Shift WorkShift Work

Or: What time is it anyway?Or: What time is it anyway?

Warren Silverman MDMedical Director

ACCESS HEALTH SYSTEMS

What is Shift Work?What is Shift Work?

Regularly scheduled work Regularly scheduled work outside of the normal daytime outside of the normal daytime working hours of 7AM-6PMworking hours of 7AM-6PM Permanent night shiftsPermanent night shifts Afternoon or evening shiftsAfternoon or evening shifts Shifts beginning before 6AMShifts beginning before 6AM

Condensed work weeks with Condensed work weeks with extra long weekendsextra long weekends

Variable or rotating shiftsVariable or rotating shifts Day to evening or day to nightDay to evening or day to night May change weekly or monthlyMay change weekly or monthly

Why do we need shift work?Why do we need shift work?

Critical services on 24 hour basisCritical services on 24 hour basis Police, fire, military, healthcare, utilities, Police, fire, military, healthcare, utilities,

transportation, transportation, A production process > 8 hours or A production process > 8 hours or

continuouscontinuous Expensive machinery that must be used Expensive machinery that must be used

continuously to be profitablecontinuously to be profitable Support services for other shift workersSupport services for other shift workers ConvenienceConvenience

Who does shift work?Who does shift work?

Men do more night and rotating Men do more night and rotating shiftsshifts

Women do more evening and part Women do more evening and part time worktime work

Younger > Older workersYounger > Older workers African-American > CaucasianAfrican-American > Caucasian Single > MarriedSingle > Married Single Mothers > Married MothersSingle Mothers > Married Mothers In 2 job married couples ¼ - 1/3 In 2 job married couples ¼ - 1/3

have at least one shift workerhave at least one shift worker

20 Million Americans 20 Million Americans do shift work ; 26% of do shift work ; 26% of men, 18% of womenmen, 18% of women

Drop out rate: 20% at Drop out rate: 20% at year 1; 33% at 2 yearsyear 1; 33% at 2 years

Tolerance declines with Tolerance declines with ageage Cumulative effectsCumulative effects Decreased physiological Decreased physiological

reserve > 40reserve > 40

Factors describing shiftFactors describing shift

Permanent (fixed) or rotatingPermanent (fixed) or rotating How long?How long? How many days before a rest dayHow many days before a rest day How many rest days on a “weekend”How many rest days on a “weekend” Overtime?Overtime? Length of rest between shiftsLength of rest between shifts Is there rest during shiftIs there rest during shift Is Schedule regular and predictableIs Schedule regular and predictable

Permanent NightsPermanent Nights

Most permanent night workers never Most permanent night workers never really get used to the schedulereally get used to the schedule

Many nights they feel tired and Many nights they feel tired and sleepysleepy

Fatigue because of return to day Fatigue because of return to day hours on days offhours on days off

Family and friends active during the Family and friends active during the dayday

Errands and chores during the dayErrands and chores during the day Sleep less during the daySleep less during the day

Rotating ShiftsRotating Shifts

Can never adapt to a set work Can never adapt to a set work scheduleschedule

Used to be more “fair” to all Used to be more “fair” to all workersworkers

Rotating shift workers have Rotating shift workers have more complaints than others more complaints than others about physical and about physical and psychological healthpsychological health

Special RisksSpecial Risks

Special FeaturesSpecial Features

SpeedSpeed The number of consecutive days The number of consecutive days

before a shift changebefore a shift change DirectionDirection

Forward or clockwise (day-Forward or clockwise (day-evening-night)evening-night)

Reverse (day-night-evening)Reverse (day-night-evening)

Longer rotations (3-4 weeks) Longer rotations (3-4 weeks) may allow better adaptation to may allow better adaptation to shiftshift

Shorter (1-2 days) allows no Shorter (1-2 days) allows no time to get used to night shift, time to get used to night shift, but can get through it quickly to but can get through it quickly to get to rest day. Used more in get to rest day. Used more in Europe than USEurope than US

Work-Rest RatiosWork-Rest Ratios

If an 8 hour shift = 16 hours to If an 8 hour shift = 16 hours to do everything else and sleepdo everything else and sleep

If a 12 hour shift, only 12 hours If a 12 hour shift, only 12 hours to do everything else.to do everything else.

Family duties do not decrease Family duties do not decrease no matter the shift time leading no matter the shift time leading to less sleep and restto less sleep and rest

Fatigue is cumulativeFatigue is cumulative

Unpredictable schedulesUnpredictable schedules

Health care workers with Health care workers with emergencies or covering call insemergencies or covering call ins

A factory breakdown or last A factory breakdown or last minute rush orderminute rush order

A last minute “call board” A last minute “call board” assignment to move an orderassignment to move an order

Being on call and getting called Being on call and getting called in (Doctors do know about this!)in (Doctors do know about this!)

How does the body workHow does the body work

Internal Biological ClockInternal Biological Clock Circadian rhythmCircadian rhythm Regulated by sunlight and Regulated by sunlight and

darknessdarkness

Circadian RhythmCircadian Rhythm

Circadian RhythmCircadian Rhythm

Different body functions vary Different body functions vary during the 24 hour dayduring the 24 hour day

Metabolism (energy from food) Metabolism (energy from food) is greatest in the afternoon to is greatest in the afternoon to eveningevening

Most people most alert 4-6 PM Most people most alert 4-6 PM and most sleepy 4-6 AMand most sleepy 4-6 AM

Personal differences between Personal differences between peoplepeople

Circadian body rhythmsCircadian body rhythms

Hormone and gastric secretionsHormone and gastric secretions Bronchial reactivityBronchial reactivity Blood PressureBlood Pressure Sexual arousalSexual arousal AnxietyAnxiety Work performanceWork performance Metabolic RateMetabolic Rate Short term memoryShort term memory Family interactionsFamily interactions

The body has a natural cycle of The body has a natural cycle of 25 hours25 hours

Internal and external factors Internal and external factors synchronize us to a 24 hour daysynchronize us to a 24 hour day

The internal clock is located in The internal clock is located in the suprachiasmatic the suprachiasmatic hypothalmushypothalmus

External clues “Zeitgebers”External clues “Zeitgebers”

Light/Dark cycleLight/Dark cycle Timing of mealsTiming of meals Social interactionsSocial interactions Actual time clockActual time clock

Sleep ( Not now!)Sleep ( Not now!)

Night workers get the least Night workers get the least sleep (6.6 hours)sleep (6.6 hours)

Evening workers get the Evening workers get the most sleep (7.1 hours)most sleep (7.1 hours)

Day workers get medium Day workers get medium amounts (6.7 hours)amounts (6.7 hours)

Rotating workers sleep the Rotating workers sleep the least of all. least of all.

Sleep during the day is usually Sleep during the day is usually 2-3 hours shorter2-3 hours shorter

It is lighter sleep and more It is lighter sleep and more easily disturbed by noiseeasily disturbed by noise

There are more activities and There are more activities and noise during the daynoise during the day

Sleep Sleep

Sleep after night workSleep after night work Shorter, less satisfying or Shorter, less satisfying or

refreshingrefreshing Delta SleepDelta Sleep

Repair and Maintenance functionsRepair and Maintenance functions

Sleep loss makes it easier to fall Sleep loss makes it easier to fall asleep at inappropriate timesasleep at inappropriate times

Will decrease concentrationWill decrease concentration Increase accidents ( driving, Increase accidents ( driving,

dangerous machinery)dangerous machinery) Sleep can occur in short Sleep can occur in short

episodes lasting a few seconds episodes lasting a few seconds without even realizing it. Very without even realizing it. Very dangerous time.dangerous time.

Night workers have a drop in Night workers have a drop in alertness at 2-4 AMalertness at 2-4 AM

Accidents at 3 Mile Island, Accidents at 3 Mile Island, Bhopal, Chernobyl, and the Bhopal, Chernobyl, and the Exxon Valdez oil spill each Exxon Valdez oil spill each occurred between midnight and occurred between midnight and 4 AM4 AM

Sleep deprivationSleep deprivation

Mild sleep disruption may not Mild sleep disruption may not have significant impacthave significant impact

Cumulative increasing each Cumulative increasing each nightnight

Disordered sleep is Disordered sleep is compounded by circadian compounded by circadian dysrhytmiadysrhytmia

Sleep DeprivationSleep Deprivation Six days of restricted sleep (4 hours Six days of restricted sleep (4 hours

per 24-hour period) caused changes per 24-hour period) caused changes to the sleep architecture similar to to the sleep architecture similar to the changes seen in people suffering the changes seen in people suffering from depression. from depression.

changes in several natural body changes in several natural body rhythms of hormone secretionrhythms of hormone secretion MelatoninMelatonin cortisol cortisol thyroid-stimulating hormone thyroid-stimulating hormone leptin leptin ProlactinProlactin growth hormone.growth hormone.

What happens if we remove cues What happens if we remove cues and disturb the internal clock?and disturb the internal clock?

Desynchronosis:Desynchronosis: Core body temperature and digestive Core body temperature and digestive

secretions may remain near daily mean secretions may remain near daily mean levelslevels

EntrainmentEntrainment When we try to regain our rhythms with When we try to regain our rhythms with

light dark cycleslight dark cycles Different physiologies may entrain at Different physiologies may entrain at

different rates and we may lose the different rates and we may lose the normal phase relationship of one to normal phase relationship of one to anotheranother

Signs of desynchronosisSigns of desynchronosis

Sleep disturbanceSleep disturbance Short term fatigueShort term fatigue IrritabilityIrritability Loss of AppetiteLoss of Appetite Judgment alteration Judgment alteration

What does The Dark do?What does The Dark do?

Triggers changes leading to Triggers changes leading to sleepsleep Dropping blood pressureDropping blood pressure Dropping heart rateDropping heart rate Dropping breathing rateDropping breathing rate Dropping temperatureDropping temperature Slowed digestionSlowed digestion

Two physiologies most critical to Two physiologies most critical to work and safety are core body work and safety are core body temperature and temperature and sleep/wakefulnesssleep/wakefulness

RotationRotation

While forward rotation works While forward rotation works better with circadian rhythms of better with circadian rhythms of the body, reverse rotation is the body, reverse rotation is more common in the US more common in the US (workers pick up an extra “day (workers pick up an extra “day off” going from night to evening)off” going from night to evening)

Clockwise shift rotationClockwise shift rotation

Phase delaying: places less Phase delaying: places less strain on the human internal strain on the human internal clockclock

Higher worker satisfactionHigher worker satisfaction Fewer health complaints and Fewer health complaints and

work schedule complaintswork schedule complaints 20% increased productivity c/w 20% increased productivity c/w

phase advanced shiftsphase advanced shifts

Counter clockwiseCounter clockwise

Phase advancing: Phase advancing: For every hour of advancement a For every hour of advancement a

full day is needed for entrainment full day is needed for entrainment (ie: phase advancement to an (ie: phase advancement to an earlier shift every 7 days earlier shift every 7 days necessitates a week or longer to necessitates a week or longer to adapt after each rotation)adapt after each rotation)

25% of workers may not adapt25% of workers may not adapt

Other observationsOther observations

Air travel:Air travel: Entrainment is much easier Entrainment is much easier

westbound than eastboundwestbound than eastbound ““Night owl” type personalities Night owl” type personalities

adapt better to night and rotating adapt better to night and rotating shifts than “morning larks”shifts than “morning larks”

Rotation every 21 days results Rotation every 21 days results in 70% fewer complaints than in 70% fewer complaints than every 7 daysevery 7 days

Sleep stagesSleep stages

Stage 1Stage 1

Initial part of sleepInitial part of sleep 10-15 minutes10-15 minutes Slow rolling eye movementsSlow rolling eye movements EEG = Alpha wavesEEG = Alpha waves If awakened during this phase, If awakened during this phase,

will deny sleepingwill deny sleeping

Stage 2Stage 2

Largest part of sleep @ 50%Largest part of sleep @ 50% Infrequent or absent eye Infrequent or absent eye

movementmovement EEG = occasional sleep spindle EEG = occasional sleep spindle

burstsbursts Deprivation of this stage may Deprivation of this stage may

lead to total sleep losslead to total sleep loss Not usually “made up” after sleep Not usually “made up” after sleep

deprivation deprivation

Stages 3 & 4Stages 3 & 4

Slow wave sleep (SWS): deepSlow wave sleep (SWS): deep Muscle tone; variableMuscle tone; variable Arousal; difficultArousal; difficult EEG: High voltage; Delta wavesEEG: High voltage; Delta waves Important to body repairImportant to body repair Not as susceptible to circadian Not as susceptible to circadian

factorsfactors

REMREM

After 1-2 hoursAfter 1-2 hours Paralysis of muscles with occasional Paralysis of muscles with occasional

twitchestwitches Body loses some thermoregulatory abilityBody loses some thermoregulatory ability Heart rate and blood pressure very variableHeart rate and blood pressure very variable Restorative and dream sleepRestorative and dream sleep Important for psychosocial adjustment and Important for psychosocial adjustment and

developmentdevelopment Greatly influenced by circadian factorsGreatly influenced by circadian factors

Cycling between stage 4 and Cycling between stage 4 and REMREM Increased with caffeineIncreased with caffeine REM suppressed with REM suppressed with

alcoholalcohol Sedatives increase Sedatives increase

stage 2 non restorative stage 2 non restorative sleepsleep

Older less SWS, more Older less SWS, more frequent awakenings frequent awakenings and less sleep timeand less sleep time

Younger greater Younger greater frequency and longer frequency and longer REM intervalsREM intervals

Health EffectsHealth Effects

ImmediateImmediate

Long termLong term

Health HazardsHealth Hazards

Gastrointestinal ProblemsGastrointestinal Problems Cardiovascular problemsCardiovascular problems Sleep and stress related disordersSleep and stress related disorders Drug and Alcohol useDrug and Alcohol use Risks from prolonged exposure to Risks from prolonged exposure to

chemical and biological substances chemical and biological substances and other hazardsand other hazards

Effects on pregnancyEffects on pregnancy

DigestiveDigestive

Increased incidence of ulcers.Increased incidence of ulcers. Often eat at night when Often eat at night when

digestion and other body digestion and other body functions are slowed downfunctions are slowed down

May eat less nutritious foods at May eat less nutritious foods at night (snack foods)night (snack foods)

Drink more caffeine products at Drink more caffeine products at nightnight

GI UpsetsGI Upsets

75% of night 75% of night workers vs. 20% of workers vs. 20% of day workersday workers

ComplaintsComplaints Loss of appetiteLoss of appetite Constipation Constipation DyspepsiaDyspepsia Heart burnHeart burn Abdominal painAbdominal pain flatulenceflatulence

Many problems Many problems may not show up may not show up until years lateruntil years later

ReasonsReasons Poor food qualityPoor food quality More caffeineMore caffeine More alcoholMore alcohol More tobaccoMore tobacco Used to keep Used to keep

awakeawake

Cardiovascular problemsCardiovascular problems

Increased incidence of ischemic Increased incidence of ischemic diseasedisease

Elevated triglyceride levels in Elevated triglyceride levels in phase advance workersphase advance workers

May be related to disturbance of May be related to disturbance of circadian blood pressure and circadian blood pressure and pulse rhythmspulse rhythms

Substance abuse more likely in Substance abuse more likely in shift workersshift workers

HypertensionHypertension

Shift workers were found to Shift workers were found to have approximately 25% greater have approximately 25% greater chance of developing significant chance of developing significant hypertension than non shift hypertension than non shift workersworkers

Cognitive AbilityCognitive Ability

Recent studies Recent studies have found have found deterioration in deterioration in cognitive ability in cognitive ability in shift workers vs. shift workers vs. non shift workers.non shift workers.

This increases with This increases with duration of duration of exposureexposure

The effect seems to The effect seems to diminish 4 years diminish 4 years after discontinuationafter discontinuation

PsychologicalPsychological

Shift workers Shift workers demonstrate:demonstrate: More depression and More depression and

despondencydespondency More likely to use More likely to use

psychotropic drugs or psychotropic drugs or require hospitalizationrequire hospitalization

Will have magnification Will have magnification of underlying depression of underlying depression or bipolar disordersor bipolar disorders

Circadian rhythm Circadian rhythm disturbance may be a disturbance may be a cause for depressioncause for depression

Social RisksSocial Risks

Number 1 problem: missing family Number 1 problem: missing family and friendsand friends

Would rather loose sleep than miss Would rather loose sleep than miss social opportunitiessocial opportunities

Some activities are flexible ( ie: Some activities are flexible ( ie: gardening, woodworking, fixing cars)gardening, woodworking, fixing cars)

Some are not (clubs, team sports, Some are not (clubs, team sports, childcare, school activities)childcare, school activities)

Social ImpactSocial Impact

IncreasesIncreases DivorceDivorce Family violenceFamily violence Social IsolationSocial Isolation Sexual dysfunctionSexual dysfunction May affect women more than menMay affect women more than men

Circadian rhythm related Circadian rhythm related issuesissues Peak bronchial reactivity between 4-7 AMPeak bronchial reactivity between 4-7 AM

Asthma may be worse in workers Asthma may be worse in workers exposed to irritantsexposed to irritants

Shift work increases glucose levels in Shift work increases glucose levels in insulin dependent diabetics. insulin dependent diabetics. One study shows a 35% increased risk for One study shows a 35% increased risk for

developing diabetesdeveloping diabetes Sleep deprivation lowers seizure threshold Sleep deprivation lowers seizure threshold Increases frequency of migrainesIncreases frequency of migraines The absorption, excretion, metabolism and The absorption, excretion, metabolism and

peak effect of medications is affected by peak effect of medications is affected by circadian rhythmscircadian rhythms

Colorectal CancerColorectal Cancer

data suggest that working a rotating data suggest that working a rotating night shift at least three nights per night shift at least three nights per month for 15 or more years may month for 15 or more years may increase the risk of colorectal cancer increase the risk of colorectal cancer in women 35%in women 35%

Shorter durations also have Shorter durations also have increased riskincreased risk

This may be due to the suppression This may be due to the suppression of melatonin production with of melatonin production with nocturnal light exposure. Melatonin nocturnal light exposure. Melatonin has anti-cancer propertieshas anti-cancer properties

Breast CancerBreast Cancer

Attributed to inhibition of Attributed to inhibition of melatonin production by light melatonin production by light exposure during the nightexposure during the night

Shift Work Sleep DisorderShift Work Sleep Disorder

Circadian Rhythm disruptionCircadian Rhythm disruption Insomnia Insomnia Disrupted sleep schedules Disrupted sleep schedules Reduced performance Reduced performance Difficulties with personal Difficulties with personal

relationships relationships Irritability/depressed mood Irritability/depressed mood Sleep apnea 11.6% vs 5% in general Sleep apnea 11.6% vs 5% in general

populationpopulation

Increased accidentsIncreased accidents

To and from workTo and from work MicrosleepsMicrosleeps

Alert to suddenly severe fatigueAlert to suddenly severe fatigue Worse with monotonous tasksWorse with monotonous tasks

Decreased vigilanceDecreased vigilance Lower performanceLower performance Higher error ratesHigher error rates 20% increase in ergonomic workers 20% increase in ergonomic workers

compensation casescompensation cases

Making an ImpactMaking an Impact

Strategies to WAKE UPStrategies to WAKE UP

Administrative ControlsAdministrative Controls

1.1. Limit shift work to essential jobsLimit shift work to essential jobs

2.2. Schedule toughest most dangerous Schedule toughest most dangerous tasks for early in the shift. Less tasks for early in the shift. Less demanding tasks for later in the demanding tasks for later in the shiftshift

3.3. Avoid scheduling demanding or Avoid scheduling demanding or dangerous tasks at the beginning dangerous tasks at the beginning of an early morning shiftof an early morning shift

1.1. Tailor supervision:Tailor supervision:1.1. Extra supervision between 3:30 AM Extra supervision between 3:30 AM

and 5:30 AMand 5:30 AM2.2. Younger workers have more accidents Younger workers have more accidents

at the start of a shift following at the start of a shift following weekendsweekends

3.3. Older workers have more accidents at Older workers have more accidents at the end of a shift.the end of a shift.

2.2. Supervise inexperienced workers Supervise inexperienced workers more closely until they learn their more closely until they learn their jobjob

Encourage good eating Encourage good eating habits at night. habits at night. Encourage light meals Encourage light meals that are nutritious and that are nutritious and easy to digesteasy to digest

Allow adequate meal Allow adequate meal and rest breaksand rest breaks

Have good emergency Have good emergency plans in place for odd plans in place for odd shifts (nighttime shifts (nighttime emergency responders emergency responders may be fewer than day)may be fewer than day)

Odd Shift OutOdd Shift Out

Compressed workweek:Compressed workweek: 3-4 days of 10-12 hour shifts3-4 days of 10-12 hour shifts

Pros:Pros: More time off and between work More time off and between work

schedulesschedules More opportunities for family and More opportunities for family and

social activitiessocial activities

Cons:Cons: Increased fatigueIncreased fatigue Decreased performance by the Decreased performance by the

end of the shiftend of the shift Daily exposure to chemical, Daily exposure to chemical,

biological and physical hazards biological and physical hazards my be increasedmy be increased

Some families may have trouble Some families may have trouble arranging childcare or eldercarearranging childcare or eldercare

Permanent afternoon, evening Permanent afternoon, evening or Night shiftor Night shift

Pro: More time to adjustPro: More time to adjust Con:Con:

Disruptive to social lifeDisruptive to social life Permanent night workers may Permanent night workers may

accumulate a greater sleep accumulate a greater sleep deficiency over timedeficiency over time

Rotating or Variable shiftsRotating or Variable shifts

Length of rotation:Length of rotation: Workers rotated to a new shift Workers rotated to a new shift

schedule too rapidly or without schedule too rapidly or without sufficient break may have trouble sufficient break may have trouble functioningfunctioning

Speed of rotationSpeed of rotation Longer rotations of 10-14 days may Longer rotations of 10-14 days may

allow more time to adjust. allow more time to adjust. Circadian rhythm may require 3 weeks to Circadian rhythm may require 3 weeks to

fully adjust to a new shiftfully adjust to a new shift Mental functions adjust more rapidlyMental functions adjust more rapidly More trouble with the first 4 shiftsMore trouble with the first 4 shifts Faster rotations of 2-3 days do not allow for Faster rotations of 2-3 days do not allow for

circadian rhythm adjustmentcircadian rhythm adjustment Faster rotation allows workers to get through Faster rotation allows workers to get through

the more difficult night shift rotation quickerthe more difficult night shift rotation quicker

Direction of the rotationDirection of the rotation Clockwise rotation from morning Clockwise rotation from morning

to afternoon to night causes fewer to afternoon to night causes fewer problems than the reverse orderproblems than the reverse order

Engineering controlsEngineering controls

Reduce night traffic, noise and Reduce night traffic, noise and distractionsdistractions

Be aware of hazards. Calculate Be aware of hazards. Calculate toxic exposures based upon shift toxic exposures based upon shift duration (i.e.: 8H TWA vs. 12 hour duration (i.e.: 8H TWA vs. 12 hour shift)shift)

Promote alertness:Promote alertness: Keep area brightly litKeep area brightly lit Reduce glare and reflective surfacesReduce glare and reflective surfaces If feasible, allow workers to play music If feasible, allow workers to play music

that will keep them awakethat will keep them awake

Maximizes safety and health controlsMaximizes safety and health controls Good ventilationGood ventilation Temperature controlTemperature control Machine guardingMachine guarding

Avoid isolating workers. Avoid isolating workers. Communicate oftenCommunicate often

Provide food preparation areas, rest Provide food preparation areas, rest areas, consider and exercise facilityareas, consider and exercise facility

Provide worker education and Provide worker education and instructioninstruction

Treat shift training like HazcomTreat shift training like Hazcom Talk about health and safety Talk about health and safety

difficultiesdifficulties Emphasize performance and Emphasize performance and

accident risksaccident risks Teach employees to recognize Teach employees to recognize

social and family problemssocial and family problems

They should know….They should know….

How to recognize health How to recognize health problems which may be related problems which may be related to shift workto shift work

How to control shift work How to control shift work hazards and methods that can hazards and methods that can be used to do so.be used to do so.

How to minimize the effects of How to minimize the effects of shift work on themselvesshift work on themselves

They can do this by…They can do this by…

Protecting their sleep periodsProtecting their sleep periods Maintaining regular rest and wake Maintaining regular rest and wake

routinesroutines Avoid exercising for 2 hours Avoid exercising for 2 hours

before going to bedbefore going to bed Keep light out the bedroomKeep light out the bedroom Disconnect the phoneDisconnect the phone Maintain a quiet sleep areaMaintain a quiet sleep area

Eat nutritious mealsEat nutritious meals Keep a regular eating routineKeep a regular eating routine Select foods high in Select foods high in

carbohydrate rather than heavy carbohydrate rather than heavy fatty high protein meals before fatty high protein meals before sleepsleep

Family and friends should be Family and friends should be made aware of the potential made aware of the potential harmful consequences of shift harmful consequences of shift workwork

Adjust family and social life to Adjust family and social life to maximize interactionmaximize interaction

Maintain physical fitnessMaintain physical fitness Learn strategies to remain Learn strategies to remain

awake at workawake at work

One last note:One last note:

Modafilin aka ProvigilModafilin aka Provigil Sept 2003: FDA advisory panel Sept 2003: FDA advisory panel

recommended use for shift work sleep recommended use for shift work sleep disorderdisorder Different mechanism than amphetaminesDifferent mechanism than amphetamines Well toleratedWell tolerated Memory improvingMemory improving mood brighteningmood brightening No jittery feeling No jittery feeling ?anxiolytic?anxiolytic