Clinical manifestations

Presentation and course

Inadequate sleep hygiene may be transient, intermittent, or chronic with insomnia usually being the presenting symptom. The patient may present with variable latencies to sleep onset and sleep maintenance difficulties, irregular sleep patterns with variable wake up times, or inappropriate daytime napping.

Excessive daytime sleepiness can be seen, usually as a secondary effect, along with mild mood disturbance, fatigue, difficulty with concentration, and irritability, as can be found with any disorder affecting the quality or quantity of sleep at night or causing irregularities in sleep-wake cycling.

Table 1. Common Contributing Factors Constituting Inadequate Sleep Hygiene

Dietary
	Caffeine Alcohol Tobacco Going to bed hungry or thirsty
Psychological
	Evening stress Obsessive clock-watching
Behavioral
	Late-night social engagements Atypical or intermittent late evening/nighttime exercise Watching television or using electronic devices near bedtime or in bed Browsing Internet Other activities in bed unrelated to sleep or sex (ie, eating, reading, etc.)
Environmental
	Pets Poorly regulated room temperature Uncomfortable mattress Excessive light (including from electronic devices) Excessive noise
Circadian
	Inappropriate napping Variable bedtimes and wake times

Usually, a combination of factors is needed, any one of which might be considered acceptable behavior in most people. Children may also develop inadequate sleep hygiene if parents/caretakers do not set appropriate limits to the components of sleep hygiene, including caffeine intake, inappropriate naps, use of electronics too close to bedtime, inconsistent wake and sleep times, or bedtime routines.

Problematic sleep practices can be pervasive across sleep disorders, particularly insomnia. Poor sleep hygiene, such as smoking and increased use of alcohol before bedtime, increased naps, and sleeping in on days when not working, was noted in a study of a group of 258 individuals with insomnia (26). In a longitudinal survey among 2076 Swedish community-dwellers, late evening nicotine use was significantly associated with concurrent insomnia at initial evaluation, and an irregular sleep schedule predicted the persistence of insomnia at 1-year follow up (25). Objective measures of tobacco exposure correlated with poorer sleep quality in one study (60). Nicotine and alcohol use within four hours of bedtime were associated with increased sleep fragmentation on actigraphy and sleep diaries in one study in African American adults (52).

Older adults experience high rates of insomnia, especially elderly nursing home residents (49). Among the nonpharmacologic treatments, sleep hygiene education is one of the easiest and most effective approaches as an initial step (47; 59).

Use of electronic devices and mobile phones has been shown to negatively affect sleep quality in college students. Bedtime mobile phone use significantly correlated with decreased scores in academic performance and sleep quality in one study (46).

Teenagers and adolescents are particularly vulnerable to poor sleep-related behaviors. In a large cohort of Italian high school students aged 17 years, 19% of girls and 11.6% of boys were found to have chronic sleep problems associated with inadequate sleep hygiene (33). Moreover, in young drivers, inadequate sleep hygiene is associated with increased motor vehicle accident rates (29; 43).

Children are not immune to poor sleep hygiene and its adverse effects. Two studies looked at predictors of sleep problems in healthy school-age children and adolescents and determined that poor sleep hygiene was a major cause of sleep problems in this age group (31; 53). With children, use of cell phones and other electronics before bed or after lights out not only reinforces bedtime resistance and sleep anxiety (20) but has also been associated with depression, obesity, and increased risk of substance abuse (08; 17). A study demonstrated that increased usage of social media in adolescents was associated with poorer sleep patterns (50). This effect is even seen in infants in whom screen media exposure leads to decreased total sleep duration (57) and in toddlers in whom electronic device usage was associated with increased sleep latency and decreased total sleep time (09). An epidemiological survey of 779 children (via parental questionnaire) showed hyperactivity and conduct problems are more common in children who exhibit bedtime resistance (07). Conversely, in a study with 385 adolescent children aged 13 to 18 years of age in South Australia, children with a parent-set bedtime were found to have earlier bedtimes, obtained more sleep, and experienced improved daytime wakefulness and less fatigue (51). Another Australian study demonstrated that a poor sleep hygiene in children was associated with a poorer quality of life, not only for themselves but for their caregiver as well (44). Use of media and caffeine before bedtime have also been shown to be associated with poor academic performance among adolescents (12).

Prognosis and complications

Assuming proper treatment, the prognosis is usually excellent. A study of Italian and American adolescents found sleep hygiene to be an important predictor of sleep quality (31). Another study of 632 young adults confirmed that sleep hygiene is strongly related to sleep quality and modestly related to perceptions of daytime sleepiness (34). When sleep hygiene is normalized, the sleep problems disappear quickly. If they do not, then other diagnoses must be considered. Without treatment, the course is less predictable. In some cases, there may be adaptation to the features of poor sleep hygiene. In one study, improper sleep scheduling in college students led to higher insomnia severity (19). One cross-sectional study of elementary school students demonstrated that electronic use and inconsistent bedtimes led to chronic poor sleep irrespective of socioeconomic status (56).

Clinical vignette

A 22-year-old university student presented to a clinic for evaluation of difficulty with sleep schedule for many years. He described his sleep-wake schedule as “30/20,” ie, alternating 30 hours of wakefulness with 20 hours of sleep. He described himself as a person who, in high school or even earlier, used to fall asleep in the early hours of the morning (usually at 3 am or 4 am) and was woken up by his mother at 6:30 am for school. He remembered sleeping 1 hour on the subway to and from school. He used to feel groggy and even took naps in classes. This problem persisted into his college years, when he usually missed his morning classes. At the time of presentation, he did not have classes, and he was a research assistant working on a project. During his 30 hours of wakefulness, he used two 17-inch monitors for work and drank caffeinated beverages. His roommates mentioned loud snoring with occasional witnessed apneas or mouth-breathing. His weight was 190 lbs and height was 5 feet 2 inches. His intra-oral exam revealed a prominent tongue with a low-lying palate. A baseline polysomnogram was ordered, which showed obstructive sleep apnea with apnea-hypopnea index (AHI) of 12.6, worse in supine position. The patient was diagnosed with delayed sleep phase type circadian rhythm disorder, poor sleep hygiene, and obstructive sleep apnea. Counseling was provided regarding these diagnoses; recommendations included chronotherapy (with light therapy and use of melatonin), sleep diary maintenance, improved sleep hygiene, and treatment with CPAP.

This case illustrates the complexities of evaluating excessive sleepiness in young adults. Treatment of the underlying sleep disorder may improve latency to sleep and help to consolidate sleep, thus minimizing the opportunity for inadequate sleep hygiene. Educating the patient is an important part of the treatment process.

Biological basis

Etiology and pathogenesis

Patients with inadequate sleep hygiene engage in specific behaviors that disrupt their sleep and increase arousal, which can cause sleep disturbances (01). These behaviors, which are often considered normal in moderation, can cause problems for susceptible individuals or when combined with other sleep-disrupting influences (06). Patients with inadequate sleep hygiene are particularly sensitive to stimulants like caffeine, alcohol, atypical exercise, and environmental disruptions like noise or light. Even minor variability in sleep schedules or daytime napping can also cause problems for these patients. Some individuals may be particularly intolerant of sleep loss due to physical or psychological illness, leading to maladaptive practices such as spending more time in bed or consuming alcohol at bedtime in a bid to hasten sleep latency.

Epidemiology

Women tend to have a higher prevalence of inadequate sleep hygiene, and subsequent excessive daytime sleepiness, especially in societies where they are employed full time and are responsible for most of the housework and childcare (13).

Cultural and regional factors also play a role in sleep hygiene. LeBourgeois and colleagues showed that Italian adolescents had better sleep hygiene and sleep quality than their American, age- and sex-matched, counterparts (30). Use of cell phones after lights out was found to be very high in Japanese adolescents, leading to disrupted sleep (39).

Sleep problems are also common among college students. In a study of students at a Hong Kong university, it was found that 57.5% of 400 university students were poor sleepers (54). Factors associated with the poor sleeper group included gender, year of study, sleep hygiene practices, and perceived inadequate sleep in the past month. A survey among a group of 628 collegiate athletes found that 42.4% of athletes identified as poor sleepers and 39.1% of athletes and 58.6% of sports teams reported mean weekday sleep duration of less than 7 hours (32).

As high as 90% of high school students get inadequate hours of sleep (fewer than 9 hours) on school nights, with 10% getting even less than 6 hours of sleep (41). In a cross-sectional study 56% of adolescents had poor sleep quality, with a higher prevalence in girls (63.1%) than in boys (44.5%), and sleep hygiene (Adolescent Sleep Hygiene Scale) was significantly worse in girls. Caffeine after dinner, increased technology time, and higher BMI were all associated with worse sleep (16).

Prevention

It is important to educate people about normal sleep patterns and habits that promote good sleep. This education should begin early in life with good sleep practices beginning ideally in the prenatal period or first six months of life (37). Although many factors can disrupt sleep, only those that cause problems need to be addressed. It is important to practice good sleep hygiene, but certain behaviors, such as drinking coffee before bed, napping occasionally, or studying in bed, may only disturb sleep in certain susceptible individuals or when multiple factors are present.

The challenge of changing ingrained "bad" sleep habits in our society's work and play practices can be hard. Therefore, it is crucial to begin treatment early when dealing with the development of insomnia or to start early education on good sleep habits. Table 2 gives a list of the main features of good sleep hygiene.

Table 2. Sleep Hygiene Guidelines

	• Creating and maintaining a consistent sleep schedule, which means going to bed and waking up at the same time every day, including weekends. Keeping a regular sleep-wake cycle helps regulate the body's natural sleep rhythms and promotes better quality sleep.
	• Aim for an adequate amount of sleep every night, which can vary from person to person. The American Academy of Sleep Medicine recommends that adults aim for at least 7 hours of sleep per night, whereas teenagers may need closer to 8 to 10 hours and younger children may need even more (11; 42). However, it is also important to listen to your body and determine your own personal sleep needs. Keeping track of your sleep patterns for a week can help you figure out how much sleep you need to feel rested and alert during the day.
	• Go to bed when you are sleepy. If you have difficulty falling asleep or wake up shortly after going to sleep, leave the bedroom and read quietly or do some other relaxing activity. Avoid overly bright lights as this can cue your wake cycle.
	• Develop sleep rituals before going to bed. Do the same things in the same order before going to bed to cue your body to slow down and relax.
	• Avoid stress and worries at bedtime. Address thoughts about the next day’s activities, concerns, or distractions earlier in the day. Certain activities, such as listening to soft music, reading, or taking a warm bath can help you wind down.
	• Use your bed for sleeping and sex only. Often, doing other activities in bed like watching TV, paying bills, or working initiates worries and concerns. Let your mind associate the bed with sleeping, relaxing, and pleasure.
	• Avoid heavy meals late in the evening; similarly, avoid going to bed hungry. A light snack, especially dairy foods, can help you sleep.
	• Reduce intake of caffeine and nicotine 4 to 6 hours before going to sleep. Stimulants interfere with your ability to fall asleep and progress into deep sleep.
	• Avoid alcohol 4 to 6 hours before bedtime. Although alcohol may initially make you feel tired and fall asleep faster, it can lead to fragmented sleep and worsen snoring and sleep apnea.
	• Exercise regularly. Regular exercise, even for 20 minutes, three times a week, promotes deep sleep. Finish exercising at least a couple of hours before you go to bed.
	• Avoid naps longer than 30 minutes and naps later in the day. Avoiding naps altogether will ensure that you are tired at night. Longer naps disrupt the body's ability to stay asleep.
	• Maintain a dark, quiet, and cool room to sleep in.
	• Use sleeping aids conservatively and avoid using them for more than 1 or 2 nights per month. Increased caution should be taken if taking sleeping pills in the setting of obstructive sleep apnea, as it can be a potentially dangerous combination.
	• Avoid screen time – electronic tablets, phones, TV, or computers – within 1 to 2 hours before bedtime. Use blue light filters when possible.

Differential diagnosis

It can be challenging to diagnose individual extrinsic sleep disorders as their symptoms can overlap with other sleep disorders. Moreover, inadequate sleep hygiene can also develop due to an underlying sleep disorder. Therefore, a thorough evaluation is necessary to identify the underlying cause of the sleep problem and develop an appropriate treatment plan. For example, in a study of 643 patients with a primary diagnosis of sleep apnea, 31% of patients had a concomitant sleep disorder with the most common being inadequate sleep hygiene (14.5%) (48).

In patients suspected of having inadequate sleep hygiene, other extrinsic sleep disorders must be considered including environmental, adjustment, and limit-setting sleep disorders, insufficient sleep syndrome, and insomnia associated with hypnotic, stimulant, or alcohol use (01). Similarities in presentation may also be seen with other sleep disorders, including circadian rhythm disorder-delayed sleep phase type or irregular sleep-wake pattern, psychophysiological insomnia, insomnia associated with psychiatric disorders (particularly the mood and anxiety disorders) and with medical disorders (particularly those associated with pain or discomfort), restless legs syndrome, periodic limb movement disorder, and the sleep apnea syndromes.

It is important to differentiate between inadequate sleep hygiene and other underlying sleep disorders, as there can be overlap in their symptoms. Although some patients with inadequate sleep hygiene may consume caffeine or alcohol or nap irregularly, if their behavior is excessive, they may require a diagnosis of stimulant- or alcohol-dependent insomnia or irregular sleep-wake pattern. Environmental factors such as an uncomfortable mattress, noise, or stress may contribute to sleep problems, but if they are severe enough to interfere with most people's sleep, then a diagnosis of an environmental sleep disorder may be appropriate. Persistent symptoms related to stress may require diagnoses such as chronic insomnia or anxiety disorders.

In young children who experience sleep disturbances due to inadequate sleep hygiene, it is important to consider the possibility of behavioral insomnia of childhood sleep-onset association type. This disorder is characterized by frequent nighttime awakenings and a requirement for the same sleep environment that was present when the child fell asleep. For example, if a parent rocks or cuddles with a child to fall asleep at the beginning of the night, the child may require the same parental presence with rocking and cuddling to be able to fall back to sleep during normal nighttime awakenings. Other sleep disorders such as circadian rhythm disorders, anxiety-related sleep disorders, and pain-related sleep disorders should also be considered and ruled out.

Diagnostic workup

The best way to diagnose inadequate sleep hygiene is with a thorough and detailed history. The examiner must be astute and cognizant of the many factors that are potential sleep disrupters. Not all daily habits and activities that can disrupt sleep for some individuals will necessarily have the same effect on others. The impact of these factors on sleep can vary depending on a person's susceptibility to sleep disruption. Therefore, it is important to identify and address individual factors that may be contributing to sleep disruption. Several instruments have been used to assess sleep hygiene including the Sleep Hygiene Self-Test (05), Sleep Hygiene Awareness and Practice Scale (28), Sleep Hygiene Index (34), and the Adolescent Sleep Hygiene Scale (31). Another scale targeting children and adolescents with headaches was validated to measure sleep habits in this population, Sleep Hygiene Inventory for Pediatrics (SHIP) (45).

Sleep charts or diaries help the patient and professional to sort out patterns over time. Administration of the Minnesota Multiphasic Personality Inventory, Beck depression inventory, Hamilton depression rating scale, or Hamilton anxiety rating scale may be useful as screening tools and may point to a need for formal psychiatric evaluation. Addressing home environment as well as possible family disorganization is helpful in assessing adolescent sleep habits and for the development of therapeutic interventions (04). Physical examination occasionally discloses unsuspected findings of medical illness or drug abuse. Otolaryngological and chest examinations should always be conducted if one of the sleep-apnea syndromes is suspected.

Laboratory tests are usually not required. Polysomnography is usually not necessary for the diagnosis of inadequate sleep hygiene; however, if performed it may show long sleep latencies, fragmented sleep, and early awakenings. Polysomnographic studies are recommended when the diagnosis is unclear or if expected treatment outcomes are not achieved (01). Sometimes, initial impressions may be incorrect, or another underlying disorder may be present. Disorders such as periodic limb movement disorder and obstructive or central sleep apnea can mimic insomnia, and a polysomnogram is needed to make a definitive diagnosis. If patients report excessive daytime sleepiness that is not in line with their sleep loss or that persists even after treatment, a multiple sleep latency test is recommended. In some cases, other neurophysiologic studies or imaging procedures may also be necessary for diagnosis.

Management

Management is generally directed at identifying and modifying the factors responsible for poor sleep hygiene. Often, patients are unaware of the importance or meaning of sleep hygiene; hence, education is key (06). In college students, one pilot study demonstrated not only improvement in sleep but also in mood and anxiety when students completed a formal course in sleep hygiene education (02). In another sample of 549 college students, those randomized to complete an online sleep education module, “Sleep to Stay Awake” (sleeptostayawake.org), had subjective improvement in sleep quality (33.3% of intervention group vs. 21.3% of controls), lower mean depression scores, and better overall sleep practices. The intervention group also reported less frequent partial all-night study sessions and 3-fold increase in earlier cessation of evening electronic use (22).

In cases where poor sleep hygiene practices have resulted in the development or persistence of insomnia, simply addressing these behaviors may not be enough to effectively treat the condition. According to a systematic review and meta-analysis, cognitive behavioral therapy for insomnia was found to be significantly more effective than sleep hygiene education in improving sleep-onset latency, wake after sleep onset, sleep efficiency, and subjective sleep quality in individuals with comorbid insomnia (10). Furthermore, cognitive and behavioral interventions were shown to improve subjective sleep quality and sleep duration in patients who did not have a concurrent sleep disorder diagnosis (40).

An afternoon nap, a cup of coffee with dinner, an evening martini, and variably late wake-up times may all seem appropriate as patients deal with (and unwittingly cause) nighttime insomnia. Giving up some of these habits may not be easy for all patients; some individuals may require careful guidance, close follow-up, gradual modification, and sometimes temporary hypnotics.

Some useful general strategies include a scheduled "worry time," progressive relaxation, biofeedback, meditation, sleep restriction, and stimulus control. Such practices aim to minimize frustration associated with attempts to fall asleep and "recondition" the patient to a positive association of seeking repose in bed.

Outcomes

In the absence of comorbid sleep disorders, such as chronic insomnia, sleep hygiene education alone may be as effective as more complicated and difficult therapies in correcting counterproductive sleep-related behaviors (15). If symptoms are not severe, and if the cause is expected to be transient, reassurance and time may be sufficient therapy. Sleep hygiene is a safe therapeutic intervention and can be beneficial in any age group and is a good alternative in conjunction with other behavioral treatments for the elderly population (24). Sleep education improved sleep duration in a randomized controlled pilot study of adolescents (27). It has even been shown to help alleviate some of the sleep complaints in patients with degenerative neurologic illnesses such as Parkinson disease (18) or Alzheimer disease (35). A study of 27 children with ADHD taking stimulant medication found that combined sleep hygiene and melatonin therapy was a safe and effective treatment for sleep-onset insomnia (58). Improving sleep hygiene, in addition to behavioral techniques, improved attention deficit hyperactivity disorder (ADHD) symptoms, quality of life, and sleep quality in children with ADHD (23) and showed improved sleep quality in patients with substance abuse disorders (38). Providing a comfortable sleeping environment along with sleep education to parents improved sleep in socioeconomically disadvantaged children (36).

Sleep hygiene can have an impact on other chronic health problems as well. Poor sleep hygiene and sleep deprivation was shown to be associated with higher risk of hypertensive heart disease (14). Another study showed that mothers with higher levels of fatigue, poor sleep quality, and low resilience levels were at high risk of developing postpartum depression (03).

Special considerations

Pregnancy

Although there is currently no direct evidence linking sleep disorders resulting from poor sleep hygiene to adverse outcomes in pregnancy or fetal development, it is possible that the fatigue and stress associated with ongoing sleep disruption could impact sympathetic tone, endocrine function, and circadian rhythm, ultimately leading to negative effects on both the mother and fetus. Additionally, there may be indirect effects to consider, such as the potential for a tired woman to be less inclined to avoid alcohol, sleep aids, and excessive caffeine consumption.

It is important to note that pregnancy itself can also cause sleep disturbances due to physical discomfort, hormonal changes, and decreased bladder capacity. These factors can lower a woman's threshold for, or exacerbate the effects of, poor sleep hygiene. A study has demonstrated that pregnant women in their third trimester who had inadequate sleep hygiene reported worse subjective sleep quality (55).

Anesthesia

There are no data that inadequate sleep hygiene has a major impact on anesthetic considerations. Increased arousal thresholds, as may occur with sleep loss, could affect estimation of anesthesia depth and possibly alter dose requirements.