Shift Work Disorder Case Studies: Applying Management Principles in Clinical Practice
Andrew D. Krystal, MD, MS
Listen to Audio Introduction
Thomas Roth, PhD
Richard D. Simon, Jr, MD
Assessment and Diagnosis
Case vignette. 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. He had had 2 car accidents due to falling asleep while driving. He reported frequent upper respiratory infections, but no other health or psychiatric problems. 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.
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. He therefore made a tentative diagnosis of shift work disorder.
The clinician first asked Mr A to keep a sleep diary for several weeks. 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. In addition, at the clinician’s suggestion, Mr. 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. His problems with upper respiratory infections also improved. The clinician felt that the diagnosis of shift work disorder was confirmed. (AV 1) shows the full criteria for shift work disorder.
Case vignette. 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. On work days, he goes to bed at about 4:00 AM. He would like to sleep until noon, but his wife, who goes to work at 7:00 AM, wakes him at 6:30 AM to get his 3 children ready for school. 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. On weekends, he tries to go to bed with his wife at 10:00 PM and wake up with her at 6:00 AM, but he tosses and turns for several hours before he can sleep so that he can’t get up with her. He consumes 6–12 cups of coffee in the morning on weekends to try to wake up and function with his family but is still exhausted. He doesn’t snore or have symptoms of restless legs syndrome. Mr B’s job requires him to work rotating shifts: 3 months on evening shifts, 3 months on graveyard shifts (midnight to 7:00 AM), and 3 months on day shifts. He has little difficulty maintaining wakefulness during the evening shift. 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. The patient says his wife is unhappy that he seems to be unwilling and unable to go to bed at 10:00 PM and wake up at 6:00 AM and participate in family events on his days off.
When on the evening shift, Mr B maintains good alertness and typically socializes for 1 to 2 hours after work before driving home. He could probably sleep until noon, but he must get up and drive his children to school.
On weekends, he can’t fall asleep at 10:00 PM with his family, who lead a “regular” diurnal life, because that is when his biological clock is very active.
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. Although tired, he also has trouble sleeping past noon, because his biological clock begins to turn on about noon.
When the patient works days, he has great difficulty getting up at 5:00 or 6:00 AM, driving to work, and staying awake during the first half of his shift, because his biological clock is basically off. During the second half of his shift, when his clock is beginning to turn on, he is better able to stay awake.
The clinician in this case asked the patient and his wife to come in for a joint visit. During this visit, the clinician explained circadian principles and the physiology of sleep and wakefulness. 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. The patient acknowledged he would need to make some changes too. The patient and his wife agreed to the following strategies.
When on the evening shift, rather than socializing after work, the patient will go home immediately, keep the environment as dark as possible between midnight and 2:00 AM, and try to sleep from 2:00 AM to 10:00 AM, with his bedroom as dark as possible. At 10:00 AM, the patient will get as much bright light as possible, to alert his brain that the day starts at 10:00 AM. His wife agreed to go to work an hour later so that she can get the children off to school.
When on the graveyard shift, the patient will wear very dark glasses on the drive home, try to sleep from 9:00 AM to 5:00 PM, get bright light after 5:00 PM, and consider taking melatonin as soon as he gets home. He will also consider having a nap and then a cup of coffee before going to work. On weekends, the patient will follow a compromise routine of sleeping from 4:00 AM to noon.
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. On weekends, rather than going to bed at 10:00 PM with his wife, he will stay up until midnight and sleep until 8:00 AM.
This 3-part system involves the patient making some compromises in his intrinsic biological sleep/wake schedule and the family accepting that, depending on what shift he is working, the patient’s sleep/wake schedule will be different. 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. 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.
When to Refer for Specialized Care
In the case of the patient described above, the clinician proposed a number of fairly simple strategies to try to resolve his sleep problems. 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). If a clinician is uncomfortable with managing or does not have the time to manage shift work/circadian issues, a referral would also be indicated. Other situations in which a referral for a specialized sleep assessment and use of more aggressive treatment strategies are likely to be needed include patients with a high likelihood of having comorbid intrinsic sleep disorders, in particular sleep apnea; patients at considerable risk of falling asleep on the drive to or from work; and patients involved in dangerous work who are likely to fall asleep at work.
By 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. 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.
- American Academy of Sleep Medicine (AASM). International Classification of Sleep Disorders Diagnostic and Coding Manual, Second Edition (ICSD-2). Westchester, IL: American Academy of Sleep Medicine; 2005