Sleep Soundly Every Night, Feel Fantastic Every Day (19 page)

Several management tools help those with irregular sleep–wake syndrome reestablish a normal sleep cycle. I encourage people to spend seven to eight hours in bed, with set sleep and wake times. Adhering to a regular schedule is also important, including the use of zeitgebers such as light, meals, and social interactions. Morning and evening treatments of light therapy of 3,000 lux each for two hours (as compared to sunlight that radiates 10,000 lux) has been shown to help establish a normal sleep cycle as well as improve nocturnal sleep in institutionalized patients, and reduce agitation in demented patients.

I understand what problems shift workers encounter because of my own experiences. When I was a medical resident at Cook County Hospital in Chicago, the medical field had absolutely no knowledge or interest in sleep. We residents routinely worked 30-hour shifts at least once a week in addition to our usual 16-hour days. There were weeks where our work time approached 100 hours. Only recently have training programs come to terms with how dangerous this is, not only for patients, but also for the residents, who can fall asleep while driving home in a very drowsy state. How would you like to be the patient admitted to my service during my 24th hour without sleep?

I can remember some overnight shifts ending at 7:00 a.m. and having just enough time for a three-hour nap before I had to see my 10:00 a.m. patient in clinic. The schedule was grueling and potentially dangerous. I recall rolling down the windows of my little Volkswagen Karmann Ghia in the dead of a Chicago winter in order to stay awake for the drive home.

It was considered a badge of honor to be able to do this. So if a resident complained, our superiors reminded us, “That‘s how it is and always has been. You just have to tough it out.” I should note that most of these archaic practices have been eliminated in the past 10 years as the field of sleep medicine has come to understand the repercussions of shift work and sleep deprivation.

I was once again exposed to this but on a lesser scale when I went into pulmonary and critical care medicine. I'd be on call for my group every fourth week. It was not unusual to get a call at 3:00 a.m. requiring me to come into the ICU and then go straight to my office with little or no sleep.

Shift work, as a sleep disorder, is also the result of external circumstances and can pose risks to health, life enjoyment,
and even safety. Most people work the typical nine-to-five day, which is aligned with the natural light–dark cycle and therefore normal circadian rhythms. However, there are many people such as health care providers, police officers, firefighters, factory workers, and truck drivers, who work overnight shifts. This schedule runs counter to the biological signals that tell us when it's time to sleep and time to wake. In order to be diagnosed with this circadian rhythm disorder, the person must “report difficulty falling asleep, staying asleep, or nonrestorative sleep for at least one month, and it must be associated with a work period that occurs during the habitual sleep phase. There are also required effects on impairment of wakefulness.”

This shift work disorder has not been given much clinical attention; however, self-assessment surveys show that night workers tend to get less sleep than people who work during the day, usually because of their sleep time conflicting with the daytime activities of their households. For example, a dad who comes home from work at 4:00 a.m. and must get up a few hours later to get his kids ready for school. Those with this disorder complain of insomnia during the day and sleepiness during their work hours, which can lead to impairment. They also have higher incidences of hypertension, obesity, and heart disease. As a result, shift work sleep disorder can result in accidents during work and other activities, such as driving. However, while the data indicates an increase in occupational accidents on the night shift, more research is necessary before a definitive statement can be made.

Treatment and management of this disorder depend on the flexibility of one's schedule. For example, some night workers are able to take a nap before their shift begins, or even during their break while at work. Bright light treatment in the evening hours, combined with limited light exposure
in the morning, can help people adjust to their schedule by resetting their circadian rhythm. This disorder is also treated with melatonin, which helps people get more sleep during the day, as well as drugs such as modafinil, to combat excessive sleepiness during their shift. Shaping the pattern of light exposure with combinations of phototherapy and light avoidance (bright light at work, wearing dark glasses on the commute home, sleeping in a darkened room) can shift the circadian pacemaker to a more appropriate phase.

Q.
 
Doesn't light affect your circadian rhythm?

A.
 
Yes, light is the strongest stimulus that affects the circadian system. If exposed to light in the morning, one tends to go to bed earlier or at normal time. If exposed to light at night, this will delay sleep.

Q.
 
I recently started a job that requires I be up by 6:00 a.m. I have always had a very hard time getting going in the morning. It can take me over an hour before I feel alert. I'm afraid this is interfering with my job. I'm also concerned about my driving in the morning. Any ideas?

A.
 
Yes. What you are describing is called sleep inertia. Most of us take about 10 minutes to fully awaken. However, some require much more time. Several recent studies have shown that bright light can help. I would suggest that you leave your blinds and drapes open so that you get bright sunlight in the morning. If that fails, there are now clocks that come with dawn light simulators. Exposure to the light has been shown to increase core body temperature. This in turn increases wakefulness.

Q.
 
My 78-year-old mother has Alzheimer's and is in a nursing home. She sleeps on and off throughout the day and night. There is no rhyme or reason as to when she falls asleep or is awake. Is this common in Alzheimer's? Is there anything that can be done to help? Most of the time when we come to visit she is asleep.

A.
 
Good question. What you are describing is called irregular sleep–wake disorder. It is fairly common in Alzheimer's sufferers. Their internal circadian clock has become completely disassociated from any semblance of a normal sleep–wake schedule. The best treatment is plenty of bright light exposure during the day along with structured activities. In some studies the addition of small doses of melatonin at night is reported to be helpful.

Q.
 
If someone wakes up every day at 11:00 a.m. and uses a SAD lamp for one hour, then goes to sleep at 3:00 a.m. in a room that is completely dark, will that person have the same health compared to if he would wake up at 5:00 a.m, use a SAD lamp for an hour, and go to sleep at 9:00 p.m.? So my question is … what, if anything, influences the body clock besides light and temperature of the body? Do the energy of the moon and sun and gravity affect the body, even if the room you sleep in is completely light-proof? Is sleep healthier at certain times, even if you sleep in a lightproof and soundproof room and use a SAD lamp immediately after you wake up?

A.
 
What you are describing is someone with delayed sleep phase syndrome. As far as the health of the person who goes to bed at 3:00 a.m. and sleeps until 11:00 a.m., his or
her health should be no different than the person with the more conventional sleep–wake cycle. The body clock is also affected by social and dietary influences such as the timing of meals. As for sunlight, if the room is dark and sunlight cannot strike the retina, there should be no influence.

Q.
 
My wife and I are traveling to England this summer. We have had problems with jet lag before. How can we prevent this?

A.
 
Since you are traveling east, you will be going to bed at a much earlier time than at home as far as your biological clock is concerned. It will take several days for your internal clock to adjust. I would advise that you progressively go to bed one hour earlier each day at home for three days, until you are going to bed three hours earlier. Expose yourself to bright sunlight upon awakening. This will help to reset your biological clock to an earlier sleep time at your destination.

Q.
 
My fiancé has the WORST time sleeping of anyone I know. She works the night shift and lives with her mom. If her baby nephew comes over during the day and cries, she wakes up and can't sleep at all. She is constantly waking up covered in sweat even though she's not hot. Her dreams wake her up and she never feels like she is fully rested. She'll get off work super tired but cannot sleep for hours once she gets home. Melatonin hasn't helped. I feel so bad for her. Any advice would be appreciated.

A.
 
Your fiancé has shift work disorder (SWD). Her bedroom needs to be very quiet. Consider white noise like a
fan while sleeping or moving to a quieter bedroom. She should be wearing sunglasses, preferably blue blockers, on the drive home. No caffeine in the last three to four hours of her shift. On her days off, try to keep her sleep–wake schedule close to her days on. Finally, I am a bit bothered by the bad dreams and sweating. That could be a sign of sleep apnea. If she continues to have these problems, a consultation with a sleep specialist would be a good idea.

Q.
 
I recently started a job working three night shifts in a row. Do you have any ideas as to when to sleep so that I can function like a normal person the rest of the week? Would it be safe to take a sleep aid when I know I have to work?

A.
 
My first thought is, are you experiencing problems? Approximately 10% of shift workers have trouble as evidenced by an inability to stay awake at work or trouble falling asleep upon returning home. Add to that increased irritability and difficulty concentrating—then you have what we call SWD.

        
The key to dealing with this problem is exposing oneself to bright light during the first five to six hours of the night shift, and then scrupulously avoiding light on the way home. Dark glasses and a visor can be very useful. Melatonin taken upon arriving home may help one to sleep. The bedroom must be dark and family members need to keep the noise level down. A one- to two-hour nap in the evening before work is helpful. Most importantly, if this is a long-term job, you must try to adhere to the schedule as much as possible, even on your days off. If you follow these guidelines, you may be able to get your biological clock aligned with your new sleep–wake schedule.

Q.
 
My husband is always getting sick. He gets at least three colds a year and has had pneumonia twice in the last three years. His doctor can find no obvious cause. He sleeps no more than six hours a night and is a shift worker. Is it possible that his lack of sleep can be a cause of his frequent illnesses?

A.
 
This is a great question. The answer is yes. Based on recent studies, we know that lack of sleep inhibits the production of antiviral antibodies. Even more impressive is that following vaccinations for viruses, such as hepatitis B or influenza, insufficient sleep leads to a weaker response to the vaccine. Finally, the incidence of infections in shift workers who have trouble sleeping is significantly higher than in the general population.

Q.
 
I have been moved to the night shift at my factory. It has been four months now and I am finding it very hard to stay awake on the job. I go to sleep as soon as I get home and sleep seven to eight hours. Despite that, I am having trouble staying awake. In this economy, I can't afford to lose my job. Would you have any ideas?

A.
 
Yes, talk to your doctor about this. The FDA has approved the medications Provigil and Nuvigil for shift workers with your problem. I would consider this as an option until you either adapt to the night shift or you return to the day shift.

Q.
 
My employer has put me on the night shift. I'm having a difficult time getting to sleep in the morning. It can take me three or more hours to fall asleep, and then I have a really hard time getting through the night. Do you have any suggestions to help me?

A.
 
You are experiencing what most shift workers go through initially. Your internal, what we call
circadian clock,
is out of phase with your new environment. There are things that you can do to hasten adaptation. First, wear dark glasses home in the morning. Exposure to sunlight will only make it more difficult to fall asleep. Second, try melatonin upon returning home and going to sleep. Melatonin will not only help you get to sleep but will speed up adaptation by your circadian clock. Last, try to stay close to your new sleep–wake schedule even on your days off.

Q.
 
I recently started working a night shift job. This is my first nighttime position and, after two months, I am still having trouble staying awake on the job. I cannot afford to lose this job. Friends tell me there are medications that might help. Is this true?

A.
 
Yes, there are currently two medications approved by the FDA for shift workers. They are Provigil and Nuvigil. Both medications are wakefulness-promoting agents. However, other measures, such as a two-hour nap before the shift, judicious use of caffeine early in the shift, and exposure to bright light may help. Also, try to stay up later on your days off.