Fatigue and sleep deprivation.Fatigue and sleep deprivation.

Michael Sannito, PhDMichael Sannito, PhDDepartments of Family Medicine and PsychiatryDepartments of Family Medicine and Psychiatry

University of Oklahoma-TulsaUniversity of Oklahoma-TulsaSchool of Community MedicineSchool of Community Medicine

Where will we go today?Where will we go today?

Definition of sleep deprivation.Definition of sleep deprivation. Effects of sleep deprivation.Effects of sleep deprivation. Sleep inertia and sleep debt.Sleep inertia and sleep debt. Some adjustments for sleep struggles.Some adjustments for sleep struggles.

FactFact

Inadequate sleep, fatigue, excessive time Inadequate sleep, fatigue, excessive time demands and poor social support represent demands and poor social support represent some of the major stressors in a resident’s some of the major stressors in a resident’s life.life.

Hillous, J.J., Adler, C.M., and Walters, D.N. (2000). A simple model of stress, burnout and symptomatology in medical Hillous, J.J., Adler, C.M., and Walters, D.N. (2000). A simple model of stress, burnout and symptomatology in medical residents. residents. Psychology Health and Medicine,Psychology Health and Medicine, 5(1): 64-73 5(1): 64-73

What is the definition of sleep What is the definition of sleep deprivation?deprivation?

The shortage of quality, undisturbed sleep The shortage of quality, undisturbed sleep that results in detrimental effects on physical that results in detrimental effects on physical and mental well being.and mental well being.

A form of psychological torture inflicted by A form of psychological torture inflicted by depriving the victim of sleep.depriving the victim of sleep.

An overall lack of the necessary amount of An overall lack of the necessary amount of sleep. A person can be deprived of sleep by sleep. A person can be deprived of sleep by their own body, and mind. Sleep can be their own body, and mind. Sleep can be actively deprived by another individual.actively deprived by another individual.

Sleep needsSleep needs

Humans on average need 8 hrs of sleep per Humans on average need 8 hrs of sleep per nightnight

< 5 hours mental performance deteriorates< 5 hours mental performance deteriorates

Baldwin and DoughertyBaldwin and Dougherty

Surveyed 3604 ResidentsSurveyed 3604 Residents 20% reported less than 5 hours of sleep per 20% reported less than 5 hours of sleep per

nightnight 66% reported less than 6 hours of sleep per 66% reported less than 6 hours of sleep per

night.night.

Baldwin, D.C., & Daugherty, S.E. (2004) Sleep deprivation and fatigue in residency training: the results of a national Baldwin, D.C., & Daugherty, S.E. (2004) Sleep deprivation and fatigue in residency training: the results of a national survey with first and second year residents. Sleep 27, 217-223.survey with first and second year residents. Sleep 27, 217-223.

What are the effects of sleep What are the effects of sleep deprivation? (< 5 hrs per night)deprivation? (< 5 hrs per night)

Cognitive changes.Cognitive changes. Mood lability.Mood lability. More sensitive to slights.More sensitive to slights. Increase in Substance abuse.Increase in Substance abuse. Exacerbation of underlying psychiatric Exacerbation of underlying psychiatric

problems (20 % of residents met criteria for problems (20 % of residents met criteria for depression).depression).

Effects continuedEffects continued

Increased accidents: Motor vehicle or Increased accidents: Motor vehicle or otherwise.otherwise.

Exacerbation or initiation of professional Exacerbation or initiation of professional relationship discord.relationship discord.

Reduction in reaction time.Reduction in reaction time. Potential for serious medical errors.Potential for serious medical errors.

Baldwin, D.C., & Daugherty, S.E. (2004) Sleep deprivation and fatigue in residency training: the results of a national Baldwin, D.C., & Daugherty, S.E. (2004) Sleep deprivation and fatigue in residency training: the results of a national survey with first and second year residents. Sleep 27, 217-223.survey with first and second year residents. Sleep 27, 217-223.

Deterioration of cognitive Deterioration of cognitive performanceperformance

After one night of NO sleep baseline After one night of NO sleep baseline cognitive performance is decreased by 25%cognitive performance is decreased by 25%

After two nights decreased by 40%.After two nights decreased by 40%. Studies using the Epworth sleepiness scale Studies using the Epworth sleepiness scale

show that sleep deprived residents score show that sleep deprived residents score the same as those with diagnosed sleep the same as those with diagnosed sleep disorders.disorders.

  

Jha, A.K. et al Fatigue, Sleepiness and Medical Errors. Chapter 46 In: Making Health Care Safer; Jha, A.K. et al Fatigue, Sleepiness and Medical Errors. Chapter 46 In: Making Health Care Safer; A Critical Analysis of Patient A Critical Analysis of Patient Safety PracticesSafety Practices. Evidence Report/Technology Assessment: Number 43 AHRQ Publication # 01-E058, July 2001. Agency for . Evidence Report/Technology Assessment: Number 43 AHRQ Publication # 01-E058, July 2001. Agency for Healthcare Research and Quality. Rockville MD.Healthcare Research and Quality. Rockville MD.

Sleep is not optionalSleep is not optional

A real physiological need A real physiological need

Impairs function without the necessary Impairs function without the necessary amount.amount.

Signs and Symptoms of FatigueSigns and Symptoms of Fatigue

Altered MoodAltered Mood ApathyApathy Impaired memoryImpaired memory Inflexible thinkingInflexible thinking Nodding offNodding off Medical errorsMedical errors MicrosleepsMicrosleeps

Signs of Fatigue (cont)Signs of Fatigue (cont)

Difficulty with focus.Difficulty with focus. Repeatedly checking work.Repeatedly checking work.

Excessive sleepinessExcessive sleepiness

May call for an evaluation as it could be a May call for an evaluation as it could be a sign of…sign of…

1.1.Medical condition such as hypothyroidism.Medical condition such as hypothyroidism.

2.2.Psychological disorder such as depressionPsychological disorder such as depression

3.3.Side effects of medication (beta blocker).Side effects of medication (beta blocker).

4.4.Primary sleep disorderPrimary sleep disorder

Fatigue as a normal response to Fatigue as a normal response to forced wakefulness.forced wakefulness.

Cannot be eliminated but can be managed.Cannot be eliminated but can be managed. Night float system seems to cause many Night float system seems to cause many

problems.problems.

The challenge of night shift workThe challenge of night shift work

Difficulty sleeping during the day.Difficulty sleeping during the day. Difficulty staying awake at night.Difficulty staying awake at night. Recognize that no real adjustment to a Recognize that no real adjustment to a

sporadic and variable night shift is possible.sporadic and variable night shift is possible. Unfortunately the literature suggests that up Unfortunately the literature suggests that up

to 95% of people scheduled on night shifts to 95% of people scheduled on night shifts do not adjust.do not adjust.

Prophylactic naps may helpProphylactic naps may help

1 hour nap prior to the night duty may help 1 hour nap prior to the night duty may help enhance awake activity.enhance awake activity.

Experienced less stressExperienced less stress Felt that work load was less burdensome.Felt that work load was less burdensome.

Adjustment to night shiftsAdjustment to night shifts

Better to limit night work to 1 or 2 shifts.Better to limit night work to 1 or 2 shifts. Sleep before night shifts (as much as Sleep before night shifts (as much as

possible)possible) Take mid/late afternoon naps.Take mid/late afternoon naps. Nap when possible during on call hours.Nap when possible during on call hours.

When to napWhen to nap

Nap prophylacticallyNap prophylactically During the afternoonDuring the afternoon Brief naps (15-20 minutes) can be helpfulBrief naps (15-20 minutes) can be helpful Be careful of longer naps (especially Be careful of longer naps (especially

nocturnal) as they may result in sleep nocturnal) as they may result in sleep inertia.inertia.

Sleep inertiaSleep inertia

Impaired cognitionImpaired cognition Severe disorientationSevere disorientation Transitory hypovigilanceTransitory hypovigilance ConfusionConfusion Difficulty in fully awakeningDifficulty in fully awakening Takes up to 30 minutes to fully clearTakes up to 30 minutes to fully clear

Sleep inertia (cont)Sleep inertia (cont)

Residents who manage to reach this stage are Residents who manage to reach this stage are particularly vulnerable as they are often called particularly vulnerable as they are often called on to function after being awakened from a on to function after being awakened from a sound sleep. (slow wave sleep..REM)sound sleep. (slow wave sleep..REM)

Many overestimate their ability to function in Many overestimate their ability to function in this state. Some of the most severe cognitive this state. Some of the most severe cognitive deficits reported are secondary to sleep inertia. deficits reported are secondary to sleep inertia. Try to take 15 minutes to awaken. Try to take 15 minutes to awaken.

Sleep DebtSleep Debt

The difference between the amount of sleep The difference between the amount of sleep needed (8+ hours) and the amount of sleep needed (8+ hours) and the amount of sleep received.received.

Sleep debt is associated withSleep debt is associated with

Slower response timeSlower response time ForgetfulnessForgetfulness ConfusionConfusion DepressionDepression Lack of MotivationLack of Motivation Decreased Morale and Initiative. Decreased Morale and Initiative.

In sleep debt, the awareness of being In sleep debt, the awareness of being sleepy is blunted!sleepy is blunted!

Strategies to fight fatigueStrategies to fight fatigue

Residency is like a marathon. Drink before you Residency is like a marathon. Drink before you become thirsty and run in a pack.become thirsty and run in a pack.

Residency is like kindergarten. Hold hands and Residency is like kindergarten. Hold hands and take naps (care for your inner circle).take naps (care for your inner circle).

Residency puts information in wet cement. Be Residency puts information in wet cement. Be careful what imprints you make.careful what imprints you make.

Savoring.Savoring. Doctoring is a sacred gift, give time to be Doctoring is a sacred gift, give time to be

grateful and that end of every day, regardless of grateful and that end of every day, regardless of how you feel.how you feel.