per day.

• He now gets anticipatory anxiety about sleep and to stave off anxiety, he now smokes and watches TV in bed.

• Since two weeks using ambien to help him fall asleep which is helping somewhat but his sleep is still not what it was

How would you treat the patient

• Increase Ambien?

• Ambien CR?

• Trazodone?

• Seroquel?

• Remeron?

• All of the above by trial and error and methylphenidate/provigil?

• Other

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Pharmacologic treatment• Can have serious side effects that far outweigh their benefits

• Is only moderately effective for insomnia and stops working over time

• Strengthen the belief that the cure for insomnia comes from external factors

• Can lead to physical or psychological dependency.

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CBT- Insomnia• Session 1: Sleep Education and Cognitive Restructuring for Insomnia

• Session 2: Sleep Medication Withdrawal and Sleep Scheduling Techniques

• Session 3: Stimulus Control Techniques

• Session 4: The Relaxation Response

• Session 5: Sleep Hygiene Techniques•

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• Although a number of factors may initially cause insomnia, treatment of chronic insomnia must focus not on the precipitating factors but on changing the thoughts and behaviors that play the main role in perpetuating insomnia.

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Insomnia

• - Inability to fall asleep

• -Inability to stay asleep

• - waking up too early

• - non restorative/ poor quality sleep

• -causes daytime impairment

Sleep Hygiene

• - All behavioral and environmental factors that precede sleep and may interfere with sleep

Inadequate sleep hygiene

• Insomnia associated with daily living activities that are inconsistent with maintenance of good quality sleep and full daytime alertness.

• these activities can be classified as

• - practices that produce increased arousal

• - practices that are inconsistent with principles of sleep organization

Practices that produce increased arousal• - caffeine, nicotine

•• -alcohol•• -stress, excitement, demanding mental activities•• -excessive physical activities

Practices inconsistent with sleep organization• - irregular sleep, wake timing

•• - day to day variation in sleep duration•• - spending too much time in bed•• -frequent napping

Associated features

• - contributes to mood and motivational disturbance

• -reduced attention, concentration

• - preoccupation with sleep difficulty

Prevalence

• - 1-2%, general

• - 5-10% sleep clinics

Diagnostic Criteria

• -Insomnia for at least one month

• -Inadequate sleep hygiene practices indicated by at least one of the above:

• Improper sleep schedule, daytime naps, excessive time in bed

• Alcohol, caffeine, nicotine at bedtime• use of bed for activities other than sleep

• Failure to maintain a comfortable sleep environment

• - not explained by any other sleep, medical or neurological disorder

Differential Diagnosis

• - Circadian rhythm disorder

• -Psychophysiologic insomnia

• -Environmental insomnia

• - Insomnia due to mental disorder

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Definitions• Sleep Onset Latency• Wake after sleep onset• Time in bed• Total sleep time

• Goal: Time in bed approximately equals total sleep time

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Work Up

• - History

• - Sleep Diary• http://www.sleepeducation.com/pdf/sleepdiary.pdf

• -Actigraphy

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Addressing Sleep Hygiene

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• ✔ Sleep diaries

A. Collect sleep diaries

B. Review sleep diaries and identify any areas of progress (sleep-onset latency, wake time after sleep onset, total sleep time, sleep meds) and review PSTs, total sleep time, time allotted for sleep, and arising time).

C. Review the rationale for sleep hygiene techniques. Sleep hygiene involves lifestyle practices that improve sleep. It also involves creating an optimal sleep environment.

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• Review the effects of alcohol on sleepA. Alcohol suppresses deep sleep and dream sleep and exacerbates snoring.

B. It also disrupts sleep by causing withdrawal effects that persist for up to four hours.

C. These effects will cause lighter, more fragmented sleep and increased awakenings.

D. For these reasons, alcohol use in the evening should be limited to two drinks and not after 7 p.m. (Because it takes about 1.5 hours to metabolize one ounce of alcohol, drinking more than two drinks later than 7 p.m. means that the alcohol will not be metabolized by bedtime and will still adversely affect sleep

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• Review the effects of caffeine on sleep.

1 Caffeine disrupts sleep because it produces stimulant effects (faster brain waves, heart rate, etc) that can persist for up to eight hours in sensitive people.

2 Excessive caffeine consumption during the morning and afternoon may result in addiction and caffeine withdrawal symptoms that can adversely affect sleep for longer than eight hours.

3 Consequently, caffeine should not be consumed after 3:00 p.m.; total daytime use should be limited to two cups.

4 Many beverages, foods, and medications contain caffeine: coffee, tea, colas, chocolates, and some analgesics.

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• Review the effects of exercise on sleep.

1 Moderate physical activity (lawn work, taking stairs instead of elevators, walking) and vigorous aerobic activity improve sleep by promoting a greater rise and fall in body temperature that persists for up to five hours. This greater rise and fall in temperature can make it easier to fall asleep and stay asleep.

2 The beneficial effect of exercise on sleep is greatest when exercise occurs within three to six hours of bedtime (because the drop in body temperature that occurs about three hours after exercise persists into sleep. Exercising closer than three hours to bedtime can make it harder to fall asleep because body temperature may be too elevated.

3 Exercise also improves sleep because it physically stresses the body. The body recovers from this stress by producing increased deep sleep.

4 Exercise also helps to ward off fatigue, has multiple health benefits, and improves sleep because it improves mood and reduces tension.

5 Try to engage in 20-30 minutes of physical activity at least every other day to improve sleep.

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• Review room temperature and baths.

1 A cooler bedroom will improve sleep by producing a drop in body temperature. In contrast, a warm room will inhibit the drop in body temperature and impair sleep. (Have a spouse or bed partner use an extra blanket if they prefer a warmer room).

2 A hot bath will also improve sleep by causing body temperature to rise and fall; the bath must be kept hot for 25 minutes and should be taken about two hours of bedtime (because body temperature does not rise as much from a bath, it falls sooner and therefore must be taken closer to bedtime).

3 The effect of a bath is not as great as the effect of exercise on sleep. However, it is a great way to relax before bedtime and a good substitute on days when you can't exercise.

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• Review bright light and sleep:

1 Bright light affects body temperature and sleep through its effect on the hormone melatonin (light inhibits melatonin, while darkness causes melatonin to be secreted).

2 To affect sleep, light must be at least 5000 luxes (room light is 500 luxes, sunrise is 10,000 luxes, and midday in summer is 100,000 luxes).

3 By reducing exposure to bright light, you may exacerbate sleep problems by disturbing the timing of the body temperature rhythm.

4 By increasing exposure to bright light in the early morning, body temperature will rise earlier and fall earlier at night, making it easier to fall asleep earlier. To increase early morning bright light (the closer to your arising time, the better), open the drapes early, and sit near eastern-exposed windows while reading the newspaper or having breakfast. Or, take an early morning walk outside.

5 Bright light in the evening delays the body temperature rhythm and reduces early morning awakenings by causing body temperature to rise later in the early morning. Thus, sit near western exposed windows, leave the drapes open, or take a walk in the evening to reduce early morning awakenings.

6 Commercial bright light boxes emit 5000-10,000 luxes of light, and are used for 30 minutes while reading the newspaper or working on a computer. They can be purchased online.

Patient Handout

•• 1. Don’t go to bed unless you are sleepy.

If you are not sleepy at bedtime, then do something else. Read a book, listen to soft music or browse through a magazine. Find something relaxing, but not stimulating, to take your mind off of worries about sleep.

• 2. Begin rituals that help you relax each night before bed. This can include such things as a warm bath, light snack or a few minutes of reading.

• 3. Get up at the same time every morning. Do this even on weekends and holidays.

• 4. Get a full night’s sleep on a regular basis. Get enough sleep so that you feel well-rested nearly every day.

• 5. Avoid taking naps if you can. If you must take a nap, try to keep it short (less than one hour). Never take a nap after 3 p.m.

• 6. Keep a regular schedule. Regular times for meals, medications, chores, and other activities help keep the inner body clock running smoothly.

Patient Handout

• 7. Don’t , write, eat, watch TV for long, talk on the phone, or play cards in bed.

• 8. Do not have any caffeine after lunch.

• 9. Do not have a beer, a glass of wine, or any other alcohol within six hours of your bedtime.

• 10. Do not have a cigarette or any other source of nicotine before bedtime.

• 11. Do not go to bed hungry, but don’t eat a big meal near bedtime either.

• 12. Avoid any tough exercise within five to six hours of your bedtime.You should exercise on a regular basis, but do it earlier in the day. (Talk to your doctor before you begin an exercise program.)

• 13. Avoid sleeping pills, or use them cautiously.Most doctors do not prescribe sleeping pills for periods of more than three weeks. Do not drink alcohol while taking sleeping pills.

• 14. Try to get rid of or deal with things that make you worry.If you are unable to do this, then find a time during the day to get all of your worries out of your system. Your bed is a place to rest, not a place to worry.

• 15. Make your bedroom quiet, dark, and a little bit cool.An easy way to remember this: it should remind you of a cave. While this may not sound romantic, it seems to work for bats. Bats are champion sleepers. They get about 16 hours of sleep each day. Maybe it’s because they sleep in dark, cool caves.

Tools available through Middlesex Hospital• CBT-I

• Actigraphy

• Sleep studies (for select circumstances)

Tools for insomnia• Apps: Pzizz sleep, Andrew Johnson, pranayama

• Monitoring: Jawbone, Fitbit one, sleep cycle.

• Sleep light

• www.cbtforinsomnia.com, Cleveland clinic : Go to sleep