Levels of evidence (I-V) and levels of recommendation (standard, guideline, and option) are defined at the end of the "Major Recommendations" field.
- Stimulus control is effective therapy in the treatment of chronic insomnia. (Standard)
Recommended by Level II evidence, and is a Grade B recommendation.
This intervention focuses on helping the patient re-associate the bed and bedroom with relaxing cues and sleep, instead of on arousal. Treatment consists of behavioral instructions of a) using the bed and bedroom for sleep and sex only, b) getting into bed only when feeling sleepy, c) getting out of bed when one is unable to fall asleep after 20 minutes, engaging in relaxing activity until drowsy, and then returning to bed, d) getting out of bed at the same time every morning, and e) avoiding naps. For the elderly, naps should be limited to 30 minutes in the early afternoon.
- Sleep Hygiene Education (Option)
Insufficient evidence was available for Sleep Hygiene Education to be recommended as a single therapy; however, it is effective when used in combination with other nonpharmacological therapies.
Sleep hygiene is typically added to other established beneficial treatments in order to be effective. This type of intervention is an educational approach designed to teach patients healthy behavioral habits to promote enhanced sleep.
Therapy includes suggestions such as:
- Regular exercise (not within 3-4 hours of bedtime)
- Avoid sleeping in after a poor night of sleep
- Avoid watching the clock
- Avoid excessive liquids or heavy evening meals
- Avoid tobacco, stimulants, caffeine, alcohol 4-6 hours before bed
- Avoid poor sleeping environments
- Avoid stimulating late-night activities, and eliminate bedroom clocks
- Vigorous exercise enhances sleep quality, unless it is performed 2-3 hours before bedtime.
- Make bedroom comfortable, dark, and quiet; sleep with earplugs or a mask if necessary.
- Avoid unpleasant tasks right before bedtime; read or think about pleasant thoughts before trying to sleep.
- In the elderly, low-impact activities such as board games and gentle stretching have been shown to improve sleep quality and daytime performance.
- All medications need to be reviewed for their effects related to sleep.
- Sleep restriction is effective therapy in the treatment of chronic insomnia. (Option)
Recommended by Level II, III, and V evidence, and is a Grade B-C recommendation.
Involves re-associating the bed with sleep alone in order to increase sleep efficiency (% sleep) and sleep quality and decrease frustration with attempts to fall asleep. Treatment geared toward decreasing the amount of time in bed to only sleep time. Includes instructing patients to maintain a sleep log and determine average total sleep time. Patients are given a "sleep prescription" by a health care provider and are followed closely with weekly visits to evaluate sleep efficiency (% sleep). Their sleep prescription is adjusted up or down based on these visits. A sleep prescription should never be less than 5 hours.
- Paradoxical intention is effective therapy in the treatment of chronic insomnia. (Guideline)
Recommended by Level II and III evidence, and is a Grade B-C recommendation.
Paradoxical intention involves advising a patient to remain awake in order to decrease any performance anxiety that could interfere with the ability to fall asleep. Patients confront fears of sleeplessness by remaining awake for as long as they can. Leads to increased sleep pattern satisfaction with chronic insomnia patients.
- Progressive muscle relaxation is effective therapy in the treatment of chronic insomnia. (Guideline)
Recommended by Level II and III evidence, and is a Grade B-C recommendation.
Progressive muscle relaxation involves alternating contraction and relaxation of muscle groups throughout the body. Intended to produce relaxation and inhibit anxiety-associated arousal that could inhibit sleep. Useful for patients who have increased levels of arousal at night and during the day.
Two types of relaxation therapies are used for insomnia. The primary focus is to reduce arousal to allow for sleep initiation or to reduce sleep latency. Progressive muscle relaxation therapy focuses on physiological arousal, and other types focus on psychological arousal (meditation).
- Biofeedback (electromyography, electroencephalography) (Guideline)
Recommended by Level II and III evidence, and is a Grade B-C recommendation.
Biofeedback involves the "use of devices that amplify physiological processes (e.g., blood pressure, muscle activity) that are ordinarily difficult to perceive without some type of amplification. Participants are typically guided through relaxation and imagery exercises and instructed to alter their physiological processes using as a guide the provided biofeedback (typically visual or auditory)."
- Cognitive Behavioral Therapy (CBT) (Guideline)
Recommended by Level II and III evidence, and is a Grade B-C recommendation.
Also termed restructuring, this attempts to identify maladaptive and distorted cognitions that are common among those with insomnia and replace these with more adaptive beliefs and attitudes. This form of therapy seeks to alter faulty beliefs and attitudes about sleep and uses multiple patient-specific techniques. Examples include decatastrophizing, reappraisal, and attention shifting. Objective of this form of therapy is to diminish the cycle of insomnia, emotional stress, dysfunctional cognitions, and further sleep disturbances.
- Tai Chi (Option)
There are no current recommendations for tai chi related to insufficient evidence supporting its use (Option).
Tai chi is a traditional Chinese low- to moderate-intensity self-paced health promoting exercise that incorporates a meditation component accompanying the rhythmical movements.
- Bright Light Exposure (Option)
There are no current recommendations for bright light therapy related to insufficient evidence supporting its use (Option).
In the elderly population, exposure to bright outdoor sunlight (preferably in the late afternoon or early evening) can improve alertness, motivation, sleep quality, and mood.
- Yoga (Option)
Yoga consists of physical exercises, breathing techniques, postures, and meditation for the purpose of improving health and well-being.
There is little research supporting the use of yoga for chronic insomnia in the elderly.
