Staff
Report

Where do all the hours of the day go? If we were our parents we might say eight hours for work, eight hours for sleep, and eight hours for everything else. For better or for worse we are not our parents and our days are no longer so evenly divided. Whatever else we might be doing with our day, we are not spending one-third of it sleeping.

The emerging American portrait is one of more work, less sleep, restless sleep, and reduced individual productivity. According to the National Sleep Foundation (NSF) 63% of American adults do not get the recommended eight hours of sleep needed for good health, safety, and optimum performance. The average American adult sleeps just under seven hours during the workweek. More than one-third of Americans sleep less now than they did just five years ago. One-third of adults (33%) sleep only six and a half hours or less every night.

The problem does not end here. America is working longer hours than any industrialized nation in the world, including Japan. It seems only yesterday we as Americans winced when we heard about the workaholic Japanese. Well, we have now left them sleeping in their beds.

In their 2001 Sleep in America poll, NSF found that more than one-third of American adults (38%) work 50 hours or more a week. According to NSF Vice President James C. Walsh, PhD, there is a direct relationship between work hours and sleep. Those who work longer, sleep fewer hours. In fact, 45% of adults polled admit that they will sleep less to accomplish more.

Things could be a lot worse. At least two-thirds of us are getting seven hours or so of solid sleep, right? Wrong. Seven in ten (69%) Americans experience frequent sleep problems, though most have not been diagnosed. Two- thirds of adults experience a sleep problem a few nights per week or more.

So, why should longer work hours and reduced, sub optimal sleep keep you awake at night? If you are an employer, consider the following.

• One-half of the American workforce (51%) reports that sleepiness on the job interferes with the amount of work they get done.

• One out of four adults (24%) has difficulty getting up for work two or more days a week.

• 40% of adults admit that the quality of their work suffers when they are sleepy.

• At least two-thirds of adults confess that sleepiness compromises the quality of their work—68% say it interferes with concentration and 66% say it makes handling stress on the job more difficult.

• Nearly one out of five adults (19%) confess making occasional or frequent work errors due to sleepiness.

• One in five adults (22%) is so sleepy during the day that it interferes with daily activities.

• When they are sleepy during the day, two-thirds of employees say they are likely to accept their sleepiness and keep going.

• Overall, employees estimate that the quality and the quantity of their work are diminished by 30% when they are sleepy.

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The bill for reduced productivity, work errors, and absenteeism due to lack of sleep comes in at a stunning $18 billion. Richard L Gelula, Executive Director of NSF says, "Sleep is viewed as expendable and something you can catch up on anytime. The problem is people aren’t catching up on sleep, they are simply continuing to accrue a sleep debt that puts them further behind as they try to keep up with life’s demands."

The personal cost of sleep debt can often be your health or even your life. According to sleep expert Dr. William Dement, inadequate sleep takes a bigger toll on your body than smoking, high blood pressure, or a sedentary lifestyle. Lack of sleep not only results in reduced productivity and impaired mental performance, it also increases the risk of morbidity and mortality. In fact, performance impairment caused by sleepiness is comparable to that caused by alcohol intoxication.

Besides sleep deprivation, what concerns the experts is "problem sleep," which further accrues the sleep debt. Problem sleep occurs when "the quantity of sleep is inadequate because of primary sleep disorders (obstructive sleep apnea, insomnia, restless legs syndrome, or narcolepsy) or other medical conditions (chronic bronchitis or congestive heart failure)."

Even though sleep deprivation is widespread, most of us know little about these sleep disorders. Sleep apnea occurs when the upper airway narrows or collapses during sleep, restricting or even preventing breathing. Although such episodes of airway collapse last for a short time, they usually occur throughout the night, thus disrupting sleep. This condition can cause hypoxemia and cardiovascular stress. Symptoms include chronic loud snoring, gasping or choking episodes during sleep, excessive daytime sleepiness, drowsiness while driving, automobile or work-related accidents, cognitive difficulties, and personality changes.

Restless Legs Syndrome is often diagnosed in conjunction with Periodic Limb Movement. The former condition occurs when sensations of creeping, crawling, pulling, and tingling cause an irresistible urge to move the legs. "These symptoms usually occur before sleep onset, making it difficult for patients to fall asleep." The latter is characterized by episodes of repetitive limb (usually leg) movement ensuing during the sleep that may disturb the patient and/or the bed partner. The limb movements are responsible for partial or complete awakening, although the patient is not always aware either of the movements or the arousal. The most telling symptom of these conditions is non-refreshing sleep.

Narcolepsy is a chronic sleep disorder. The two primary symptoms of this disease are cataplexy, which is defined as a sudden episode of muscle weakness triggered by emotional reactions (laughter, anger, or fear) as well as excessive wake-time sleepiness despite adequate sleep. Other symptoms include sleep paralysis, which is the inability to talk or move while falling asleep and/or while waking up, and hypnagogic hallucinations, which are described as vivid, frightening, dreamlike experiences that occur while dozing or falling sleep.

Insomnia, the most commonly known sleep disorder, is also the most prevalent. Nearly 40% of American adults report some form of insomnia. The condition is defined as the perception or complaint of inadequate or poor sleep because of difficulty falling asleep, waking up frequently during the night with difficulty returning to sleep, waking up too early in the morning, and/or less than refreshing sleep. Symptoms of this disorder range from tiredness to difficulty concentrating to irritability.

Shift workers are at greater risk for contracting insomnia and accruing a greater sleep debt due to their lifestyle. They are the ones who run our indispensable 24/7 world while the rest of us sleep. They are our emergency personnel manning the hospitals, police stations, and firehouses. They are the long haul truckers bringing us groceries and gasoline. Making up approximately 20–25% of the American work force, they are the ones at a double disadvantage. Not only do they tend to sleep fewer hours, they also suffer from poor sleep because of displaced timing of sleep. When the shift falls during the night it becomes challenging to stay alert, and equally hard to fall asleep and stay asleep during the day.

The 24-hour period of wakefulness and sleepiness is regulated in humans by an internal circadian clock, which is tuned to nature’s clock of light and darkness. The internal clock is responsible for regulating cycles in body temperature, hormones, heart rate, and other body functions. The desire to sleep is the strongest between midnight and six a.m. It is no surprise, then, that 10– 20% of night shift workers confess falling asleep on the job, usually during the second half of the shift. They also find it hard to go to bed during the day.

The problem with shift changes is that they occur more drastically than the body’s ability to adjust its circadian rhythms—at most they can adjust an hour or two per day. Also, since the circadian clock is tied in with light and darkness, when the night shift worker goes home in the morning, the body automatically goes into the "awake" mode because of bright daylight, making it difficult to get restful sleep.

The around-the-clock world is a reality that is here to stay. Does this mean that we will become a nation of zombies, caught in the vicious cycle of reduced productivity due to sleep deprivation, and increased hours of work to make up for that reduced productivity?

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The good news is that this nightmare can be prevented without too much trouble. Problem sleepiness is generally correctable when it is recognized. The reason diagnosis is hardly proportional to the extent of the problem is simply that we do not talk about it. For instance, during your annual physical examination, did your primary physician ask you how long and how well you usually sleep, or whether you feel fatigued during the day or have difficulty falling asleep?

The answer is probably not. NSF found in a recent poll that even though physicians believe they should address patients’ sleep problems in a routine checkup, they rarely or never do. A disconnect exists in terms of how they view sleep disorders and what they do about them. Physicians rank sleep higher (than the public) as being important to health, see the risk of an auto crash (66%) or injury (61%) as a consequence of insomnia, and perceive (83%) untreated acute insomnia as leading to chronic insomnia. However, they fail to incorporate a sleep history into their physical examinations. [Editor’s Note: Occupational medicine providers often do review the sleep patterns of injured workers as pain is another deterrent to effective sleep. If pain interrupts sleep, the injured worker can become discouraged as well as increasing her/his chance of further injury.]

The poll also found that physicians believe that just 14–16% of their patients suffer from insomnia/sleep disorders. This, despite surveys and studies indicating the prevalence to be significantly higher and despite the fact that almost half (48%) of the physicians surveyed indicated that their family members have experienced some form of insomnia.

However, the physicians are more inclined to talk about sleep problems if patients initiate the conversation, if the office visit is longer, or if they have easy-to-use tools for diagnosis. Physicians indicated a need to be more knowledgeable about sleep problems, and were in favor of continuing education and training during residency. Twenty-five percent (25%) of physicians received six hours of training in sleep medicine, but most physicians reported receiving only three hours, ever.

So given that most of our primary care physicians are not taught to look for sleep disorders, what can they do?

Sleep experts recommend physicians ask questions regarding specific sleep/wake habits and activities. "When assessing whether a patient is getting enough sleep, it is best to ask about bedtimes and rising times, because asking how long the patient sleeps is likely to yield an inaccurate answer. Comparing sleep quantity on days off versus workdays may be helpful. Patients who sleep several hours longer on their days off (by sleeping in or napping) may not be getting enough sleep during the workweek. They may describe feeling more alert on their days off."

Input from a family member, especially a bed partner, might yield pertinent information regarding how well the patient sleeps. The patient might not know how often, how long or how loudly they snore; the patient might not know how much their limbs move on a nightly basis and the patient might not realize that their bed partner might be sleep deprived because of snoring and/or limb movement.

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Employers share some responsibility to make the workplace safer and more productive for their shift workers. Keep in mind that more than 22 million Americans are shift workers and that number is growing by 3% each year. Experts point out that it does not take an exorbitant amount of money to institute change. Employers can start with educating managers and employees about the need for sleep and dangers of fatigue. It is cost-effective and does make a difference in employee health. According to a poll conducted by NSF, respondents said that they would sleep more if they believed it would benefit their overall health, safety, and memory.

Scheduling shifts effectively is imperative. Shifts should allow sufficient breaks and days off, especially when workers are required to work all shifts. Remember the circadian clock adapts very slowly, and days off can be crucial to that adjustment. Each shift should be long enough to allow the off shift worker to not only sleep, but also attend to personal life. Experts add that promoting overtime is extremely unproductive and can damage morale.

Employers should also encourage napping by providing a sleep friendly space and time for employees. A short nap has been proven to increase alertness, judgment, safety, and productivity. Installation of bright lights in the work areas is also advisable since light signals the body to be awake.

But do such measures work? Well, for at least two companies they have.

Canadian railways and a principal union were facing restrictive regulations on hours because of safety concerns. They went to Circadian Technologies, Inc. (CTI) to see if there was a better way to reduce fatigue. CTI not only demonstrated that the proposed regulations would not work, but also illustrated how scheduling, work practices, and environment contributed to impaired alertness and human error. A series of countermeasures were devised and implemented under what became a national project called CANALERT. The result was increased alertness and improved quality of life for locomotive engineers, reduced absenteeism, improved efficiency of operations, and relief from costly regulatory burdens.

In fact, one of the locomotive engineers was quoted as saying, "We’re no longer working when we are tired or trying to sleep when we are wide awake. With a circadian schedule, we can make a complete run and remember every part of it. That’s never happened before."

Similarly, a glass manufacturing plant was not meeting its production goal, lagging in morale, and becoming increasingly unsafe within just three years of operation. The rate of absenteeism and turnover was also unacceptably high. In came CTI and changed much of that. CTI started by conducting educational sessions for executives, managers, and employee representatives from each shift. This was followed by an "Alertness Assurance" design that included a "biocompatible" shift scheduling process and employee training.

The result was a decrease in absenteeism by 72%, reduction in safety accidents by 80%, scrap and rework went down by 50%, and morale went sky high.

These examples prove that it is possible to have a rested workforce without compromising the bottom line. In fact, overtime and unhealthy shift scheduling have proven to decrease worker productivity. 

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Tips for Sleeping

Sound

Wear ear plugs

Use a white noise machine, like a fan, to block other noises

Install carpeting to absorb sound

Unplug the telephone

Food

Avoid alcohol and caffeine within five hours of bedtime

Eat a light snack—don’t go to bed too hungry or too full

Avoid exercising within three hours of bedtime

Take a warm bath

Lower the room temperature (a cool environment improves sleep)

Don’t activate your brain by doing exciting or stressful activities

Darken the bedroom and bathroom

Install heavy (sound and light blocking) curtains or shades.

Wear eye shades

Resources

Sleep Strategies for Shift Workers, www.sleepfoundation.org/publications/shiftworker.html.

Groggy Workforce, Sleepy "Generation Y" Among Key Poll Findings, www.sleepfoundation.org/pressarchive/new_stats.html.

Sleeplessness Taking a Toll on Nation’s Workforce, www.sleepfoundation.org/pressarchives/workforce.html.

Talk to Your Doctor About Sleep, www.sleepfoundation.org/askdoc.html.

Allen, Jennifer, Adapting to Shift Changes, www.circadian.com/webarticle.htm.

"Recognizing Problem Sleepiness in Your Patients," American Family Physician, Feb. 15, 1999.

Besides the specific articles referenced above, be sure to check out a wealth of on-line resources available at:

www.allhealth.com (pick Sleep Disorders from the drop-down menu on the left)

www.sleepfoundation.org (NSF’s web site)

www.circadian.com

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