Fatigue and sleep deprivation.

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Fatigue and sleep deprivation.

• Michael Sannito, PhD
• Departments of Family Medicine and Psychiatry
• University of Oklahoma-Tulsa
• School of Community Medicine

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Where will we go today?

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

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Fact

• Inadequate sleep, fatigue, excessive time demands
  and poor social support represent some of the
  major stressors in a residents 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

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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.

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Sleep needs

• Humans on average need 8 hrs of sleep per night
• lt 5 hours mental performance deteriorates

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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.

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What are the effects of sleep deprivation? (lt 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).

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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.

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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.

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Sleep is not optional

• A real physiological need
• Impairs function without the necessary amount.

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Signs and Symptoms of Fatigue

• Altered Mood
• Apathy
• Impaired memory
• Inflexible thinking
• Nodding off
• Medical errors
• Microsleeps

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Signs of Fatigue (cont)

• Difficulty with focus.
• Repeatedly checking work.

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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

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Fatigue as a normal response to forced
wakefulness.

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

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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.

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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.

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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.

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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.

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Sleep inertia

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

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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.

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Sleep Debt

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

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Sleep debt is associated with

• Slower response time
• Forgetfulness
• Confusion
• Depression
• Lack of Motivation
• Decreased Morale and Initiative.

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

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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.

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