**5.1 Sleep hygiene**

Sleep hygiene involves basic education on how the sleep environment, caffeine, alcohol, nicotine, food and exercise affect sleep (Smith et al., 2002). Sleep Hygiene is an educational approach designed to teach insomnia patients as well as the population at large how to maintain healthy behavioral habits which promote better sleep. It is important to understand that successful treatment is only possible if the patient complies with suggestions to improve sleep hygiene (*Edinger et al., 2001)*. Below are summarized tips for sleep hygiene

### *Sleep hygiene tips*


Sleep in Patients with ESRD Undergoing Hemodialysis 419

Structured exercise programs may also improve symptoms of insomnia (Montgomery & Dennis., 2004). Despite the promise of CBT the relative efficacy of these various nonpharmacologic approaches has not been well established. Data also suggest that CBTin contrast to medications may have a lasting effect beyond the termination of treatment. The extent to which the concomitant use of nonpharmacologic therapy augments the performance of pharmacologic treatments needs to be established in further studies (Novak et al., 2006).

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

If not asleep within about 10 minutes, patient gets out of bed, and does not return to

Bed is used only for sleeping (not for watching television, reading exciting books, etc).

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

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

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

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

When patient returns to bed, if not asleep within 15 minutes, gets out of bed.

enhanced when the instructions and their rationales are explained to the patient.

onset and sleep-maintenance insomnia (Espie et al., 1989; Lacks et al., 1993)

 Pattern is repeated until patient can fall asleep within a few minutes. Must get up at the same time each morning (even if only slept 2 hours).

**5.3 Stimulus-control therapy** 

bed until sleepy.

**5.4 Sleep restriction therapy** 

the bed and bedroom with the rapid onset of sleep.

*Instructions for Stimulus-Control Therapy*  Patient goes to bed only when sleepy.

All naps during the day must be avoided.


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 (Montgomery & Dennis, 2004).

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).

### **5.2 Relaxation and biofeedback techniques**

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

 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 (Martin, 2000).

Structured exercise programs may also improve symptoms of insomnia (Montgomery & Dennis., 2004). Despite the promise of CBT the relative efficacy of these various nonpharmacologic approaches has not been well established. Data also suggest that CBTin contrast to medications may have a lasting effect beyond the termination of treatment. The extent to which the concomitant use of nonpharmacologic therapy augments the performance of pharmacologic treatments needs to be established in further studies (Novak et al., 2006).
