How can I improve my sleep duration and quality?

Improving Sleep Duration and Quality

To optimize your sleep, aim for 7-9 hours nightly with a consistent sleep-wake schedule, practice evidence-based sleep hygiene techniques, and consider cognitive behavioral therapy for insomnia (CBT-I) before any pharmacological interventions. 1

Target Sleep Duration

The American Thoracic Society establishes that optimal sleep duration for adults is 7-9 hours per 24-hour period for good health at the population level. 1 Sleeping less than 6 hours is associated with adverse outcomes including mortality, while sleeping more than 9-10 hours may also be associated with adverse health outcomes and warrants investigation for underlying causes. 1

Core Sleep Hygiene Practices

Schedule and Routine

• Maintain a regular sleep-wake schedule every day, including weekends. This is the single most important intervention. 1, 2
• Go to bed only when sleepy and maintain a consistent rising time each day. 1, 2
• If you cannot fall asleep within 20 minutes, get out of bed and return only when sleepy (stimulus control). 1

Environmental Optimization

• Keep your bedroom cool (thermoneutral at 16-19°C with clothing), dark, and quiet. 1
• Noise above 50 dB shortens total sleep time and causes cardiovascular reactivity even when you subjectively adapt. 3
• Ensure your sleeping environment is safe, predictable, and comfortable. 1

Light Exposure Management

• Seek bright light exposure during the day, especially in the morning. 1, 2
• Avoid bright light at night, particularly in the hours before bedtime, as it delays sleep onset by suppressing melatonin. 1
• Evening use of electronic devices suppresses melatonin levels and increases alertness—avoid these before bed. 1

Substance Avoidance

• Avoid caffeine at least 6 hours before bedtime (it blocks adenosine receptors, shortens total sleep time, and reduces deep sleep stages). 1, 3
• Avoid alcohol close to bedtime—while it may reduce time to fall asleep, it fragments sleep quality and causes nighttime awakenings through sympathetic activation. 1, 3
• Avoid nicotine, which is a stimulant at high concentrations. 1, 3
• Avoid heavy meals and excessive liquids at night to prevent reflux and bathroom trips. 1

Additional Behavioral Strategies

• Use your bed only for sleep (and sex)—avoid other activities in bed. 1
• Avoid obsessive clock-watching, which increases mental activity and makes resuming sleep more difficult. 1
• Engage in regular physical exercise, preferably in the morning or afternoon (not close to bedtime). 2, 4

When Sleep Hygiene Alone Is Insufficient

Cognitive Behavioral Therapy for Insomnia (CBT-I)

The American Thoracic Society and American Academy of Sleep Medicine strongly recommend CBT-I as first-line treatment for chronic insomnia, before considering hypnotics or sedatives. 1, 2 CBT-I includes:

• Sleep restriction therapy: Limiting time in bed to match actual sleep duration. 1, 2
• Stimulus control: Going to bed only when sleepy, maintaining regular rising times. 1, 2
• Cognitive restructuring and psychoeducation about sleep. 1

Multiple randomized trials demonstrate that CBT-I improves both sleep quality and fatigue in patients with chronic insomnia, with sustained benefits over time. 1

Pharmacological Interventions

Medications should only be considered after behavioral interventions have been unsuccessful. 2 Important caveats:

• The FDA has issued warnings about severe allergic reactions and complex sleep-related behaviors (including sleep-driving) with sedative-hypnotic drugs. 1
• Eszopiclone (2-3 mg for adults, 1-2 mg for elderly) decreases sleep latency and improves sleep maintenance, but causes next-morning psychomotor and memory impairment that can persist up to 11.5 hours after dosing. 5
• Subjects may not perceive their sedation or impairment even when objectively impaired. 5
• Low-dose sedating antidepressants (trazodone, doxepin) are potential second-line options for persistent sleep maintenance issues. 2

Implementation Algorithm

1. Start with sleep hygiene education and stimulus control techniques. 2
2. Add sleep restriction therapy if insufficient improvement after 2 weeks. 2
3. Consider CBT-I (multiple sessions with trained provider) for persistent insomnia. 1, 2
4. Reserve pharmacological interventions only after behavioral approaches fail. 2

Special Populations

• Adolescents: School start times should be delayed to align with their circadian propensity for later sleep-wake times. 1
• Children: Age-based recommendations should enable spontaneous awakening through regular schedules. 1
• Elderly: Target 7-9 hours but investigate if sleeping >9-10 hours for underlying causes. 1

Critical Pitfall to Avoid

Do not rely on subjective perception of alertness or coordination as an indicator of actual impairment—whether from sleep deprivation or medications, objective impairment can exist without subjective awareness. 5 This has profound implications for driving safety and workplace performance. 1