design-sleep-hygiene-protocol

Design Sleep Hygiene Protocol

Build an individualized set of sleep environment and behavioral practices that create optimal conditions for consistent, restorative sleep.

Why This Is Best Practice

Adopted by: AASM clinical practice guidelines, NHS Sleep Council UK, CDC sleep recommendations, NIH National Sleep Foundation guidelines, military Sleep Tactics training (US Army).

Impact: Sleep hygiene education as part of CBT-I reduces sleep onset latency by 40–50% and waking after sleep onset by 30% in RCTs (Morgenthaler et al. Sleep 2006); Walker (2017) research: every 1-hour reduction in sleep below 7h is associated with 30–40% increased infection risk and 12% increased mortality risk (Gallicchio & Kalesan 2009 meta-analysis, n=1.3M).

Why best: Sleep hygiene addresses the behavioral and environmental determinants of sleep quality that are modifiable without medication; it underpins all other sleep interventions (stimulus control, sleep restriction) and must be established first.

Sources: Hauri "Sleep Hygiene" Am Sleep Disorders Assoc (1977); AASM Practice Parameters (2006); Walker (2017) ch. 2–7; Stepanski & Wyatt Sleep Med Rev 7:215–225 (2003).

Steps

1. Assess current sleep patterns — collect a 1–2 week sleep diary: bedtime, rise time, sleep onset latency, night wakings (number and duration), total sleep time, daytime naps, and subjective sleep quality (1–10). Calculate sleep efficiency = total sleep time / time in bed × 100.

2. Set a consistent wake time — fix a wake time 7 days per week and commit to it regardless of how long it took to fall asleep or how tired you feel. A consistent wake time is the most powerful single lever for regulating circadian rhythm. Choose a time that can be maintained permanently.

3. Anchor bedtime to sleepiness, not the clock — go to bed only when genuinely sleepy, not simply at a scheduled time. Lying in bed awake for >20 min trains the brain to associate the bed with wakefulness. Target sleep efficiency ≥85% before extending time in bed.

4. Optimize the sleep environment — temperature: 18–19°C (65–67°F) is optimal for most adults (core body temperature must drop ~1°C to initiate sleep); dark: blackout curtains or sleep mask; quiet: earplugs or white noise if environmental noise is unavoidable; reserve the bedroom exclusively for sleep and sex.

5. Manage light exposure — morning: 10–30 min of bright outdoor light within 1 hour of wake time (advances circadian phase, increases daytime alertness); evening: dim all screens and overhead lights 60–90 min before bed; blue light blocking glasses or f.lux/Night Shift can reduce melatonin suppression by ~50%.

6. Manage caffeine — half-life of caffeine is 5–7 hours; cut off all caffeine (coffee, tea, cola, pre-workout) by 14:00 for a 22:00 bedtime. Genetic slow metabolizers (CYP1A2 gene) may need earlier cutoff.

7. Manage alcohol — alcohol is sedating but fragments sleep architecture: it suppresses REM sleep, causes early morning awakening as it metabolizes, and worsens OSA. If consuming alcohol, allow 1 hour per standard drink before sleep. Ideally avoid within 3 hours of bed.

8. Regulate exercise timing — regular aerobic exercise improves sleep quality by 15–20% (Reid et al. Mental Health Phys Act 2010); morning or afternoon exercise is preferable; vigorous exercise within 2 hours of bed raises core body temperature and delays sleep onset in some individuals.

9. Create a wind-down routine (30–60 min) — same sequence each night: dim lights → low-stimulation activity (reading, stretching, warm bath) → no problem-solving or device use → bed. Warm bath 1–2h before bed raises then drops skin temperature, accelerating core temperature decline and promoting sleep onset.

10. Manage the clock — face clocks away from view; checking the time during night waking triggers anxiety that extends wakefulness. If awake >20 min, get up and do a quiet activity in dim light until sleepy again (stimulus control principle).

Rules

• Wake time is non-negotiable — sleeping in to "catch up" shifts circadian phase, making subsequent nights' sleep onset later; social jetlag accumulates and perpetuates insomnia.
• Never use the bedroom for work, eating, screen use, or stimulating activity — classical conditioning of the bed → sleep association is the foundation of stimulus control.
• Sleep hygiene alone has modest evidence for chronic insomnia — for established insomnia (>3 months), it must be combined with stimulus control and sleep restriction (CBT-I; see apply-stimulus-control-therapy).
• Naps should be <20 min and before 15:00 — longer or later naps reduce sleep pressure (adenosine) and impair nighttime sleep onset.

Common Mistakes

• Spending extra time in bed hoping to get more sleep — spending 9–10 hours in bed with fragmented sleep produces the same quantity as spending 8 hours in bed sleeping efficiently; excess time in bed worsens insomnia.
• Inconsistent weekend schedule — sleeping 2+ hours later on weekends is "social jetlag" equivalent to flying 2 time zones east each Sunday; it impairs Monday performance and disrupts the entire week's circadian rhythm.
• Using phone in bed — the combination of blue light + stimulating content + horizontal position with device trains the brain that bed is for awake, engaged activity — the opposite of what stimulus control requires.
• Relying on alcohol to initiate sleep — alcohol reduces sleep onset latency but causes rebound arousal during the second half of the night; quality and architecture of sleep are worse overall.

When NOT to Use

• For sleep disorders requiring medical diagnosis: obstructive sleep apnea (needs CPAP), restless legs syndrome (needs medical evaluation), narcolepsy (requires specialist management)
• For acute insomnia during a specific stressor (normal adaptation; apply sleep hygiene but expect resolution with stressor removal)
• As a substitute for CBT-I in chronic insomnia — sleep hygiene is one component; sleep restriction and stimulus control (the most effective components) must be added for clinical insomnia