SLEEP HYGIENE OVERVIEW

1. The bedroom and its environment are important in treating patients complaining of chronic Insomnia. The room should be physically comfortable and should always be associated with sleep. Chronic insomniacs have a tendency to move non-bedroom activities into the bedroom to bide time until they get sleepy. For example, watching television, balancing the checkbook or doing work brought home from the office are not functions associated with falling to sleep. Watching television in bed is also something that may actually disturb sleep and it is important to emphasize the bedroom should have an immediate association with the objective of going to sleep and all activities such as the above should be moved out of the bedroom so that the room itself will be associated with the act of going to bed and falling to sleep. In addition, the room temperature should be kept at a comfortable level and a slight cool temperature is preferred to one that is over warm.

2. A regular sleep/wake schedule is important. It appears that maintaining a regular time of rising in the morning is important as excessive long times in bed (sleeping in on the weekend) seems to fragment and disturb sleep subsequently, over the next few days. Since a sleep/wake cycle is a biologic rhythm, it follows that maintaining a regular sleep/wake schedule tends to stabilize this rhythm. A patient complaining of chronic insomnia should target a going to bedtime and getting up time, on an extremely regular basis when attempts are made to treat problem insomnia.

3. Exercise on a regular basis appears to benefit and the best timing of such exercise would be in the afternoon or early evening at least 3 hours before going to bed. Exercise in the late evening is not as effective and exercise immediately before bed may actually disturb sleep.

4. Evening Bathing/Shower - Recent studies have demonstrated that when the body temperature is dropping, it is easier to initiate sleep. Consequently, it may benefit patients with insomnia to take a hot shower, steamy bath or shower 3 to 4 hours before bedtime. This increases the body temperature slightly and the subsequent fall in body temperature appears to ease falling to sleep.

5. Diet and Medications which Influence Sleep:

A. Caffeine and caffeine-like substances are stimulants and there is a broad variability over which individuals react to these stimulants. Coffee, teas, and even chocolate include substances that can cause prolonged stimulation. In addition, colas such as Coca-Cola and Pepsi-Cola as well as other colas include a significant amount of caffeine and even Decaf coffee and decaffeinated colas may have some caffeine substances and should be avoided. Again, sensitivity of individuals is quite variable and it is probably advisable to avoid all substances that may include caffeine. Please note that some over-the counter medications include stimulants such as caffeine, some examples are Excedrin, Anacin, and others (please check the label of over-the-counter medications). lf non—prescription medications are used routinely, it is important to ascertain as to whether stimulants are included in the medication preparation.

B. Alcohol has been used for centuries to induce sleep. In actuality alcohol disturbs sleep increasing fragmentations and may well cause insomnia. Although it may promote the initial onset of sleep, there appears to be an excitatory phase several hours later that may often wake the individual and even with no clear cut awakening, sleep studies have demonstrated significant sleep fragmentation and consequently when treating chronic insomnia, alcohol should be meticulously avoided.

C. Over-the-counter sleeping medications may actually potentate insomnia by several mechanisms. Hypnotic medications available by prescription may have short- term benefit for people who have trouble falling asleep. However, the chronic use of sleeping medication may use long-term problems. By their very nature, these medications will produce a tolerance to their effect and sleep medications for chronic insomnia problems should be administered under the direct supervision of a sleep specialist.

D. Hunger may disturb sleep and a light snack before bedtime may help induce sleep.

Some foods that may help are those that contain tryptophan such as:

•Cheddar cheese with crackers

•Cottage cheese

•A glass of milk (warm or cold)

•Oats and dates

•Bananas

•Yogurt

•Sunflower, pumpkin, and sesame seeds

E. Individuals who have difficulty falling asleep often feel frustrated because of the problem. It sometimes helps to attempt not to try harder to fall asleep and therefore, worsen the pressure and frustration associated with sleep. The harder one tries and one actually sleeps less. The following approach is sometimes helpful to avoid this pattern. Establish a regular sleep pattern and rise the same time each morning, whether sleep has been refreshing or not. Use the bed for sleeping, do not read, do not watch TV, and do not do your checkbook, etc. If unable to fall asleep after one hour, get up, go to another room and the environment in this room should be quite and fairly dark. Do not engage in activities in that room which are not associated with sleeping and rest (watching TV, reading, etc.), Stay up until you are really sleepy and return to bed. lf sleep does not come easily, get out of bed once again and repeat the process by leaving the room. The objective is associating the bed and bedroom with falling asleep, quickly. In this scenario, even if there have been several hours out of bed, out of the bedroom before finally falling asleep; it is essential that the individual get out of bed at a designated time the following morning.

7. Medical disorders which may contribute to sleep difficulties should be evaluated. This includes associated heart and lung abnormalities, metabolic abnormalities including diabetes, abnormal thyroid function test as well as problems that cause frequency in urination or bowel activity.

8. For some individuals, relaxation techniques (biofeedback, stress management approaches, insomnia support groups) may be helpful and should be considered under the advisement of the sleep specialist.

John Penek, M.D., FCCP, FAASM

Medical Director, Sleep Health Institute