SHIFT WORK DISORDER - myCME.com

Managing the patient withshift-work disorderMichael J. Thorpy, MDDirector of the Sleep-Wake Disorders CenterMontefiore Medical CenterBronx, New YorkPractice recommendationsy Behavioral measures, eg, exercise andimproved sleep hygiene, can enhancesleep quality and combat insomniaand excessive sleepiness (ES) in shiftworkers and individuals with shiftworkdisorder (SWD) (SOR: B).y Napping before a shift followed byconsumption of a caffeinated drink and, ifappropriate, scheduled naps at work, mayimprove ES in patients with SWD (SOR: C).y Use of bright light therapy to partiallyre-entrain the circadian clock should beexplored for all night-shift workers—particularly those with SWD (SOR: B).y The wakefulness-promoting agentsarmodafinil and modafinil are FDA approvedfor the treatment of ES in patients with SWD.Alongside nonpharmacologic interventions,they can be included in a comprehensivemanagement plan for SWD (SOR: A).y Melatonin or other sleep-promotingagents may help shift workers achievesleep during required rest periods andwhen adjusting to night-shift work;studies are needed in patients with SWDto better evaluate the utility of theseagents in this population (SOR: C).Dr Thorpy reports that he serves as a consultantto and on the speakers bureaus of Cephalon, Inc.,and Jazz Pharmaceuticals, Inc.The goals of treatment for individuals with shift-workdisorder (SWD) are to ensure sustained wakefulnesswhen wakefulness is required and to facilitate restorativesleep when sleep is required. Several nonpharmacologicinterventions are available for the treatment of SWD, such asthe improvement of sleep hygiene, exercise, and timed exposureto light. Although these treatments are recommended aspart of the Practice Parameter Guidelines for the Evaluationand Treatment of Circadian Rhythm Sleep Disorders fromthe American Academy of Sleep Medicine, 1,2 most have beenevaluated in shift workers generally, rather than specifically inthose with SWD. However, the current definition of SWD requiresfurther validation, and while the delineation betweenworkers who do not thrive under shift-work conditions andindividuals who develop SWD remains indistinct, it is likelythat literature specific to SWD will remain sparse. 2Regardless, such nonpharmacologic interventions shouldbe introduced for all individuals presenting with SWD. Pharmacotherapymay also be required. Two pharmacologic agents—modafinil and its R-enantiomer armodafinil—have beenevaluated specifically in patients with excessive sleepiness (ES)associated with SWD and are approved as wakefulness-promotingagents for this indication by the US Food and Drug Administration(FDA).This article reviews appropriate management strategiesand specific interventions—both nonpharmacologic andpharmacologic—that primary care physicians can offer toindividuals diagnosed with SWD.Addressing comorbid conditionsFor the individual presenting with SWD, it is essential to identifyand address any comorbid conditions that might contributeto poor sleep hygiene and/or cause ES or fatigue duringrequired periods of wakefulness. Perhaps the most relevantcomorbidities are other sleep disorders, such as obstructivesleep apnea (OSA), and mood disorders, such as depression.Referral to a sleep specialist may be necessary for individualsS24 January 2010 / Vol 59, No 1 • Supplement to The Journal of Family Practice