Healthy Sleep Patterns

Sleep Hygiene

Sleep Hygiene can be defined as the practices and habits one can create to promote good
sleep on a regular basis. Sleep hygiene has been defined as those behaviors that are believed
to promote improved quantity and quality of sleep (Stepanski & Wyatt, 2003).

Signs of Poor Sleep Hygiene

Having a hard time falling asleep, experiencing frequent sleep disturbances, and suffering
daytime sleepiness are the most telling signs of poor sleep hygiene. An overall lack of
consistency in sleep quantity or quality can also be a symptom of poor sleep hygiene.

Ways to improvise Sleep Hygiene

Foods and Other Substances

It’s now known that a number of foods and other substances can disturb sleep due to their
stimulant effects and/or the disruption they cause to the digestive system. These substances
maintain wakefulness by activating neurobiological systems, and that’s why sleep hygiene
specialists recommend the avoidance of substances such as –

Stimulants

Having any form of stimulant close to bedtime can interfere with sleep. Caffeine stays in the
system for an average duration of 3-5 hours, and could remain for as long as 12 hours. Most
people are aware of this, but think that it won’t affect them. The effects of caffeine may last
for several hours after ingestion. Caffeine can fragment sleep, and cause difficulty initiating
sleep. If you drink caffeine, use it only before noon. Remember that soda and tea contain
caffeine as well.

Avoid Alcohol & Drugs

Avoiding alcohol or drugs near bedtime will improve your quality of sleep. While these are
often viewed as sedatives and it may be true that they will promote initially falling asleep,
they often cause night time disturbances and awakenings, leading to poor quality sleep.

In addition, it’s believed that smoking before bed reduces sleep quality by reducing the
amount of time spent in deep sleep, thus leading to nocturnal restlessness and sleep
fragmentation.

Food Intake

Interestingly, disrupted sleep has also been associated with both hunger, and the consumption
of a large meal prior to bedtime (which requires a large effort to metabolize). It may be
recommended by your clinician that you eat a light snack before bedtime. And finally, sleep
interruptions can be prevented by limiting the intake of liquids before bedtime, resulting in
less urination.

Get Into a Routine

Having a regular routine before bed can greatly increase the effectiveness of falling asleep
and reduce inadequate sleep hygiene. There should be a relaxing activity such as listening to
relaxing music, meditating or bathing. Having an active and healthy lifestyle will also aid in
good sleep behavior. On top of the routine, you should also have a regular bedtime. This will
become ingrained in your internal clock, and should facilitate sleep when combined with
other quality sleep hygiene methods. Sleep Schedule

One of the recommendations for sleep hygiene relates to the timing of sleep, or allowing
enough time for sleep. Adults who get less than seven or eight hours’ sleep can experience
mental and physical health deficits, and that’s why this is one of the top sleep hygiene
recommendations.

Generally, clinicians will advise that these hours of sleep must be achieved at night, and not
through napping, because even though naps can be useful after sleep deprivation, naps under
normal conditions may be detrimental to night time sleep. It has been discovered that the
negative effects of daytime naps on performance and sleep depend on timing and duration,
with the least disruptive naps being midday naps. There’s also a lot of focus on the
importance of having a regular sleep schedule and awakening at the same time every
morning.

Practice Calming the Mind

Poor sleep can also be caused by the mind being too active and not ‘shutting down’. This is
commonly caused by stress, anxiety, fear or excitement. If you find yourself regularly having
trouble falling asleep despite practicing many other good sleeping habits, you may need to
develop mind tricks or exercises to help take your mind off other things, and prepare it to shut
down for sleep. You will also find that after getting in a routine, sleep will naturally come
much easier, even without the practice of these exercises. For more serious mental issues that
are not easily resolved and are preventing you from falling asleep, you should consult your
doctor, a sleep specialist or a therapist.

Sleep Environment

Sleeping in a comfortable environment will promote quality sleep. This includes a mattress
and pillow that are comfortable and right for you, as well as sleeping in an environment that
has the proper darkness, sound and temperature levels. This can vary by individual. Some
people may actually sleep better with low playing music left on, or with lights on, but in
general you should sleep in a dark, quiet and cool environment. A temperature below
standard room temperature is encouraged, as being under blankets will increase your body
temperature. Too cool of an environment can make it difficult to sleep though, as any
exposed skin will become clammy, and pillows may become too cool to rest your face on,
leading to awakenings. Crack a window to make sure you have plenty of fresh air. If you
want to avoid a draft, use an air purifier that removes bacteria and odours from the room air.

Avoid daytime naps

Naps decrease the ‘Sleep Debt’ that is so necessary for easy sleep onset. Each of us needs a
certain amount of sleep per 24-hour period. We need that amount, and we don’t need more
than that. When we take naps, it decreases the amount of sleep that we need the next night –
which may cause sleep fragmentation and difficulty initiating sleep, and may lead to
insomnia and sleep deprivation.

Don’t stay in bed awake for more than 5-10 minutes

If you find your mind racing, or worrying about not being able to sleep during the middle of
the night, get out of bed, and sit in a chair in the dark. Do your mind racing in the chair until
you are sleepy, and then return to bed. No TV or internet during these periods! That will just
stimulate you more than desired. If this happens several times during the night, that is OK.
Just maintain your regular wake time, and try to avoid naps.

Don’t watch TV, use the computer, or read in bed

When you watch TV or read in bed, you associate the bed with wakefulness. The blue light
from the screen can actually adversely affect your circadian rhythm. Using an inexpensive
pair of blue light blocking glasses 2 hours before bed has been shown to improve the duration
and quality of sleep.

Exercise

Exercise promotes continuous sleep. Avoid rigorous exercise before bedtime. Rigorous
exercise circulates endorphins into the body which may cause difficulty initiating sleep.
Exercising just before bed is not recommended as it increases body temperature and mental
alertness. Exercising should be done during the middle of the day.

Calming Rituals to improve sleep

Guided Meditation to Help You Fall Asleep

Guided meditation is known to be effective in reducing stress as well as improving the

overall quality of life. The purpose of this practice is to slow down and eventually stop our
minds from any activity. Some refer to this as “thoughtless awareness.”

To practice guided meditation you will need a soundtrack, which can now be found on many
smartphone apps. Turn on the soundtrack and leave it playing quietly at your bedside. Close
your eyes and follow the commands. The objective is to stop your mind’s activity, not to
focus on breathing or posture, and it should not take any mental effort.

Mindfulness to Help You Fall Asleep

Many people with stress in their lives spend a lot of time with negative thoughts and trying to
solve problems. This can be tiring and cause anxiety, which also results in difficulty falling
asleep. With mindfulness, an overactive mind can be put at ease. This practice is known to
lessen anxiety and depression, improve mood, and help you feel relaxed.

Unlike meditation where you are “zoning out” and slowing down your mind, mindfulness is
“zoning in” and being focused on living in the moment. It involves accepting everything the
way it is right at this moment, without analyzing or judging your feelings, just being aware of
their existence.

Progressive muscle relaxation to Help You Fall Asleep

Progressive muscle relaxation is a technique used to relieve tension in your muscles, which
then helps you relieve tension in your mind. It distracts your mind from worry by focusing on
your body.

To practice this technique, begin by breathing in slowly and deeply for a few minutes. When
you feel ready, take a deep breath, tense your feet along with your toes for a few seconds (3-4
seconds should be enough), and slowly exhale while releasing the tension. Next, take another
deep breath while tensing your lower leg muscles, hold your breath as you did before, and
exhale while releasing the tension. Continue this pattern working your way up your body,
next with the muscles in your upper legs, then abdominal muscles and muscles of your lower
back, upper back with chest, arms, hands, and then finishing with your shoulders and neck.
Make sure to hold your breath each time while tensing your muscles, and to relax each time
you exhale.

Deep breathing exercises to Help You Fall Asleep

Focusing on deep breathing can make you feel calm, relax your muscles, and lower your
heart rate. It can take your attention away from worry and it can be done anywhere while
sitting, standing, or lying down. For just a moment while closing your eyes, try to relax your
muscles and focus on your breathing. For deep breathing exercises, focus on abdominal
breathing. If you’re unsure how to do this, place a hand on your stomach and the other one on
your chest. Breathe in slowly so that the hand over your stomach rises.

To practice this exercise, breathe in slowly with your abdomen, hold your breath for about 5
seconds, and exhale for about another 5 seconds. You can do this for about 5 minutes
although there is no set time. Many people practice this breathing until they fall asleep.

Other bedtime rituals to consider:

 Bedtime yoga: A regular bedtime yoga routine can help you unwind and relieve
stress, helping your body relax and get to sleep.
 Essential oils: Some essential oils including lavender and chamomile are known to
help with relaxation. They can be consumed in tea, used for massage, and also used in
an essential oil diffuser for inhalation.
  Warm milk: Milk contains tryptophan, a sleep-inducing amino acid (also found in
turkey). Some people add nutmeg to their milk with the belief that nutmeg calms the
mind.
 Many describe a feeling of relaxation after listening to ASMR.

ASMR stands for Autonomous Sensory Meridian Response and is described by many who
experience this as a tingling sensation that starts in the head or neck and travels down the
spine. It can make you feel relaxed, calm or even make you feel like you could fall asleep.
ASMR is typically triggered by certain sounds or personal attention, and also sometimes
visual.

The sounds that trigger ASMR can really be anything, depending on the person. Usually, they
are dull, boring, ongoing sounds. It could be whispering, a computer typing, someone using a
blow drier, tapping, buzzing, or the sound of rain. Personal attention seems to be a common
trigger as well. If you’ve ever felt a slight tingle, as well as extremely relaxed while someone
was brushing your hair, you have probably had this experience. Other forms of attention that
may cause this sensation are getting your nails done, getting a haircut, massage, or having
someone rub your arm. These are just examples, but really anything could trigger this feeling
in someone.

 Sleep Apps - New technology to help you monitor your sleep

COVID-19 and Sleep

One of the best things you can do if you do get sick with COVID-19 or any virus is to get
plenty to sleep. Loss of sleep lowers your immune system. When you sleep, your immune
system releases cytokines. Some cytokines play a role in how your immune system functions.
According to research in the peer-reviewed journal Brain, Behaviour and Immunity, lack of
sleep may alter cytokines and affect the immune system response.

 Take a warm bath: A warm bath may ease muscle soreness. It is also a nice way to
relax before trying to sleep.
 Go to sleep a little earlier: Now is not the time to skimp on sleep. Try to get another
hour or two of sleep each night. Also, if you need a nap during the day, take one.
 Use a humidifier: Place a cool-mist humidifier in your room to add moisture to the air.
The increased moisture may help decrease congestion and ease coughing.
 Elevate your head: If you have congestion, placing a few pillows under your head to
prop yourself up may decrease stuffiness.
 Create the right environment: The right environment helps promote sleep regardless
of whether you are sick or not. But since getting enough rest helps your immune
system, it is even more important to get the sleep you need. Most people sleep best in
a dark and quiet environment that is not too warm.
 Relax before going to sleep: With all the current uncertainty in the world, it can be
hard to quiet your mind. But taking some time before you try to sleep to relax is
helpful. Put aside your phone and log off social media. Instead, find something that
 helps you unwind, such as listening to music, reading, or doing deep breathing
exercises.

Assessments

Sleep Hygiene Index

The Sleep Hygiene Index, first presented here, is a 13-item self-administered index intended
to assess the presence of behaviors thought to comprise sleep hygiene. Participants were
asked to indicate how frequently they engage in specific behaviors (always, frequently,
sometimes, rarely, never). Items constructing the Sleep Hygiene Index were derived from the
diagnostic criteria for inadequate sleep hygiene in the International Classification of Sleep
Disorders (American Sleep Disorders Association, 1990). Item scores were summed
providing a global assessment of sleep hygiene. Higher scores are indicative of more
maladaptive sleep hygiene status.

Epworth Sleepiness Scale

The Epworth Sleepiness Scale is a self-report 8-item questionnaire producing scores from 0
to 24. Scores greater than 10 suggest significant daytime sleepiness (Johns, 1991). The
Epworth Sleepiness Scale has good psychometric properties (Johns, 1991), correlates with
objective measures of sleepiness (Chervin et al., 1997), and has been shown to differentiate
between individuals with and without sleep disorders (Chervin et al., 1997) and those who are
and are not sleep deprived (Johnson, 1997).

Pittsburgh Sleep Quality Index

The Pittsburgh Sleep Quality Index is a self rated 19-item instrument intended to assess sleep
quality and sleep disturbance over a 1-month period in clinical and nonclinical populations
(Buysse et al., 1989). Scores range from 0 to 21 with the higher scores indicating poorer sleep
quality. The Pittsburgh Sleep Quality Index has been demonstrated to have good internal
reliability, stability over time, evidence of validity (Buysse et al., 1989), and is well regarded
in the sleep research community

Supporting Studies

Research in other healthy adult populations shows that evening activities and conditions
while falling asleep affect sleep quality (Brown, Buboltz, & Soper, 2002; Mastin, Bryson, &
Corwyn, 2006). Other sleep hygiene recommendations include decreasing schedule
irregularity; night time exercise; and caffeine, alcohol, and tobacco use (Stepanski & Wyatt,
2003). Activities in bed, such as reading or watching television, have also been associated
with subjective measurements of poor sleep (Mastin et al., 2006).

Sleep loss, as measured by daytime sleepiness, has been shown to negatively impact
academic performance in medical students (Rodrigues, Viegas, Abreu, & Tavares, 2002).
Another study among medical students found that exam anxiety, environment, and irregular
schedules contributed to poor sleep quality (Feng, Chen, & Yang, 2005). Recently, (Frank et
al. ,2006) described demographics and sleep duration in a large sample of U.S. medical
students, finding a relationship between increased class year and lower sleep duration.

The best-known facts concern the effects of CNS stimulants, especially the night time
ingestion of caffeine in beverages, food or pain, weight and allergy controlling medications.
Caffeine is well-established as a powerful sleep-disturbing stimulant (Regestein, 1983). For
example, one study demonstrated that two cups of a caffeinated beverage prior to bedtime
produced changes in most standard EEG sleep parameters; four cups heightened these effects
(Karacan, Thornby, Anch, Booth, Williams and Salis, 1976). Eliminating caffeine in 10
psychiatric inpatients reduced the number of awakenings and requests for sleep medication
(Edelstein, Keaton-Brasted and Burg, 1984). Sleep was also significantly improved when the
use of nicotine, another CNS stimulant, was eliminated in a group of chronic cigarette
smokers (Soldatos, Kales, Scharf, Bixler and Kales, 1980). Paradoxically, consumption of
alcohol, a CNS depressant, also disrupts sleep. Alcohol leads to decreased REM and deep
sleep and more fragmented sleep (Hauri, 1982; Maxmen, 1981).

Some activities can be conductive to good sleep, such as a steady habit of physical exercise
(Baekeland and Lasky, 1966). However, morning exercise aids sleep less than activity in the
late afternoon or early evening (Home and Porter, 1976; Hobson, 1968). Other factors that
have been found to have a significant effect on sleep and are commonly included in the
definition of sleep hygiene are: noise, light, temperature, hunger, naps, sleep scheduling,
sleep medications, attitude, worry and bed partner (Hauri, 1982)

Unfortunately, students are often unaware of how sleep deprivation influences their cognitive
functioning. (Pilcher JJ et. Al 1997) found that students who stay up all night before
examinations that require critical thinking rated their performances better than those students
who slept 8 hours, although the all-nighters' performance was actually much worse. The
prevalence and implications of sleep difficulties warrant further exploration into underlying
factors that contribute to such problems.

A group of researcher who were aware of these concerns investigated the relationship of
college students' course schedules, sleep-wake variations, sleep quality, and health status.
They found that students with early classes during the week had greater sleep-wake variations
than those whose classes were later in the day. Furthermore, the students with more variations
in their sleep schedules had shorter sleep duration and greater difficulties awakening during
the week. (Machado ERS et. Al, 1998 )This finding suggested that inconsistencies between
students' social and academic schedules may promote variations in sleep schedules and may
be a contributing factor to their sleep difficulties

References

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Disorders: Diagnostic and Coding Manual, American Sleep Disorders Association,
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Brown, F. C., Buboltz, W. C., Jr., & Soper, B. (2002). Relationship of sleep hygiene
awareness, sleep hygiene practices, and sleep quality in university students. Behavioral
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Chervin, R. D., Aldrich, M. S., and Pickett, R. (1997). Comparison of the results of the
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Edelstein B. A., Keaton-Brasted C. and Burg M. M. (1984) Effects of caffeine withdrawal on

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Frank, E., Carrera, J. S., Elon, L., & Hertzberg, V. S. (2006). Basic demographics, health
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Karacan I., Thomby J. I., Anch A. M., Booth G. H.. Williams R. L. and Salis P. J. (1976)
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Maxmen J. (1981) A Good Night’s Sleep. Contemporary Books, Chicago, 111.

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Rodrigues, R. N., Viegas, C. A., Abreu, E. S., & Tavares, P. (2002). Daytime sleepiness and
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