Sleep Hygiene (Healthy Sleep Habits)
Part 2 of a Multipart Series on Sleep by William M. DeMayo, MD
In the first article (Insomnia, The Lack of Restful Sleep), I discussed the importance of identifying insomnia as well as the effect it can have exacerbating pain and, impairing function (especially in the polio survivor). It stressed the importance of quality of sleep (amount of deep sleep) as well as quantity of sleep (total duration of sleep). In this article we will focus on “Sleep Hygiene” or “healthy sleep habits”. Sleep Hygiene has the goal of improving both.
In understanding the importance of Sleep Hygiene, it is essential to look at sleep as a trained behavior. While many factors can influence sleep, we will be looking at sleep from the behavioral perspective as an activity that can be modified by changing habits. As an example, if someone works the graveyard shift at night they can train themselves to sleep during the day. In order to make this work well, they will need to take several steps to intentionally modify their lifestyle and environment. In the same way all of us can improve our total duration of sleep and how much deep sleep we get each evening. Other factors such as pain, family/environmental, and other issues are not changed as easily. For purposes of this article, we will focus on the factors that are under our control. As mentioned in Part I, you may want to consider a sleep diary or an activity monitor (e.g., Fitbit) to track how your habits affect your sleep.
The following are routine tips on behaviors that will facilitate a healthy sleep:
Set a specific bedtime and wake time.
Without budgeting eight hours for sleep it is impossible to achieve this goal. I once heard it said, “Those who fail to plan, plan to fail”. Not setting a goal is a surefire way of not reaching it.\
Establish a specific bedtime routine.
Perform activities such as bathing, dressing for bed, and relaxation in a specific order, exactly the same each night. This will trigger a “trained response” letting your body know it is almost time to sleep before you even get in bed.
Avoid activities such as watching TV, reading, or talking on the phone during your bedtime routine.
Be sure your bedroom is an environment conducive to peaceful sleep.
The room should be dark and quiet and temperature should be comfortable/cool. Avoid activities such as watching TV, reading, or even having stressful conversations in the bedroom so that it can be a room that is associated with peacefulness.
Be sure your mattress and pillow are comfortable.
If your mattress is worn, then consider a new mattress. Firmness of mattress and pillows is a very individual choice, so be sure your selection meets your needs. Also consider trying a firm body pillow-this will support you in a side lying position with your feet, knees, and hips at the same level while preventing rotation of the spine. The arm can be draped over the top of the pillow and leaning over the pillow can shift some of one’s weight onto the chest, further improving comfort and facilitating deep sleep.
Avoid any stimulating activity between bedtime and wake time.
Activities such as reading, watching TV, or using a computer/cell phone in the middle the night will stimulate the brain and train the individual to be more likely to wake up again the next night.
Consider the analogy of training a dog to be housebroken. If the dog does the opposite of the trained behavior and soils the carpet, one would never try to make the animal feel better and give him a doggy treat. This would obviously encourage the undesired behavior. Similarly, any stimulating activity during sleep time should be considered a “reward” for being awake and should be avoided.
Caffeine (coffee, tea, soft drinks, chocolate, etc.) as well as nicotine and alcohol should be avoided for several hours prior to sleep. The side effect of medication(s) should also be considered.
Nicotine and alcohol can sometimes help induce sleep but ruin the quality of sleep and lead to nonrestorative sleep by reducing deep sleep.
Many prescription sleep medications also reduce deep sleep and are approved for short term use only. Ask your physician and pharmacist about all your medications and how they affect quality of sleep with chronic use.
Address hyperactive bladder or prostate problems that can lead to awakenings at night and ruin the quality of sleep. (Discuss this with your physician).
Exercise during the day to improve quality of sleep at night. Some professionals believe that exercise prior to bed, can impede a deep sleep. Newer research calls this into question.
Always avoid daytime naps unless you are sleeping, 7-8 hours at night without interruption.
Napping during the day can reduce fatigue in the short term yet disturb sleep quality at night and even lead to nighttime awakenings.
Physical rest without napping can also address daytime fatigue without adversely affecting nighttime sleep.
Do not lay awake in bed for more than 15 minutes.
As we consider our training model for sleep, our bed/ pillow should be our “command” and should be followed promptly by the “response” of sleep. Lying in bed for prolonged periods of time associates the bed/pillow with being awake and disassociates the “command-response” reflex. Consider taking a well-trained dog for a walk every day and repeating the command to “sit” without stopping to allow the dog to comply. After this is done several times, the dog is not likely to respond appropriately to the same command when you actually do want him to sit.
If unable to sleep within 15 minutes, one should get out of bed and sit quietly but avoid any stimulating activities (as listed above). This would be a good time to utilize relaxing sounds, aromatherapy, or meditation until one is able to return to bed and quickly fall asleep.
Remember that falling asleep quickly after sitting elsewhere will immediately reassociate the bed/pillow with sleep and increase the chances of falling asleep quickly the next night. This is very different than the phenomenon experienced by most people with sleep difficulties who lie down and mentally say “here we go again” expecting to lay awake.
Consider how to minimize the impact of stress on sleep.
Emotional and spiritual relaxation is extremely important prior to sleep. It is obvious that watching a horror movie before sleep will negatively impact sleep yet not quite as obvious that the opposite is also true and peacefulness prior to sleep can dramatically improve sleep.
The concept of a “Emotional and Spiritual Shower” can be helpful. After working in the garden or on one’s car, no one would hop into a clean bed without taking a physical shower. In the same way, we should avoid dragging our daytime stress into bed with us. Just 10 minutes of peacefulness before getting to bed can make a dramatic difference.
Peaceful relaxation is very different than distraction. Many individuals will use the term “winding down” with regard to activities such as watching TV, computer use, or reading prior to bed. These activities can be helpful but are very different than peaceful relaxation and should be done before the bedtime routine and not be part of the routine. Peaceful relaxation is very individual in nature but may include:
Prayer/Scripture-Preferably used as a mantra and repeated the same way multiple times each evening. Reading a scripture passage for the first time or praying for a family member with cancer just prior to sleep can negatively impact quality of sleep and should be considered at other times of the day.
Peaceful sounds-Relaxation tapes/CDs can be used relaxation apps on smart phones (consider “Relaxing Melodies”, “Relax”, or many others in your app or favorite CD store).
Aromatherapy-Lavender can be helpful inducing a deep sleep.
Other relaxation techniques-consider discussing with a trained psychologist. That being said, counseling is often focused on long-term issues to reduce chronic daytime stress with little attention focused on eliminating the stress prior sleep (a much more obtainable short term goal). If you are currently seeing a counselor, I would recommend specifically asking about “Sleep Priming”.
Improving your Sleep Hygiene is likely to improve sleep quality and quantity for nearly anyone. Some individuals may have underlying sleep disorders. Examples would be Obstructive Sleep Apnea, Central Sleep Apnea, and Periodic Leg Movement Disorder. (We hope to discuss these in another article).
It is important to remember that individuals with underlying sleep disorders almost always develop bad sleep habits and treatment of the underlying diagnosis may not improve sleep until Sleep Hygiene also improves.