Or: What time is it anyway? Warren Silverman MD Medical Director ACCESS HEALTH SYSTEMS Shift Work Or: What time is it anyway?

What is Shift Work? Regularly scheduled work outside of the normal daytime working hours of 7AM-6PM Permanent night shifts Afternoon or evening shifts Shifts beginning before 6AM

Condensed work weeks with extra long weekends Variable or rotating shifts Day to evening or day to night May change weekly or monthly

Why do we need shift work? Critical services on 24 hour basis Police, fire, military, healthcare, utilities, transportation, A production process > 8 hours or continuous Expensive machinery that must be used continuously to be profitable Support services for other shift workers Convenience

Who does shift work? Men do more night and rotating shifts Women do more evening and part time work Younger > Older workers African-American > Caucasian Single > Married Single Mothers > Married Mothers In 2 job married couples ¼ - 1/3 have at least one shift worker

20 Million Americans do shift work ; 26% of men, 18% of women Drop out rate: 20% at year 1; 33% at 2 years Tolerance declines with age Cumulative effects Decreased physiological reserve > 40

Factors describing shift Permanent (fixed) or rotating How long? How many days before a rest day How many rest days on a “weekend” Overtime? Length of rest between shifts Is there rest during shift Is Schedule regular and predictable

Permanent Nights Most permanent night workers never really get used to the schedule Many nights they feel tired and sleepy Fatigue because of return to day hours on days off Family and friends active during the day Errands and chores during the day Sleep less during the day

Rotating Shifts Can never adapt to a set work schedule Used to be more “fair” to all workers Rotating shift workers have more complaints than others about physical and psychological health Special Risks

Special Features Speed Direction The number of consecutive days before a shift change Direction Forward or clockwise (day-evening-night) Reverse (day-night-evening)

Longer rotations (3-4 weeks) may allow better adaptation to shift Shorter (1-2 days) allows no time to get used to night shift, but can get through it quickly to get to rest day. Used more in Europe than US

Work-Rest Ratios If an 8 hour shift = 16 hours to do everything else and sleep If a 12 hour shift, only 12 hours to do everything else. Family duties do not decrease no matter the shift time leading to less sleep and rest Fatigue is cumulative

Unpredictable schedules Health care workers with emergencies or covering call ins A factory breakdown or last minute rush order A last minute “call board” assignment to move an order Being on call and getting called in (Doctors do know about this!)

How does the body work Internal Biological Clock Circadian rhythm Regulated by sunlight and darkness

Circadian Rhythm

Circadian Rhythm Different body functions vary during the 24 hour day Metabolism (energy from food) is greatest in the afternoon to evening Most people most alert 4-6 PM and most sleepy 4-6 AM Personal differences between people

Circadian body rhythms Hormone and gastric secretions Bronchial reactivity Blood Pressure Sexual arousal Anxiety Work performance Metabolic Rate Short term memory Family interactions

The body has a natural cycle of 25 hours Internal and external factors synchronize us to a 24 hour day The internal clock is located in the suprachiasmatic hypothalmus

External clues “Zeitgebers” Light/Dark cycle Timing of meals Social interactions Actual time clock

Sleep ( Not now!) Night workers get the least sleep (6.6 hours) Evening workers get the most sleep (7.1 hours) Day workers get medium amounts (6.7 hours) Rotating workers sleep the least of all.

Sleep during the day is usually 2-3 hours shorter It is lighter sleep and more easily disturbed by noise There are more activities and noise during the day

Sleep Sleep after night work Delta Sleep Shorter, less satisfying or refreshing Delta Sleep Repair and Maintenance functions

Sleep loss makes it easier to fall asleep at inappropriate times Will decrease concentration Increase accidents ( driving, dangerous machinery) Sleep can occur in short episodes lasting a few seconds without even realizing it. Very dangerous time.

Night workers have a drop in alertness at 2-4 AM Accidents at 3 Mile Island, Bhopal, Chernobyl, and the Exxon Valdez oil spill each occurred between midnight and 4 AM

Sleep deprivation Mild sleep disruption may not have significant impact Cumulative increasing each night Disordered sleep is compounded by circadian dysrhytmia

Sleep Deprivation Six days of restricted sleep (4 hours per 24-hour period) caused changes to the sleep architecture similar to the changes seen in people suffering from depression. changes in several natural body rhythms of hormone secretion Melatonin cortisol thyroid-stimulating hormone leptin Prolactin growth hormone.

What happens if we remove cues and disturb the internal clock? Desynchronosis: Core body temperature and digestive secretions may remain near daily mean levels Entrainment When we try to regain our rhythms with light dark cycles Different physiologies may entrain at different rates and we may lose the normal phase relationship of one to another

Signs of desynchronosis Sleep disturbance Short term fatigue Irritability Loss of Appetite Judgment alteration

What does The Dark do? Triggers changes leading to sleep Dropping blood pressure Dropping heart rate Dropping breathing rate Dropping temperature Slowed digestion

Two physiologies most critical to work and safety are core body temperature and sleep/wakefulness

Rotation While forward rotation works better with circadian rhythms of the body, reverse rotation is more common in the US (workers pick up an extra “day off” going from night to evening)

Clockwise shift rotation Phase delaying: places less strain on the human internal clock Higher worker satisfaction Fewer health complaints and work schedule complaints 20% increased productivity c/w phase advanced shifts

Counter clockwise Phase advancing: For every hour of advancement a full day is needed for entrainment (ie: phase advancement to an earlier shift every 7 days necessitates a week or longer to adapt after each rotation) 25% of workers may not adapt

Other observations Air travel: Entrainment is much easier westbound than eastbound “Night owl” type personalities adapt better to night and rotating shifts than “morning larks” Rotation every 21 days results in 70% fewer complaints than every 7 days

Sleep stages

Stage 1 Initial part of sleep 10-15 minutes Slow rolling eye movements EEG = Alpha waves If awakened during this phase, will deny sleeping

Stage 2 Largest part of sleep @ 50% Infrequent or absent eye movement EEG = occasional sleep spindle bursts Deprivation of this stage may lead to total sleep loss Not usually “made up” after sleep deprivation

Stages 3 & 4 Slow wave sleep (SWS): deep Muscle tone; variable Arousal; difficult EEG: High voltage; Delta waves Important to body repair Not as susceptible to circadian factors

REM After 1-2 hours Paralysis of muscles with occasional twitches Body loses some thermoregulatory ability Heart rate and blood pressure very variable Restorative and dream sleep Important for psychosocial adjustment and development Greatly influenced by circadian factors

Cycling between stage 4 and REM Increased with caffeine REM suppressed with alcohol Sedatives increase stage 2 non restorative sleep Older less SWS, more frequent awakenings and less sleep time Younger greater frequency and longer REM intervals

Health Effects Immediate Long term

Health Hazards Gastrointestinal Problems Cardiovascular problems Sleep and stress related disorders Drug and Alcohol use Risks from prolonged exposure to chemical and biological substances and other hazards Effects on pregnancy

Digestive Increased incidence of ulcers. Often eat at night when digestion and other body functions are slowed down May eat less nutritious foods at night (snack foods) Drink more caffeine products at night

GI Upsets 75% of night workers vs. 20% of day workers Complaints Loss of appetite Constipation Dyspepsia Heart burn Abdominal pain flatulence Many problems may not show up until years later Reasons Poor food quality More caffeine More alcohol More tobacco Used to keep awake

Cardiovascular problems Increased incidence of ischemic disease Elevated triglyceride levels in phase advance workers May be related to disturbance of circadian blood pressure and pulse rhythms Substance abuse more likely in shift workers

Hypertension Shift workers were found to have approximately 25% greater chance of developing significant hypertension than non shift workers

Cognitive Ability Recent studies have found deterioration in cognitive ability in shift workers vs. non shift workers. This increases with duration of exposure The effect seems to diminish 4 years after discontinuation

Psychological Shift workers demonstrate: More depression and despondency More likely to use psychotropic drugs or require hospitalization Will have magnification of underlying depression or bipolar disorders Circadian rhythm disturbance may be a cause for depression

Social Risks Number 1 problem: missing family and friends Would rather loose sleep than miss social opportunities Some activities are flexible ( ie: gardening, woodworking, fixing cars) Some are not (clubs, team sports, childcare, school activities)

Social Impact Increases Divorce Family violence Social Isolation Sexual dysfunction May affect women more than men

Circadian rhythm related issues Peak bronchial reactivity between 4-7 AM Asthma may be worse in workers exposed to irritants Shift work increases glucose levels in insulin dependent diabetics. One study shows a 35% increased risk for developing diabetes Sleep deprivation lowers seizure threshold Increases frequency of migraines The absorption, excretion, metabolism and peak effect of medications is affected by circadian rhythms

Colorectal Cancer data suggest that working a rotating night shift at least three nights per month for 15 or more years may increase the risk of colorectal cancer in women 35% Shorter durations also have increased risk This may be due to the suppression of melatonin production with nocturnal light exposure. Melatonin has anti-cancer properties

Breast Cancer Attributed to inhibition of melatonin production by light exposure during the night

Shift Work Sleep Disorder Circadian Rhythm disruption Insomnia Disrupted sleep schedules Reduced performance Difficulties with personal relationships Irritability/depressed mood Sleep apnea 11.6% vs 5% in general population

Increased accidents To and from work Microsleeps Decreased vigilance Alert to suddenly severe fatigue Worse with monotonous tasks Decreased vigilance Lower performance Higher error rates 20% increase in ergonomic workers compensation cases

Making an Impact Strategies to WAKE UP

Administrative Controls Limit shift work to essential jobs Schedule toughest most dangerous tasks for early in the shift. Less demanding tasks for later in the shift Avoid scheduling demanding or dangerous tasks at the beginning of an early morning shift

Tailor supervision: Extra supervision between 3:30 AM and 5:30 AM Younger workers have more accidents at the start of a shift following weekends Older workers have more accidents at the end of a shift. Supervise inexperienced workers more closely until they learn their job

Encourage good eating habits at night Encourage good eating habits at night. Encourage light meals that are nutritious and easy to digest Allow adequate meal and rest breaks Have good emergency plans in place for odd shifts (nighttime emergency responders may be fewer than day)

Odd Shift Out Compressed workweek: Pros: 3-4 days of 10-12 hour shifts More time off and between work schedules More opportunities for family and social activities

Cons: Increased fatigue Decreased performance by the end of the shift Daily exposure to chemical, biological and physical hazards my be increased Some families may have trouble arranging childcare or eldercare

Permanent afternoon, evening or Night shift Pro: More time to adjust Con: Disruptive to social life Permanent night workers may accumulate a greater sleep deficiency over time

Rotating or Variable shifts Length of rotation: Workers rotated to a new shift schedule too rapidly or without sufficient break may have trouble functioning

Speed of rotation Longer rotations of 10-14 days may allow more time to adjust. Circadian rhythm may require 3 weeks to fully adjust to a new shift Mental functions adjust more rapidly More trouble with the first 4 shifts Faster rotations of 2-3 days do not allow for circadian rhythm adjustment Faster rotation allows workers to get through the more difficult night shift rotation quicker

Direction of the rotation Clockwise rotation from morning to afternoon to night causes fewer problems than the reverse order

Engineering controls Reduce night traffic, noise and distractions Be aware of hazards. Calculate toxic exposures based upon shift duration (i.e.: 8H TWA vs. 12 hour shift) Promote alertness: Keep area brightly lit Reduce glare and reflective surfaces If feasible, allow workers to play music that will keep them awake

Maximizes safety and health controls Good ventilation Temperature control Machine guarding Avoid isolating workers. Communicate often Provide food preparation areas, rest areas, consider and exercise facility

Provide worker education and instruction Treat shift training like Hazcom Talk about health and safety difficulties Emphasize performance and accident risks Teach employees to recognize social and family problems

They should know…. How to recognize health problems which may be related to shift work How to control shift work hazards and methods that can be used to do so. How to minimize the effects of shift work on themselves

They can do this by… Protecting their sleep periods Maintaining regular rest and wake routines Avoid exercising for 2 hours before going to bed Keep light out the bedroom Disconnect the phone Maintain a quiet sleep area

Eat nutritious meals Keep a regular eating routine Select foods high in carbohydrate rather than heavy fatty high protein meals before sleep

Family and friends should be made aware of the potential harmful consequences of shift work Adjust family and social life to maximize interaction Maintain physical fitness Learn strategies to remain awake at work

One last note: Modafilin aka Provigil Sept 2003: FDA advisory panel recommended use for shift work sleep disorder Different mechanism than amphetamines Well tolerated Memory improving mood brightening No jittery feeling ?anxiolytic