What are the latest evidence-based recommendations for improving sleep quality in adults?

Evidence-Based Sleep Recommendations for Adults

All adults should aim for 7-9 hours of sleep per night, maintain consistent sleep-wake schedules with less than 60 minutes variability, and prioritize cognitive behavioral therapy for insomnia (CBT-I) over medications when sleep problems develop. 1, 2, 3, 4

Optimal Sleep Duration

• Adults require at least 7 hours of sleep per 24-hour period to promote optimal health, as recommended by the American Academy of Sleep Medicine and Sleep Research Society 4, 5
• The National Sleep Foundation recommends 7-9 hours for most adults, with individual variations acknowledged 6
• Sleeping less than 7 hours per night increases risk for obesity, diabetes, hypertension, coronary heart disease, stroke, frequent mental distress, and all-cause mortality 5
• Currently, only 65.2% of U.S. adults meet the minimum 7-hour sleep duration recommendation 5

Sleep Schedule Consistency

• Maintaining regular bed and wake times with variability less than 60 minutes is critical for achieving adequate sleep duration 3
• Adults with sleep schedule variability exceeding 60 minutes have 2.38 times higher odds of sleeping less than 7 hours per night 3
• Go to bed and wake up at the same time every day, including weekends, as this regularity is one of the most practical and efficacious strategies for supporting healthy sleep duration 3, 2

Sleep Hygiene Fundamentals

Sleep hygiene education should be standard practice but is insufficient as a standalone treatment for chronic insomnia 1, 2. Key evidence-based sleep hygiene practices include:

• Bedroom environment: Keep the bedroom quiet, dark, and at a comfortable temperature 2
• Caffeine and nicotine: Avoid for at least 6 hours before bedtime 2
• Alcohol: Consume only in moderation and avoid within 4 hours of bedtime 2
• Exercise: Regular physical activity improves sleep, but avoid vigorous exercise within 2-4 hours of bedtime 2
• Fluid intake: Limit excess fluids before bedtime to reduce nocturia 2
• Daytime napping: Avoid napping, as it can interfere with nighttime sleep consolidation 2, 7
• Clock watching: Do not watch the clock at night, as this increases anxiety about sleep 2

Physical Activity and Sleep

Moderate-to-vigorous physical activity of 120-150 minutes per week significantly improves sleep quality in adults with sleep problems 1. The evidence is particularly strong for:

• Adults with insomnia: Exercise training programs produce improvements in sleep onset latency (0.58 standardized mean difference) and overall sleep quality (0.47 standardized mean difference) that are comparable to hypnotic medications 1
• Adults with obstructive sleep apnea: Physical activity significantly reduces apnea-hypopnea index, decreases daytime sleepiness, and improves sleep efficiency 1
• Timing matters: Avoid exercise within 2-4 hours of bedtime, as late evening exercise can interfere with sleep onset 2

First-Line Treatment for Chronic Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the mandatory first-line treatment for chronic insomnia disorder in all adults before considering any medication 1, 2. This is a strong recommendation based on moderate-quality evidence from the American College of Physicians 1.

CBT-I Components and Implementation

CBT-I combines multiple evidence-based behavioral interventions 2, 7:

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time, gradually increasing as sleep efficiency improves; sleep compression (gradual reduction) is better tolerated than immediate restriction, especially in older adults 2
• Stimulus control: Use the bedroom only for sleep and sex; leave the bedroom if unable to fall asleep within 20 minutes; return only when sleepy; maintain consistent sleep-wake times 2
• Cognitive restructuring: Address dysfunctional beliefs and anxiety about sleep 2, 7
• Relaxation techniques: Progressive muscle relaxation, guided imagery, and diaphragmatic breathing to achieve a calm state conducive to sleep 2

CBT-I effects are sustained for up to 2 years and demonstrate superior long-term outcomes compared to pharmacotherapy 2, 7

Pharmacological Treatment (Second-Line Only)

Medications should only be considered when CBT-I alone has been unsuccessful, using shared decision-making that discusses benefits, harms, and costs of short-term use 1, 2. This is a weak recommendation based on low-quality evidence 1.

Medication Selection by Symptom Pattern

• Sleep onset insomnia: Ramelteon (melatonin receptor agonist) or short-acting Z-drugs (zolpidem immediate-release) 2
• Sleep maintenance insomnia: Suvorexant (orexin receptor antagonist) or low-dose doxepin 2
• Both onset and maintenance: Eszopiclone or extended-release zolpidem 2

Critical Medication Safety Points

• Start at the lowest available dose due to risk of next-day impairment, memory problems, and complex sleep behaviors 2, 8, 9
• Zolpidem 10 mg causes next-morning psychomotor and memory impairment that persists up to 11.5 hours after dosing, even when patients do not subjectively perceive sedation 8
• Eszopiclone 3 mg produces clinically meaningful psychomotor and memory impairment 7.5 to 11.5 hours after dosing 9
• Limit to short-term use whenever possible and reassess regularly for effectiveness and adverse effects 2
• Follow patients every few weeks initially to assess effectiveness and side effects 2

Medications to Avoid

• Benzodiazepines: Higher risk of falls, cognitive impairment, and dependence in all adults, particularly older adults 2
• Over-the-counter antihistamines (diphenhydramine): Should be avoided, especially in older adults, due to anticholinergic effects 2
• Sedating antidepressants (trazodone, amitriptyline, mirtazapine): Only use when comorbid depression/anxiety exists; no systematic evidence for effectiveness in primary insomnia 2
• Herbal supplements (valerian, melatonin): Not recommended due to lack of efficacy and safety data 2

Assessment of Sleep Problems

Before initiating treatment, systematically evaluate 1, 2, 7:

• Primary vs. comorbid insomnia: Determine if insomnia is independent or associated with psychiatric disorders (depression, anxiety), medical conditions (cardiopulmonary disease, chronic pain, neurologic disorders), or other sleep disorders (obstructive sleep apnea, restless legs syndrome) 1
• Medication review: Identify drugs that may cause or exacerbate insomnia, including β-blockers, bronchodilators, corticosteroids, decongestants, diuretics, SSRIs, SNRIs, and cholinesterase inhibitors 2, 7
• Sleep-impairing behaviors: Assess for frequent daytime napping, excessive time in bed, insufficient daytime activity, late evening exercise, insufficient bright light exposure, excess caffeine, evening alcohol, smoking in the evening, late heavy meals, watching television at night, and anxiety about sleep 2, 7
• Sleep diary: Complete for a minimum of 2 weeks to objectively assess sleep patterns 1

Special Considerations for Older Adults

Older adults (≥65 years) require the same 7-9 hours of sleep as younger adults, contrary to the myth that older people need less sleep 1, 4. However, age-related changes and comorbidities require modified approaches:

• Start all medications at the lowest available dose due to reduced drug clearance and increased sensitivity to peak effects 2
• Zolpidem should be limited to 5 mg in older adults to reduce next-day residual effects 8
• Eszopiclone should be started at 1-2 mg in elderly patients rather than the standard 2-3 mg adult dose 9
• CBT-I remains first-line treatment with effects sustained up to 2 years in older adults 2, 7
• Avoid benzodiazepines, antihistamines, antipsychotics, and anticonvulsants for primary insomnia due to unfavorable risk-benefit profiles 2

Common Pitfalls to Avoid

• Do not prescribe sleep medications without first attempting CBT-I unless there are compelling reasons why behavioral therapy cannot be implemented 1, 2
• Do not rely on sleep hygiene education alone for chronic insomnia; it must be combined with other CBT-I components 1, 2
• Do not prescribe long-term pharmacotherapy without concurrent CBT-I trials whenever possible 2
• Do not ignore medication timing: Many commonly prescribed medications (diuretics, SSRIs, bronchodilators) can disrupt sleep when taken at the wrong time of day 2, 7
• Do not assume subjective alertness indicates absence of impairment: Patients taking zolpidem or eszopiclone may be objectively impaired even when they feel alert 8, 9

Monitoring and Follow-Up

• Reassess every few weeks initially when starting any sleep intervention to evaluate effectiveness and identify adverse effects 2
• For chronic medication use: Consider intermittent dosing (three nights per week) or as-needed administration rather than nightly use 2
• Employ the lowest effective maintenance dosage and taper when conditions allow 2
• Monitor for next-day residual effects, including impaired driving ability, memory problems, and psychomotor impairment 8, 9