Night Shift: The Silent Killer

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night shift: The silent killer


About Dr. Schmitt

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Matthew Schmitt, M.D. received his medical degree from St. George’s University School of Medicine. He went on to complete his internal medicine internship and residency at Orlando Regional Medical Center in Orlando, Florida, where he also served as chief resident. He achieved his fellowships in pulmonary disease and sleep medicine from Norwalk Hospital affiliated with Yale School of Medicine in Norwalk, Connecticut. He completed his fellowship in critical care medicine in New Haven, CT from the Yale School of Medicine. Dr. Schmitt has published numerous scholarly articles in medical journals. He holds board certifications in internal medicine, pulmonary disease, and critical care medicine. Dr. Schmitt treats pulmonary and sleep medicine patients. He has a special interest in COPD, obstructive sleep apnea, and central sleep apnea.


Night Shift Physiology: Why does night shift hurt you?

  • Inherent intrinsic rhythm of day: Sleep/wake times on night shift run counter to normal light/dark cycle

    • Sleep quality usual isn’t as well and duration of sleep is shortened affecting performance

    • Most people aren’t “evening owls” that truly feel wonderful at 3 AM

  • Going against two process model: Process S and Process C

    • Process S: drive for sleep

      • dependent on time since you left slept - e.g. sleepy because you did not sleep will the night before

    • Process C: inherent rhythmic variation of sleep propensity

      • Governed by activities, light/darkness, eating schedule, exercise, etc -> tell our brain when to be awake

  • Things that can go wrong with sleep itself

    • Sleep eating, OSA, sleep walking, narcolepsy, insomnia

  • Social factors:

    • Still have to get dry cleaning done, bills paid, etc; difficult to get restful sleep during day

What can night shift do to you?

  • Increased risk of obesity, diabetes, gastric disorders

  • Increased risk of cardiovascular disease

  • Increased frequency of automobile accidents

  • More incidence of divorce/abuse/depression

  • Short or long hours of sleep = lower survival overall.

    • In study of danish nurses, there was increased all cause mortality (LINK HERE)

stages of sleep

  • Non-REM sleep

    • Stage 1: lightest sleep

    • Stage 2: intermediate, where we spend most of our night

    • Stage 3: deep delta sleep; restorative sleep

  • REM sleep

    • Most of our dreaming; often remember glimpses of dream but rare to remember entire dream itself (protective mechanism for you to know that it’s a dream vs real)

  • Usually should get 7-9 hours of sleep

    • If you’re a short sleeper during week, may be able to make it up on the weekends: some studies done showing same mortality risk as normal sleepers

Can Fitbit let you know what stage you were in? Look at it for hours of sleep, but take stages of sleep with grain of salt

how to combat this

Sleep Hygiene and Sleep Environment

  • Don’t have electronics in room; don’t use technology for bed

  • Keep a regular sleep schedule - adult brain is not far off from childs brain when it comes to sleep

  • When you leave night shift:

    • Wear sunglasses from the time you leave to the time you get home, avoid sunlight and bright light

  • Keep room dark you sleep in - black out curtains

    • Darkness releases melatonin

  • Ear plugs, eye masks

  • Keep room cool to enhance sense of wanting to go to bed (63-73 deg Fahrenheit)

  • Light box therapy - bright light to increase alertness during awake phase

  • White noise, meditation - focus the brain on something other than traffic; “quiets your brain”

What about coffee?

  • Caffeine

    • Depends on tolerance

      • Reduce caffeine on off days by cup or two to prevent tolerance from building up

    • During night shift: 1-4 cups of coffee (~150-400 mg/shift)

      • “Front load the caffeine” - 2-3 cups early on in night shift; another cup a few hours later

    • If you start drinking late in your shift, likely to hang around and make it harder for you to sleep

      • General rule of thumb: last dose of caffeine 4 hours prior to sleep, although this varies per person (caffeine is effective 4-6 hours)

otc medications

melatonin

  • Melatonin is NOT a “sleeping pill/sleeping aid” - it is a circadian alerting molecule that your body makes to help you clue it into bedtime

    • 1/3 of people - makes them extra relaxed

  • Stick to small doses. Most common dosages are 5 or 10mg, but the average person should ONLY take 1-3mg, sometimes 5mg

    • Once you go above 5mg, you’ll get same effect as 1-5 mg but it will hang around so you will likely feel groggy

    • Try extended release formulation - will having keep you asleep

  • Try multiple forms of melatonin before you call it quits; it’s natural, likely safer long term

    • 71% didn’t have what they said they had in them - either no melatonin or 4x the melatonin

    • Random additives

    • You don’t know how you will react until you try it

  • When to take it? 30-60 min before bedtime when you get home - leave it on your counter and take it as soon as you get home

  • Does it affect your endogenous melatonin? as far as we know, you will still make melatonin if you stop taking it after taking it long term

antihistamines/diphenhydramine

  • Histamine is naturally occurring alerting hormones - so if you block it it makes you drowsy

  • You will build up tolerance - They have their place when you have a tough night every once in a while; suddenly going from night to day shift, etc but shouldn’t be used daily

  • Use the lowest dose possible that work for you

  • Problem: lots of “hangover” effect, a “fog”

hypnotics

  • Ambien/Lunesta/etc - non-benzodiazepine receptor agonists (“non-benzo benzos”)

  • Long term association studies have shown that people (JCSM, South Korea) who take a lot of these pills don’t live as long - increased all cause mortality, increased risk of Alzheimers

    • Increased risk of sleep walking, car accidents, etc

  • For patients with true insomnia it DOES improve sleep time

    • May not feel like you got better sleep -you still are thrown off from your circadian rhythm despite getting actual sleep

    • For true insomnia: CBTI (Cognitive Behavioral Therapy for Insomnia) is preferred treatment

  • Always have a plan for getting on and off this medication; use lowest dose possible. Use it as sparingly as possible

wake promoting agents

  • Nuvigil, provigil

  • Gentler than true stimulants; tend to not have as much as a “high” feeling but keep you more awake

  • Moderate quality evidence that they can help keep you more alert and more awake for night shift

  • For many people Nuvigil 150mg 30-60 min before night shift, Provigil 200mg 30-60 min before shift

Attributes

"The Last Question", “Squinting at the Sun” by Lee Rosevere is licensed under CC BY-NC 4.0 / Song has been cropped in length from original form

"get out", “our rules” by Jahzzar is licensed under CC BY-SA 3.0 / Song has been cropped in length from original form

"Trickle Down” by Podington Bear is licensed under CC BY-NC 3.0 / Songs have been cropped in length from original form

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