Fatigue and sleep deprivation.

1. Fatigue and sleep deprivation. Michael Sannito, PhD Departments of Family Medicine and Psychiatry University of Oklahoma-Tulsa School of Community Medicine

3. Where will we go today? • Definition of sleep deprivation. • Effects of sleep deprivation. • Sleep inertia and sleep debt. • Some adjustments for sleep struggles.

4. Fact • Inadequate sleep, fatigue, excessive time demands and poor social support represent some of the major stressors in a resident’s life. Hillous, J.J., Adler, C.M., and Walters, D.N. (2000). A simple model of stress, burnout and symptomatology in medical residents. Psychology Health and Medicine, 5(1): 64-73

5. What is the definition of sleep deprivation? • The shortage of quality, undisturbed sleep that results in detrimental effects on physical and mental well being. • A form of psychological torture inflicted by depriving the victim of sleep. • An overall lack of the necessary amount of sleep. A person can be deprived of sleep by their own body, and mind. Sleep can be actively deprived by another individual.

6. Sleep needs • Humans on average need 8 hrs of sleep per night • < 5 hours mental performance deteriorates

7. Baldwin and Dougherty • Surveyed 3604 Residents • 20% reported less than 5 hours of sleep per night • 66% reported less than 6 hours of sleep per night. 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.

8. What are the effects of sleep deprivation? (< 5 hrs per night) • Cognitive changes. • Mood lability. • More sensitive to slights. • Increase in Substance abuse. • Exacerbation of underlying psychiatric problems (20 % of residents met criteria for depression).

9. Effects continued • Increased accidents: Motor vehicle or otherwise. • Exacerbation or initiation of professional relationship discord. • Reduction in reaction time. • Potential for serious medical errors. 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.

10. Deterioration of cognitive performance • After one night of NO sleep baseline cognitive performance is decreased by 25% • After two nights decreased by 40%. • Studies using the Epworth sleepiness scale show that sleep deprived residents score the same as those with diagnosed sleep disorders. Jha, A.K. et al Fatigue, Sleepiness and Medical Errors. Chapter 46 In: Making Health Care Safer; A Critical Analysis of Patient Safety Practices. Evidence Report/Technology Assessment: Number 43 AHRQ Publication # 01-E058, July 2001. Agency for Healthcare Research and Quality. Rockville MD.

11. Sleep is not optional • A real physiological need • Impairs function without the necessary amount.

12. Signs and Symptoms of Fatigue • Altered Mood • Apathy • Impaired memory • Inflexible thinking • Nodding off • Medical errors • Microsleeps

13. Signs of Fatigue (cont) • Difficulty with focus. • Repeatedly checking work.

14. Excessive sleepiness • May call for an evaluation as it could be a sign of… • Medical condition such as hypothyroidism. • Psychological disorder such as depression • Side effects of medication (beta blocker). • Primary sleep disorder

15. Fatigue as a normal response to forced wakefulness. • Cannot be eliminated but can be managed. • Night float system seems to cause many problems.

16. The challenge of night shift work • Difficulty sleeping during the day. • Difficulty staying awake at night. • Recognize that no real adjustment to a sporadic and variable night shift is possible. • Unfortunately the literature suggests that up to 95% of people scheduled on night shifts do not adjust.

17. Prophylactic naps may help • 1 hour nap prior to the night duty may help enhance awake activity. • Experienced less stress • Felt that work load was less burdensome.

18. Adjustment to night shifts • Better to limit night work to 1 or 2 shifts. • Sleep before night shifts (as much as possible) • Take mid/late afternoon naps. • Nap when possible during on call hours.

19. When to nap • Nap prophylactically • During the afternoon • Brief naps (15-20 minutes) can be helpful • Be careful of longer naps (especially nocturnal) as they may result in sleep inertia.

20. Sleep inertia • Impaired cognition • Severe disorientation • Transitory hypovigilance • Confusion • Difficulty in fully awakening • Takes up to 30 minutes to fully clear

21. Sleep inertia (cont) • Residents who manage to reach this stage are particularly vulnerable as they are often called on to function after being awakened from a sound sleep. (slow wave sleep..REM) • Many overestimate their ability to function in this state. Some of the most severe cognitive deficits reported are secondary to sleep inertia. Try to take 15 minutes to awaken.

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

23. Sleep debt is associated with • Slower response time • Forgetfulness • Confusion • Depression • Lack of Motivation • Decreased Morale and Initiative.

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

25. Strategies to fight fatigue • Residency is like a marathon. Drink before you become thirsty and run in a pack. • Residency is like kindergarten. Hold hands and take naps (care for your inner circle). • Residency puts information in wet cement. Be careful what imprints you make. • Savoring. • Doctoring is a sacred gift, give time to be grateful and that end of every day, regardless of how you feel.