SHIFT WORK DISORDER - myCME.com

with a suspected or confirmed comorbidsleep disorder (see “Recognition of shiftworkdisorder in primary care” on page S18of this supplement). An algorithm for themanagement of SWD in the primary caresetting, including steps to evaluate comorbiddisorders, appears in Figure 1.NonpharmacologicinterventionsA range of nonpharmacologic options havebeen evaluated to relieve the ES often reportedby shift workers. These interventionsinclude steps to improve sleep hygiene,scheduled nap times, exercise, andtimed exposure to light. Although not all ofthese interventions have been specificallyevaluated among individuals with SWD,such approaches may prove useful as partof a wider management program alongsidepharmacotherapy.figure 1 Primary care management algorithm for theindividual with shift-work disorder• Review currentsleep/wake patterns• Identify troublesomesymptoms• Review flexibility ofworking conditionsStep 1: EvaluateEvaluate forcomorbid sleepdisordersEvaluate forcomorbid medicaldisordersEvaluate forcomorbid mooddisordersStep 2: Develop management strategyPriority A• Advise on sleep hygiene• Explore potential for changes toshift-work pattern• Explore potential for schedulednapping• Explore potential for simple brightlight therapyRefer for specialist careas appropriateRefer for specialist careas appropriateInitiate appropriatemedication and/orcounseling supportPriority B• Initiate a wakefulness-promotingagent• Consider use of sleep-promotingagents before the required sleepperiodEvaluating the work patternCertain shift patterns have been shown tobe more detrimental than others in terms oftheir effects on performance. 3 For example,Folkard and Tucker 3 analyzed data from 7studies that evaluated the risk for incidents(including accidents and injuries) during successivenight shifts. They found that the risk approximately doubledwith each shift worked, from ~6% during the secondnight shift to 17% during the third night shift and 36%during the fourth night shift (FIGURE 2). Additional studiesevaluating the effects of >4 consecutive night shifts, whichwere not included in the analysis by Folkard and Tucker, 3confirm the risk for decreased cognitive performance andincreased severe ES. 4,5 The observed marked increase inthe risk for incidents during working hours suggests thatworking more than 4 consecutive 12-hour night shiftsshould be avoided. Individuals should also be counseledto avoid work shifts that are longer than 12 hours due tothe risk accumulated on an hourly basis. 3 Individuals ona rotating shift schedule should be encouraged to rotatetheir shifts in a clockwise rather than a counterclockwisemanner (morning to evening to night shift as opposed tonight to evening to morning shift) (FIGURE 3). It is easier tochange the sleep/wake cycle to a clockwise shift rotation,as this follows the natural adaptive pattern of delayingthe sleep period. 6,7 However, a change of rotation directiondoes not eliminate the risks associated with SWD.Evaluate for changes in perceivedsleepiness (eg, Epworth SleepinessScale), accidents/near misses atwork or on the commute homeFigure 2 Risk for incidents during successivenight shiftsRelative risk1.41.31.21.11.00.9Step 3: Review effectivenessRefer for specialist care and furthersleep/wake phase adjustment1 2 3 4Successive nightsReprinted from Occupational Medicine (London), Volume 53, Issue 2, FolkardS and Tucker P. Shift work, safety and productivity; pp 95–101, Copyright ©2003, with permission from Oxford University Press. 3Supplement to The Journal of Family Practice • Vol 59, No 1 / January 2010 S25