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. According to 1 study of a group of 258 individuals with insomnia sufferers, they tend to engage in poor sleep hygiene, such as smoking close to bedtime and increased use of alcohol. They nap more and sleep in on days when not working (25). 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 (24). Objective measures of tobacco exposure correlated with poorer sleep quality in one study (59). Nicotine and alcohol use within 4 hours of bedtime were associated with increased sleep fragmentation on actigraphy and sleep diaries in one study in African-American adults (51).

Older adults experience high rates of insomnia, especially elderly nursing home residents (48). Among the nonpharmacologic treatments, sleep hygiene education is one of the easiest and most effective approaches as an initial step (46; 58).

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 (45).

Teenagers and adolescents are also 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 had chronic sleep problems associated with inadequate sleep hygiene (32). Moreover, in young drivers, inadequate sleep hygiene is associated with high vehicular accident rates (28; 42).

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 (30; 52). With children, use of cell phones and other electronics before bed or after lights out not only reinforces bedtime resistance and sleep anxiety (19) but has also been associated with depression, obesity, and increased risk of substance abuse (Oshima et al 2012; 07; 16). A study demonstrated that increased social media use in adolescents was associated with poorer sleep patterns (49). This effect is even seen in infants in whom screen media exposure leads to decreased total sleep duration (56) and in toddlers in whom electronic device usage was associated with increased sleep latency and decreased total sleep time (08). An epidemiological survey of 779 children (via parental questionnaire) showed hyperactivity and conduct problems are more common in children who exhibit bedtime resistance (Carvalho Bos et al 2009). 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 (50). Another Australian study demonstrated that children who did not follow proper sleep hygiene and went to bed late had a poorer quality of life, not only for themselves but for their caregiver as well (43). Use of media and caffeine before bedtime have also been shown to be associated with poor academic performance among adolescents (11).

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 (30). Another study of 632 young adults confirmed that sleep hygiene is strongly related to sleep quality and modestly related to perceptions of daytime sleepiness (33). 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 (18). One cross-sectional study of elementary school students demonstrated that electronic use and inconsistent bedtimes led to chronic poor sleep irrespective of socioeconomic status (55).

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 circadian rhythm disorder-delayed sleep phase type, poor sleep hygiene, and obstructive sleep apnea. Counseling was provided in regard to 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 exhibit specific voluntary behaviors that increase arousal or in some way disrupt normal sleep organization (01). These are behavioral practices that, in moderation, are usually considered normal but cause sleep disturbances when they occur in susceptible persons or in conjunction with other sleep disrupting influences.

Patients diagnosed with inadequate sleep hygiene seem to be unusually sensitive to even small amounts of stimulants (caffeine, nicotine), alcohol, atypical exercise, excitement, or environmental disruptions such as noise, light, or extreme temperatures (05). There are studies showing that caffeine taken up to 6 hours prior to bedtime can cause sleep disruption (13). Such patients' circadian control centers also seem to be sensitive to even minor variability in sleep schedules or the occurrence of daytime napping (01). Some patients, because of psychological or physical illness or predisposition, may be particularly intolerant of the effects of even occasional sleep loss and may quickly resort to maladaptive practices, such as spending more time in bed in an attempt to get more sleep or consuming alcohol at bedtime to hasten sleep onset. A combination of such factors, added to hypersensitive arousal centers, seems necessary to cause symptoms.

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 child care (12).

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 (29). Use of cell phones after lights out was found to be very high in Japanese adolescents, leading to disrupted sleep (38).

Sleep problems are also common among college students. In 1 study of students at a Hong Kong university, it was found that 57.5% of 400 university students were poor sleepers (53). 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 (31).

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 (40). 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 (15).

Prevention

Education should be provided on expectations of normal sleep parameters, such as taking up to 30 minutes to fall asleep and up 30 minutes of wake after sleep onset are normal. Furthermore, practices to promote optimal sleep should be discussed. Education should begin as early as possible, including the prenatal period or the first 6 months of life (36).

Most people will, at various times, be exposed to a large number of potential sleep disrupters; usually only those that are found to cause trouble need to be modified. Careful sleep hygiene is good practice for everyone, but a cup of coffee close to bedtime, an occasional nap, a stuffy bedroom, or studying in bed may disturb the sleep of only certain susceptible individuals. Even these indiscretions in sleep hygiene may be tolerated in isolation, with sleep problems appearing only when multiple factors are present simultaneously.

One cautionary note: evidence raises the issue of how difficult it may be to change "bad" sleep habits that are ingrained in our society's work and play practices. Thus, it is important to start treatment early in the course of a developing insomnia or at an early age if possible. Table 3 gives a list of the main features of good sleep hygiene.

Table 2. Sleep Hygiene Guidelines

	• Establish a regular routine that includes going to bed and getting up at the same time every day, even on weekends. Maintaining a regular sleep-wake cycle is the key to better health overall.
	• Get an adequate amount of sleep every night. Determine the amount of sleep you need by keeping track of how long you sleep without using an alarm clock for a week. Maintain this "personal" sleep requirement.
	• 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 tomorrow'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 your 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. As a depressant that slows brain activity, alcohol may initially make you tired, but you will end up having fragmented sleep. In addition, being tired intensifies the effects of alcohol. Alcohol also aggravates snoring and sleep apnea.
	• Exercise regularly. Regular exercise, even for 20 minutes, 3 times a week, promotes deep sleep. Finish exercising at least a couple of hours before you go to bed.
	• Don't nap for more than 30 minutes or after 3 pm. 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. Avoid sleeping pills altogether if you have obstructive sleep apnea; it can be a deadly 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

The diagnosis of individual extrinsic sleep disorders is complicated by the overlap among features of several closely related sleep disorders. In addition, inadequate sleep hygiene may develop due to another underlying sleep disorder. 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%) (47).

In patients suspected of having inadequate sleep hygiene, the 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 in a 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.

Patients with inadequate sleep hygiene may consume coffee or alcohol, or nap irregularly, but if this occurs to a degree that would be considered excessive in most people, a diagnosis of stimulant- or alcohol-dependent insomnia or irregular sleep-wake pattern would be warranted. Similarly, an uncomfortable mattress, a noisy environment, or evening stress may contribute to a patient's sleep problems, but if the discomfort, disruption, or tension caused by these factors alone would interfere with most people's sleep, then the diagnosis of an environmental sleep disorder would be more accurate. If symptoms related to stress become persistent, then diagnoses such as chronic insomnia or anxiety disorders should also be considered.

In a young child in whom a sleep disturbance appears to be due to inadequate sleep hygiene, one must also consider behavioral insomnia of childhood sleep-onset association type. This disorder is typically manifested when the child has several nighttime awakenings. The child requires the same environment that was present when the child fell asleep to also be present during the night when the child has normally expected awakenings. For example, a parent rocks or cuddles with a child to fall asleep at the beginning of the night. When the child has a normal awakening during the night, they are unable to self-soothe and require the parental presence with rocking and cuddling to be able to fall back to sleep. Circadian rhythm sleep disorders and sleep disorders due to anxiety or pain must also be ruled out.

Confusing conditions

The diagnosis of individual extrinsic sleep disorders is complicated by the overlap among features of several closely related sleep disorders. In addition, inadequate sleep hygiene may develop due to another underlying sleep disorder. 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%) (47).

In patients suspected of having inadequate sleep hygiene, the 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 in a 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.

Patients with inadequate sleep hygiene may consume coffee or alcohol, or nap irregularly, but if this occurs to a degree that would be considered excessive in most people, a diagnosis of stimulant- or alcohol-dependent insomnia or irregular sleep-wake pattern would be warranted. Similarly, an uncomfortable mattress, a noisy environment, or evening stress may contribute to a patient's sleep problems, but if the discomfort, disruption, or tension caused by these factors alone would interfere with most people's sleep, then the diagnosis of an environmental sleep disorder would be more accurate. If symptoms related to stress become persistent, then diagnoses such as chronic insomnia or anxiety disorders should also be considered.

In a young child in whom a sleep disturbance appears to be due to inadequate sleep hygiene, one must also consider behavioral insomnia of childhood sleep-onset association type. This disorder is typically manifested when the child has several nighttime awakenings. The child requires the same environment that was present when the child fell asleep to also be present during the night when the child has normally expected awakenings. For example, a parent rocks or cuddles with a child to fall asleep at the beginning of the night. When the child has a normal awakening during the night, they are unable to self-soothe and require the parental presence with rocking and cuddling to be able to fall back to sleep. Circadian rhythm sleep disorders and sleep disorders due to anxiety or pain must also be ruled out.

Diagnostic workup

The best way to diagnose inadequate sleep hygiene is with a careful and detailed history. The examiner must be astute and cognizant of the many factors that are potential sleep disrupters because the various daily habits and activities that are incompatible with normal sleep in a susceptible individual may not be a cause of sleep disruption in most people. Several instruments have been used to assess sleep hygiene including the Sleep Hygiene Self-Test (04), Sleep Hygiene Awareness and Practice Scale (27), Sleep Hygiene Index (33), and the Adolescent Sleep Hygiene Scale (30). Another scale targeting children and adolescents with headaches was validated to measure sleep habits in this population, Sleep Hygiene Inventory for Pediatrics (SHIP) (44).

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 (03). 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 only occasionally helpful. 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 should be considered when the diagnosis is uncertain or when the expected response to treatment does not occur (01). Initial impressions may be wrong, or a coexisting disorder may be present. Periodic limb movement disorder and obstructive or central sleep apnea, for example, are syndromes that may present as insomnia but require a polysomnogram for diagnosis. Patients with reports of daytime sleepiness that seem out of proportion to sleep loss or who have sleepiness that persists after treatment without good explanation should have a multiple sleep latency test. Other neurophysiologic studies and imaging procedures may be clinically indicated.

Management

Management is generally directed at removing or modifying the factors responsible for poor sleep hygiene. Often, patients are unaware of the importance or meaning of sleep hygiene, and education is key (05). In college students 1 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 (21).

If insomnia has developed or persists as a comorbidity with poor sleep hygiene practices, correcting these behaviors may not be a sufficient therapeutic approach. In a systematic review and metaanalysis, cognitive behavioral therapy for insomnia but not sleep hygiene education was found to be significantly more effective in improving sleep-onset latency, wake after sleep onset, sleep efficiency, and subjective sleep quality in patients with concurrent insomnia (09). Cognitive and behavioral interventions also significantly improved subjective sleep quality and sleep duration in patients without a coexisting sleep disorder diagnosis (39).

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 (14). 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 (23). Sleep education improved sleep duration in a randomized controlled pilot study of adolescents (26). It has even been shown to help alleviate some of the sleep complaints in patients with degenerative neurologic illnesses such as Parkinson disease (17) or Alzheimer disease (34). 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 (57). 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 (22) and also showed improved sleep quality in patients with substance abuse disorders (37). Providing a comfortable sleeping environment along with sleep education to parents improved sleep in socioeconomically disadvantaged children (35).

Special considerations

Pregnancy

Although no data show direct effects of the sleep disorders caused by inadequate sleep hygiene on the course of pregnancy or fetal development, it is conceivable that tiredness and stress associated with ongoing sleep disruption could alter sympathetic tone, endocrine function, and circadian rhythmicity, with subsequent untoward effects on the mother and fetus. Indirect effects could also be considered, including alteration of a tired woman's resolve to abstain from alcohol, sleep medications, and excessive caffeine.

Pregnancy itself, however, is a cause of sleep disturbance because of the effects of physical discomfort, hormonal changes, and decreased bladder capacity. All of this may lower a woman's threshold to, or compound the effects of, inadequate sleep hygiene. One study demonstrated that women in the third trimester who had poor sleep hygiene had worsened subjective sleep quality (54).

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.