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.
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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
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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 (61). 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 (53).
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Older adults experience high rates of insomnia, especially elderly nursing home residents (50). Among the nonpharmacologic treatments, sleep hygiene education is one of the easiest and most effective approaches as an initial step (48; 60).
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 (47).
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 (34). Moreover, in young drivers, inadequate sleep hygiene is associated with increased motor vehicle accident rates (30; 44). One prospective correlational study assessing sleep quality, quantity, latency, and hygiene in relation to appetite, dietary intake, and BMI levels among adolescents (ages 12-18 years) showed a significant correlation between poor sleep hygiene practices and poor sleep quality scores as well as appetite and dietary intake (27).
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 (32; 54). 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 (51). This effect is even seen in infants in whom screen media exposure leads to decreased total sleep duration (58) 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 (52). 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 (45). 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 (32). Another study of 632 young adults confirmed that sleep hygiene is strongly related to sleep quality and modestly related to perceptions of daytime sleepiness (35). 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 (57).
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.
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