SLEEP, FATIGUE AND ALERTNESS An Educational Module for Residents, Fellows and Faculty Southern Illinois University School of Medicine Office of Residency Affairs Press the Page Down Key or click the down arrow on the right-hand scroll bar to advance to each slide.

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The information in this module is adapted from: • Sleep Alertness and Fatigue Education in Residency The American Academy of Sleep Medicine

• Monitoring Fatigue and Performance: Implications for Resident Duty Hours David F. Dinges, PhD. University of Pennsylvania School of Medicine

Both Used with Permission Slide 2 of 71

IMPORTANT INSTRUCTIONS!! •

After you complete this presentation please return to the homepage and take the post test. NOTE: Once you submit the post test your score will be recorded and the system will reflect that you have completed the course.

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There are 9 slides in this module that are optional, and labeled as such across the top. They contain supplementary information on sleep physiology to enhance your understanding of this topic, but are not vital to your mastery of core concepts and not covered on the post-test. If you wish to stick to core concepts, you may skip these slides.

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Please feel free to provide feedback on this educational module by sending an e-mail to [email protected]

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Learning Objectives 1. List factors that increase risk for sleepiness and fatigue. 2. Describe the impact of sleep loss on residents’ personal and professional lives. 3. Recognize signs of sleepiness and fatigue in yourself and others. 4. Challenge common misconceptions among physicians about sleep and sleep loss. 5. Adapt alertness management tools and strategies for yourself and your program. © American Academy of Sleep Medicine Slide 4 of 71

Introduction • Why we sleep – is not fully understood • Sleep has a restorative and replenishing function for brain and body. • Sleep is essential for survival • Sleep has a role in consolidating memory of experiences during waking hours.

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Introduction Acute and chronic sleep loss can substantially impair physical, cognitive, and emotional functioning in human beings. In addition, the influence of circadian physiology dictates that both wakefulness and alertness are maximized during daylight hours and sleepiness is maximized during the night. However, medical training demands performance and productivity on a 24-hour basis. Long, continuous work periods, reduced opportunities for sleep, and minimal recuperation time traditionally experienced by medical students and house staff during training (and frequently by physicians in practice as well) impact their work, health and wellbeing, as well as the quality of their educational experience. In response to these concerns, limitations on resident work hours were instituted in 2003 with new standards established in 2011. The goal is to create the opportunity for medical trainees to get adequate rest and to enable them to learn and perform at their optimal level.

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Work hour regulations alone are not sufficient to meet this goal. As the next slide shows, ACGME regulations limit work hours to a much lesser extent than other countries or occupations. Education regarding the causes and consequences of fatigue and alertness maintaining strategies must be part of any comprehensive approach to the issue. Slide 7 of 71

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Residents report sleepiness tendencies that are equivalent to those found in some populations of patients with sleep apnea or narcolepsy. The Epworth Sleepiness Scale (ESS) is an 8 item self-report scale that asks respondents to rate their likelihood of dozing under several specified conditions. The next slide shows mean ESS values for normal subjects and patients with a variety of sleep disorders, compared with medical residents Slide 9 of 71

Epworth Sleepiness Scale Narcolepsy

20

Residents Sleep Apnea

15 Normal

10

Insomnia

5 0

Mean

Normal

Insomnia

Sleep Apnea

5.90

2.20

11.70

Residents Narcolepsy 14.70

17.50

Sleepiness in residents is equivalent to that found in patients with serious sleep disorders. Mustafa and Strohl, unpublished data. Papp, 2002 © American Academy of Sleep Medicine

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What causes sleepiness?

© American Academy of Sleep Medicine

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Myth: “It’s the really boring noon conferences that put me to sleep.”

Fact: Environmental factors (passive learning situation, room temperature, low light level, etc) may unmask but DO NOT CAUSE SLEEPINESS. © American Academy of Sleep Medicine Slide 12 of 71

Physiologic Factors that Cause Sleepiness Sleep homeostatic drive (sleep load) builds up during the day, reaching a maximum in the late evening. The circadian system facilitates awakening and throughout the day usually acts as a counterbalance to the progressive accumulation of sleep load. Thus, the relative level of sleepiness or alertness at any given time during a 24 hour period is determined by the duration and quality of previous sleep, and time awake since last sleep period, interacting with the 24 hour rhythm characterized by clock-dependent periods of maximum sleepiness and maximum alertness.

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Interaction of Circadian Rhythms and Sleep Sleep Homeostatic drive (Sleep Load)

Wake

Sleep

Alertness level Circadian alerting signal 9 AM

3 PM

© American Academy of Sleep Medicine

9 PM Time

3 AM

9 AM Slide 14 of 71

The Circadian Clock Impacts You • It is easier to stay up later than to try to fall asleep earlier. • It is easier to adapt to shifts in forward (clockwise) direction (day evening night). • Night owls may find it easier to adapt to night shifts. © American Academy of Sleep Medicine

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Sleep Needed vs Sleep Obtained • Myth: “I’m one of those people who only need 5 hours of sleep, so none of this applies to me.” • Fact: Individuals may vary somewhat in their tolerance to the effects of sleep loss, but are not able to accurately judge this themselves. • Fact: Human beings need 8 hours of sleep to perform at an optimal level. • Fact:

Getting less than 8 hours of sleep starts to create a “sleep debt” which must be paid off.

© American Academy of Sleep Medicine

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Sleep Requirements Individuals may have differences in their optimal sleep requirements. The adult sleep requirement is typically between 6-10 hours of sleep per 24 hour period. When adults get less than 5 hours of sleep over a 24 hour period, peak mental abilities begin to decline. Restricted sleep for just a couple of days results in slower response times. After one night of missed sleep, cognitive performance may decrease as much as 25% from baseline. After the second night of missed sleep, cognitive performance can fall to nearly 40% of baseline. A discrepancy between the amount of sleep needed and the amount actually obtained builds up a sleep debt. Sleep debt accumulates over time until adequate recovery sleep is obtained. Sleep debt leads to lower response times, altered mood and motivation, and reduced morale and initiative. Sleep debt may be due to insufficient sleep, fragmented sleep, shift changes or primary sleep disorders.

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OPTIONAL SLIDE – Interesting information that’s not on the test

Review of Sleep Stages Non-REM Sleep makes up 75-80% of sleep in healthy young adults and may be viewed as a period of relatively low brain activity during which the regulatory capacity of the brain is active and body movements are preserved. It is divided into: – Stage N1 sleep (2-5%) occurs at the sleep-wake transition and is often referred to as “light” sleep. – Stage N2 sleep (45-55%) is considered the initiation of “true sleep” and is characterized by bursts of rhythmic rapid EEG activity (sleep spindles) and high amplitude slow wave spikes called K-complexes. – Stages of N3 sleep (3-23%) are sometimes called “deep” sleep, slow-wave sleep or delta sleep. People are most difficult to waken during delta sleep. This is the most restorative stage of sleep, and tends to be preserved if the total amount of sleep is restricted. The relative percentage of delta sleep is increased during the recovery sleep that follows sleep loss. Frequent awakenings reduce the amount of time spent in delta sleep. Slide 18 of 71

OPTIONAL SLIDE – Interesting information that’s not on the test

Review of Sleep Stages, cont’d. REM Sleep occurs 4-6 times per night and makes up 20-25% of sleep. It is characterized by paralysis or nearly absent muscle tone, high levels of cortical activity associated with dreaming, irregular respiration and heart rate, and episodic bursts of rapid phasic eye movements. Non-REM and REM sleep alternate throughout the night in cycles of about 90-110 minutes. Brief arousals normally followed by a rapid return to sleep often occur at the end of each sleep cycle, 4-6 times per night. The relative proportion of REM and Non-REM sleep per cycle changes across the night, such that slow wave sleep predominates in the first third of the night and REM sleep in the last third.

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Sleep Fragmentation Affects Sleep Quality

NORMAL SLEEP = Paged

MORNING ROUNDS

ON CALL SLEEP

© American Academy of Sleep Medicine

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Adaptation to Sleep Loss Myth: “I’ve learned not to need as much sleep during my residency.” Fact: Sleep needs are genetically determined and cannot be changed. Fact: Human beings do not “adapt” to getting less sleep than they need. Fact: Although performance of tasks may improve somewhat with effort, optimal performance and consistency of performance do not! © American Academy of Sleep Medicine

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NOT A GOOD PLAN

Effects of Sleep Loss • Sleep Loss can impact: – Neurocognition – Learning – Health and Well-being – Professionalism – Family Relationships – Driving Safety – All of the above compromise a person’s own and his/her patient’s safety Slide 23 of 71

Neurobehavioral Effects of Sleep Loss • • • • • • •

Shortened sleep latencies Microsleeps intrude into wakefulness Errors of omission Errors of commission Increased trade-off between speed and accuracy Learning and recall deficits Decline in working memory and related executive functions

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OPTIONAL SLIDE – Interesting information that’s not on the test PVT:

Psychomotor Vigilance Task

• Dinges #17

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OPTIONAL SLIDE – Interesting information that’s not on the test

• Dinges 24

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Summary of the Neurocognitive Effects of Sleep Loss •

Sleepiness manifests as increased moment-to-moment variability in attention and waking cognitive functions requiring executive attention processes

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Driving and other tasks requiring sustained attention and rapid responses are especially vulnerable to sleep deprivation. Post-call residents often drive home during the morning low point of circadian wakefulness

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There may be differential vulnerability to sleepiness, with some people being impaired sooner and more severely than others

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Chronic partial sleep deprivation can lead to neurobehavioral deficits as severe as those found after acute total sleep deprivation, but the affected person may not fully appreciate the impairment risk.

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100 90 80 70 60 50 40 30 20 10 0

100 90 80 70 60 50 40 30 20 10 0 < 4 hrs

5-6 hrs

> 7 hrs

Work Hrs/wk

Percent

Work Hrs/wk

Work Hours, Medical Errors, and Workplace Conflicts by Average Daily Hours of Sleep*

% Reporting Serious Medical Errors % Reporting Serious Staff Conflicts

*Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents

Hours of Sleep © American Academy of Sleep Medicine

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Impact on Medical Education • Residents working longer hours report decreased satisfaction with learning environment and decreased motivation to learn. Baldwin et al 1997 • Study of surgical residents showed less operative participation associated with more frequent call. Sawyer et al 1999

© American Academy of Sleep Medicine

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Sleep Loss and Fatigue: Safety Issues • 58% of emergency medicine residents reported near-crashes driving -- 80% post night-shift -- Increased with number of night shifts/month Steele et al 1999

• 50% greater risk of blood-borne pathogen exposure incidents (needlestick, laceration, etc) in residents between 10pm and 6am Parks 2000 © American Academy of Sleep Medicine

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• Surgery: 20% more errors and 14% more time required to perform simulated laparoscopy post-call (two studies) Taffinder et al, 1998; Grantcharov et al, 2001

• Internal Medicine: efficiency and accuracy of ECG interpretation impaired in sleep-deprived interns Lingenfelser et al, 1994

• Pediatrics: time required to place an intra-arterial line increased significantly in sleep-deprived Storer et al, 1989 © American Academy of Sleep Medicine

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Across Tasks Emergency Medicine: significant reductions in comprehensiveness of history & physical exam documentation Bertram 1988 in second-year residents Family Medicine: scores achieved on the ABFM practice in-training exam negatively correlated with pre-test sleep Jacques et al 1990 amounts © American Academy of Sleep Medicine

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Impact on Medical Errors • Surveys: more than 60 % of anesthesiologists report making fatigue-related errors Gravenstein 1990

• Case Reviews: - 3% of anesthesia incidents Morris 2000 - 5% “preventable incidents” “fatigue-related” - 10% drug errors Williamson 1993 - Post-op surgical complication rates 45%, higher if resident was post-call Haynes et al 1995 © American Academy of Sleep Medicine

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Bottom Line: You need to be alert to take the best possible care of your patients and yourself

© American Academy of Sleep Medicine

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Adverse Health Consequences by Average Daily Hours of Sleep* 60 % Reporting Signif Wt Change

Percent

50 40

% Reporting Med Use to Stay Awake

30 20

% Reporting Increased Alcohol Use

10 0 7 hrs

*Baldwin and Daugherty, 1998-9 Survey of 3604 PGY1,2 Residents

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RECOGNIZING SLEEPINESS IN YOURSELF AND OTHERS

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•Myth: “If I can just get through the

night (on call), I’m fine in the morning.” •Fact: A decline in performance

starts after about 15-16 hours of continued wakefulness. •Fact: The period of lowest

alertness after being up all night is between 6am and 11am (eg, morning rounds). © American Academy of Sleep Medicine

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Estimating Sleepiness Myth:“I can tell how tired I am and I know when I’m not functioning up to par.” Fact: Studies show that sleepy people underestimate their level of sleepiness and overestimate their alertness. Fact: The sleepier you are, the less accurate your perception of degree of impairment. Fact: You can fall asleep briefly (“microsleeps”) without knowing it! © American Academy of Sleep Medicine

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Anesthesia Resident Study • Residents did not perceive themselves to be asleep almost half of the time they had actually fallen asleep • Residents were wrong 76% of the time when they reported having stayed awake Howard et al 2002

© American Academy of Sleep Medicine

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Recognize The Warning Signs of Sleepiness

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Recognize The Warning Signs of Sleepiness • Falling asleep in conferences or on rounds • Feeling restless and irritable with staff, colleagues, family, and friends • Having to check your work repeatedly • Having difficulty focusing on the care of your patients • Feeling like you really just don’t care © American Academy of Sleep Medicine

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Fatigue Mitigation and Alertness Management Strategies

© American Academy of Sleep Medicine

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Myth: “I’d rather just power through when I’m tired; besides, even when I can nap, it just makes me feel worse.”

© American Academy of Sleep Medicine

Fact:

Some sleep is always better than no sleep.

Fact:

At what time and for how long you sleep are key to getting the most out of napping. Slide 43 of 71

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Napping Pros: Naps temporarily improve alertness Types: preventative (pre-call) operational (on the job) Length: short naps: no longer than 30 minutes to avoid the grogginess (sleep inertia) that occurs when you’re awakened from deep sleep long naps: 2 hours (range 30 to 180 minutes) © American Academy of Sleep Medicine

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Sleep Inertia • Disorientation, confusion and cognitive dysfunction that occurs upon awakening from sleep - especially slow wave or delta sleep and/or sleep following sleep deprivation • Occurs with as little as 30 minutes sleep • Adversely affects a wide range of cognitive functions • “Amnesia” for the awakening and cognition that occurred during it • Rate of recovery is exponential – can last up to 2 hours • Reduced by increased metabolic activity (exercise, caffeine)

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Napping Timing: -- if possible, take advantage of circadian “windows of opportunity” (2-5 am and 2-5 pm); -- but if not, nap whenever you can! Cons: sleep inertia; allow adequate recovery time. Caffeine taken before a nap can help reduce the effects of sleep inertia. Bottom line: Naps take the edge off but do not replace adequate sleep. © American Academy of Sleep Medicine

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Healthy Sleep Habits • Get adequate (7 to 9 hours) sleep before anticipated sleep loss. • Avoid starting out with a sleep deficit!

© American Academy of Sleep Medicine

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Recovery from Sleep Loss Myth: “All I need is my usual 5 to 6 hours the night after call and I’m fine.” Fact: Recovery from on-call sleep loss generally takes 2 nights of extended sleep to restore baseline alertness Fact: Recovery sleep generally has a higher percentage of deep sleep, which is needed to counteract the effects of sleep loss © American Academy of Sleep Medicine

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Healthy Sleep Habits • Go to bed and get up at about the same time every day when you can • Develop a pre-sleep routine • Use relaxation to help you fall asleep • Protect your sleep time; enlist your family and friends!

© American Academy of Sleep Medicine

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Healthy Sleep Habits • Sleeping environment: – Cooler temperature – Dark (eye shades, room darkening shades) – Quiet (unplug phone, turn off pager, use ear plugs, white noise machine) • Avoid going to bed hungry, but no heavy meals within 3 hours of sleep • Get regular exercise but avoid heavy exercise within 3 hours of sleep

© American Academy of Sleep Medicine

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Healthy Sleep Habits • Avoid watching TV before sleep • Avoid excitement, or stimulant use before sleep • Associate your bed with sleep (i.e. being in bed should bring a desire to sleep – so avoid reading, computer use and other distractions that will prolong sleep onset

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SIU School of Medicine Policy It is the policy of SIU that all duty hours must be consistent with ACGME requirements. Programs are responsible for monitoring resident activities to ensure that resident fatigue does not contribute to diminished learning or detract from patient safety. Residents can help by ensuring that they get enough sleep during their off hours and by monitoring themselves for fatigue. The most effective strategy to counter fatigue is sleep. Even a short nap can temporarily reverse the impact of sleep loss. Any resident who is feeling overly fatigued at the end of his or her work day (or night) should take a short nap before driving home, catch a ride with a co-worker, or take a taxi. If you need to take a taxi because you are too fatigued to drive home safely after a duty period, the Office of Residency Affairs will reimburse you. Dark glasses worn on the way home if it is light out when you leave and you want to sleep when you get home can help you fall asleep more easily when you get home. Slide 53 of 71

July 2011 ACGME Requirements - Duty periods of PGY-1 residents must not exceed 16 hrs - PGY2 and above – max 24hr continuous duty in hospital - To improve patient-safety and residentlearning, extra time should be utilized to get adequate sleep before and after clinical responsibilities Slide 54 of 71

Resident and Patient Safety – A Shared Responsibility July 2011 ACGME Requirements It is the responsibility of programs and institutions to:

•Educate residents and faculty to recognize the signs of fatigue and sleep deprivation •Educate residents and faculty in alertness management and fatigue mitigation processes •Adopt fatigue mitigation processes •Have a process to ensure patient care if a resident is to tired to do so •Provide adequate sleep facilities and/or safe transportation options for residents who are too fatigued to drive home

It is the responsibility of residents and faculty to:

•Manage their time before, during and after clinical assignments to assure their fitness for duty •Recognize fatigue in themselves and their peers •Responsibly utilize fatigue mitigation measures Slide 55 of 71

Recognize Signs of DWD * • Trouble focusing on the road • Difficulty keeping your eyes open • Nodding • Yawning repeatedly • Drifting from your lane, missing signs or exits • Not remembering driving the last few miles • Closing your eyes at stoplights * Driving While Drowsy

© American Academy of Sleep Medicine

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Risk Factors for Drowsy Driving Taking any sedating medications Drinking even small amounts of alcohol Having a sleep disorder (sleep apnea) Driving long distances without breaks Driving alone or on a boring road Number Crashes Num ber of of Crashes

• • • • •

450 400 350 300 250 200 150 100 50 0 0:00

3:00

Pack et al 1995 © American Academy of Sleep Medicine

6:00

9:00

12:00

15:00

18:00

21:00

Time of Day Time of Day

Driving home post-call Slide 57 of 71

Drive Smart; Drive Safe • AVOID driving if drowsy • If you are really sleepy, get a ride home, take a taxi, or use public transportation • Take a 20 minute nap and/or drink a cup of coffee before going home post-call • Stop driving if you notice the warning signs of sleepiness • Pull off the road at a safe place, take a short nap

© American Academy of Sleep Medicine

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Drowsy Driving: What Does Not Work • • • • • •

Turning up the radio Opening the car window Chewing gum Blowing cold air (water) on your face Slapping (pinching) yourself hard Promising yourself a reward for staying awake

© American Academy of Sleep Medicine

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It takes only a 4 second lapse in attention to have a drowsy driving crash

© American Academy of Sleep Medicine

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Drugs as Countermeasures for Fatigue • Melatonin: little data in residents • Hypnotics: may be helpful in specific situations (eg, persistent insomnia) • AVOID: using stimulants (methylphenidate, dextroamphetamine, modafinil) to stay awake • AVOID: using alcohol to help you fall asleep; it induces sleep onset but disrupts sleep later on

© American Academy of Sleep Medicine

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Caffeine • Strategic consumption is key • Effects within 15 – 30 minutes; half-life 3 to 7 hours • Use for temporary relief of sleepiness • Cons: – disrupts subsequent sleep (more arousals) – tolerance may develop – diuretic effects

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Adapting To Night Shifts • Myth: “I get used to night shifts right away; no problem.” • Fact: It takes at least a week for circadian rhythms and sleep patterns to adjust • Fact: Adjustment often includes physical and mental symptoms (think jet lag) • Fact: Direction of shift rotation affects adaptation (forward/clockwise easier to adapt) © American Academy of Sleep Medicine

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How To Survive Night Float • • • •

Protect your sleep Nap before work Consider “splitting” sleep into two 4 hour periods Have as much exposure to bright light as possible when you need to be alert • Avoid light exposure in the morning after night shift (be cool and wear dark glasses driving home from work – but only drive if you’re, if not too sleepy!)

© American Academy of Sleep Medicine

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“The best laid plans…” Study: Impact of night float coverage (2am to 6am) Results: “protected” interns slept less than controls; used time to catch up on work, not sleep; thus there was no

improvement in performance Richardson et al 1996

© American Academy of Sleep Medicine

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Time Management Tips:

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Summary of Alertness Strategies • Know your own vulnerability to sleep loss. • Learn what works for you from a range of strategies. • Sleep! – Prophylactic napping – Restorative napping – Circadian windows: early AM, late afternoon • Increased metabolic activity (jumping jacks!) • Bright light (especially to reduce sleep inertia) • Judicious use of caffeine • Unlike Dilbert’s world, there needs to be a shared responsibility for fatigue management © American Academy of Sleep Medicine

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In Summary… • Fatigue is an impairment like alcohol or drugs. • Drowsiness, sleepiness, and fatigue cannot be eliminated in residency, but can be managed. • Recognition of sleepiness and fatigue, and use of alertness management strategies, are simple ways to help combat sleepiness in residency. • If sleepiness interferes with your performance or health, talk to your supervisor or program director. © American Academy of Sleep Medicine

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You have now completed the Sleep, Fatigue and Alertness presentation. You must take and pass the post test. To take the post-test do the following: 1. Close or minimize this browser window to return to Blackboard 2. Click the HOMEPAGE link at the top of the active window 3. Click the POST TEST icon 4. Enter and save your answers and submit your completed test when finished 5. Be sure to log out of Blackboard when you are ready to exit the system

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