Lack of sleep becomes a barrier
Edited transcript of the interview with Nancy Nadolski
"Our bodies are meant to sleep. We’re sleeping an hour and a half less than our grandparents did. Our bodies still require it. Our bodies still need it. Our bodies are asking us to do it."
This is an edited transcript of an Idaho Health interview with Nancy Nadolski, a family nurse practitioner who sees people with sleep problems from 9 a.m. to 2 p.m. Monday-Wednesday. In this interview, Idaho Health focused on shift work sleep disorder, recognizing that the Treasure Valley’s biggest employers are open around the clock.
Twenty five percent of night-shifters have trouble sleeping
Twenty-five percent of all shift workers have trouble with sleep. It becomes a barrier. Their mood plummets. They are not even able to put two or three hours of sleep together. Their appetite changes. When they (researchers) started really looking at this, it had a lot to do with what happened with pilots and with truck drivers driving at night. Some truck drivers were driving 50 hours a week, and many of them were driving at night because they can go faster. If you look at traffic safety, from two until five in the morning was the highest incidence of single truck accidents. There were no skid marks, so no evidence of waking up to try to overcorrect. They just simply went off the road, tumbled and went into somebody else across the median. That kind of brought to light the question, What is it about this time of night that makes us more vulnerable? It is the time in the 24-hour period when our melatonins are highest, and we need to respond to that and go to sleep.
There’s no getting around it: We all need sleep
Sleep is one of those universal needs. When we look at treating shift workers, we want to treat performance. In other words, how are they doing on the job, as well as how do we support them getting the sleep that they need. They need safety on the job, safety for themselves, being able to be productive, having critical skills, being able to remember, being able to perform their jobs as well as they can during that shift and also getting home.
Among the medications we use now, Provigil is the one that has FDA (Food and Drug Administration) approval for shift work sleep disorder. Not only did it help workers stay awake during their shift, but it also got them home.
Provigil
Health insurance often covers the cost of Provigil for shift work sleep disorder. It was first prescribed for narcolepsy, because it works in the part of the brain that stabilizes the on-off switch, and then it was approved for obstructive sleep apnea and the sedation related to that and then shift work sleep disorder.
Shift workers are everywhere
They are working at the hospital. A big one is the hospitals because many folks are working the three 12 (hour shifts). They are on three (shifts) and then off three (shifts) and then on for three and off for five, and it’s a wonderful way to do night shift. It gives some balance back to the family. If you work the 3 to 11 p.m. shift, socially, you are a loser. If you are trying to see people and working the night shift on weekends, it is very, very difficult. But there is more and more shift work because of technology. So I see people who work in the hospital. I see truck drivers. I see police, emergency-care workers and firemen, all on 24-hour shifts.
About their troubles
They are trying to figure out how to consolidate their sleep. What has happened is their circadian rhythms have been so messed up because their sleep drive has been messed up. I know very, very few shift workers who are able to consolidate seven and a half to eight hours of sleep during the day.
Kids make days more complicated
There are a lot of folks who sleep when the kids are sleeping. That television is a wonderful, wonderful distraction and oftentimes the shift worker will be sleeping on the couch in the room with the children watching the television. They’ve locked the doors. They’ve made sure the kids can’t leave the room. But people get desperate to be able to get some sleep. They think if I can just sleep for two hours ... but that’s not enough, because we need five or six of those whole sets of stage one through four and the REM sleep. When we are sleep-deprived, our body will go for the stage three and four sleep because of the restoration. That’s where our cells renew themselves. That’s where we get the growth hormone and the REM sleep, which helps us with emotional and memory restoration. Those other needs are farther down the line, so when people say they catch up, they really are moving toward that REM sleep they need not only that stage three and four, but also the REM sleep.
I was on my way to Texas a few weeks ago, and I saw this one physician that I have known forever and said, "How is your sleep?" and he said, "I get by."
And I said, "Tell me what you mean by that."
"Well, I just don’t like to go to bed at night. There is so much to do and so much to read and sometimes I have to be at the hospital at 6 a.m."
I said, "What would you tell your patients to do?"
And he said, "My patients would die with my lifestyle."
But, needless to say, that whole belief system says I can cheat on this. Sleep is for wimps. Well, it is not, especially when I look at the patients I see, the firefighters and the police force and just realizing that again that universal link for humans is being able to get good, restorative sleep, and it’s nourishment that we can’t get anywhere else. I wish we could get it someplace. All the exercise in the world does not make up for the value of a good night’s sleep. Nobody feels as good after exercise as they do after a good night’s sleep.
The other thing is body temperature. When we’re working the night shift, everybody wears layers, because early in the morning, your body temperature goes way down, and that is when your melatonin levels are the highest. Everybody was cold on the night shift, everybody.
I recommend for anybody who is working the night shift to make their sleep a priority, and that includes on their days off. In other words, keep at least a part of that pattern of sleeping during the day, sleeping from 9 in the morning until 2 in the afternoon and then staying up.
Provigil helps.
It doesn’t give back all of the benefits of a good night’s sleep, but what it does is during that time when you have to be vigilant and to be awake, it stabilizes that on-off switch. The data supported very, very well the folks that were on it, their psychomotor vigilance tests, their balance tests, all of those things were much better when they were on the Provigil. It’s not a stimulant. It doesn’t work in that pathway, so the whole idea about addiction, about selling it on the street, the whole James Brown I-feel-good neighborhood, it just doesn’t go there. Sometimes it’s disappointing because some patients are expecting the buzz that you get from the methamphetamines, but it doesn’t do that. It just wakes them up. One of the other benefits is it doesn’t get in the way of being able to get to sleep when you need to. Another thing that has been studied for shift work sleep disorder is caffeine, to be able to ingest it at the very start of the shift. They are looking at tea more than coffee because if all of those antioxidant effects. The green tea is the one they probably have done the most study about.
Protect your sleep
To be able to protect the sleep environment takes a lot of communication with family. Put a sign on the door, "Do not ring the doorbell: Night shift worker." Intermittent noise is what wakes people up — kids knocking on the door, garbage truck, blackout curtains, whatever you can do to mimic the night. The other thing is, if it is light out on the way home, you have to put dark glasses on, because the moment you get sun on your face, that melatonin level will plummet, and then you are awake. Put on the sunglasses, the wraparound kind. Wear them in the car. Don’t take them off until you are in the house.
Gaining weight is an issue
Metabolisms change. There are a lot of studies about being a short sleeper, about how much at risk you are of metabolic syndrome (a group of risk factors that increase your risk of heart disease or diabetes). When you sleep less than six hours a night, you are at a much higher risk for all kinds of glucose clearance problems.
When you are off shift in the morning, you don’t usually have that much of a sleep drive. You say, "Gosh, I’m awake now. Why did I think I needed sleep? It was 4 in the morning, and I was falling asleep. Now, it’s 8, I’m awake, and I’m watering my plants. I’ll stay awake for awhile." That’s because you don’t have a drive at that point. Your drive has plummeted.
Hope is the best medicine
Give them hope, and the greatest hope is that first of all they are not alone, that one third of Americans every single night have trouble either getting to sleep, staying asleep or their sleep is not restorative. Insomnia is such a slippery beast. Your insomnia is different from mine. I wish there were blood work that I could do and say look, you’ve got insomnia.
The challenge for lots of my patients is they’ve been told they’re crazy. We’ll just have to treat your depression, we have to treat your anxiety, and then your sleep will be restored. That’s not the truth. We get real conscious about what you are doing to respect that sleep time between 11 p.m. and 7 a.m., make it absolutely holy, and not let anything get in the way.
We need to sleep
Some (people) say they don’t sleep and don’t see any help. For those folks, we need to be able to get insight into what it takes every single day to be able to get to sleep, stay asleep and feel restored the next day. It’s a conscious, very conscious process. When I work with a patient and get them to look at a 24-hour period, and discern, well, I didn’t sleep well Tuesday, what happened on Monday that led to this broken sleep. Our bodies are meant to sleep. We are meant to sleep. What is it about our society that has changed that? We’re sleeping an hour and a half less than our grandparents did. Our bodies still require it. Our bodies still need it. Our bodies are asking us to do it.
Women and sleep
We see more insomnia in women. A lot of it has to do with making sleep a priority. They’re making sure that all the kids are taken care of and everything else is taken care of, and then they can go to sleep. But what does it take for them to realize they don’t have to stand sentry on everybody else in the family
New moms
New moms have a 700-hour sleep debt the first year postpartum. Post-partum depression is real, and if we can help them consolidate their sleep, that minimizes the risk.
We need more research on sleep and insomnia
We want to treat insomnia with the same vigilance that we treat hypertension. Mostly, they (health-care providers) don’t know what to do with somebody who is an insomniac. They say, ‘Nancy, we are so glad you are here because I don’t want to deal with it. It takes time. It takes lots and lots of willingness to take apart the day, treating it with the same seriousness that somebody treats hypertension, because the side effects of insomnia are lethal. When I hear people saying, I can’t take medication because of all the side effects, I say look at all the side effects of not sleeping. It’s toxic.
It starts with education. It’s almost like learning about food and exercise. Sleep is kind of where exercise and nutrition were 30 years.