Does your gut need a reset?

Yes, I'm Ready

Do you want to start feeling better?

Yes, Where Do I Start?

Do you want to start feeling better?

Yes, Where Do I Start?

How to Improve Sleep Efficiency for More Restful Nights

More Sleep Efficiency = Less Time Awake in Bed

Key Takeaways
  • Sleep efficiency refers to the amount of time you spend sleeping vs. the amount of time you lie in bed. So if you spend 10 hours in bed a night but only sleep for 8 hours, you have an 80% rate of sleep efficiency
  • A normal rate of sleep efficiency for adults is about 85%, but the higher the percentage, the better. You don’t want to go below 80%.
  • You can track your sleep efficiency using a biometric tracking device like the Oura ring.

If you’ve ever had sleep problems, you’re probably familiar with phrases like sleep quality, sleep hygiene, and certainly sleep deprivation, but what do you know about your sleep efficiency

Sleep efficiency refers to the total amount of time spent in your bed — whether it’s waiting to fall asleep, awakening in the middle of the night to roll over, or the time spent trying to sleep after you’re fully awake in the morning — vs. the amount of time you actually spend sleeping.



The sleep efficiency equation looks like this [1]:

  • [Time spent sleeping] divided by [Total time spent in bed] = Sleep efficiency

For example, a sleep efficiency of 7.5 hours slept with nine hours in bed would be about 83%.

Calculating your sleep efficiency provides a more quantitative way to gauge how well you’re sleeping, and tracking it allows you to see your progress as you improve your sleep. 

Let’s take a more detailed look at sleep efficiency, how it changes as we age, signs you may have low sleep efficiency, and the best ways to increase sleep efficiency. 

What Is Sleep Efficiency and Why Should We Care About It?

Here’s that sleep efficiency equation again: 

  • [Time spent sleeping] / [Total time spent in bed] = Sleep efficiency

Knowing our sleep efficiency goes one step beyond simply understanding our sleep duration, taking into account how much “effort” it takes to fall asleep and stay asleep. 

For example, we may be getting seven hours of sleep a night, but if that sleep is banked by two hours spent falling asleep and one hour awake during the middle of the night before falling asleep again, that would only be 70% sleep efficiency.

We may be technically meeting the seven-hour threshold of enough sleep, but that sleep efficiency score means it may not have been a very restful night of sleep. It may have even been stressful to reach those seven hours, and that’s the opposite of what we want. 
Taking steps to improve sleep efficiency can translate to better quality sleep and less time spent lying awake in bed.

Sleep Efficiency Declines With Aging

Sleep studies tell us that sleep efficiency generally decreases with age.

Sleep efficiency tends to drop from 85% in 39- to 49-year-olds, to 81% in 60- to 69-year-olds, and even further to 76% in people over 80 [1].

Research also shows that sleep efficiency below 80% is significantly associated with an increased risk of death in elderly people [1].

A systematic review and meta-analysis (the highest quality of scientific research) looking at 5,273 participants found that, with every decade of age in healthy adults [2]:

  • Total sleep time dropped by 10.1 minutes
  • Sleep efficiency decreased by 2.1%
  • Waking after sleep onset increased by 9.7 minutes
  • Waking events increased by 2.1 events per hour
  • Apnea events increased by 1.2 per hour
  • Mean blood oxygen saturation decreased by 0.6%
  • Periodic limb movements increased by 1.2 events per hour

So as we get older, it’s even more important to pay attention to how much sleep we’re getting, as well as sleep quality, to counteract the natural decline in sleep with aging. 

What Is a Good Sleep Efficiency Ratio? 

When it comes to sleep efficiency, the higher the better. If you fell asleep as soon as your head hit the pillow and didn’t wake up for a full eight hours, that would be 100% sleep efficiency.

That’s next to impossible for most people, so we want to aim for the next best thing. 

A normal sleep efficiency score for adults is 85-89% [3]. I would consider anything above 90% very healthy. 

Here are some more sleep efficiency scores for reference. Where do you fall on an average night of sleep? 

  • Spend 15 minutes awake in bed (8/8.25): 97%
  • Spend 30 minutes awake in bed (8/8.5): 94%
  • Spend 45 minutes awake in bed (8/8.75): 91%
  • Spend an hour awake in bed (8/9): 88%
  • Spend 75 minutes awake in bed (8/9.25): 86%
  • Spend 90 minutes awake in bed (8/9.5): 84%
  • Spend an hour and 45 minutes awake in bed (8/9.75): 82%
  • Spend 2 hours awake in bed (8/10): 80%

Poor sleep efficiency would be anything below 80%. You definitely want to stick to above 80% for your overall health, but most research seems to suggest that 85% is normal for adults.

How to Improve Sleep Efficiency for More Restful Nights - Signs%20of%20Compromised%20Sleep%20Quality Landscape L

Signs You May Have Low Sleep Efficiency

Of course, significant sleep disorders like insomnia and sleep disruption throughout the night (such as with a newborn) are obvious signs of low sleep efficiency. 

But you may have other signs of low sleep efficiency that are more subtle than lying awake in bed for hours trying to fall asleep. For example, snoring or restricted breathing is a significant issue for many people and greatly affects sleep quality. And yet many people don’t even know they have breathing restrictions. 

Fatigue upon awakening and daytime sleepiness are other signs of poor-quality sleep, and an indicator that you may be experiencing sleep disruptions that you don’t remember in the morning. 

How to Track Your Sleep Efficiency

There are a few ways to take a more scientific look at your sleep and identify your sleep efficiency. 

One way is a sleep study, also called a polysomnography. This is a test that tracks some of your body’s functions as you sleep or try to sleep [4].

Polysomnography measures sleep cycles and stages by tracking [4]:

  • Air passing in and out of your lungs as you breathe
  • Oxygen level in the blood
  • Body position(s)
  • Brain waves
  • How easy or hard it is to breathe
  • How fast or slow you breathe
  • Muscular activity
  • Eye movements
  • Heart rate

However, this involves being in a controlled environment (i.e., not your home), hooked up to testing equipment, and not sleeping in your own bed. 

If you’re already a sensitive sleeper, you know how much sleeping in a different environment can affect your quality of sleep. So at the Ruscio Institute for Functional Medicine, we typically recommend at-home tracking methods to our patients who are concerned about sleep quality. 

One tool I’ve discussed many times on the podcast is the Oura ring, which can document your sleep-wake cycles almost as well as traditional sleep studies. It may even be more accurate, since you’re able to use it in the comfort of your own home, where you sleep every night. Another test I may have patients do at home is the WatchPAT sleep test. I’ve used this at-home sleep apnea test myself, and have found the data useful for many of my patients.

How to Improve Sleep Efficiency for More Restful Nights - How%20to%20Improve%20Sleep Square L

Best Ways to Increase Sleep Efficiency

Once you have a baseline for your sleep efficiency, how can you go about improving it? 

Here’s a quick overview of the most helpful treatments in sleep medicine, according to research

  • Cognitive behavioral therapy for insomnia (CBT-I) in-person and online [5, 6, 7, 8]
  • Exercise [9, 10, 11]
  • Acupuncture [12, 13]
  • Positional therapy and CPAP (for obstructive sleep apnea) [14]
  • Mindfulness meditation [15]
  • Music [16]
  • Warm bath before bed [17]

A 2022 study analyzed 54 randomized controlled trials (11,815 participants) to compare the subjective effectiveness of digital CBT-I approaches in adults with insomnia. Compared with those who received usual care, those who received web-based CBT-I with a therapist experienced:

  • More total sleep time (by 23.19 minutes on average)
  • Less time to fall asleep (by 18.76 minutes on average)
  • Less waking after sleep onset (by 31.40 minutes on average)
  • More sleep efficiency (by 10.37% on average)

Overall, CBT-I was effective at improving insomnia parameters, including sleep efficiency, and may be an optimal treatment for adults with insomnia [6].

Another study analyzed 21 RCTs (755 participants) to understand the effects of high-intensity interval training (HIIT) on adult sleep quality, including sleep efficiency.

Overall, those who did HIIT tended to report large increases in sleep quality and small to medium improvements in sleep efficiency afterward [10].

Based on 11 RCTs with 775 participants, limited evidence suggests that acupuncture (particularly 12 sessions or more) can improve total sleep time, sleep efficiency, and awakenings in people with primary insomnia [12].

Developing good sleep habits, such as winding down activity at least an hour before bed, dimming lights at night, putting yourself on a sleep schedule with a regular lights-off and wake-up time, and maybe something like keeping a sleep diary each day to track your progress, are all additional practices for better sleep. These will also help regulate your circadian rhythm over time, which has far-reaching health benefits even beyond feeling well-rested.

Other promising treatments may include:

  • Lemon balm [18]
  • Tryptophan [19]
  • Cooler air temperature [20]
  • N-acetylcysteine [21]

I discuss several of these approaches in my conversation with Dr. Nik Hedberg on my podcast, Dr. Ruscio Radio. You can listen to that episode here. We also touch on the benefits of mouth taping, which sleep research hasn’t caught onto yet, but I’ve found it effective with many of my patients. 

As a quick note, treatments that did not improve sleep efficiency in adults include:

  • Melatonin [22, 23]
  • Omega-3 fatty acids [24]
  • Trazodone [25]

Sleep Efficiency Is Important, But It’s Not Everything

It occurs to me that sleep efficiency can be one marker that we may be tempted to fixate on, possibly to our detriment overall. Sleep health is incredibly important, but the difference between 97% efficiency and 99% is redundant. 

Do the best you can to improve your sleep efficiency and dial in your other pillars of health for a bigger picture of overall well-being. 

If you want to know more about my first-hand experience, I did a full episode of Dr. Ruscio Radio on my journey to sleep optimization, including the testing I did and the misleading advice I received along the way. 

You can also reach out to us at the Ruscio Institute for Functional Medicine for one-on-one guidance regarding how to improve inconsistent or poor sleep.

The Ruscio Institute has developed a range of high-quality formulations to help our patients and audience. If you’re interested in learning more about these products, please click here. Note that there are many other options available, and we encourage you to research which products may be right for you.

➕ References

  1. Desjardins S, Lapierre S, Hudon C, Desgagné A. Factors involved in sleep efficiency: a population-based study of community-dwelling elderly persons. Sleep. 2019 May 1;42(5). DOI: 10.1093/sleep/zsz038. PMID: 30768200. PMCID: PMC6519908.
  2. Boulos MI, Jairam T, Kendzerska T, Im J, Mekhael A, Murray BJ. Normal polysomnography parameters in healthy adults: a systematic review and meta-analysis. Lancet Respir Med. 2019 Jun;7(6):533–43. DOI: 10.1016/S2213-2600(19)30057-8. PMID: 31006560.
  3. Reed DL, Sacco WP. Measuring sleep efficiency: what should the denominator be? J Clin Sleep Med. 2016 Feb;12(2):263–6. DOI: 10.5664/jcsm.5498. PMID: 26194727. PMCID: PMC4751425.
  4. Polysomnography: MedlinePlus Medical Encyclopedia [Internet]. Available from: https://medlineplus.gov/ency/article/003932.htm
  5. van Straten A, van der Zweerde T, Kleiboer A, Cuijpers P, Morin CM, Lancee J. Cognitive and behavioral therapies in the treatment of insomnia: A meta-analysis. Sleep Med Rev. 2018 Apr;38:3–16. DOI: 10.1016/j.smrv.2017.02.001. PMID: 28392168.
  6. Hasan F, Tu Y-K, Yang C-M, James Gordon C, Wu D, Lee H-C, et al. Comparative efficacy of digital cognitive behavioral therapy for insomnia: A systematic review and network meta-analysis. Sleep Med Rev. 2022 Feb;61:101567. DOI: 10.1016/j.smrv.2021.101567. PMID: 34902820.
  7. Seyffert M, Lagisetty P, Landgraf J, Chopra V, Pfeiffer PN, Conte ML, et al. Internet-Delivered Cognitive Behavioral Therapy to Treat Insomnia: A Systematic Review and Meta-Analysis. PLoS ONE. 2016 Feb 11;11(2):e0149139. DOI: 10.1371/journal.pone.0149139. PMID: 26867139. PMCID: PMC4750912.
  8. Blake MJ, Sheeber LB, Youssef GJ, Raniti MB, Allen NB. Systematic Review and Meta-analysis of Adolescent Cognitive-Behavioral Sleep Interventions. Clin Child Fam Psychol Rev. 2017 Sep;20(3):227–49. DOI: 10.1007/s10567-017-0234-5. PMID: 28331991.
  9. Kredlow MA, Capozzoli MC, Hearon BA, Calkins AW, Otto MW. The effects of physical activity on sleep: a meta-analytic review. J Behav Med. 2015 Jun;38(3):427–49. DOI: 10.1007/s10865-015-9617-6. PMID: 25596964.
  10. Min L, Wang D, You Y, Fu Y, Ma X. Effects of High-Intensity Interval Training on Sleep: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health. 2021 Oct 19;18(20). DOI: 10.3390/ijerph182010973. PMID: 34682718. PMCID: PMC8535574.
  11. Stutz J, Eiholzer R, Spengler CM. Effects of Evening Exercise on Sleep in Healthy Participants: A Systematic Review and Meta-Analysis. Sports Med. 2019 Feb;49(2):269–87. DOI: 10.1007/s40279-018-1015-0. PMID: 30374942.
  12. Zhao F-Y, Fu Q-Q, Kennedy GA, Conduit R, Zhang W-J, Wu W-Z, et al. Can acupuncture improve objective sleep indices in patients with primary insomnia? A systematic review and meta-analysis. Sleep Med. 2021 Apr;80:244–59. DOI: 10.1016/j.sleep.2021.01.053. PMID: 33610071.
  13. Fang Q-Q, Wang X-Q, Liu C-Y, Xi H-Q, Wan Q-Y, Qin S, et al. The efficacy of acupuncture on the sleep structure of patients with insomnia: A systematic review and meta-analysis. Anat Rec (Hoboken). 2021 Nov;304(11):2412–25. DOI: 10.1002/ar.24745. PMID: 34498795.
  14. Ha SCN, Hirai HW, Tsoi KKF. Comparison of positional therapy versus continuous positive airway pressure in patients with positional obstructive sleep apnea: a meta-analysis of randomized trials. Sleep Med Rev. 2014 Feb;18(1):19–24. DOI: 10.1016/j.smrv.2013.05.003. PMID: 23831268.
  15. Gong H, Ni C-X, Liu Y-Z, Zhang Y, Su W-J, Lian Y-J, et al. Mindfulness meditation for insomnia: A meta-analysis of randomized controlled trials. J Psychosom Res. 2016 Jul 26;89:1–6. DOI: 10.1016/j.jpsychores.2016.07.016. PMID: 27663102.
  16. Feng F, Zhang Y, Hou J, Cai J, Jiang Q, Li X, et al. Can music improve sleep quality in adults with primary insomnia? A systematic review and network meta-analysis. Int J Nurs Stud. 2018 Jan;77:189–96. DOI: 10.1016/j.ijnurstu.2017.10.011. PMID: 29100201.
  17. Haghayegh S, Khoshnevis S, Smolensky MH, Diller KR, Castriotta RJ. Before-bedtime passive body heating by warm shower or bath to improve sleep: A systematic review and meta-analysis. Sleep Med Rev. 2019 Aug;46:124–35. DOI: 10.1016/j.smrv.2019.04.008. PMID: 31102877.
  18. Haybar H, Javid AZ, Haghighizadeh MH, Valizadeh E, Mohaghegh SM, Mohammadzadeh A. The effects of Melissa officinalis supplementation on depression, anxiety, stress, and sleep disorder in patients with chronic stable angina. Clin Nutr ESPEN. 2018 Aug;26:47–52. DOI: 10.1016/j.clnesp.2018.04.015. PMID: 29908682.
  19. van Dalfsen JH, Markus CR. The serotonin transporter gene-linked polymorphic region (5-HTTLPR) and the sleep-promoting effects of tryptophan: A randomized placebo-controlled crossover study. J Psychopharmacol (Oxford). 2019 Aug;33(8):948–54. DOI: 10.1177/0269881119855978. PMID: 31237183. PMCID: PMC6628462.
  20. Valham F, Sahlin C, Stenlund H, Franklin KA. Ambient temperature and obstructive sleep apnea: effects on sleep, sleep apnea, and morning alertness. Sleep. 2012 Apr 1;35(4):513–7. DOI: 10.5665/sleep.1736. PMID: 22467989. PMCID: PMC3296793.
  21. Sadasivam K, Patial K, Vijayan VK, Ravi K. Anti-oxidant treatment in obstructive sleep apnoea syndrome. Indian J Chest Dis Allied Sci. 2011 Sep;53(3):153–62. PMID: 21838198.
  22. Lim S, Park S, Koyanagi A, Yang JW, Jacob L, Yon DK, et al. Effects of exogenous melatonin supplementation on health outcomes: An umbrella review of meta-analyses based on randomized controlled trials. Pharmacol Res. 2022 Feb;176:106052. DOI: 10.1016/j.phrs.2021.106052. PMID: 34999224.
  23. Li T, Jiang S, Han M, Yang Z, Lv J, Deng C, et al. Exogenous melatonin as a treatment for secondary sleep disorders: A systematic review and meta-analysis. Front Neuroendocrinol. 2019 Jan;52:22–8. DOI: 10.1016/j.yfrne.2018.06.004. PMID: 29908879.
  24. Dai Y, Liu J. Omega-3 long-chain polyunsaturated fatty acid and sleep: a systematic review and meta-analysis of randomized controlled trials and longitudinal studies. Nutr Rev. 2021 Jul 7;79(8):847–68. DOI: 10.1093/nutrit/nuaa103. PMID: 33382879. PMCID: PMC8262633.
  25. Yi X-Y, Ni S-F, Ghadami MR, Meng H-Q, Chen M-Y, Kuang L, et al. Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med. 2018 May;45:25–32. DOI: 10.1016/j.sleep.2018.01.010. PMID: 29680424.

Getting Started

Book your first visit

Discussion

I care about answering your questions and sharing my knowledge with you. Leave a comment or connect with me on social media asking any health question you may have and I just might incorporate it into our next listener questions podcast episode just for you!