**5.3 Stimulus-control therapy**

418 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

Regular sleep-wake schedule is important. Get up and go to bed the same time every

Regular exercise improves sleep but most people should refrain from exercise at least 4

Develop sleep rituals (listening to musicetc.). It is important to give your body cues that

Only use your bed for sleeping and intimacy. Refrain from using your bed to watch TV

Stay away from caffeine-containing beverages foods and medications nicotine and

Have a light snack before bed with a glass of milk which contains sleep-promoting

Take a hot bath 90 min before bedtime. A hot bath will raise your body temperature but

 Make sure your bed and bedroom are quiet and comfortable. Use appropriate curtains ear plugs or a white noise machine if necessary. A cooler room is recommended. Use a

These suggestions often combine several methods and may sound trivial. Compliance with such advice is still relatively poor however as it frequently requires changes in persistent "bad" habits which are ingrained (Morin et al., 1999). Building a regular sleep schedule and creating an appropriate sleeping environment as well as regular physical activity are very important in combating insomnia or insomnia-like presentations in RLS/PLMD

In terms of sleep hygiene for RLS/PLMD, there are a two main points that bear highlighting. First, the avoidance of alcohol, caffeine and nicotine may be underscored because of their potential contribution to RLS symptoms and/or PLMs. Second, other sleep hygiene practices may or may not have any utility for patients with RLS. Particularly when sleep hygiene is provided to patients as a handout or pamphlet, there is no indication that this helps promote sleep in any patient group. (Martin, 2000; Pigeon &Yurcheshen, 2009).

Relaxation and biofeedback techniques for treating insomnia are based on the assumption that insomnia patients are overly aroused and anxious, and this interferes with their ability to initiate and/or maintain sleep (Lacks, 1993). Relaxation techniques are designed simply to teach patients to relax, and thus improve their ability to sleep. Of several relaxation methods, none has been shown to be more efficacious than the others. Progressive muscle relaxation, autogenic training and electromyographic biofeedback seek to reduce somatic arousal (e.g., muscle tension), whereas attention-focusing procedures such as imagery training and meditation are intended to lower presleep cognitive arousal (e.g., intrusive

 In general, biofeedback training is an effective treatment for some insomnia patients, and is as effective as other non-pharmacologic interventions (Morin et al., 1999). If patients can train themselves to relax before sleep or at night after an awakening, they are more capable or falling asleep and staying asleep. It is believed that the beneficial effects of these methods extend beyond the sleep problems in that they facilitate better coping skills in general

it is the drop in body temperature that may leave you feeling sleepy.

day even on weekends.

it is time to slow down and sleep.

alcohol at least 4–6 hr before bedtime.

humidifier if the air is too dry.

**5.2 Relaxation and biofeedback techniques** 

thoughts, racing mind) (Spielman et al., 1987).

(Martin, 2000).

(Montgomery & Dennis, 2004).

hr before bedtime.

or work.

tryptophan.

Stimulus-control therapy is a behavioral approach based on the premise that some sleep disturbances are behaviorally conditioned, so that the patient associates the bedroom environment with arousal. The main objective of stimulus control therapy is to reassociate the bed and bedroom with the rapid onset of sleep.

Below are summarized instructions for stimulus-control therapy (Martin, 2000).

*Instructions for Stimulus-Control Therapy* 


This method focuses primarily on shortening sleep onset, however, in the case of sleep maintenance insomnia, the instructions may be followed when the patient awakens and cannot fall back to sleep during the night. The patient should avoid lying awake in bed as much as possible and only go to bed when sleepy. No stimulating or distracting activities (e.g. reading exciting books or articles, watching television, looking at a clock) should be available. Although the patient cannot control sleep onset, wake up time should be fixed, so that a regular sleep/wake schedule will develop. Pro hibiting daytime naps is important to take advantage of the sleep deficit accumulated since the sleep period on the previous night, which in itself can shorten sleep onset. As with all psychological therapies, compliance is enhanced when the instructions and their rationales are explained to the patient.

Stimulus control therapy has been shown to be effective in shortening sleep latency compared with placebo intervention in insomnia patients (Lacks, Bertelson, Gans & Kunkel, 1996). Clinical trials have documented the efficacy of stimulus control therapy for both sleep onset and sleep-maintenance insomnia (Espie et al., 1989; Lacks et al., 1993)

### **5.4 Sleep restriction therapy**

Sleep restriction therapy, is based on the observation that many insomnia patients spend an excessive amount of time in bed in futile attempts to achieve more sleep (Spielman, Saskin, & Thorpy, 1987).. Sleep restriction therapy consists of curtailing the amount of time spent in bed to increase the percentage of time spent asleep. This improves the patient's sleep efficiency (time asleep/time in bed). For example, a person who reports staying in bed for eight hours but sleeping an average of five hours per night would initially be told to decrease the time spent in bed to five hours. The allowable time in bed per night is increased 15 to 30 minutes as sleep efficiency improves. Adjustments are made over a period of weeks

Sleep in Patients with ESRD Undergoing Hemodialysis 421

to improve sleep. This could include changes in sleep schedule and changes in the contingencies and reinforcers that promote sleep. The cognitive approach focuses on looking internally to examine, manage, or modify sleep interfering thoughts and beliefs that can interfere with sleep. Cognitive behavioral therapy for insomnia in the routine general practice setting improved sleep quality reduced hypnotic drug use and improved healthrelated quality of life at a favorable cost in chronic insomniacs. Randomized controlled trials (RCTs) report somewhat conflicting results on the effectiveness of CBT in patients with insomnia but one systematic review including six RCTs (282 people) found that group or individual cognitive behavioral therapy (including sleep hygiene stimulus control sleep restriction muscle relaxation and sleep education) significantly improved PSQI scores compared with no treatment immediately after treatment and at 3 months (*Montgomery &Dennis, 2004)*. Furthermore another meta-analysis involving 2102 patients in 59 trials found that sleep restriction and stimulus control therapies were more effective than

Considering that the most frequent sleep complaints, such as insomnia, OSAS and RLS, are related to a significant negative impact on functional health status in uraemic patients, the nephrologists should improve their recognition and treatment of these conditions to restore the quality of life of their patients. A good sleep history and, when indicated, a sleep recording, will help the clinician to make an accurate diagnosis and thus identify the best treatment. Nonpharmacologic methods such as behavioral techniques and cognitive therapyas well as pharmacologic approaches and combinations of these methods should be

Afshar, R., Emany, A. Saremi, A., Shavandi, N., & Sanavi, S. (2011). Effects of intradialytic

Allen, R. (2004). Dopamine and iron in the pathophysiology of restless legs syndrome (RLS).

Allen, R.P., Picchietti, D., Hening, W.A., Trenkwalder, C., Walters, A.S., & Montplaisi, J.

Ancoli-Israel, S., Kripke, D. F., Klauber, M. R., Fell, R., Stepnowsky, C., Estline, E., Khazeni,

Auckley, D.H., Schmidt-Nowara, W., & Brown, L.K. (1999). Reversal of sleep apnea

Benz, R.L., Pressman, M.R., Hovick, E.T. *,* & Peterson, D. D. (1999). A preliminary study of

Ballard, R. D. (2005). Sleep and medical disorders. *Prim Care,* Vol. 35, pp. 511–533.

community dwelling elderly. *Sleep,* Vol. 19, pp. 277–282.

aerobic training on sleep quality in hemodialysis patients. *Iranian Journal of Kidney* 

(2003). Restless legs syndrome: Diagnostic criteria, special considerations, and epidemiology. A report from the restless legs syndrome diagnosis and epidemiology workshop at the National Institute of Health. *Sleep Med*, pp. 101–119

N. & Chinn, A.(1996). Morbidity, mortality and sleep disordered breathing in

hypopnea syndrome in end-stage renal disease after kidney transplantation. *Am J* 

the effects of anemia with recombinant human erythropoietin therapy on sleep,

relaxation techniques when used alone (*Edinger & Sampson., 2003)*.

used for the treatment of sleep problems in hemodialysis patients.

*Diseases,* Vol. 5, No. 2, Apr, pp. 119-23.

*Sleep Med,* Vol*.* 5, pp. 385-391.

*Kidney Dis*, Vol. 34, pp. 739–744.

**6. Conclusion** 

**7. References** 

until an optimal sleep duration is achieved. Typically, it is best to alter the bedtime and to keep the rising time constant in order to maintain a regular sleep-wake rhythm. By creating a mild state of sleep deprivation, this therapy promotes more rapid sleep onset and more efficient sleep (Hauri, 2000). To minimize daytime sleepiness, time in bed should not be reduced to less than five hours per night. Sleep restriction therapy is modified in older adults by allowing a short afternoon nap.

Lichstein and Reidel (1994) concluded that sleep restriction therapy is actually the preferred technique for insomnia in older patients. In a later study they combined sleep restriction with sleep education for older insomnia patients, comparing a self-help technique (a guiding video) with therapist guidance (Riedel et al., 1995). While the self-help technique alone showed improvement on some sleep variables, therapist guidance was superior in that it improved sleep latency, wake time after sleep onset and sleep satisfaction.

Implementation of this technique requires a high level of motivation and compliance on the patient's part, and close follow up by the clinician. Below are listed the rules for sleep restriction therapy.

### *Instructions for Sleep Restriction Therapy*

