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Recognition of shift-workdisorder in primary careJonathan R. L. Schwartz, MDUniversity of Oklahoma Health Sciences CenterINTEGRIS Sleep Disorders Center of OklahomaOklahoma City, OklahomaPractice recommendationsy To recognize shift-work disorder (SWD),primary care physicians can screen forpersistent excessive sleepiness (ES)and insomnia in patients who worknight or rotating shifts (SOR: B).y If SWD is suspected, a differential diagnosisshould be generated, as ES and insomniaare commonly associated with othermorbidities. Ask patients about symptoms ofother common sleep/wake disorders, suchas obstructive sleep apnea and periodiclimb movement disorder (SOR: B).y The Epworth Sleepiness Scale is a usefultool for subjectively evaluating ES (SOR: A).Shift-work disorder (SWD) is experienced by individualswhose work schedule overlaps with the normalsleep period, causing misalignment between thebody’s endogenous circadian clock and the time at whichthe worker is able to rest. The International Classificationof Sleep Disorders, 2nd edition (ICSD-2) defines SWD as thepresence of excessive sleepiness (ES) and/or insomnia forat least 1 month, in association with a shift-work schedule. 1This classification results in the shift-work population beingseparated into 3 distinct groups: those who have no impairment;those who have impairment but do not meet theICSD-2 criteria for the diagnosis of SWD; and those who haveSWD. Individuals in the last 2 groups are less likely to be ableto meet the demands of shift work and, therefore, often returnto non–shift-work schedules or retire from the workforce. Thiscreates a “healthy worker effect,” whereby workers remainingon night- or rotating-shift patterns are the best suited for thistype of work. 2,3 However, retirement or changes to shift-workschedules are not an option for many workers, and patientswith SWD must be recognized and treated in order to preservetheir health and livelihood.This article aims to characterize the symptoms and riskfactors associated with SWD, with a view to assisting primarycare physicians in the diagnosis and recognition of this consistentlyunderrecognized sleep/wake disorder. 4Dr Schwartz reports that he serves as a consultant toand on the speakers bureaus of AstraZeneca, BoehringerIngelheim Pharmaceuticals, Inc., Cephalon, Inc., Pfizer Inc,Sepracor Inc., Takeda Pharmaceuticals North America, Inc,and GlaxoSmithKline.Symptoms of SWDInsomnia and ES (drowsiness and a propensity to sleep) arethe defining symptoms of SWD and can result in fatigue (wearinessand depleted energy), difficulty concentrating, reducedwork performance, headache, irritability or depressed mood,and feeling unrefreshed after sleeping. 4,5 The consequences ofinsomnia and ES may, therefore, also be useful warning signsfor SWD, and patients presenting with one or more of thesesequelae should be evaluated for risk factors for SWD andasked about their symptoms using the differential diagnosisdescribed below and in the Figure.S18 January 2010 / Vol 59, No 1 • Supplement to The Journal of Family Practice
figure Questions to ask patients who present with insomnia and/or ES(as assessed by an ESS score ≥10)Does your occupation requireyou to work shifts?YESNoWhen sleeping, do you feeldiscomfort in your legsor jerk them involuntarily?When sleeping, do you feeldiscomfort in your legsor jerk them involuntarily?NoYesYesNoDo you snore orDo you snore orexperience episodes ofexperience episodes ofchoking during sleep?No/Don't know YesPatients may have restlesslegs syndrome—Check serum ferritin and considera trial of a dopamine agonistYeschoking during sleep?No/Don't knowDo you have a dry, sorethroat on waking?Do you have a dry, sorethroat on waking?No Yes Yes NoHave your ES and/or insomniapersisted for ≥1 month?Patient may have obstructive sleepapnea—Refer to a sleep specialistfor polysomnographyNoYesPatient does not have SWD butexperiences impairment whenworking shifts—Suggest improvementsin sleep hygienePatient may have SWD—Review sleephygiene and consider trial of therapyPatient’s symptoms may be dueto other causes eg, a mood disorder,stimulant or sedative medications,or substance abuse—Further assessment is requiredES, excessive sleepiness; ESS, Epworth Sleepiness Scale; SWD, shift-work disorder.These questions aim to aid in differentiating between common sleep/wake disorders in shift-working patients who present with sleepiness or have trouble sleepingand should not be viewed as an exhaustive or definitive list of potential questions or potential diagnoses.Risk factors for SWDVulnerability to SWD is dependent on certain predisposingand precipitating factors, including shift characteristics,circadian preference, job satisfaction, andsusceptibility to sleep disturbance (see “The characterizationand pathology of circadian rhythm sleep disorders”on page S12 of this supplement). The effects ofsome physiological and lifestyle factors, such as age andgender, on an individual’s propensity to develop SWDhave not been well quantified to date.Shift type and patternNight-shift workers are reportedly most susceptible toSWD, with an estimated 32.1% of this group experiencingsymptoms that meet the minimum diagnostic criteria forSWD compared with 26.1% of rotating-shift workers. 6 Arecent study by Waage and others 7 found that 23.3% of oilrig swing-shift workers (2 weeks working 12-hour day/night shifts followed by 4 weeks off) met ICSD-2 criteriafor SWD. The relatively high prevalence of SWD in nightshiftworkers is thought to be due to exposure to lightduring rest periods and dark during the hours when theworkers are attempting to be most productive. 6 Morningshiftworkers are more susceptible to SWD than eveningshiftworkers, as delaying sleep appears to be more easilyachieved than attempting to advance the rest period. 8Supplement to The Journal of Family Practice • Vol 59, No 1 / January 2010 S19
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Practice Management Tips ForSHIFT W
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Patient QuestionnaireDo you often f
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PHQ-9 QUICK DEPRESSION ASSESSMENTFo
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Current Treatment Options in Neurol
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398 Sleep Disordersand sleep loss,
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