28.04.2015
Listen to Audio Introduction Circadian Rhythm Sleep DisordersAccording to the second edition of the American Academy of Sleep Medicine’s International Classification of Sleep Disorders (ICSD-2),1 the major feature of circadian rhythm sleep disorders is “a misalignment between the patient’s sleep pattern and the sleep pattern that is desired or regarded as the societal norm” (AV 1). In addition to shift work disorder (SWD), the ICSD-2 lists 8 other types of circadian rhythm sleep disorders, including time zone change (jet lag) syndrome and delayed and advanced sleep phase syndromes. Consequences of Shift Work DisorderJust as animal studies have found that disruptions in circadian rhythm can affect health outcomes, studies in humans have produced similar findings. Gastrointestinal problems (eg, ulcers, functional bowel disorders) are significantly increased in individuals who work night or rotating shifts. Straif K, Baan R, Grosse Y, et al, on behalf of the WHO International Agency for Research on Cancer Monograph Working Group. The clinician determined that the patient had no history of other sleep problems, including narcolepsy or breathing-related sleep disorder, and no psychiatric illness or substance abuse problems.
When on the evening shift, Mr B maintains good alertness and typically socializes for 1 to 2 hours after work before driving home. On the graveyard shift, Mr B is very sleepy during the last few hours of work, which is when he normally goes to bed (4:00 AM), and has a great deal of trouble driving home because his biological clock has turned off. When working the day shift, his most difficult shift, the patient will try to wake up at 5:30 AM, have some coffee, and get as much light as possible, and perhaps take some melatonin in the evening. When to Refer for Specialized CareIn the case of the patient described above, the clinician proposed a number of fairly simple strategies to try to resolve his sleep problems. SummaryBy enlisting the support of family, appropriately identifying and treating comorbid sleep disorders, and appropriately timing light and dark exposure (supplemented by melatonin), many shift workers can improve their ability to sleep and maintain wakefulness and possibly decrease the metabolic and other adverse effects of shift work.
A primary complaint of excessive sleepiness or insomnia which is temporally associated with a work period (usually night work) that occurs during the habitual sleep phase. The ICSD-2 diagnostic criteria for circadian rhythm sleep disorder, shift work type, are shown in (AV 4). However, the increased prevalence of ulcers is associated not just with shift work, but also with SWD. Shift work (whether or not the person has SWD) has been found to be a risk factor for cancer. The prevalence of depression is significantly higher in those who work rotating and night shifts than in day workers. Insomnia is associated with excessive sleepiness, which can impair functioning, in rotating shift workers compared with day workers.12 Studies have found a 12% frequency of drowsy driving and an increased risk of driving accidents related to sleepiness in rotating shift workers with SWD compared with those without the disorder. International Classification of Sleep Disorders Diagnostic and Coding Manual, Second Edition (ICSD-2).


Workers on Flexible and Shift Schedules in May 2004 (Data from the May 2004 Current Population Survey). Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Rotating night shifts and risk of breast cancer in women participating in the Nurses’ Health Study.
Prospective cohort study of the risk of prostate cancer among rotating-shift workers: findings from the Japan collaborative cohort study. Effects of extended work shifts and shift work on patient safety, productivity, and employee health. Mr A, a 45-year-old police officer, was referred for evaluation of “probable narcolepsy.” He had been experiencing sleepiness, irritability, problems with job performance, social limitations, and trouble falling asleep. This diary clearly showed that Mr A had an extremely variable sleep pattern that differed by more than 2 to 4 hours from one day to another. Mr B, a 44-year-old man who complains of insomnia and daytime fatigue, currently works the evening shift (4:00 PM to midnight) and has a 60-minute drive to work. Although tired, he also has trouble sleeping past noon, because his biological clock begins to turn on about noon.
During the second half of his shift, when his clock is beginning to turn on, he is better able to stay awake.
During this visit, the clinician explained circadian principles and the physiology of sleep and wakefulness.
The clinician also asked the patient and his wife to consider whether he needed to continue working shifts as well as whether it might be possible to move closer to work and reduce his commute time. If these strategies did not help and the patient continued to have difficulties with insomnia, or excessive sleepiness when he wishes to be awake, the clinician should consider other interventions, such as use of medications to promote sleep or alertness and possible referral for a specialized sleep consultation (AV 4).
More aggressive treatment strategies and referral to a sleep specialist should be considered in patients in whom these simple measures are not as effective as desired. Problems can also arise when there is chronic dyssynchrony between the person’s internal clock and external light and dark (ie, when a person is required to stay awake and work when it is dark and sleep when it is light), which can, in some cases, lead to SWD. No matter how many hours you have slept during the day, trying to work during the downside of the circadian rhythm (eg, between 12 AM and 6 AM) is very difficult unless you can shift your internal clock. The differential diagnosis of SWD includes excessive sleepiness due to obstructive sleep apnea, narcolepsy, restless legs syndrome, and chronic insufficient sleep due to daytime conflicts (eg, child care, environmental factors, “moonlighting” at a second job). Increased odds ratios for breast cancer have been found in large samples of women who worked night shifts, particularly with increasing duration of nighttime employment.15-19 A study20 of 14,052 working men in Japan also found a significantly increased risk of prostate cancer in those who worked rotating shifts.


Potential targets for treatment are (1) the person’s work schedule, (2) difficulty sleeping during the day, and, most important, given the accident data discussed above, (3) difficulty functioning because of excessive sleepiness (eg, commuting home safely).
This helped the patient’s wife understand that he does not have as much choice about when he sleeps as she thought and allowed her to “buy in” to the idea that the patient must have protected sleep time, the timing of which will vary depending on the shift he is working. His wife agreed to go to work an hour later so that she can get the children off to school. On weekends, the patient will follow a compromise routine of sleeping from 4:00 AM to noon. The clinician also discussed the possible long-term effects of shift work and explained that few data are available concerning whether a compromise re-entrainment, such as proposed here, will reduce the long-term negative health effects of chronic circadian misalignment.
They reported that 24 (23.3%) of the shift workers were suffering from SWD and that, during their 4-week period off work, the workers with SWD reported significantly poorer sleep quality, more subjective health complaints, and greater problems in coping than individuals who did not have SWD. Comorbid conditions (eg, increased prevalence of sleep apnea in shift workers) can complicate the diagnosis of SWD. A was able to switch from shift work to a daytime schedule for a period of several weeks; his difficulties with insomnia and excessive sleepiness completely resolved, his job performance and social life improved, and he had more energy. Shift workers without SWD reported results similar to those of day workers on the rig with regard to sleep, sleepiness, subjective health complaints, and coping. Clinicians should also rule out comorbid disorders that can cause insomnia and excessive sleepiness (eg, primary insomnia, insomnia associated with psychiatric disorders such as major depression), as well as consider whether the person may be taking medications or abusing drugs or alcohol to help with sleep, which may be causing impairment at work. Zhen Lu et al14 found that the prevalence of functional bowel disorders was higher in a sample of nurses who worked rotating shifts (38%) than in those who worked day shifts (20%) and that functional bowel disorder symptoms were positively correlated with level of sleep disturbance.
Mr A first began having problems with insomnia and sleepiness 4 years earlier when he started his new job, which requires at least 1 to 3 night shifts per week. He gets home at 8:00 AM after taking the children to school and sleeps until noon, when he gets up to do household chores. However, when he works the graveyard shift, he has great difficulty maintaining alertness on the drive home, and when he gets home, has trouble sleeping past noon.
On day shift, he has incredible difficulty maintaining alertness on the drive to work and during the first half of his shift.



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