Shift Work Sleep Disorder

Human sleep and immunity: The role of circadian patterns

It is well established that sleep promotes health and welfare. Literature data suggests that sleep is a recurrent resting state that performs multiple biological functions, such as memory consolidation and regulation of glucose, lipid metabolism, energy metabolism, eating behavior, and blood pressure, besides, regulating the immune system. These immunological functions depend on regular sleep and circadian rhythms, as both impact the magnitude of immune responses. Circadian rhythm is the 24-h internal clock in our brain that regulates cycles of alertness and sleepiness by responding to light changes in our environment. It encompasses physical and behavioral daily oscillations. Sleep deprivation and circadian misalignment affect immunity, and both have been related to adverse health effects and chronic diseases. Studies have shown that individuals with regular and consistent sleep patterns have a more effective immune response. Thus, understanding how sleep disturbance will affect the immune response is vital in developing interventions to prevent the health burden of irregular sleep patterns and circadian misalignment, favoring a homeostatic immune defense to microbial or inflammatory insults. Therefore, the scope of this chapter is to explore evidence that regular circadian rhythms and sleep patterns are needed for optimal resistance to infectious challenges.

Relationship between long-term shift work; night work; sleep deficiency and stroke: A systematic review and meta-analysis

BACKGROUND

The association between shift/night work and the risk of stroke is not supported by strong evidence.

OBJECTIVE

This study aimed to obtain evidence of a potential relationship between shift/night shift work and the risk of stroke.

METHODS

We searched PubMed, Embase, the Cochrane Library and Web of science databases for eligible studies from inception to January 19, 2024. We followed the statement in the Preferred Reporting Items for Systematic Evaluations and Meta-Analysis (PRISMA). STATA 14.0 software was used for meta-analysis.

RESULTS

A total of five studies involving 700,742 subjects were included in this meta-analysis. We found that shift/night workers had a 1.08 times higher risk of stroke than non-shift/night workers (RR: 1.08; 95 % CI: 1.05-1.10; P < 0.001).

CONCLUSION

Shift/night work may be a risk factor for stroke. More objective prospective studies are needed to further support this result.

The Effect of Sleep Quality on Coronary Lesion Severity and Prognosis in the Young Acute Coronary Syndrome Population

This study aimed to explore the effect of long-term (≥1 year) sleep quality on coronary lesion complexity and cardiovascular prognosis in young acute coronary syndrome (ACS) patients. We consecutively recruited young patients aged from 18 to 44 years old with first-episode ACS and significant epicardial stenosis on coronary angiography from January 2016 to January 2017. Coronary lesion complexity was evaluated based on SYNTAX scores. Long-term sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) (PSQI ≤ 5 and PSQI > 5 groups). The primary endpoints were major adverse cardiovascular events (MACEs). A total of 466 young ACS patients (93.13% male; median age, 41 years) were included. Poor sleepers (PSQI > 5) had higher SYNTAX scores. After adjusting for confounders, PSQI scores (continuous variables, OR: 1.264; 95%CI: 1.166-1.371; p < 0.001) and PSQI grade (binary variable, OR: 3.864; 95%CI: 2.313-6.394; p = 0.001) were significantly associated with an increased risk of complex coronary lesions. During a median follow-up of 74 months, long-term poor sleep quality (PSQI > 5) was significantly associated with an increased risk of MACEs (HR: 4.266; 95%CI: 2.274-8.001; p < 0.001). Long-term poor sleep quality was a risk factor for complex coronary lesions and has adverse effects on cardiovascular prognosis in the young ACS population.

Firefighter Health: A Narrative Review of Occupational Threats and Countermeasures

Structural firefighters are responsible for protecting properties and saving lives during emergency operations. Despite efforts to prepare firefighters for these hazardous occupational demands, the unfortunate reality is that the incidence of health morbidities is increasing within the fire service. Specifically, cardiovascular disease, cancer, and mental health disorders are among the most documented morbidities in firefighters. Pubmed and Google Scholar search engines were used to identify peer-reviewed English language manuscripts that evaluated firefighters' occupational health threats, allostatic factors associated with their occurrence, and evidence-based strategies to mitigate their impact. This narrative review provides fire departments, practitioners, and researchers with evidence-based practices to enhance firefighters' health.

Shift-work sleep disorder among health care workers at public hospitals, the case of Sidama national regional state, Ethiopia: A multicenter cross-sectional study

Introduction

Shift-work disrupts circadian rhythm, resulting in disturbed sleep time and excessive sleepiness during the work shift. Little is known about shift-work sleep disorder among health care workers in Ethiopia. This study examined the magnitude and associated factors of shift-work sleep disorder among health care workers in Public Hospitals in Sidama National Regional State, Southern Ethiopia.

Methods

An institution-based cross-sectional study was carried out on 398 health care workers selected using a systematic random sampling technique. A self-administered structured questionnaire consisting of insomnia, sleepiness scales and international classification of sleep disorder criteria items was employed. Epi data version 4.6 and Stata 14 were used for data entry and statistical analysis respectively. Binary logistic regression was fitted to determine associated factors and decision for the statistical significance was made at p<0.05 in the multivariable binary logistic regression.

Results

Three hundred and ninety-eight health care workers (female = 53%) were included in the analysis with a response rate of 94.8%. The prevalence of shift-work sleep disorder was 33.67% (95% CI: 29.17%-38.45%). Being married (AOR = 1.88 (1.01–3.28)), three-shift (AOR = 1.078 (1.00–3.16)), ≥11 night shifts per month (AOR = 2.44 (1.36–4.38)), missing nap (AOR = 1.85 (1.04–3.30)), daily sleep time < 7hours (AOR = 1.88 (1.05–3.38)), khat chewing (AOR = 2.98 (1.27–8.09)), alcohol drinking (AOR = 2.6(1.45–4.92)), and cigarette smoking (AOR = 3.32 (1.35–8.14)) were significantly associated with shift-work sleep disorder.

Conclusion

This study showed a high prevalence of shift-work sleep disorder. Two shift schedule, napping, and reduction of substance use might reduce shift-work sleep disorder.

Prevalence of Insomnia in Various Industries and Associated Demographic Factors in Night-Shift Workers Using Workers' Specific Health Examination Data

This study aimed to investigate the prevalence of insomnia in various industries and the associated demographic factors. We searched the nationwide night-shift Workers’ Specific Health Examination (nsWSHE) data extracted in 2015 information on factors associated with insomnia, including sex, age, and the number of workers in the workplace. The prevalence of moderate insomnia in the total industry was 4.6%. Industries with a high prevalence of insomnia included the arts, sports, and recreation-related services industry, followed by the activities of household as employers industry, financial and insurance activities industry, human health and social welfare industry, and accommodation and food services activities industry. The prevalence of insomnia was higher in women. Age was a significant factor. In general, insomnia was highest among those aged ≥60 years. Insomnia was highest in small-sized companies with fewer than five employees compared to large enterprises with more than 1000 employees. This study is the first to analyze the prevalence of insomnia among night-shift workers who participated in the WSHEs. The findings of this study can be used to prioritize intervention policies for insomnia among night-shift workers.

Association of rotating shift work schedules and the use of prescribed sleep medication: A prospective cohort study

We examined whether working rotating shifts, with or without night work, is associated with the purchase of prescribed sleep medication, and whether the association is dependent on age. Data were obtained from a longitudinal cohort study of Finnish public sector employees who responded to questions on work schedule and background characteristics in 2000, 2004 and 2008. The data were linked to national register data on redeemed prescriptions of hypnotic and sedative medications, with up to 11 years of follow-up. Age stratified Cox proportional hazard regression models were computed to examine incident use of medication comparing two groups of rotating shift workers (those working shifts that included night shifts and those whose schedules did not include night shifts) with day workers who worked in a similar range of occupations. Shift work with night shifts was associated with increased use of sleep medication in all age groups, after adjustments for sex, occupational status, marital status, alcohol consumption, smoking and physical activity levels (hazard ratio [HR], [95% confidence interval, CI] 1.14 [1.01-1.28] for age group ≤39 years; 1.33 [1.19-1.48] for age group 40-49 years; 1.28 [1.13-1.44] for age group ≥50 years). Shift work without nights was associated with medication use in the two older age groups (HR [95% CI] 1.14 [1.01-1.29] and 1.17 [1.05-1.31] for age groups 40-49 years and >50 years, respectively). These findings suggest that circadian disruption and older age puts rotating shift workers, and especially those who work nights, at increased risk of developing clinically significant levels of sleep problems.

Differential DNA methylation in recovery from shift work disorder

The human DNA methylome is responsive to our environment, but its dynamics remain underexplored. We investigated the temporal changes to DNA methylation (DNAme) in relation to recovery from a shift work disorder (SWD) by performing a paired epigenome-wide analysis in an occupational cohort of 32 shift workers (25 men, age = 43.8 ± 8.8 years, 21 SWD cases). We found that the effect of vacation on DNAme was more prominent in the SWD-group as compared to controls, with respect to the amount of significantly differentially methylated positions (DMPs; P_unadj < 0.05) 6.5 vs 3.7%, respectively. The vast majority (78%) of these DMPs were hypomethylated in SWD but not in controls (27%) during the work period. The Gene Ontology Cellular component "NMDA glutamate receptor" (P_FDR < 0.05) was identified in a pathway analysis of the top 30 genes in SWD. In-depth pathway analyses revealed that the Reactome pathway "CREB phosphorylation through the activation of CaMKII" might underlie the recovery. Furthermore, three DMPs from this pathway, corresponding to GRIN2C, CREB1, and CAMK2B, correlated with the degree of recovery (P_unadj < 0.05). Our findings provide evidence for the dynamic nature of DNAme in relation to the recovery process from a circadian disorder, with biological relevance of the emerging pathways.

The impact of stress on sleep: Pathogenic sleep reactivity as a vulnerability to insomnia and circadian disorders

Sleep reactivity is the trait-like degree to which stress exposure disrupts sleep, resulting in difficulty falling and staying asleep. Individuals with highly reactive sleep systems experience drastic deterioration of sleep when stressed, whereas those with low sleep reactivity proceed largely unperturbed during stress. Research shows that genetics, familial history of insomnia, female gender and environmental stress influence how the sleep system responds to stress. Further work has identified neurobiological underpinnings for sleep reactivity involving disrupted cortical networks and dysregulation in the autonomic nervous system and hypothalamic-pituitary-adrenal axis. Sleep reactivity is most pathologically and clinically pertinent when in excess, such that high sleep reactivity predicts risk for future insomnia disorder, with early evidence suggesting high sleep reactivity corresponds to severe insomnia phenotypes (sleep onset insomnia and short sleep insomnia). High sleep reactivity is also linked to risk of shift-work disorder, depression and anxiety. Importantly, stress-related worry and rumination may exploit sensitive sleep systems, thereby augmenting the pathogenicity of sleep reactivity. With the development of cost-effective assessment of sleep reactivity, we can now identify individuals at risk of future insomnia, shift-work disorder and mental illness, thus identifying a target population for preventive intervention. Given that insomniacs with high sleep reactivity tend to present with severe insomnia phenotypes, patient sleep reactivity may inform triaging to different levels of treatment. Future research on sleep reactivity is needed to clarify its neurobiology, characterize its long-term prospective associations with insomnia and shift-work disorder phenotypes, and establish its prognostic value for mental illness and other non-sleep disorders.

Cross-sectional analysis of sleep-promoting and wake-promoting drug use on health, fatigue-related error, and near-crashes in police officers

OBJECTIVES

To examine sleep-promoting and wake-promoting drug use in police officers and associations between their use and health (excessive sleepiness, stress and burnout), performance (fatigue-related errors) and safety (near-crashes) outcomes, both alone and in combination with night-shift work.

DESIGN

Cross-sectional survey.

SETTING

Police officers from North America completed the survey either online or via paper/pencil at a police station.

PARTICIPANTS

4957 police participated, 3693 online (91.9%, participation rate) and 1264 onsite (cooperation rate 63.1%).

MAIN OUTCOME MEASURES

Sleep-promoting and wake-promoting drug use, excessive sleepiness, near-crash motor vehicle crashes, dozing while driving, fatigue errors, stress and burnout.

RESULTS

Over the past month, 20% of police officers reported using sleep-promoting drugs and drugs causing sleepiness, while wake-promoting agents were used by 28% of police (5% used wake-promoting drugs, 23% used high levels of caffeine and 4% smoked to stay awake). Use of sleep-promoting drugs was associated with increased near-crashes (OR=1.61; 95% CI 1.21 to 2.13), fatigue-related errors (OR=1.75; 95% CI 1.32 to 2.79), higher stress (OR=1.41; 95% CI 1.10 to 1.82), and higher burnout (OR=1.83; 95% CI 1.40 to 2.38). Wake-promoting drug use, high caffeine and smoking to stay awake were associated with increased odds of a fatigue-related error, stress and burnout (ORs ranging from 1.68 to 2.56). Caffeine consumption was common, and while smoking was not, of those participants who did smoke, one-in-three did so to remain awake. Night-shift work was associated with independent increases in excessive sleepiness, near-crashes and fatigue-related errors. Interactions between night-shift work and wake-promoting drug use were also found for excessive sleepiness.

CONCLUSIONS

Police who use sleep-promoting and wake-promoting drugs, especially when working night shifts, are most vulnerable to adverse health, performance and safety outcomes. Future research should examine temporal relationships between shift work, drug use and adverse outcomes, in order to develop optimal alertness management strategies.

Sleep in the Postpartum: Characteristics of First-Time, Healthy Mothers

Goals for the present study were to (a) describe the sleep of healthy new mothers over a 6-month postpartum period, (b) examine how sleep quality relates to daytime levels of fatigue and sleepiness, and (c) evaluate the relationship between mothers' and infants' sleep parameters. The sample consisted of 37 healthy, partnered, first-time mothers who had experienced full-term vaginal birth and had a healthy infant. We investigated infants' sleep parameters and mothers' sleep, mood, and daytime functioning 2 and 6 months postpartum. We found that at 2 months postpartum, mothers reported sleeping 6 hours at night and just under one hour during the day. Despite relatively frequent nocturnal awakenings, mothers experienced minimal insomnia, nonrefreshing sleep, anxiety, depression, daytime sleepiness, or fatigue at either 2 or 6 months. The most robust relationship between mothers' and infants' sleep was in the number of nocturnal sleep-wake episodes. Of note is that none of the infant sleep parameters was related to mothers' anxiety, depression, fatigue, sleepiness, or nonrefreshing sleep at either time period. Our results indicate that (1) selected low risk new mothers are resilient in terms of sleep quality, daytime functioning, and mood and (2) these are independent of their infants' sleep parameters.

Relationship between menstruation status and work conditions in Japan

Background

Menstrual problems can significantly impact daily and work life. In reaction to a shrinking population, the Japanese government is encouraging more women to participate in the labor force. Actual success in achieving this aim, however, is limited. Specifically, participation in the workforce by women during their reproductive years is impacted by their health, which involves not only work conditions, but also traditional family circumstances. Therefore, it is important to further assess and gather more information about the health status of women who work during their reproductive years in Japan. Specifically, women’s health can be represented by menstruation status, which is a pivotal indicator. In this study, we assessed the association between short rest periods in work intervals and menstruation and other health status indicators among female workers in Japan.

Methods

Study participants were recruited from the alumnae of a university, which provided a uniform educational level. All 9864 female alumnae were asked to join the survey and 1630 (17%) accepted. The final sample of study participants (n = 505) were aged 23–43 years, had maintained the same job status for at least 1 year, and were not shift workers, had no maternal status, and did not lack any related information. The participants were divided into two groups according to interval time, with 11 h between end of work and resumption of daily work as a benchmark. This interval time was based on EU regulations and the goal set by the government of Japan. Health outcomes included: menstrual cycle, dysmenorrhoea symptoms, anxiety regarding health, and satisfaction in terms of health. Multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for health indexes in association with interval time by adjusting for confounding variables that included both psychosocial and biological factors.

Results

We compared the health status of women in the workforce with and without a sufficient interval time of 11 h/day. Workers who had a short interval time had a significantly higher prevalence of anxiety about health and dissatisfaction with their health. For menstruation status, only abnormal menstruation cycles were observed more often among workers in the short interval group than those of the long interval group. However, this association disappeared when biological confounding factors were adjusted in a multivariable regression model. Dysmenorrhea symptoms did not show a statistically significant association with short interval time.

Conclusions

This study found a significant association between a short interval time of less than 11 h/day and subjective health indicators and the menstrual health status of women in the workforce. Menstrual health was more affected by biological factors than social psychological factors. A long work time and short interval time could increase worker anxiety and dissatisfaction and may deteriorate the menstrual cycle.

Attenuation of short wavelengths alters sleep and the ipRGC pupil response

PURPOSE

Exposure to increasing amounts of artificial light during the night may contribute to the high prevalence of reported sleep dysfunction. Release of the sleep hormone melatonin is mediated by the intrinsically photosensitive retinal ganglion cells (ipRGCs). This study sought to investigate whether melatonin level and sleep quality can be modulated by decreasing night-time input to the ipRGCs.

METHODS

Subjects (ages 17-42, n = 21) wore short wavelength-blocking glasses prior to bedtime for 2 weeks. The ipRGC-mediated post illumination pupil response was measured before and after the experimental period. Stimulation was presented with a ganzfeld stimulator, including one-second and five-seconds of long and short wavelength light, and the pupil was imaged with an infrared camera. Pupil diameter was measured before, during and for 60 s following stimulation, and the six-second and 30 s post illumination pupil response and area under the curve following light offset were determined. Subjects wore an actigraph device for objective measurements of activity, light exposure, and sleep. Saliva samples were collected to assess melatonin content. The Pittsburgh Sleep Quality Index (PSQI) was administered to assess subjective sleep quality.

RESULTS

Subjects wore the blue-blocking glasses 3:57 ± 1:03 h each night. After the experimental period, the pupil showed a slower redilation phase, resulting in a significantly increased 30 s post illumination pupil response to one-second short wavelength light, and decreased area under the curve for one and five-second short wavelength light, when measured at the same time of day as baseline. Night time melatonin increased from 16.1 ± 7.5 pg mL^-1 to 25.5 ± 10.7 pg mL^-1 (P < 0.01). Objectively measured sleep duration increased 24 min, from 408.7 ± 44.9 to 431.5 ± 42.9 min (P < 0.001). Mean PSQI score improved from 5.6 ± 2.9 to 3.0 ± 2.2.

CONCLUSIONS

The use of short wavelength-blocking glasses at night increased subjectively measured sleep quality and objectively measured melatonin levels and sleep duration, presumably as a result of decreased night-time stimulation of ipRGCs. Alterations in the ipRGC-driven pupil response suggest a shift in circadian phase. Results suggest that minimising short wavelength light following sunset may help in regulating sleep patterns.

Genes, body clocks and prevention of sleep problems

Chronobiologists argue that their scientific findings have implications for prevention of sleep problems. They claim that some sleep problems are caused by the fact that people live against their individual body clock rather than adjusted to it. They also claim that by taking the findings of chronobiology seriously in policy-making some sleep problems can be prevented. I investigate applications of chronobiology in two social areas-school schedules and shift work-and show that in order for these applications to be justified certain implicit presumptions have to be justified. The first presumption is explanatory, namely that a chronobiological explanation is an adequate explanation of the sleep problems at hand. In addition I analyse three ethical presumptions. The first ethical presumption is that sleep is of vital value. The second is that sleep is not an exclusively private issue. The third ethical presumption is that the preventive measures to be undertaken are ethically acceptable. My main point is that it is not possible to simply "read off" policy measures from the empirical findings of chronobiology.

Prevention of fatigue and insomnia in shift workers-a review of non-pharmacological measures

Background

Excessive fatigue and insomnia are common among shift workers and can lead to negative effects such as reduced work performance, processing errors, accidents at work, absenteeism, reduced quality of life, and symptoms of depression. Moreover, work in rotating shifts can be a risk factor for different somatic and psychiatric diseases and may contribute to poor health, especially in elder adults and women. This review aims to show non-pharmacological preventive measures against fatigue and insomnia in shift workers.

Method

Computerized literature searches in MedLine and in the Cochrane Library were performed with the following key words: shift work disorder, fatigue, insomnia, shift work, measures, treatment, therapy, strategies and coping. The search was limited to non-pharmacological studies that were conducted on human subjects and published as English-language articles in peer-reviewed journals since 1970. Additional studies were identified through the reference sections of relevant articles. Eighteen articles on fatigue in shift workers, including six original research articles with a total sample size of 3504 probands consisting of industrial workers, office employees, aircraft maintenance engineers, and non-shift workers working in simulated shifts, were analyzed, as well as seven articles on insomnia, including an original research article with a sample size of 26 media workers. Also, 4 reviews on shift work disorder were analyzed.

Main

The occurrence of fatigue and insomnia in shift workers associated with a working period is described as shift work disorder. Estimations on the prevalence of shift work disorder in shift workers vary between 5 % and about 20 %; about one in three shift workers is affected by insomnia and up to 90 % of shift workers report regular fatigue and sleepiness at the workplace. We concluded that there is a necessity for treatments to improve the sleep quality of the shift working population. The most common non-pharmacological recommendations to improve sleep quality and to reduce insomnia and fatigue were scheduling, bright light exposure, napping, psychoeducation for sleep hygiene, and cognitive-behavioral measures.

Conclusion

Some important preventive coping strategies for fatigue associated with shift work such as napping and exposure to bright light have already been investigated and are generally approved. A few studies also provide good evidence for the efficacy of cognitive-behavioral techniques in the treatment of chronic primary and comorbid insomnia. These coping strategies summarized in this paper should be considered in the workplace health promotion programs of each work environment to improve working conditions for shift workers and to save money.

Circadian disruption: New clinical perspective of disease pathology and basis for chronotherapeutic intervention

Biological processes are organized in time as innate rhythms defined by the period (τ), phase (peak [Φ] and trough time), amplitude (A, peak-trough difference) and mean level. The human time structure in its entirety is comprised of ultradian (τ < 20 h), circadian (20 h > τ < 28 h) and infradian (τ > 28 h) bioperiodicities. The circadian time structure (CTS) of human beings, which is more complicated than in lower animals, is orchestrated and staged by a brain central multioscillator system that includes a prominent pacemaker - the suprachiasmatic nuclei of the hypothalamus. Additional pacemaker activities are provided by the pineal hormone melatonin, which circulates during the nighttime, and the left and right cerebral cortices. Under ordinary circumstances this system coordinates the τ and Φ of rhythms driven by subservient peripheral cell, tissue and organ clock networks. Cyclic environmental, feeding and social time cues synchronize the endogenous 24 h clocks and rhythms. Accordingly, processes and functions of the internal environment are integrated in time for maximum biological efficiency, and they are also organized and synchronized in time to the external environment to ensure optimal performance and response to challenge. Artificial light at night (ALAN) exposure can alter the CTS as can night work, which, like rapid transmeridian displacement by air travel, necessitates realignment of the Φ of the multitude of 24 h rhythms. In 2001, Stevens and Rea coined the phrase "circadian disruption" (CD) to label the CTS misalignment induced by ALAN and shift work (SW) as a potential pathologic mechanism of the increased risk for cancer and other medical conditions. Current concerns relating to the effects of ALAN exposure on the CTS motivated us to renew our long-standing interest in the possible role of CD in the etiopathology of common human diseases and patient care. A surprisingly large number of medical conditions involve CD: adrenal insufficiency; nocturia; sleep-time non-dipping and rising blood pressure 24 h patterns (nocturnal hypertension); delayed sleep phase syndrome, non-24 h sleep/wake disorder; recurrent hypersomnia; SW intolerance; delirium; peptic ulcer disease; kidney failure; depression; mania; bipolar disorder; Parkinson's disease; Smith-Magenis syndrome; fatal familial insomnia syndrome; autism spectrum disorder; asthma; byssinosis; cancers; hand, foot and mouth disease; post-operative state; and ICU outcome. Poorly conceived medical interventions, for example nighttime dosing of synthetic corticosteroids and certain β-antagonists and cyclic nocturnal enteral or parenteral nutrition, plus lifestyle habits, including atypical eating times and chronic alcohol consumption, also can be causal of CD. Just as surprisingly are the many proven chronotherapeutic strategies available today to manage the CD of several of these medical conditions. In clinical medicine, CD seems to be a common, yet mostly unrecognized, pathologic mechanism of human disease as are the many effective chronotherapeutic interventions to remedy it.

Interactive Effects of Dorsomedial Hypothalamic Nucleus and Time-Restricted Feeding on Fractal Motor Activity Regulation

One evolutionary adaptation in motor activity control of animals is the anticipation of food that drives foraging under natural conditions and is mimicked in laboratory with daily scheduled food availability. Food anticipation is characterized by increased activity a few hours before the feeding period. Here we report that 2-h food availability during the normal inactive phase of rats not only increases activity levels before the feeding period but also alters the temporal organization of motor activity fluctuations over a wide range of time scales from minutes up to 24 h. We demonstrate this multiscale alteration by assessing fractal patterns in motor activity fluctuations—similar fluctuation structure at different time scales—that are robust in intact animals with ad libitum food access but are disrupted under food restriction. In addition, we show that fractal activity patterns in rats with ad libitum food access are also perturbed by lesion of the dorsomedial hypothalamic (DMH)—a neural node that is involved in food anticipatory behavior. Instead of further disrupting fractal regulation, food restriction restores the disrupted fractal patterns in these animals after the DMH lesion despite the persistence of the 24-h rhythms. This compensatory effect of food restriction is more clearly pronounced in the same animals after the additional lesion of the suprachiasmatic nucleus (SCN)—the central master clock in the circadian system that generates and orchestrates circadian rhythms in behavior and physiological functions in synchrony with day-night cycles. Moreover, all observed influences of food restriction persist even when data during the food anticipatory and feeding period are excluded. These results indicate that food restriction impacts dynamics of motor activity at different time scales across the entire circadian/daily cycle, which is likely caused by the competition between the food-induced time cue and the light-entrained circadian rhythm of the SCN. The differential impacts of food restriction on fractal activity control in intact and DMH-lesioned animals suggest that the DMH plays a crucial role in integrating these different time cues to the circadian network for multiscale regulation of motor activity.

Prevalence of Depressive Symptoms and Related Factors in Korean Employees: The Third Korean Working Conditions Survey (2011)

The aim of this study was to analyze the association between general working conditions and depressive symptoms among Korean employees. The target population of the study was native employees nationwide who were at least 15 years old, and 50,032 such individuals were enrolled in the study. Depressive symptoms was assessed using the WHO-5 wellbeing index. Associations between general characteristics, job-related characteristics, work environment, and depressive symptoms were tested using chi-square tests, t-tests, and multiple logistic regression analysis. The prevalence of depressive symptoms was 39% (40.7% in males and 36.5% in females). Multiple regression analysis revealed that male subjects, older subjects, subjects with higher education status, subjects with lower monthly income, current smokers, and frequent drinkers were more likely to have depressive symptoms. In addition, longer weekly work hours, occupation type (skilled, unskilled, operative, or economic sector), shift work, working to tight deadlines, exposure to stress at work, and hazard exposure were associated with depressive symptoms. This representative study will be a guide to help manage depression among Korean employees. We expect that further research will identify additional causal relationships between general or specific working conditions and depression.

Cross-talk between circadian clocks, sleep-wake cycles, and metabolic networks: Dispelling the darkness

Integration of knowledge concerning circadian rhythms, metabolic networks, and sleep‐wake cycles is imperative for unraveling the mysteries of biological cycles and their underlying mechanisms. During the last decade, enormous progress in circadian biology research has provided a plethora of new insights into the molecular architecture of circadian clocks. However, the recent identification of autonomous redox oscillations in cells has expanded our view of the clockwork beyond conventional transcription/translation feedback loop models, which have been dominant since the first circadian period mutants were identified in fruit fly. Consequently, non‐transcriptional timekeeping mechanisms have been proposed, and the antioxidant peroxiredoxin proteins have been identified as conserved markers for 24‐hour rhythms. Here, we review recent advances in our understanding of interdependencies amongst circadian rhythms, sleep homeostasis, redox cycles, and other cellular metabolic networks. We speculate that systems‐level investigations implementing integrated multi‐omics approaches could provide novel mechanistic insights into the connectivity between daily cycles and metabolic systems.

Shift work disorder, depression, and anxiety in the transition to rotating shifts: the role of sleep reactivity

AIM

The aim of this study is to investigate premorbid sleep reactivity as a vulnerability to incident shift work disorder (SWD), and related changes in depression as well as anxiety following a transition to a rotating shifts work schedule.

METHODS

This is a longitudinal study with two waves of data collection. The community-based sample included normal sleeping non-shift workers (N = 96; 62.5% female; 47.9 ± 13.3 years) without a lifetime history of insomnia or baseline excessive daytime sleepiness who transitioned to rotating shift work one year later. Participants reported demographic characteristics, trait sleep reactivity on the Ford Insomnia Response to Stress Test, depression symptoms on the Quick Inventory of Depression Symptomatology, and anxiety symptoms on the Beck Anxiety Inventory. SWD was determined based on significant sleep disturbance and/or excessive sleepiness in the context of working in a rotating-shift schedule.

RESULTS

Analyses revealed that the odds were over five times greater for highly sleep-reactive individuals to develop SWD after transitioning to rotating shifts (OR = 5.59, p = 0.04). Nearly 90% of participants who suffered from SWD were accurately identified as high risk at one year before disease onset. Furthermore, individuals who developed SWD reported greater increases in symptoms of depression and anxiety. Finally, analyses revealed significant indirect effects wherein high sleep reactivity increased risk for SWD, which led to greater severity of anxiety and depression symptoms.

CONCLUSIONS

The Ford Insomnia Response to Stress Test (FIRST) accurately identifies a focused target population in which the premorbid psychobiological processes complicit in SWD onset and progression, as well as shift work-related depression and anxiety changes, can be better investigated, thus improving future preventative efforts.

[Sleep disorders among physicians on shift work]

Sleep disorders in physicians who perform shift work can result in increased risks of health problems that negatively impact performance and patient safety. Even those who cope well with shift work are likely to suffer from sleep disorders. The aim of this manuscript is to discuss possible causes, contributing factors and consequences of sleep disorders in physicians and to identify measures that can improve adaptation to shift work and treatment strategies for shift work-associated sleep disorders. The risk factors that influence the development of sleep disorders in physicians are numerous and include genetic factors (15 % of the population), age (> 50 years), undiagnosed sleep apnea,, alcohol abuse as well as multiple stress factors inherent in clinical duties (including shift work), research, teaching and family obligations. Several studies have reported an increased risk for medical errors in sleep-deprived physicians. Shift workers have an increased risk for psychiatric and cardiovascular diseases and shift work may also be a contributing factor to cancer. A relationship has been reported not only with sleep deprivation and changes in food intake but also with diabetes mellitus, obesity, hypertension and coronary heart disease. Nicotine and alcohol consumption are more frequent among shift workers. Increased sickness and accident rates among physicians when commuting (especially after night shifts) have a socioeconomic impact. In order to reduce fatigue and to improve performance, short naps during shiftwork or naps plus caffeine, have been proposed as coping strategies; however, napping during adverse circadian phases is less effective, if not impossible when unable to fall asleep. Bright and blue light supports alertness during a night shift. After shiftwork, direct sunlight exposure to the retina can be avoided by using dark sunglasses or glasses with orange lenses for commuting home. The home environment for daytime sleeping after a night shift should be very dark to allow endogenous melatonin secretion, which is a night signal and supports continuous sleep. Sleep disorders can be treated with timed light exposure, as well as behavioral and environmental strategies to compensate for sleep deprivation. Fatigue due to sleep deprivation can only be systematically treated with sleep.

Understanding the health behaviors of India’s information technology and business process outsourcing employees

Purpose

– The purpose of this paper is to investigate the behaviors of India’s information technology (IT) and business process outsourcing (BPO) employees in relation to diet, exercise, sleep, stress, and social habits.

Design/methodology/approach

– This was a qualitative research study, using in-depth, semi-structured interviews. Descriptive data were collected from a two-stage purposive sample of 28 IT-BPO employees from three IT companies and two BPOs in Bangalore, India.

Findings

– The majority of interviewees reported having an unhealthy diet and/or sedentary lifestyle. Lack of time due to demanding work schedules was the largest barrier to diet and exercise. Call-centers were described as a social environment with a young workforce.

Research limitations/implications

– Given the qualitative study design and limited sampling frame, results may not be generalizable. However, the qualitative data suggests that India’s young IT-BPO employees may be at greater risk of lifestyle-related diseases than the general population. The data also suggests that interventions incorporating social influence may be a promising solution, particularly at international call centers.

Originality/value

– There is a lack of literature on the lifestyle of IT-BPO employees in India. The results from this study provide qualitative insight on the motives for health behaviors of IT-BPO employees, as well as the barriers and facilitators for leading a healthy lifestyle in this industry. The findings provide the framework for future workplace wellness interventions.

The relationship between working condition factors and well-being

OBJECTIVES

Working conditions can exert influence on the physical, mental, and even social health of workers. Well-being is an appropriate index for the evaluation of a person's overall health. This paper investigated the association between various working conditions and worker's well-being.

METHODS

Data from 10,019 interviews were collected from the second wave of the Korean Working Conditions Survey (2010) conducted by the Korea Occupational Safety and Health Agency between June and October 2010. The data from 5,995 employed workers were examined in this study. Well-being was measured through the WHO Five Well-Being Index (1998 version). Sociodemographic and working conditions were analyzed. Adjusted odds ratios for well-being were calculated with adjusted sociodemographic factors, working condition factors, or both.

RESULTS

Workers' well-being was significantly higher when they were satisfied with their working conditions (OR = 1.656, 95% CI = 1.454-1.885), when their actual working hours were the same as their anticipated working hours (OR = 1.366, 95% CI: 1.120-1.666) or exceeding less than 10 hours (OR = 1.245, 95% CI: 1.004-1.543), and when their employment was stable (OR = 1.269, 95% CI: 1.098-1.467).

CONCLUSIONS

This study supports the association between working condition factors and well-being in workers.

Predictors of shift work disorder among nurses: a longitudinal study

BACKGROUND

Shift work is associated with sleep problems and impaired health. The main aim of the present study was to explore predictors of developing shift work disorder (SWD) among Norwegian nurses using a longitudinal design.

METHODS

A total of 1533 nurses participating in a survey on shift work, sleep and health responded to questionnaires at baseline and at follow-up about two years later. SWD was defined as problems of excessive sleepiness and/or complaints of insomnia related to the work schedule.

RESULTS AND CONCLUSIONS

There was a significant reduction (p < 0.001) in the prevalence of SWD from baseline to follow-up, from 35.7% to 28.6%. Logistic regression analyses showed significant risks of having SWD at follow-up and the following variables measured at baseline: number of nights worked the last year (OR = 1.01, 95% CI = 1.01-1.02), having SWD (OR = 5.19, 95% CI = 3.74-7.20), composite score on the Epworth Sleepiness Scale (OR = 1.08, 95% CI = 1.04-1.13), use of melatonin (OR = 4.20, 95% CI = 1.33-13.33), use of bright light therapy (OR = 3.10, 95% CI 1.14-8.39), and symptoms of depression measured by the Hospital Anxiety and Depression Scale (OR = 1.07, 95% CI = 1.00-1.14). In addition, leaving night work between baseline and follow-up was associated with a significantly reduced risk of SWD at follow-up (OR = 0.12, 95% CI = 0.07-0.22).

The role of the circadian system in fractal neurophysiological control

Many neurophysiological variables such as heart rate, motor activity, and neural activity are known to exhibit intrinsic fractal fluctuations - similar temporal fluctuation patterns at different time scales. These fractal patterns contain information about health, as many pathological conditions are accompanied by their alteration or absence. In physical systems, such fluctuations are characteristic of critical states on the border between randomness and order, frequently arising from nonlinear feedback interactions between mechanisms operating on multiple scales. Thus, the existence of fractal fluctuations in physiology challenges traditional conceptions of health and disease, suggesting that high levels of integrity and adaptability are marked by complex variability, not constancy, and are properties of a neurophysiological network, not individual components. Despite the subject's theoretical and clinical interest, the neurophysiological mechanisms underlying fractal regulation remain largely unknown. The recent discovery that the circadian pacemaker (suprachiasmatic nucleus) plays a crucial role in generating fractal patterns in motor activity and heart rate sheds an entirely new light on both fractal control networks and the function of this master circadian clock, and builds a bridge between the fields of circadian biology and fractal physiology. In this review, we sketch the emerging picture of the developing interdisciplinary field of fractal neurophysiology by examining the circadian system's role in fractal regulation.

Sleep medicine pharmacotherapeutics overview: today, tomorrow, and the future (Part 1: insomnia and circadian rhythm disorders)

Over the past 10 years, significant strides have been made in the understanding, development, and availability of sleep disorder therapeutics. In this review series, we discuss the current evidence surrounding the mechanisms of actions, indications, efficacy, and adverse side effects associated with the available armamentarium of sleep over-the-counter and pharmacotherapeutics. This article is the first of a two-part series that covers the therapeutics for insomnia and circadian rhythm disorders.

Shift work disorder in a random population sample--prevalence and comorbidities

Few studies have investigated the presence of shift work disorder (SWD) in the general community. We addressed many of the limitations in this literature and present new findings. SWD has been treated as an ‘all or none’ construct but we propose the need to consider the ‘severity’ of the disorder. Using random digit dialling, we randomly recruited 1163 participants. Participants completed an extensive battery of scales and questions concerning work, health and individual differences. Three questions based on the criteria from the International Classification for Sleep Disorders were used to categorise participants with SWD (n = 176). In addition, we asked participants whether SWD interfered with aspects of their life and high ratings were used to define severe shift work disorder (SSWD). The prevalence of SWD was 32.1% among night workers and 10.1% in day workers (p<.001). SSWD was present in 9.1% of night workers and 1.3% of day workers (p<.001). Adjusted logistic regression analyses found significant associations between SWD and night work (OR  = 3.35, CI 2.19-5.12), weekly work hours (OR  = 1.02, CI 1.00–1.04), short sleep (≤6 h; OR  = 2.93, CI 1.94–4.41), languidity (OR  = 1.11, CI 1.06–1.16) and resilience (OR  = 0.56, CI 0.43–0.81). Night work, short sleep, languidity, and hypertension were significantly associated with SSWD. Overall, participants with SSWD slept 0.80 h less than other participants (p<.001). Night work, short sleep and languidity were associated with both SWD and SSWD. Day workers with SWD symptoms reported significantly shorter sleep duration, higher levels of languidity and worked longer working hours compared to day workers without SWD.

Sleep disturbance and neurobehavioral performance among postpartum women

STUDY OBJECTIVES

Sleep disturbances cause neurobehavioral performance and daytime functioning impairments. Postpartum women experience high levels of sleep disturbance. Thus, the study objective was to describe and explore the relation between neurobehavioral performance and sleep among women during the early postpartum period.

DESIGN

Longitudinal field-based study.

PARTICIPANTS

There were 70 primiparous women and nine nulliparous women in a control group.

INTERVENTIONS

None.

METHODS AND RESULTS

During their first 12 postpartum weeks, 70 primiparous women wore continuous wrist actigraphy to objectively monitor their sleep. Each morning they self-administered the psychomotor vigilance test (PVT) to index their neurobehavioral performance. Nine nulliparous women in a control group underwent the same protocol for 12 continuous weeks. Postpartum PVT mean reciprocal (1/RT) reaction time did not differ from that of women in the control group at postpartum week 2, but then worsened over time. Postpartum slowest 10% 1/RT PVT reaction time was significantly worse than that of women in the control group at all weeks. Despite improvements in postpartum sleep, neurobehavioral performance continued to worsen from week 2 through the end of the study. Across the first 12 postpartum weeks, PVT measures were more frequently associated with percent sleep compared with total sleep time, highlighting the deleterious consequences of sleep disruption on maternal daytime functioning throughout the early postpartum period.

CONCLUSIONS

Worsened maternal neurobehavioral performance across the first 12 postpartum weeks may have been influenced by the cumulative effects of sleep disturbance. These results can inform future work to identify the particular sleep profiles that could be primary intervention targets to improve daytime functioning among postpartum women, and indicate need for further research on the effectiveness of family leave policies. The time when postpartum women return to control-level daytime functioning is unknown.

Recognition and management of excessive sleepiness in the primary care setting

BACKGROUND

Excessive sleepiness often goes unrecognized in the primary care setting despite its high prevalence and deleterious effects on both individual and public safety. Patients with neurologic and psychiatric illnesses, as well as those with acute and chronic medical conditions, plus those with sleep disorders, often have symptoms of excessive sleepiness, tiredness, and fatigue. Recognition and prompt treatment of these symptoms are important, even though their etiology may not be immediately understood. This review focuses on the underlying causes, consequences, identification, and treatment of excessive sleepiness.

DATA SOURCES

A search of the literature to 2007 was performed using the PubMed search engine. English-language articles were identified using the following search terms: excessive sleepiness, fatigue, circadian rhythm, obstructive sleep apnea, shift work disorder, narcolepsy, drowsy driving, and wakefulness. Additional references were identified through bibliography reviews of relevant articles.

DATA SYNTHESIS

Current assessments of the prevalence, consequences, and etiologies of excessive sleepiness, with leading treatment strategies, were extracted, reviewed, and summarized to meet the objectives of this article.

CONCLUSIONS

Excessive sleepiness is associated with a wide range of medical, neurologic, and psychiatric disorders frequently seen in primary care practice. Excessive sleepiness is a serious, debilitating, potentially life-threatening condition, yet also treatable, and it is important to initiate appropriate intervention as early as possible. Physicians should place increasing emphasis on the substantial benefits that accompany improvements in wakefulness.

The effects of shift work on physical and mental health

Occupational engagement is a pre-requisite for continuous income opportunities. Among the changing social circumstances work-related conditions play an increasingly eminent role in psychological and mental well-being. The public discusses the question of a possible association between the demands of modern work life and the increases of psychological, psychosomatic and cardiovascular disorders. Given the socioeconomic implications of psychiatric and psychosomatic suffering in the general population, there is a need to further elucidate the causes of their increasing incidence. From a medical point of view, any organization of work disrupting the phased circadian rhythms for bio-psycho-social processes and functioning of the individual are interesting against the background of clock genes and certain biological functions that are organized in a circadian fashion. The authors review the influence of shift work as a form of systematic desynchronization of inner clock systems on the endocrine, the physical, and the mental level. The significance of the findings in the field is discussed along with future directions of conclusive research.

Reciprocal cholinergic and GABAergic modulation of the small ventrolateral pacemaker neurons of Drosophila's circadian clock neuron network

The relatively simple clock neuron network of Drosophila is a valuable model system for the neuronal basis of circadian timekeeping. Unfortunately, many key neuronal classes of this network are inaccessible to electrophysiological analysis. We have therefore adopted the use of genetically encoded sensors to address the physiology of the fly's circadian clock network. Using genetically encoded Ca(2+) and cAMP sensors, we have investigated the physiological responses of two specific classes of clock neuron, the large and small ventrolateral neurons (l- and s-LN(v)s), to two neurotransmitters implicated in their modulation: acetylcholine (ACh) and γ-aminobutyric acid (GABA). Live imaging of l-LN(v) cAMP and Ca(2+) dynamics in response to cholinergic agonist and GABA application were well aligned with published electrophysiological data, indicating that our sensors were capable of faithfully reporting acute physiological responses to these transmitters within single adult clock neuron soma. We extended these live imaging methods to s-LN(v)s, critical neuronal pacemakers whose physiological properties in the adult brain are largely unknown. Our s-LN(v) experiments revealed the predicted excitatory responses to bath-applied cholinergic agonists and the predicted inhibitory effects of GABA and established that the antagonism of ACh and GABA extends to their effects on cAMP signaling. These data support recently published but physiologically untested models of s-LN(v) modulation and lead to the prediction that cholinergic and GABAergic inputs to s-LN(v)s will have opposing effects on the phase and/or period of the molecular clock within these critical pacemaker neurons.

Is shift work making your patient sick? Emerging theories and therapies for treating shift work disorder

"Shift work" is a term that applies to a wide array of nontraditional work schedules. Shift work disorder (SWD) is a circadian rhythm sleep disorder experienced by a subset of shift workers that is characterized by excessive sleepiness during work and/or insomnia during scheduled sleep times. It is estimated to affect up to 2 million Americans, and is associated with increased morbidity and mortality from metabolic risk factors, cardiovascular and gastrointestinal diseases, depression, accidents, and some kinds of cancers. Patient history is all that is needed to make a diagnosis with the International Classification of Sleep Disorders-Second Edition criteria as described herein. Circadian rhythm disorders, in which an underlying misalignment of circadian rhythm with the sleep-wake cycle occurs, may be treated by behavioral and pharmacologic approaches, including the use of hypnotics to improve the duration of sleep. However, evidence is limited with these approaches in patients diagnosed with SWD. Other treatment options may include pharmacologic interventions such as modafinil and armodafinil, which have shown efficacy in this population. Combined therapy can reduce insomnia and excessive sleepiness, and improve attention and alertness during work shifts and the subsequent commute home.

Shift work and sleep: optimizing health, safety, and performance

Shift work is a fundamental component of the US workforce and an integral part of the lifestyles of a large proportion of the population. More than 22 million Americans work on shifts as part of their work life. Emerging research suggests that shift workers are at higher risk for a range of metabolic disorders and diseases (eg, obesity, cardiovascular disease, peptic ulcers, gastrointestinal problems, abnormal blood glucose levels, and metabolic syndrome). Sleep disorders associated with shift work also pose a serious public health risk, as they can impair an individual's ability to perform effectively and may lead to occupational and traffic accidents.

Evening exposure to a light-emitting diodes (LED)-backlit computer screen affects circadian physiology and cognitive performance

Many people spend an increasing amount of time in front of computer screens equipped with light-emitting diodes (LED) with a short wavelength (blue range). Thus we investigated the repercussions on melatonin (a marker of the circadian clock), alertness, and cognitive performance levels in 13 young male volunteers under controlled laboratory conditions in a balanced crossover design. A 5-h evening exposure to a white LED-backlit screen with more than twice as much 464 nm light emission {irradiance of 0,241 Watt/(steradian × m(2)) [W/(sr × m(2))], 2.1 × 10(13) photons/(cm(2) × s), in the wavelength range of 454 and 474 nm} than a white non-LED-backlit screen [irradiance of 0,099 W/(sr × m(2)), 0.7 × 10(13) photons/(cm(2) × s), in the wavelength range of 454 and 474 nm] elicited a significant suppression of the evening rise in endogenous melatonin and subjective as well as objective sleepiness, as indexed by a reduced incidence of slow eye movements and EEG low-frequency activity (1-7 Hz) in frontal brain regions. Concomitantly, sustained attention, as determined by the GO/NOGO task; working memory/attention, as assessed by "explicit timing"; and declarative memory performance in a word-learning paradigm were significantly enhanced in the LED-backlit screen compared with the non-LED condition. Screen quality and visual comfort were rated the same in both screen conditions, whereas the non-LED screen tended to be considered brighter. Our data indicate that the spectral profile of light emitted by computer screens impacts on circadian physiology, alertness, and cognitive performance levels. The challenge will be to design a computer screen with a spectral profile that can be individually programmed to add timed, essential light information to the circadian system in humans.

Excessive daytime sleepiness among Japanese public transportation drivers engaged in shiftwork

OBJECTIVE

To explore the actual condition of sleep disorders underlying subjective excessive daytime sleepiness (EDS) among train and bus drivers engaged in shiftwork.

METHODS

This study targeted 3109 public transportation drivers. Clinical diagnoses were made based on 147 drivers who claimed to have subjective EDS, and 285 drivers who were judged to have obstructive sleep apnea syndrome (OSAS), based on the screening process.

RESULTS

Among these subjects, the prevalence of OSAS was 3.7% and that of shiftwork disorder (SWD) was 1.5%. SWD was common among drivers who had EDS (32.7% of drivers with EDS), and their EDS severity was higher than that of OSAS drivers. The drivers with SWD were mostly young and neither obese nor hypertensive.

CONCLUSIONS

Encouraging awareness of SWD and OSAS could be necessary to prevent sleepiness-related accidents.

Excessive sleepiness: under-recognized and essential marker for sleep/wake disorder management

BACKGROUND

Research during the past few decades has provided substantial evidence indicating that excessive sleepiness (ES) and associated sleep/wake disorders can result in significant morbidity and mortality. However, symptomatology (e.g., ES) and the relationships among common morbidities (e.g., cardiovascular disease, metabolic disorders, mood impairment) and sleep/wake disorders remain under-recognized in clinical practice, particularly in primary care. Yet assessment of sleep/wakefulness and associated symptoms can often be easily conducted in the primary care setting, providing valuable information to facilitate the diagnosis and management of sleep/wake disorders.

OBJECTIVE

To provide a conceptual and educational framework that helps primary care physicians comprehensively assess, differentially diagnosis, and appropriately manage patients presenting with ES or ES-related sleep/wake disorders.

METHODS

Comprised of six sleep specialists and six primary care physicians, the Sleep/Wake Disorders Working Group (SWG) used a modified, two-round Delphi approach to create and harmonize consensus recommendations for the assessment, diagnosis, treatment, and ongoing management of patients with common sleep/wake disorders related to ES.

RESULTS

After a review of the relevant literature, the SWG arrived at consensus on a number of clinical recommendations for the assessment and management ES and some of the most commonly associated sleep/wake disorders. Ten consensus statements – five each for assessment/diagnosis and treatment/ongoing care – were created for ES, insomnia, obstructive sleep apnea, circadian rhythm disorders, restless legs syndrome, and narcolepsy.

CONCLUSION

ES and ES-related sleep/wake disorders are commonly encountered in the primary care setting. By providing an educational framework for primary care physicians, the SWG hopes to improve patient outcomes by emphasizing recognition, prompt diagnosis, and appropriate ongoing management of ES and associated sleep/wake disorders.

Armodafinil in the treatment of sleep/wake disorders

Excessive sleepiness (ES) is a major but underestimated public health concern associated with significant impairments in alertness/wakefulness and significant morbidity. The term ES has been used in the sleep medicine literature for years, but due to its nonspecific symptoms (ie tiredness or fatigue), it frequently goes unrecognized or is misdiagnosed in primary care. In some cases ES arises due to poor sleep habits or self-imposed sleep deprivation; however, ES is also a key component of a number of sleep/wake disorders and multiple medical and psychiatric disorders. Identification and treatment of ES is critical to improve the quality of life and well-being of patients and for the safety of the wider community. The inability of patients to recognize the nature, extent, and symptomatic profile of sleep/wake disorders requires vigilance on the part of healthcare professionals. Interventions to address ES and its associated impairments, treatment of the underlying sleep/wake disorder, and follow-up are a priority given the potential for serious consequences if left untreated. Wakefulness-promoting agents are available that treat ES associated with sleep/wake disorders. This review examines current approaches for managing this debilitating and potentially life-threatening condition, focusing on the place of armodafinil as a wakefulness-promoting agent.

Armodafinil in the treatment of excessive sleepiness

Excessive sleepiness (ES) is a widespread condition, commonly the result of a sleep/ wake disorder such as obstructive sleep apnea (OSA), shift-work disorder (SWD), or narcolepsy. ES poses significant health and safety concerns in patients. Numerous interventions are available to treat the underlying causes of ES and ES itself, including behavioral measures, mechanical devices, and pharmacologic agents. This review explores the evidence supporting the use of armodafinil to treat ES associated with OSA, SWD, and narcolepsy. Armodafinil is an oral non-amphetamine wake-promoting agent, the R-isomer of racemic modafinil. Armodafinil and modafinil share many clinical and pharmacologic properties and are distinct from central nervous system stimulants; however, the mechanisms of action of modafinil and armodafinil are poorly characterized. Compared with modafinil, the wake-promoting effects of armodafinil persist later in the day. It is for this reason that armodafinil may be a particularly appropriate therapy for patients with persistent ES due to OSA, SWD, or narcolepsy.