WorkingAgainsttheClock:PraccalStrategiesforDiagnosisand ... Files/Spring 2014 Syllabu… · Session 3: Working Against the ... Clinical PsychiatryINSOM Magazine, , and International

Working Against the Clock: Prac4cal Strategies for Diagnosis and Management of Shi; Work Disorder (SWD) March 20, 2014Houston, Texas

Session 3: Working Against the Clock: Practical Strategies for Diagnosis and Management of Shift Work Disorder (SWD) Learning Objectives

1. Describe the pathophysiologic basis of circadian rhythm misalignment and its relationship to sleep/wakefulness and overall health

2. Establish the differential diagnosis of shift work disorder (SWD) based on symptomatology, patient history, and findings obtained from a thorough sleep history and other assessment tools

3. Formulate evidence based initial and ongoing treatment plans for SWD that incorporate nonpharmacologic and pharmacologic modalities

Faculty

Paul P. Doghramji, MD FAAFP Attending Family Physician Collegeville Family Practice Medical Director, Health Services Ursinus College Collegeville, Pennsylvania

Dr Paul Doghramji cofounded Brookside Family Practice & Pediatrics Pottstown, Pennsylvania. He has also been attending physician in family practice, chair of the utilization management committee, and physician sdvisor at Pottstown Memorial Medical Center; senior staff member at Collegeville Family Practice, assistant medical director for health services at the Hill School in Pottstown;, and preceptor in the physiciana ssistant program at Arcadia University, Glenside, Pennsylvania and nurse practitioner program at LaSalle University, Philadelphia, PA. Board certified by the American Board of Family Practice and a fellow of the American Academy of Family Physicians, Dr Doghramji holds membership in the American Academy of Family Physicians and Pennsylvania Academy of Family Physicians. He has received the physician’s recognition award from the American Academy of Family Physicians in every qualifying year since completing his residency in 1985. Dr Doghramji’s work on sleep medicine has been published in Postgraduate Medicine, Journal of Clinical Psychiatry, INSOM Magazine, and International Journal of Clinical Practice, as well as on such Web sites as Medscape and Pri-Med. He coauthored a textbook, “Clinical Management of Insomnia,” released January 2007. Dr Doghramji lectures nationally on topics relating to sleep medicine.

Christopher L. Drake, PhD FAASM Senior Bioscientific Staff Henry Ford Hospital Sleep Center Associate Professor of Psychiatry and Behavioral Neurosciences School of Medicine, Wayne State University Detroit, Michigan

Dr Christopher Drake is a licensed clinical psychologist, board certified in sleep medicine and a fellow of the American Academy of Sleep Medicine. Dr Drake’s research interests are focused on human sleep research with an emphasis on the factors that predispose individuals to sleep disorders broadly and insomnia and circadian rhythm disorders specifically. He serves on the editorial board of the journals Sleep and Behavioral Sleep Medicine; he is currently the chairman of the National Sleep Foundation. Faculty Financial Disclosure Statements The presenting faculty reported the following: Dr Doghramji has received honoraria from Teva, Takeda, and Purdue. He also serves on advisory boards for Merck and Astra Zeneca. Dr Drake has received honoraria from Teva. He has received research grants from Merck and equipment for research use from Phillips and The Sunbox Company.

Education Partner Financial Disclosure Statement The content collaborators at Ardgillan Group LLC have reported the following: Karen Roy MSc. CCMEP at Ardgillan Group LLC, has no financial relationship to disclose. Suggested Reading List

American Academy of Sleep Medicine (AASM). International Classification of Sleep Disorders Diagnostic and Coding Manual, Second Edition (ICSD-2). Westchester, IL: American Academy of Sleep Medicine; 2005.

Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–821.

Drake C, Roehrs T, Richardson G, Walsh J, Roth T. Shift work sleep disorder: prevalence and consequences beyond that of symptomatic day workers. Sleep.2004;27(8):1453-1462.

Drake C, Wright K. Shift work, shift work disorder, and jet lag. In: Kryger MH, Roth T, Dement WC, editors. Principles and Practice of Sleep Medicine. 5th ed. Philadelphia:Saunders;2011:784-798.

Hayes SM, Murray S, Castriotta RJ, Landrigan CP, Malhotra A. (Mis) Perceptions and interactions of sleep specialists and generalists: obstacles to referrals to sleep specialists and the multidisciplinary team management of sleep disorders. J Clin Sleep Med. 2012;8(6):633-642.

Morgenthaler TI, Lee-Chiong T, Alessi C, et al. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders. An American Academy of Sleep Medicine report. Sleep.2007;30(11):1445–1459.

Scheer FA, Hilton MJ, Mantzoros CS, Shea. SA. Adverse metabolic and cardiovascular consequences of circadian misalignment. Proc Natl Acad Sci USA. 2009;106(11):4433-4438.

Wright KP, Bogan RK, Wyatt JK. Shift work and the assessment and management of shift work disorder (SWD). Sleep Medicine Reviews.2013;(17):41-54.

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Working Against the Clock: Practical Strategies for Diagnosis and Management of Shift Work Disorder (SWD)

March 20th Houston

Drug List

Generic Trade

Armodafinil NUVIGIL Tablets (C‐IV)Modafinil PROVIGIL Tablets (C‐IV)

Learning Objectives

1. Describe pathophysiologic basis of circadian rhythm misalignment and its relationship to sleep/wakefulness and overall health.

2. Establish the differential diagnosis of Shift Work Disorder based on symptomatology, patient history, and findings obtained from a thorough sleep history and other assessment tools.

3. Formulate evidence‐based initial and ongoing treatment plans for Shift Work Disorder that incorporate nonpharmacologic and pharmacologic modalities.

IN YOUR PRACTICE

What is Shift Work Disorder?

Diagnostic CriteriaICSD‐3 CriteriaCriteria A‐D must be met

A. There is a report of insomnia and/or excessive sleepiness, accompanied by a reduction of total sleep time, which is associated with a recurring work schedule that overlaps the usual time for sleep.

B. The symptoms have been present and associated with the shiftwork schedule for at least three months.

C. Sleep log and actigraphy monitoring (whenever possible and preferably with concurrent light exposure measurement) for at least 14 days (work and free days) demonstrate a disturbed sleep and wake pattern.

D. The sleep an/or wake disturbance are not better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use, or substance use disorder.

American Academy of Sleep Medicine (AASM)International Classification of Sleep Disorders Diagnostic Manual, Third Edition;2014

Alternative Work Shift Types

Shift Type Regular Start Time % workforce

Night Shift Workers 6pm – 4am 4.25%

Early Morning Shift Workers

4am – 7am 12.4%

Evening/Afternoon Shift Workers

2pm – 6pm 4.3%

Rotating Shift Workers

Variable 2.7%


2

Who Works Shifts?

Protective Services 50.4%

Food Preparation/Serving 49.4%

Transportation 29.0%

Healthcare Support 27.9%

Personal Care/Service 27.6%

Healthcare Practitioners/Technicians 24.0%

Production 24.0%

Sales 23.3%

McMenamin TM et al Monthly Labor Rev.2007;130:9‐11

Prevalence of Shift Work Disorder

• Prevalence among rotating and night shift workers estimated to be 10%‐38%

• Early morning or split‐shift workers also at risk, prevalence less well known

• Estimated prevalence of 2%‐5% of the general population


IN YOUR PRACTICE

Patient Presentation May be Non‐specific

Christina Talks About Tiredness

• Tired

• Struggle

• Problems Concentrating

• Errors

• Lack of Energy

• Zoned Out

IN YOUR PRACTICE

Differential Diagnosis of Sleep Disorders

Causes of Sleepiness

• Reduced sleep• Restriction

• Sleep fragmentation e.g. obstructive sleep apnea

• CNS disorders e.g. narcolepsy.• Circadian rhythm misalignment.

• CNS medications.

Roehrs T. In Kryger MH, Roth T, Dement WC, editors. Principles and Practices of Sleep Medicine. 5th ed. Philadelphia:Saunders:2011

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IN YOUR PRACTICE

SWD May Be Assessed And Managed In Primary Care Practices

Assessment of SWD

• Determine circadian misalignment.

• Assess sleep disturbance:• Difficulty falling asleep, staying asleep or having nonrestorative sleep.

• Degree of alertness or sleepiness.• Assess falling asleep during inappropriate times/circumstances.

• Important job‐related factors e.g. commute, type of shift.

• Determine impact on social and domestic responsibilities.

Drake C et al. In Kryger MH, Roth T, Dement WC, editors. Principles and Practices of Sleep Medicine. 5th ed 2011

IN YOUR PRACTICE

Take a Thorough Sleep History

Taking a Sleep History

• On average, how much sleep per night are you getting?• Do you have uninterrupted sleep?• Have you been told that you snore loudly (louder than

talking or loud enough to be heard through closed doors) or do anything else unusual in your sleep?

• Do you have problems falling asleep?• What time do you go to bed and when do you get up?• Is your sleep pattern regular? • Do you have problems waking up?• Are you taking any CNS medications?

• Are you having problems with alertness while driving?

Taking a Sleep History

• On average, how much sleep per night are you getting?• Do you have uninterrupted sleep?• Have you been told that you snore loudly (louder than

talking or loud enough to be heard through closed doors) or do anything else unusual in your sleep?

• Do you have problems falling asleep?• What time do you go to bed and when do you get up?

• Is your sleep pattern regular?

• Do you have problems waking up?• Are you taking any CNS medications?

• Are you having problems with alertness while driving?

IN YOUR PRACTICE

Assessing Sleepiness

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Epworth Sleepiness Scale (ESS)SITUATION CHANCE OF DOZING (0‐3)

Sitting and reading 0 1 2 3

Watching television 0 1 2 3

Sitting inactive in a public place –for example, a theater or meeting

0 1 2 3

As a passenger in a car for an hour without a break 0 1 2 3

Lying down to rest in the afternoon 0 1 2 3

Sitting and talking to someone 0 1 2 3

Sitting quietly after lunch (when you’ve had no alcohol) 0 1 2 3

In a car, while stopped in traffic 0 1 2 3

Total Score

0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

ESS total score ≥10 indicates excessive sleepiness

Johns MW. Sleep. 1991;14(6):540‐545.

Single Question Sleepiness Assessment

“Please measure your sleepiness on a typical day” where 0 is none and 10 is highest.

Score of 7 is indicative of excessive sleepiness.

Burkhalter H et al. Prog Transplant.2013;23:220‐228

Insomnia Severity IndexInsomnia Problem None Mild Moderate Severe Very Severe

1. Difficulty falling asleep 0 1 2 3 4

2.Difficulty staying asleep 0 1 2 3 4

3.Problems waking up too early 0 1 2 3 4

4. How SATISFIED/DISSATISFIED are you with your CURRENT sleep pattern?Very satisfied Satisfied Moderately Satisfied Dissatisfied Very Dissatisfied

0 1 2 3 45. How NOTICEABLE to others do you think your sleep problem is in terms of impairing the quality of your life?

Not at all noticeable A Little Somewhat Much Very Much Noticeable0 1 2 3 4

6. How WORRIED/STRESSED are you about your current sleep problem?Not at all worried A Little Somewhat Much Very Much Worried

0 1 2 3 47. To what extent do you consider your sleep problem to INTERFERE with your daily functioning(e.g. daytime fatigue, mood, ability to function at work/daily chores ,concentration, memory, mood etc.) CURRENTLY?

Not at all interfering A Little Somewhat Much Very Much Worried 0 1 2 3 4

Add scores for all seven items for total score:________0‐7=no clinically significant insomnia8‐14=subthreshold insomnia15‐21=clinical insomnia (moderate severity)22‐28=clinical insomnia (severe)

Bastien et al. Sleep Med 2001;2(4);297‐307

IN YOUR PRACTICE

Sleep/Wake Cycle

Christina Shares Her Schedule

• Monday‐Friday schedule

• Awake at 3am

• Work shift 4am – 12 noon

• Afternoon nap opportunity often missed

• Evening with family

• Bed time 9pm rarely possible

• Disturbed 11pm by husband

IN YOUR PRACTICE

Diagnostic Algorithm for Shift Work Disorder

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ALGORITHM FOR DIAGNOSIS OF SHIFT WORK DISORDER

Adapted from Barger LK et al. Sleep. 2012;35(12):1693-1703.Is the patient a shift worker?

Shift Work Disorder ruled out

Yes

No

Remember the most common occupations for shift work schedules

include: •Protective services •Food preparation/serving •Transportation•Healthcare/healthcare support

Nonstandard schedules:

Hours outside of standard

7am to 6pm work day


Does the patient complain of insomnia or excessive sleepiness? No

Yes

Is the complaint associated with impairment of social, occupational or other areas of functioning?

ICSD‐3 criteria for diagnosis of Shift Work Disorder requires

presence of excessive sleepiness and/or insomnia.

Inquire about the impact of symptoms on everyday

activities.

No



Does the patient complain of insomnia or excessive sleepiness?

ICSD‐3 criteria for diagnosis of Shift Work Disorder requires

presence of excessive sleepiness and/or insomnia.

Shift Work Disorder ruled

out

Is the complaint temporally associated with shift work schedule?

No

Yes

When did the patient first notice problems with insomnia or excessive

sleepiness?

Have the symptoms and associated shift work schedule lasted at least one month?

No

ICSD‐ 3 criteria for diagnosis of Shift Work Disorder require

symptoms associated with the schedule for at least three

months.


Is the sleep disturbance better explained by another current sleep disorder, medical or neurological disorder, mental disorder, medication use or substance use disorder?

Take full sleep and medical history to explore possible

other causes of sleep disturbance.

No

Yes

Diagnosis: Shift Work Disorder

Consider a differential diagnosis or whether SWD is comorbidwith other disorders.

Consider referral to sleep specialist if another sleep disorder is suspected.

IN YOUR PRACTICE

Comorbidities of Circadian Misalignment

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Christina’s InformationLast Appointment Today

Weight 175lb 190lb

Blood pressure 128/82 142/92

Height 5’6” 5’6”

Normal Ranges Result

Triglycerides 30‐149mg/dL 170mg/dL

Glucose (fasting) <100mg/dL 108mg/dL

Cholesterol, Total <200mg/dL 180mg/dL

HDL Cholesterol >35mg/dL 36mg/dL

LDL Cholesterol 65‐180mg/dL 130mg/dL

AST <31 U/L (Female) 28 U/L

ALT <20 U/L (female) 18 U/L

BMI: 30

Wang X‐ et al.Occupational Medicine. 2011;61:78‐89Scheer FA Proc Natl Acad Sci USA 2009;106(11):4433‐8

Morbidities Associated With Circadian Misalignment

•Insulin Resistance•Malabsorption•Diarrhea•Electrolyte Imbalance•Cancer•Cardiovascular Disease•Inflammation•Obesity

0

10

20

30

40

1st Qtr 2nd Qtr

Gastrointestinal Disorders in Night‐Shift Workers

% of Nurses

Day Shift Rotating Shift

†P = 0.04 vs day shift.Zhen LW, et al. Eur J Gastroenterol Hepatol. 2006;18:623‐627.

†

Functional Bowel Disorders Among rotating shift nurses:• Increased functional bowel

disorder symptom score.• Increased sleep disturbance

score.

• Increased anxiety score.

Increased Risk for Cancer Among Shift Workers

In 2007, International Agency for Research on Cancer determined that “Shift work that involves circadian disruption is probably carcinogenic to humans.”

1) Hansen J. Epidemiology. 2001;12:74‐77 . 2) Grundy A et al Occup Envir Med doi:1136/oemed.3013.101482 33) Schernhammer ES, Epidemiology. 2006;17:108‐111; 4) Kubo T, et al. Am J Epidemiol. 2006;164:549‐555.

Type of Cancer Odd Ratio 95% CI

Breast Cancer

Night Shift > 0.5yr 1 Night Shift > 6yrs 1Night Shift >30yrs 2Rotating Shift Work >20yrs 3

1.51.72.121.79

1.3‐1.71.3‐1.71.14‐4.311.04‐1.78

Prostate Cancer

Rotating Shift Workers (mixed occupations) 4 3.0 1.2‐7.7

Significantly More Missed Family and Social Activities

ES, excessive sleepiness; Drake C, et al. Sleep. 2004;27:1453-1462.

Day Shift Night Shift Rotating Shift

Mis

sed

Fam

ily a

nd

Soci

al A

ctiv

ities

, Day

s/M

onth

Insomnia and/or ES

No Insomnia and/or ES

12

10

8

6

4

2

0

*

*

Group x Symptom Interaction (P<0.001)*P<0.05 vs Day

IN YOUR PRACTICE

Treatment Goals for Shift Work Disorder

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Recommendations for Management of Shift Work DisorderI. Regular Physicals.

• Attention to psychological, gastrointestinal, cardiovascular and potential cancer risks

II. Removal from Shift Work if possible.• May not be feasible for many patients

III. Determine Patient Specific Therapeutic Approach.IV. Address work, social and domestic factors.

Drake C et al. In Kryger MH, Roth T, Dement WC, editors. Principles and Practices of Sleep Medicine. 5th ed. Philadelphia:Saunders:2011

Practice Parameters (AASM) 2007

Intervention Recommendation Level

Planned Sleep Schedules Standard

Timed Light Exposure Guideline

Timed MelatoninAdministration

Guideline

Hypnotics Guideline

Stimulants/Caffeine Option

Alerting Agents Guideline

Morgenthaler TI et al. Sleep.2007;30:1145‐1459

•Sleep hygiene education

•Hypnotic medication

•Melatonin 3 mg at bedtime Increase sleep durationIncrease sleep duration

Increase alertnessIncrease alertness

Addressing Circadian Misalignment and Sleep Deprivation

Sleep durationAlertnessSleep durationAlertness

Circadian AlignmentCircadian Alignment•Bright light during work•Melatonin •Avoid morning bright light

•Naps

•Caffeine

•Stimulants

•Wake promoters


Circadian Interventions

Align circadian rhythm of alertness with the shift work and sleepiness with sleep schedule

• Avoid bright light after work shift in preparation for sleep opportunity. 2

• Have a dark, quiet bedroom.

• Get bright light exposure during the shift. 1,2

• Split sleep opportunities may avoid starting shift with sleep debt.

1. Dawson D et al, Sleep 1991;14:511‐516 . 2. Burgess HJ, et al. Sleep Med Rev 2002;6:407‐420

Goals for Use of Medications in Shift Work Disorder

• Enhance wakefulness during work shift:• Improve alertness• Facilitate normal levels of attention and energy throughout the wake‐period

• Facilitate good sleep when desired:• Ensure adequate sleep duration• Improve sleep quality

• Minimize side effects that impair functioning or normal sleep patterns.

Management of Shift Work Disorder: Focus on Insomnia

• Hypnotics may improve daytime sleep, but do not improve subsequent nighttime alertness.

• Short‐acting hypnotics of little help to most night shift workers, as sleep maintenance and not sleep onset problems are more common.

• Potential carryover effects (eg, sedation) during work hours should be considered.


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Management of Shift Work Disorder:Focus on Excessive Sleepiness

• Prophylactic and strategic use of caffeine.• Wakefulness promoting medication prior to shift.• Medications approved by FDA for treatment of adults with excessive sleepiness associated with SWD:

• Modafinil C‐IV 200mg‐400mg*

• Armodafinil C‐IV 150mg‐250mg

Morgenthaler TI et al. Sleep.2007;30:1145‐1459. [email protected]

* Generic formulations available

* ** * *

Czeisler C et al. Mayo Clin Proc. 200984(11).958‐972

Armodafinil Improves MSLT in Patients with SWD

MSLT= Multiple Sleep Latency Test

Armodafinil in SWD: TolerabilityArmodafinil was generally well tolerated :

• Headache was the most frequently reported adverse event

• The majority of adverse events were considered mild or moderate in severity

• Drug‐drug interactions: CYP2C9.• Label warning: serious rash.

Czeisler C et al. Mayo Clin Proc. 2009 84(11).958‐972 Drugs@FDA

Potential for Circadian Regulation

Melatonin/Agonists• Possess circadian phase‐dependent hypnotic properties.• Attenuate the wake‐promoting drive from the circadian

system.

• Allow consolidation of sleep occurring out of phase with endogenous melatonin secretion.

• Have little effect when taken at times when endogenous levels are high or rising.

• May reduce sleep latency times.

• Investigational: No FDA approvals for SWD.

Wyatt JK et al. Sleep. 2006;29:609‐618.

PLA 0.3mg 5.0mg PLA 0.3mg 5.0mg75

80

85

90 *

[OUT OF PHASE] [IN PHASE]

*

Sleep Efficiency

PER

CEN

T (sem)

Exogenous Melatonin Improves Sleep During the Biological Day but not the Biological Night

Wyatt JK et al. Sleep. 2006;29:609‐618.

*p<0.05

Management of Shift Work Disorder:Work, Social, and Domestic Factors

Countermeasure General Concepts

Family & Social Support• Family rules and planning calendar• Informing friends/relatives about sleep/wake schedule

Commuting• Car pooling or public transportation • Naps before driving; use of radio, A/C, & varied route

Sleep at Home• Routine sleep/wake schedules, especially on days off• Noise & light reduction during sleep periods

Alertness & Wellness • Exercise; on‐duty naps; adequate light and breaks Shift Worker Participation • Compromise between employer goals & employee needsWorking Conditions • Staffing levels; workload; job rotation; rest breaks

Ergonomic Design• Consecutive number, direction, & sequence of shifts• Start, end, and duration of shifts

Health Care • Medical surveillance of shift workers; staff education re: SWD

Personal Health & Behavior • Diet; active living; coping strategies

Education• Manager awareness and social support• “Shift Work Awareness” programs

Knauth P et al Occup Med. 2003;53:109-116. Drake C et al. In Kryger MH, Roth T, Dement WC, editors. Principles and Practices of Sleep Medicine. 5th ed. 2011

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Ongoing Management of Shift Work Disorder

• Regular reviews.• Increased monitoring for comorbidities/health consequences.

• Consultation with sleep specialists for more complex patients or if comorbid sleep disorders are suspected.

Summary

• Circadian misalignment is associated with multiple health morbidities.

• A thorough sleep history must include assessment of sleep timing in addition to quality and quantity of sleep.

• Personalized management plans are required to address symptoms, circadian misalignment and social, work or domestic factors.

• Shift Work Disorder may be assessed and managed within primary care practices, in most cases.

• Regular follow up with patients is advised.

Question & Answer

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WorkingAgainsttheClock:PraccalStrategiesforDiagnosisand ... Files/Spring 2014 Syllabu… · Session 3: Working Against the ... Clinical PsychiatryINSOM Magazine, , and International