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Gulyani S, Salas RE, Gamaldo CE. Sleep medicine pharmacotherapeutics overview: today, tomorrow, and the future (Part 1: insomnia and circadian rhythm disorders). Chest 2013. [PMID: 23208340 DOI: 10.1378/chest.12-0465] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Over the past 10 years, significant strides have been made in the understanding, development, and availability of sleep disorder therapeutics. In this review series, we discuss the current evidence surrounding the mechanisms of actions, indications, efficacy, and adverse side effects associated with the available armamentarium of sleep over-the-counter and pharmacotherapeutics. This article is the first of a two-part series that covers the therapeutics for insomnia and circadian rhythm disorders.
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Affiliation(s)
- Seema Gulyani
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, MD.
| | - Rachel E Salas
- Department of Neurology, Johns Hopkins University, Baltimore, MD
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102
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Golombek DA, Casiraghi LP, Agostino PV, Paladino N, Duhart JM, Plano SA, Chiesa JJ. The times they're a-changing: effects of circadian desynchronization on physiology and disease. ACTA ACUST UNITED AC 2013; 107:310-22. [PMID: 23545147 DOI: 10.1016/j.jphysparis.2013.03.007] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Circadian rhythms are endogenous and need to be continuously entrained (synchronized) with the environment. Entrainment includes both coupling internal oscillators to external periodic changes as well as synchrony between the central clock and peripheral oscillators, which have been shown to exhibit different phases and resynchronization speed. Temporal desynchronization induces diverse physiological alterations that ultimately decrease quality of life and induces pathological situations. Indeed, there is a considerable amount of evidence regarding the deleterious effect of circadian dysfunction on overall health or on disease onset and progression, both in human studies and in animal models. In this review we discuss the general features of circadian entrainment and introduce diverse experimental models of desynchronization. In addition, we focus on metabolic, immune and cognitive alterations under situations of acute or chronic circadian desynchronization, as exemplified by jet-lag and shiftwork schedules. Moreover, such situations might lead to an enhanced susceptibility to diverse cancer types. Possible interventions (including light exposure, scheduled timing for meals and use of chronobiotics) are also discussed.
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Affiliation(s)
- Diego A Golombek
- Laboratory of Chronobiology, National University of Quilmes/CONICET, Buenos Aires, Argentina.
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103
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Darwish M, Bond M, Ezzet F. Armodafinil and Modafinil in Patients With Excessive Sleepiness Associated With Shift Work Disorder: A Pharmacokinetic/Pharmacodynamic Model for Predicting and Comparing Their Concentration-Effect Relationships. J Clin Pharmacol 2013; 52:1328-42. [DOI: 10.1177/0091270011417825] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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104
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Abstract
Bipolar depression represents a high priority research field, due to its pervasiveness, and high economic and personal (suicidality, impaired function, quality of life) costs, and the limited evidence base to inform therapeutics. Mood stabilizers and second-generation antipsychotics for bipolar depression are commonly only partially effective, and their side-effects may overlap with depressive symptoms such as hypersomnia, daytime drowsiness, fatigue, psychomotor retardation, and weight gain. Moreover, the use of antidepressants in bipolar depression is controversial due to concerns regarding the risks of inefficacy or switching to mood elevation. Stimulants and related compounds such as modafinil and armodafinil have on occasion been used as adjuncts in bipolar depressed patients with encouraging results, but their use is limited by the paucity of systematic evidence of efficacy and safety. The present review aims to provide an updated perspective on the use of stimulants and stimulant-like medications in adult bipolar depression, considering not only recent randomized controlled trials, but also open naturalistic studies, in order to clarify the strengths and limitations of using these agents.
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105
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Barger LK, Ogeil RP, Drake CL, O'Brien CS, Ng KT, Rajaratnam SMW. Validation of a questionnaire to screen for shift work disorder. Sleep 2012; 35:1693-703. [PMID: 23204612 PMCID: PMC3490362 DOI: 10.5665/sleep.2246] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVE At least 15% of the full-time work force is shift workers. Working during the overnight hours, early morning start times, and variable or rotating schedules present a challenge to the circadian system, and these shifts are associated with adverse health and safety consequences. Shift work disorder (SWD), a primary (circadian rhythm) sleep disorder indicated by excessive daytime sleepiness and/or insomnia associated with a shiftwork schedule, is under-recognized by primary care physicians. We sought to develop and validate a questionnaire to screen for high risk of SWD in a shift working population. DESIGN Shift workers completed a 26-item questionnaire and were evaluated by a sleep specialist (physician) who diagnosed them as either positive or negative for SWD. The physician assessment of SWD was guided by a flow chart that operationalized the ICSD-2 criteria for SWD. SETTING 18 sleep clinics in the USA. PATIENTS OR PARTICIPANTS 311 shift workers. INTERVENTIONS Not applicable. MEASUREMENTS AND RESULTS Responses to the items in the questionnaire were entered into a series of discrimination function analyses to determine the diagnostic value of the items and the fewest number of questions with the best predictive value. The function was then cross-validated. A final 4-item questionnaire has 89% positive predictive value and 62% negative predictive value (sensitivity = 0.74; specificity = 0.82). CONCLUSIONS This Shiftwork Disorder Screening Questionnaire may be appropriate for use in primary care settings to aid in the diagnosis of SWD.
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Affiliation(s)
- Laura K Barger
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA.
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106
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Abstract
Narcolepsy and other syndromes associated with excessive daytime sleepiness can be challenging to treat. New classifications now distinguish narcolepsy/hypocretin deficiency (also called type 1 narcolepsy), a lifelong disorder with well-established diagnostic procedures and etiology, from other syndromes with hypersomnolence of unknown causes. Klein-Levin Syndrome, a periodic hypersomnia associated with cognitive and behavioral abnormalities, is also considered a separate entity with separate therapeutic protocols. Non hypocretin-related hypersomnia syndromes are diagnoses of exclusion. These diagnoses are only made after eliminating sleep deprivation, sleep apnea, disturbed nocturnal sleep, and psychiatric comorbidities as the primary cause of daytime sleepiness. The treatment of narcolepsy/hypocretin deficiency is well-codified, and involves pharmacotherapies using sodium oxybate, stimulants, and/or antidepressants, plus behavioral modifications. These therapies are almost always needed, and the risk-to-benefit ratio is clear, notably in children. Detailed knowledge of the pharmacological profile of each compound is needed to optimize use. Treatment for other syndromes with hypersomnolence is more challenging and less codified. Preferably, therapy should be conservative (such as modafinil, atomoxetine, behavioral modifications), but it may have to be more aggressive (high-dose stimulants, sodium oxybate, etc.) on a case-by-case, empirical trial basis. As cause and evolution are unknown in these conditions, it is important to challenge diagnosis and therapy over time, keeping in mind the possibility of tolerance and the development of stimulant addiction. Kleine-Levin Syndrome is usually best left untreated, although lithium can be considered in severe cases with frequent episodes. Guidelines are provided based on the literature and personal experience of the author.
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Affiliation(s)
- Emmanuel J M Mignot
- Stanford Center for Sleep Sciences and Medicine, Stanford University Medical School, Palo Alto, CA 94304, USA.
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107
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Smith MR, Eastman CI. Shift work: health, performance and safety problems, traditional countermeasures, and innovative management strategies to reduce circadian misalignment. Nat Sci Sleep 2012; 4:111-32. [PMID: 23620685 PMCID: PMC3630978 DOI: 10.2147/nss.s10372] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
There are three mechanisms that may contribute to the health, performance, and safety problems associated with night-shift work: (1) circadian misalignment between the internal circadian clock and activities such as work, sleep, and eating, (2) chronic, partial sleep deprivation, and (3) melatonin suppression by light at night. The typical countermeasures, such as caffeine, naps, and melatonin (for its sleep-promoting effect), along with education about sleep and circadian rhythms, are the components of most fatigue risk-management plans. We contend that these, while better than nothing, are not enough because they do not address the underlying cause of the problems, which is circadian misalignment. We explain how to reset (phase-shift) the circadian clock to partially align with the night-work, day-sleep schedule, and thus reduce circadian misalignment while preserving sleep and functioning on days off. This involves controlling light and dark using outdoor light exposure, sunglasses, sleep in the dark, and a little bright light during night work. We present a diagram of a sleep-and-light schedule to reduce circadian misalignment in permanent night work, or a rotation between evenings and nights, and give practical advice on how to implement this type of plan.
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Affiliation(s)
- Mark R Smith
- Biological Rhythms Research Laboratory, Rush University Medical Center, Chicago, IL, USA
| | - Charmane I Eastman
- Biological Rhythms Research Laboratory, Rush University Medical Center, Chicago, IL, USA
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108
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Di Milia L, Rogers NL, Åkerstedt T. Sleepiness, long distance commuting and night work as predictors of driving performance. PLoS One 2012; 7:e45856. [PMID: 23029278 PMCID: PMC3448712 DOI: 10.1371/journal.pone.0045856] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 08/23/2012] [Indexed: 11/26/2022] Open
Abstract
Few studies have examined the effect of working night shift and long distance commuting. We examined the association between several sleep related and demographic variables, commuting distance, night work and use of mobile phones on driving performance. We used a prospective design to recruit participants and conducted a telephone survey (n = 649). The survey collected demographic and journey details, work and sleep history and driving performance concerning the day the participant was recruited. Participants also completed the Karolinska Sleepiness Scale and the Epworth Sleepiness Scale. Night workers reported significantly more sleepiness, shorter sleep duration and commuting longer distances. Seven variables were significant predictors of lane crossing. The strongest predictor was acute sleepiness (OR = 5.25, CI, 1.42–19.49, p<0.01) followed by driving ≥150 kms (OR = 3.61, CI, 1.66–7.81, p<0.001), obtaining less than 10 hours sleep in the previous 48 hours (OR = 2.58, CI, 1.03–6.46, p<0.05), driving after night shift (OR = 2.19, CI, 1.24–3.88, p<0.001), being <43 years old (OR = 1.95, CI, 1.11–3.41, p<0.05) and using mobile phones during the journey (OR = 1.90, CI, 1.10–3.27, p<0.05). Sleep related variables, long-distance commuting and night work have a major impact on lane crossing. Several interventions should be considered to reduce the level of sleepiness in night workers.
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Affiliation(s)
- Lee Di Milia
- The Institute of Health and Social Science Research, School of Management, Central Queensland University, Rockhampton, Queensland, Australia.
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109
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Schwartz JRL, Roth T, Hirshkowitz M, Wright KP. Recognition and management of excessive sleepiness in the primary care setting. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2012; 11:197-204. [PMID: 19956456 DOI: 10.4088/pcc.07r00545] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Accepted: 10/29/2008] [Indexed: 10/20/2022]
Abstract
BACKGROUND Excessive sleepiness often goes unrecognized in the primary care setting despite its high prevalence and deleterious effects on both individual and public safety. Patients with neurologic and psychiatric illnesses, as well as those with acute and chronic medical conditions, plus those with sleep disorders, often have symptoms of excessive sleepiness, tiredness, and fatigue. Recognition and prompt treatment of these symptoms are important, even though their etiology may not be immediately understood. This review focuses on the underlying causes, consequences, identification, and treatment of excessive sleepiness. DATA SOURCES A search of the literature to 2007 was performed using the PubMed search engine. English-language articles were identified using the following search terms: excessive sleepiness, fatigue, circadian rhythm, obstructive sleep apnea, shift work disorder, narcolepsy, drowsy driving, and wakefulness. Additional references were identified through bibliography reviews of relevant articles. DATA SYNTHESIS Current assessments of the prevalence, consequences, and etiologies of excessive sleepiness, with leading treatment strategies, were extracted, reviewed, and summarized to meet the objectives of this article. CONCLUSIONS Excessive sleepiness is associated with a wide range of medical, neurologic, and psychiatric disorders frequently seen in primary care practice. Excessive sleepiness is a serious, debilitating, potentially life-threatening condition, yet also treatable, and it is important to initiate appropriate intervention as early as possible. Physicians should place increasing emphasis on the substantial benefits that accompany improvements in wakefulness.
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Affiliation(s)
- Jonathan R L Schwartz
- INTEGRIS Sleep Disorders Centers, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, USA.
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110
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Müller U, Rowe J, Rittman T, Lewis C, Robbins T, Sahakian B. Effects of modafinil on non-verbal cognition, task enjoyment and creative thinking in healthy volunteers. Neuropharmacology 2012; 64:490-5. [PMID: 22820554 PMCID: PMC3485563 DOI: 10.1016/j.neuropharm.2012.07.009] [Citation(s) in RCA: 101] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 07/02/2012] [Accepted: 07/04/2012] [Indexed: 12/22/2022]
Abstract
Background Modafinil, a putative cognitive enhancing drug, has previously been shown to improve performance of healthy volunteers as well as patients with attention deficit disorder and schizophrenia, mainly in tests of executive functions. The aim of this study was to investigate the effects of modafinil on non-verbal cognitive functions in healthy volunteers, with a particular focus on variations of cognitive load, measures of motivational factors and the effects on creative problem-solving. Methods A double-blind placebo-controlled parallel design study evaluated the effect of 200 mg of modafinil (N = 32) or placebo (N = 32) in non-sleep deprived healthy volunteers. Non-verbal tests of divergent and convergent thinking were used to measure creativity. A new measure of task motivation was used, together with more levels of difficulty on neuropsychological tests from the CANTAB battery. Results Improvements under modafinil were seen on spatial working memory, planning and decision making at the most difficult levels, as well as visual pattern recognition memory following delay. Subjective ratings of enjoyment of task performance were significantly greater under modafinil compared with placebo, but mood ratings overall were not affected. The effects of modafinil on creativity were inconsistent and did not reach statistical significance. Conclusions Modafinil reliably enhanced task enjoyment and performance on several cognitive tests of planning and working memory, but did not improve paired associates learning. The findings confirm that modafinil can enhance aspects of highly demanding cognitive performance in non-sleep deprived individuals. This article is part of a Special Issue entitled ‘Cognitive Enhancers’.
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Affiliation(s)
- U. Müller
- Department of Psychiatry, University of Cambridge, School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
- MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute (BCNI), University of Cambridge, Cambridge, UK
| | - J.B. Rowe
- MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute (BCNI), University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - T. Rittman
- Department of Clinical Neuroscience, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - C. Lewis
- Department of Psychiatry, University of Cambridge, School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
| | - T.W. Robbins
- MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute (BCNI), University of Cambridge, Cambridge, UK
- Department of Experimental Psychology, Downing Street, University of Cambridge, Cambridge, UK
| | - B.J. Sahakian
- Department of Psychiatry, University of Cambridge, School of Clinical Medicine, Addenbrooke's Hospital, Cambridge, UK
- MRC/Wellcome Trust Behavioural and Clinical Neuroscience Institute (BCNI), University of Cambridge, Cambridge, UK
- Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
- Corresponding author. University of Cambridge, Department of Psychiatry (Box 189), Addenbrooke's Hospital, Hill's Road, Cambridge CB2 2QQ, UK. Tel.: +44 (0)1223 768506; fax: +44 (0)1223 336968.
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111
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Schaefer EW, Williams MV, Zee PC. Sleep and circadian misalignment for the hospitalist: a review. J Hosp Med 2012; 7:489-96. [PMID: 22290766 DOI: 10.1002/jhm.1903] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Revised: 11/05/2011] [Accepted: 11/20/2011] [Indexed: 11/10/2022]
Abstract
Shift work is necessary for hospitalists to provide on-site 24-hour patient care. Like all shift workers, hospitalists working beyond daylight hours are subject to a misalignment between work obligations and the endogenous circadian system, which regulates sleep and alertness patterns. With chronic misalignment, sleep loss accumulates and can lead to shift work disorder or other chronic medical conditions. Hospitalists suffering from sleep deprivation also risk increased rates of medical errors. By realigning work and circadian schedules, a process called circadian adaptation, hospitalists can limit fatigue and potentially improve safety. Adaptation strategies include improving sleep hygiene before work, caffeine use at the start of the night shift, bright light exposure and planned naps during the shift, and short-term use of a mild hypnotic after night work. If these attempts fail and chronic fatigue persists, then a diagnosis of shift work disorder should be considered, which can be treated with stronger pharmacotherapy. Night float scheduling strategies may also help to limit chronic sleep loss. More research is urgently needed regarding the sleep patterns and job performance of hospitalists working at night to improve scheduling decisions and patient safety.
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Affiliation(s)
- Eric W Schaefer
- Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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112
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Forbes-Robertson S, Dudley E, Vadgama P, Cook C, Drawer S, Kilduff L. Circadian disruption and remedial interventions: effects and interventions for jet lag for athletic peak performance. Sports Med 2012; 42:185-208. [PMID: 22299812 DOI: 10.2165/11596850-000000000-00000] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Jet lag has potentially serious deleterious effects on performance in athletes following transmeridian travel, where time zones are crossed eastwards or westwards; as such, travel causes specific effects related to desynchronization of the athlete's internal body clock or circadian clock. Athletes are particularly sensitive to the effects of jet lag, as many intrinsic aspects of sporting performance show a circadian rhythm, and optimum competitive results require all aspects of the athlete's mind and body to be working in tandem at their peak efficiency. International competition often requires transmeridian travel, and competition timings cannot be adjusted to suit individual athletes. It is therefore in the interest of the individual athlete and team to understand the effects of jet lag and the potential adaptation strategies that can be adopted. In this review, we describe the underlying genetic and physiological mechanisms controlling the circadian clock and its inherent ability to adapt to external conditions on a daily basis. We then examine the fundamentals of the various adaptation stimuli, such as light, chronobiotics (e.g. melatonin), exercise, and diet and meal timing, with particular emphasis on their suitability as strategies for competing athletes on the international circuit. These stimuli can be artificially manipulated to produce phase shifts in the circadian rhythm to promote adaptation in the optimum direction, but care must be taken to apply them at the correct time and dose, as the effects produced on the circadian rhythm follow a phase-response curve, with pronounced shifts in direction at different times. Light is the strongest realigning stimulus and careful timing of light exposure and avoidance can promote adjustment. Chronobiotics such as melatonin can also be used to realign the circadian clock but, as well as timing and dosage issues, there are also concerns as to its legal status in different countries and with the World Anti-Doping Agency. Experimental data concerning the effects of food intake and exercise timing on jet lag is limited to date in humans, and more research is required before firm guidelines can be stated. All these stimuli can also be used in pre-flight adaptation strategies to promote adjustment in the required direction, and implementation of these is described. In addition, the effects of individual variability at the behavioural and genetic levels are also discussed, along with the current limitations in assessment of these factors, and we then put forward three case studies, as examples of practical applications of these strategies, focusing on adaptations to travel involving competition in the Rugby Sevens World Cup and the 2016 Summer Olympics in Rio de Janeiro, Brazil. Finally, we provide a list of practice points for optimal adaptation of athletes to jet lag.
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Affiliation(s)
- Sarah Forbes-Robertson
- Sport and Exercise Science Portfolio, School of Engineering, Swansea University, Swansea, UK.
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113
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Wright KP, Bogan RK, Wyatt JK. Shift work and the assessment and management of shift work disorder (SWD). Sleep Med Rev 2012; 17:41-54. [PMID: 22560640 DOI: 10.1016/j.smrv.2012.02.002] [Citation(s) in RCA: 247] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 02/10/2012] [Accepted: 02/13/2012] [Indexed: 11/25/2022]
Abstract
Nearly 20% of the labor force worldwide, work shifts that include work hours outside 07:00 h to 18:00 h. Shift work is common in many occupations that directly affect the health and safety of others (e.g., protective services, transportation, healthcare), whereas quality of life, health, and safety during shift work and the commute home can affect workers in any field. Increasing evidence indicates that shift-work schedules negatively influence worker physiology, health, and safety. Shift work disrupts circadian sleep and alerting cycles, resulting in disturbed daytime sleep and excessive sleepiness during the work shift. Moreover, shift workers are at risk for shift work disorder (SWD). This review focuses on shift work and the assessment and management of sleepiness and sleep disruption associated with shift work schedules and SWD. Management strategies include approaches to promote sleep, wakefulness, and adaptation of the circadian clock to the imposed work schedule. Additional studies are needed to further our understanding of the mechanisms underlying the health risks of shift work, understanding which shift workers are at most risk of SWD, to investigate treatment options that address the health and safety burdens associated with shift work and SWD, and to further develop and assess the comparative effectiveness of countermeasures and treatment options.
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Affiliation(s)
- Kenneth P Wright
- Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado at Boulder, 1725 Pleasant Street, Boulder, CO 80309, USA.
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114
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Wright KP, Lowry CA, LeBourgeois MK. Circadian and wakefulness-sleep modulation of cognition in humans. Front Mol Neurosci 2012; 5:50. [PMID: 22529774 PMCID: PMC3328852 DOI: 10.3389/fnmol.2012.00050] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2011] [Accepted: 03/27/2012] [Indexed: 11/13/2022] Open
Abstract
Cognitive and affective processes vary over the course of the 24 h day. Time of day dependent changes in human cognition are modulated by an internal circadian timekeeping system with a near-24 h period. The human circadian timekeeping system interacts with sleep-wakefulness regulatory processes to modulate brain arousal, neurocognitive and affective function. Brain arousal is regulated by ascending brain stem, basal forebrain (BF) and hypothalamic arousal systems and inhibition or disruption of these systems reduces brain arousal, impairs cognition, and promotes sleep. The internal circadian timekeeping system modulates cognition and affective function by projections from the master circadian clock, located in the hypothalamic suprachiasmatic nuclei (SCN), to arousal and sleep systems and via clock gene oscillations in brain tissues. Understanding the basic principles of circadian and wakefulness-sleep physiology can help to recognize how the circadian system modulates human cognition and influences learning, memory and emotion. Developmental changes in sleep and circadian processes and circadian misalignment in circadian rhythm sleep disorders have important implications for learning, memory and emotion. Overall, when wakefulness occurs at appropriate internal biological times, circadian clockwork benefits human cognitive and emotion function throughout the lifespan. Yet, when wakefulness occurs at inappropriate biological times because of environmental pressures (e.g., early school start times, long work hours that include work at night, shift work, jet lag) or because of circadian rhythm sleep disorders, the resulting misalignment between circadian and wakefulness-sleep physiology leads to impaired cognitive performance, learning, emotion, and safety.
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Affiliation(s)
- Kenneth P. Wright
- Department of Integrative Physiology, Sleep and Chronobiology Laboratory, University of Colorado, BoulderCO, USA
| | - Christopher A. Lowry
- Department of Integrative Physiology, Behavioral Neuroendocrinology Laboratory, University of Colorado, BoulderCO, USA
| | - Monique K. LeBourgeois
- Department of Integrative Physiology, Sleep and Development Laboratory, University of Colorado, BoulderCO, USA
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115
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Appropriate therapeutic selection for patients with shift work disorder. Sleep Med 2012; 13:335-41. [DOI: 10.1016/j.sleep.2011.11.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 10/27/2011] [Accepted: 11/14/2011] [Indexed: 11/23/2022]
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116
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Artsy E, McCarthy DC, Hurwitz S, Pavlova MK, Dworetzky BA, Lee JW. Use of modafinil in patients with epilepsy. Epilepsy Behav 2012; 23:405-8. [PMID: 22420936 DOI: 10.1016/j.yebeh.2012.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 01/29/2012] [Accepted: 02/01/2012] [Indexed: 11/17/2022]
Abstract
Fatigue and excessive daytime sleepiness are common symptoms in patients with neurological injury. Modafinil has been shown to ameliorate these symptoms, but its use in patients with seizures has been limited because of safety concerns. Using a large centralized clinical registry, we performed a retrospective chart review of patients with a diagnosis of epilepsy who were given modafinil over a 10-year period. A total of 205 patients were analyzed. There were 91 patients who had seizures while taking modafinil; there was no relationship between modafinil dosage and whether the patient had seizures. There were 6 patients in whom modafinil was discontinued because of concern for seizure exacerbation, and 4 patients had de novo seizures after starting modafinil. In 29 patients with epilepsy only, no major seizure exacerbation was seen. Modafinil is potentially safe in patients with epilepsy, but further prospective studies are needed to fully determine its safety and efficacy.
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Affiliation(s)
- Elinor Artsy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA 02115, USA
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117
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Effect of Pharmacological Enhancement on the Cognitive and Clinical Psychomotor Performance of Sleep-Deprived Doctors. Ann Surg 2012; 255:222-7. [DOI: 10.1097/sla.0b013e3182306c99] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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118
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Wang W, Xiang S, Zhou X, Ji Y, Xiang B. Enantiomeric separation and determination of the enantiomeric impurity of armodafinil by capillary electrophoresis with sulfobutyl ether-β-cyclodextrin as chiral selector. Molecules 2011; 17:303-14. [PMID: 22210169 PMCID: PMC6268399 DOI: 10.3390/molecules17010303] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 12/27/2011] [Accepted: 12/28/2011] [Indexed: 11/25/2022] Open
Abstract
A selective capillary electrophoresis method using sulfobutyl ether-β-cyclodextrin as a chiral selector was developed and validated for the determination of the enantiomeric impurity of (R)-modafinil, i.e., armodafinil. Several parameters were optimized for a satisfactory enantioresolution, including the type and concentration of chiral selector and organic modifier, pH of background electrolyte (BGE), capillary temperature. The finally adopted condition was: 20 mmol/L phosphate buffer at pH 7.5, containing 20 mmol/L sulfobutyl ether-β-cyclodextrin and 20% methanol, at temperature of 25 °C. A good resolution of 3.3 for the two enantiomers of modafinil was achieved by applying the optimal conditions. The limit of detection (LOD) and limit of quantification (LOQ) of (S)-modafinil were 1.25 μg/mL and 2.50 μg/mL, respectively. The established method was also proven to display good selectivity, repeatability, linearity and accuracy. Finally, the method was used to investigate the enantiomeric purity of armodafinil in bulk samples.
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Affiliation(s)
- Wei Wang
- Department of Analytical Chemistry, China Pharmaceutical University, Nanjing 211198, China
| | - Suyun Xiang
- College of Life Science, Nanjing Normal University, Nanjing 210046, China
| | - Xiaojuan Zhou
- Department of Analytical Chemistry, China Pharmaceutical University, Nanjing 211198, China
| | - Yibing Ji
- Department of Analytical Chemistry, China Pharmaceutical University, Nanjing 211198, China
| | - Bingren Xiang
- Key Laboratory of Drug Quality Control and Pharmacovigilance (Ministry of Education), China Pharmaceutical University, Nanjing 210009, China
- Center for Instrument Analysis, China Pharmaceutical University, Nanjing, 210009, China
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Rosenberg R, Doghramji PP. Is shift work making your patient sick? Emerging theories and therapies for treating shift work disorder. Postgrad Med 2011; 123:106-15. [PMID: 21904092 DOI: 10.3810/pgm.2011.09.2465] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
"Shift work" is a term that applies to a wide array of nontraditional work schedules. Shift work disorder (SWD) is a circadian rhythm sleep disorder experienced by a subset of shift workers that is characterized by excessive sleepiness during work and/or insomnia during scheduled sleep times. It is estimated to affect up to 2 million Americans, and is associated with increased morbidity and mortality from metabolic risk factors, cardiovascular and gastrointestinal diseases, depression, accidents, and some kinds of cancers. Patient history is all that is needed to make a diagnosis with the International Classification of Sleep Disorders-Second Edition criteria as described herein. Circadian rhythm disorders, in which an underlying misalignment of circadian rhythm with the sleep-wake cycle occurs, may be treated by behavioral and pharmacologic approaches, including the use of hypnotics to improve the duration of sleep. However, evidence is limited with these approaches in patients diagnosed with SWD. Other treatment options may include pharmacologic interventions such as modafinil and armodafinil, which have shown efficacy in this population. Combined therapy can reduce insomnia and excessive sleepiness, and improve attention and alertness during work shifts and the subsequent commute home.
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Affiliation(s)
- Russell Rosenberg
- The Atlanta School of Sleep Medicine and Technology, Atlanta, GA 30342, USA.
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Abstract
OPINION STATEMENT With the growth of the 24-hour global marketplace, a substantial proportion of workers are engaged in nontraditional work schedules and frequent jet travel across multiple time zones. Thus, shift work disorder and jet lag are prevalent in our 24/7 society and have been associated with significant health and safety repercussions. In both disorders, treatment strategies are based on promoting good sleep hygiene, improving circadian alignment, and targeting specific symptoms.Treatment of shift work must be tailored to the type of shift. For a night worker, circadian alignment can be achieved with bright light exposure during the shift and avoidance of bright light (with dark or amber sunglasses) toward the latter portion of the work period and during the morning commute home. If insomnia and/or excessive sleepiness are prominent complaints despite behavioral approaches and adequate opportunity for sleep, melatonin may be administered prior to the day sleep period to improve sleep, and alertness during work can be augmented by caffeine and wake-promoting agents.For jet lag, circadian adaptation is suggested only for travel greater than 48 h, with travel east more challenging than travel west. Although advancing sleep and wake times and circadian timing for eastward travel with evening melatonin and morning bright light several days prior to departure can help avoid jet lag at the new destination, this approach may be impractical for many people, Therefore, strategies for treatment at the destination, such as avoidance of early morning light and exposure to late-morning and afternoon light alone or in conjunction with bedtime melatonin, can accelerate re-entrainment following eastward travel. For westward travel, a circadian delay can be achieved after arrival with afternoon and early-evening light with bedtime melatonin.Good sleep hygiene practices, together with the application of circadian principles, can improve sleep quality, alertness, performance, and safety in shift workers and jet travelers. However, definitive multicenter randomized controlled clinical trials are still needed, using traditional efficacy outcomes such as sleep and performance as well as novel biomarkers of health.
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Affiliation(s)
- Phyllis C Zee
- , 710 North Lake Shore Drive, 5th Floor, Chicago, IL, 60611, USA
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Abstract
Shift work is a fundamental component of the US workforce and an integral part of the lifestyles of a large proportion of the population. More than 22 million Americans work on shifts as part of their work life. Emerging research suggests that shift workers are at higher risk for a range of metabolic disorders and diseases (eg, obesity, cardiovascular disease, peptic ulcers, gastrointestinal problems, abnormal blood glucose levels, and metabolic syndrome). Sleep disorders associated with shift work also pose a serious public health risk, as they can impair an individual's ability to perform effectively and may lead to occupational and traffic accidents.
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Armodafinil versus Modafinil in Patients of Excessive Sleepiness Associated with Shift Work Sleep Disorder: A Randomized Double Blind Multicentric Clinical Trial. Neurol Res Int 2011; 2011:514351. [PMID: 21766023 PMCID: PMC3135062 DOI: 10.1155/2011/514351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Accepted: 03/31/2011] [Indexed: 11/17/2022] Open
Abstract
Aim. To compare the efficacy and safety of armodafinil, the R-enantiomer of modafinil, with modafinil in patients of shift work sleep disorder (SWSD). Material and Methods. This was a 12-week, randomized, comparative, double-blind, multicentric, parallel-group study in 211 patients of SWSD, receiving armodafinil (150 mg) or modafinil (200 mg) one hour prior to the night shift. Outcome Measures. Efficacy was assessed by change in stanford sleepiness score (SSS) by at least 2 grades (responder) and global assessment for efficacy. Safety was assessed by incidence of adverse events, change in laboratory parameters, ECG, and global assessment of tolerability. Results. Both modafinil and armodafinil significantly improved sleepiness mean grades as compared to baseline (P < .0001). Responder rates with armodafinil (72.12%) and modafinil (74.29%) were comparable (P = .76). Adverse event incidences were comparable. Conclusion. Armodafinil was found to be safe and effective in the treatment of SWSD in Indian patients. The study did not demonstrate any difference in efficacy and safety of armodafinil 150 mg and modafinil 200 mg.
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Jung CM, Ronda JM, Czeisler CA, Wright KP. Comparison of sustained attention assessed by auditory and visual psychomotor vigilance tasks prior to and during sleep deprivation. J Sleep Res 2011; 20:348-55. [PMID: 20819145 PMCID: PMC3603691 DOI: 10.1111/j.1365-2869.2010.00877.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
To date, no detailed examination of the pattern of change in reaction time performance for different sensory modalities has been conducted across the circadian cycle during sleep deprivation. Therefore, we compared sustained auditory and visual attention performance during 40h of sleep deprivation assessing multiple metrics of auditory and visual psychomotor vigilance tasks (PVT). Forty healthy participants (14 women) aged 30.8±8.6years were studied. Subjects were scheduled for an ∼8h sleep schedule at home prior to three-six laboratory baseline days with an 8 h sleep schedule followed by 40h sleep deprivation. Visual and auditory PVTs were 10min in duration, and were administered every 2h during sleep deprivation. Data were analysed with mixed-model anova. Sleep deprivation and circadian phase increased response time, lapses, anticipations, standard deviation of response times and time on task decrements for visual and auditory PVTs. In general, auditory vigilance was faster and less variable than visual vigilance, with larger differences between auditory and visual PVT during sleep deprivation versus baseline. Failures to respond to stimuli within 10s were four times more likely to occur to visual versus auditory stimuli. Our findings highlight that lapses during sleep deprivation are more than just long responses due to eye closure or visual distraction. Furthermore, our findings imply that the general pattern of change in attention during sleep deprivation (e.g. circadian variation, response slowing, lapsing and anticipations, time on task decrements and state instability) is similar among sensory-motor behavioral response modalities.
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Affiliation(s)
- Christopher M. Jung
- Sleep and Chronobiology Laboratory, Department of Integrative Physiology, Center for Neuroscience, University of Colorado, Boulder, Colorado 80309-0354, USA
| | - Joseph M. Ronda
- Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Charles A. Czeisler
- Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
| | - Kenneth P. Wright
- Sleep and Chronobiology Laboratory, Department of Integrative Physiology, Center for Neuroscience, University of Colorado, Boulder, Colorado 80309-0354, USA
- Division of Sleep Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Abstract
This article begins with a review of the major central nervous system functional systems that allow for optimal alertness during the waking day, and the rapid initiation and good maintenance of sleep at night. Subsequent sections discuss each of the 6 primary circadian rhythm sleep disorders. Attention is paid to known or suspected pathophysiology, diagnostic criteria and assessment methodology, and treatment options. The article concludes with a discussion of challenges that must be met to improve the recognition and treatment of these quite impactful sleep disorders.
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Affiliation(s)
- James K Wyatt
- Sleep Disorders Service and Research Center, Rush University Medical Center, Chicago, IL 60612-3833, USA.
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Lavault S, Dauvilliers Y, Drouot X, Leu-Semenescu S, Golmard JL, Lecendreux M, Franco P, Arnulf I. Benefit and risk of modafinil in idiopathic hypersomnia vs. narcolepsy with cataplexy. Sleep Med 2011; 12:550-6. [DOI: 10.1016/j.sleep.2011.03.010] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2010] [Revised: 02/07/2011] [Accepted: 03/07/2011] [Indexed: 10/18/2022]
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Basner M, Dinges DF. Maximizing sensitivity of the psychomotor vigilance test (PVT) to sleep loss. Sleep 2011; 34:581-91. [PMID: 21532951 DOI: 10.1093/sleep/34.5.581] [Citation(s) in RCA: 533] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY OBJECTIVES The psychomotor vigilance test (PVT) is among the most widely used measures of behavioral alertness, but there is large variation among published studies in PVT performance outcomes and test durations. To promote standardization of the PVT and increase its sensitivity and specificity to sleep loss, we determined PVT metrics and task durations that optimally discriminated sleep deprived subjects from alert subjects. DESIGN Repeated-measures experiments involving 10-min PVT assessments every 2 h across both acute total sleep deprivation (TSD) and 5 days of chronic partial sleep deprivation (PSD). SETTING Controlled laboratory environment. PARTICIPANTS 74 healthy subjects (34 female), aged 22-45 years. INTERVENTIONS TSD experiment involving 33 h awake (N = 31 subjects) and a PSD experiment involving 5 nights of 4 h time in bed (N = 43 subjects). MEASUREMENTS AND RESULTS In a paired t-test paradigm and for both TSD and PSD, effect sizes of 10 different PVT performance outcomes were calculated. Effect sizes were high for both TSD (1.59-1.94) and PSD (0.88-1.21) for PVT metrics related to lapses and to measures of psychomotor speed, i.e., mean 1/RT (response time) and mean slowest 10% 1/RT. In contrast, PVT mean and median RT outcomes scored low to moderate effect sizes influenced by extreme values. Analyses facilitating only portions of the full 10-min PVT indicated that for some outcomes, high effect sizes could be achieved with PVT durations considerably shorter than 10 min, although metrics involving lapses seemed to profit from longer test durations in TSD. CONCLUSIONS Due to their superior conceptual and statistical properties and high sensitivity to sleep deprivation, metrics involving response speed and lapses should be considered primary outcomes for the 10-min PVT. In contrast, PVT mean and median metrics, which are among the most widely used outcomes, should be avoided as primary measures of alertness. Our analyses also suggest that some shorter-duration PVT versions may be sensitive to sleep loss, depending on the outcome variable selected, although this will need to be confirmed in comparative analyses of separate duration versions of the PVT. Using both sensitive PVT metrics and optimal test durations maximizes the sensitivity of the PVT to sleep loss and therefore potentially decreases the sample size needed to detect the same neurobehavioral deficit. We propose criteria to better standardize the 10-min PVT and facilitate between-study comparisons and meta-analyses.
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Affiliation(s)
- Mathias Basner
- Division of Sleep and Chronobiology, Department of Psychiatry, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Nguyen TL, Tian YH, You IJ, Lee SY, Jang CG. Modafinil-induced conditioned place preference via dopaminergic system in mice. Synapse 2011; 65:733-41. [PMID: 21157933 DOI: 10.1002/syn.20892] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 10/31/2010] [Indexed: 12/22/2022]
Abstract
Modafinil, a psychostimulant, is used in the treatment of narcolepsy, shift work sleep disorder, and excessive daytime sleepiness associated with obstructive sleep apnea. Preclinical and clinical studies suggest that modafinil may have reinforcing effects. However, a possible rewarding property of modafinil has not been fully investigated. In this study, we assessed the potential rewarding property of modafinil using the conditioned place preference (CPP) paradigm in mice. Using radiolabeled ligands, we observed changes in dopamine, glutamate, and GABA receptor binding in the brains of mice after treatment with modafinil. Modafinil produced significant CPP in mice at an intraperitoneal (i.p.) dose of 125 mg kg⁻¹ and prevented normal body weight gain of mice in a dose-dependent manner. A significant reduction in normal body weight gain was observed when mice were administrated 125 mg kg⁻¹ modafinil. In addition, there were widespread changes in receptor binding in the brains of modafinil-treated mice; Dopamine D₁ binding was increased in the caudate putamen, the accumbens, and the substantia nigra, while dopamine D₂ binding was decreased in the caudate putamen and the accumbens. Dopamine transporter (DAT) binding was increased in the prefrontal cortex, the caudate putamen, and the nucleus accumbens. No changes were observed in NMDA and GABA(A) receptor binding. These data indicate that modafinil had a significant rewarding property and could be abused as a recreational drug. Dopamine systems may play a key role in the rewarding property of modafinil.
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Affiliation(s)
- Thi-Lien Nguyen
- Department of Pharmacology, School of Pharmacy, Sungkyunkwan University, Suwon 440-746, Republic of Korea
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Measuring critical care air support teams' performance during extended periods of duty. AACN Adv Crit Care 2011; 21:298-306. [PMID: 20683231 DOI: 10.1097/nci.0b013e3181e6f017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The Royal Air Force (RAF) Critical Care Air Support Teams (CCASTs) aeromedically evacuate seriously injured service personnel. Long casualty evacuation chains create logistical constraints that must be considered when aeromedically evacuating patients. One constraint is the length of a CCAST mission and its potential effect on team member performance. Despite no evidence of patient care compromise, the RAF has commissioned a study to investigate whether CCAST mission length influences performance. Describing and understanding the role of a CCAST enabled fatigue to be defined. Factors essential to studying fatigue were then identified that were used to develop a theoretical model for designing a study to measure the effects of fatigue on CCAST performance. Relevant factors include the patient's clinical condition, team members' cognition and vigilance levels, and the occupational aviation environment. Further factors influencing overall performance include the duration and complexity of patient interventions, mission length, circadian influences, and fatigue countermeasures.
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Balkin TJ, Horrey WJ, Graeber RC, Czeisler CA, Dinges DF. The challenges and opportunities of technological approaches to fatigue management. ACCIDENT; ANALYSIS AND PREVENTION 2011; 43:565-72. [PMID: 21130217 DOI: 10.1016/j.aap.2009.12.006] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2009] [Accepted: 12/08/2009] [Indexed: 05/24/2023]
Abstract
There are a number of different strategies to mitigate the effects of fatigue in transportation and other occupational settings. Many are centered on regulatory or organizational approaches, such as work scheduling restriction and employer screening practices. While these generally benefit safety and productivity, there are clearly limitations to these approaches. Technologies that objectively detect or predict operator fatigue may be used to effectively complement or even supplant organizational or regulatory approaches. Over the past decade and a half, there have been considerable advances in relevant technologies, including onboard devices that monitor drivers' state or level of performance as well as devices that predict fatigue in advance of a work cycle or trip. In this paper, we discuss the challenges and opportunities for technological approaches to fatigue management, beginning with a discussion of the "ideal" system, followed by some of the general issues and limitations of current technologies. We also discuss some of the critical and outstanding issues related to the human interaction with these systems, including user acceptance and compliance. Finally, we discuss future directions in next generation technology for fatigue management.
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Affiliation(s)
- Thomas J Balkin
- Walter Reed Army Institute of Research, Dept of Behavioral Biology, Silver Spring, MD 20910, USA.
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Wake-promoting agent modafinil worsened attentional performance following REM sleep deprivation in a young-adult rat model of 5-choice serial reaction time task. Psychopharmacology (Berl) 2011; 213:155-66. [PMID: 20865249 DOI: 10.1007/s00213-010-2019-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2010] [Accepted: 09/07/2010] [Indexed: 10/19/2022]
Abstract
RATIONALE Individuals who experience sleep loss may exhibit certain physiological abnormalities. Central stimulant drugs have been studied in sleep-loss conditions, and some of them might be therapeutically beneficial. Modafinil (diphenyl-methyl-sulfinyl-2-acetamide, MOD) has been increasingly employed for elevating alertness and vigilance in recent years, yet the underlying mechanism of actions for MOD is not fully understood. OBJECTIVES To examine the behavioral effect of MOD following rapid eye movement sleep deprivation (REMD) in rats. A five-choice serial reaction time task (5-CSRTT) was employed to investigate animals' attentional performance and impulsive reactivity. MATERIALS AND METHODS Rats of different ages were trained to learn the 5-CSRTT. REMD with the water platform method was applied for 96 h. The impacts of REMD on 5-CSRTT in middle-age (32-weeks-old) and young-adult (12-week-old) rats were compared with baseline or a condition with shorter visual stimulus duration. RESULTS The results revealed that following REMD, young-adult but not middle-age rats were liable to be affected in their performances of the 5-CSRTT. In young-adult rats, while MOD had no contributions to the effect of REMD, it worsened rats' performance following REMD when the stimulus duration was shortened, as shown by the reduced number of correct responses and prolonged magazine latency. CONCLUSIONS These results suggest that aging might be a crucial factor for the physiological impact following REMD. MOD should be used cautiously, particularly, in conditions that require REM sleep.
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Abstract
The sleep-wake cycle is regulated by the interaction of endogenous circadian and homeostatic processes. The circadian system provides timing information for most physiological rhythms, including the sleep and wake cycle. In addition, the central circadian clock located in the suprachiasmatic nucleus of the hypothalamus has been shown to promote alertness during the day. Circadian rhythm sleep disorders arise when there is a misalignment between the timing of the endogenous circadian rhythms and the external environment or when there is dysfunction of the circadian clock or its entrainment pathways. The primary synchronizing agents of the circadian system are light and melatonin. Light is the strongest entraining agent of circadian rhythms and timed exposure to bright light is often used in the treatment of circadian rhythm sleep disorders. In addition, timed administration of melatonin, either alone or in combination with light therapy has been shown to be useful in the treatment of the following circadian rhythm sleep disorders: delayed sleep phase, advanced sleep phase, free-running, irregular sleep wake, jet lag and shift work.
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Hamidovic A, Dlugos A, Palmer AA, de Wit H. Catechol-O-methyltransferase val158met genotype modulates sustained attention in both the drug-free state and in response to amphetamine. Psychiatr Genet 2010; 20:85-92. [PMID: 20414144 DOI: 10.1097/ypg.0b013e32833a1f3c] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Variation in the catechol-O-methyltransferase (COMT) val(158)met polymorphism has been associated with executive cognition and working memory, presumably mediated by the prefrontal cortex. Here, we extend these observations by examining two measures of cognitive function, lapses in attention and visuo-spatial-motor speed of processing, in both the drug-free state and after administration of d-amphetamine. METHODS Healthy Caucasian male and female participants (n=161) participated in a double-blind, crossover design study where they received placebo or d-amphetamine (10 and 20 mg). The outcome measures included self-reported mood states, a simple reaction time task, and a task measuring visuo-spatial-motor speed of processing. We first evaluated whether the genotypic groups differed on any of the measures in the absence of drug administration, including a measure of personality. We then determined whether the genotypic groups differed in their responses to acute doses of d-amphetamine (10 or 20 mg). RESULTS We found that without drug, val/val and val/met carriers showed greater lapses in attention on the reaction time task than met/met carriers, but the genotypic groups did not differ on the visuo-spatial-motor speed of processing task. Val/val carriers scored higher on a personality measure of extraversion than val/met and met/met carriers. Compared with placebo, the lower dose of d-amphetamine (10 mg) improved lapses in attention and visuo-spatial-motor speed of processing in val/val carriers, and decreased lapses in attention in val/met carriers. The highest dose of d-amphetamine (20 mg) improved performance on lapses in attention and visuo-spatial-motor speed of processing tasks in both val/val and val/met carriers, but not in met/met carriers. None of the genotypic groups differed on mood states, either with or without drug administration. CONCLUSION The results of this study extend earlier findings with the COMT genotypes to additional measures of cognition, and suggest that the presence of the val allele is associated with poorer performance and greater improvement with a stimulant drug. The results further suggest that this polymorphism does not affect the mood-altering effects of d-amphetamine, consistent with the preferential influence of COMT in cortical regions.
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Affiliation(s)
- Ajna Hamidovic
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois 60637, USA
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Walsh JK, Hall-Porter JM, Griffin KS, Dodson ER, Forst EH, Curry DT, Eisenstein RD, Schweitzer PK. Enhancing slow wave sleep with sodium oxybate reduces the behavioral and physiological impact of sleep loss. Sleep 2010; 33:1217-25. [PMID: 20857869 PMCID: PMC2938863 DOI: 10.1093/sleep/33.9.1217] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES To investigate whether enhancement of slow wave sleep (SWS) with sodium oxybate reduces the impact of sleep deprivation. DESIGN Double-blind, parallel group, placebo-controlled design SETTING Sleep research laboratory PARTICIPANTS Fifty-eight healthy adults (28 placebo, 30 sodium oxybate), ages 18-50 years. INTERVENTIONS A 5-day protocol included 2 screening/baseline nights and days, 2 sleep deprivation nights, each followed by a 3-h daytime (08:00-11:00) sleep opportunity and a recovery night. Sodium oxybate or placebo was administered prior to each daytime sleep period. Multiple sleep latency test (MSLT), psychomotor vigilance test (PVT), Karolinska Sleepiness Scale (KSS), and Profile of Mood States were administered during waking hours. MEASUREMENTS AND RESULTS During daytime sleep, the sodium oxybate group had more SWS, more EEG spectral power in the 1-9 Hz range, and less REM. Mean MSLT latency was longer for the sodium oxybate group on the night following the first daytime sleep period and on the day following the second day sleep period. Median PVT reaction time was faster in the sodium oxybate group following the second day sleep period. The change from baseline in SWS was positively correlated with the change in MSLT and KSS. During recovery sleep the sodium oxybate group had less TST, SWS, REM, and slow wave activity (SWA) than the placebo group. CONCLUSIONS Pharmacological enhancement of SWS with sodium oxybate resulted in a reduced response to sleep loss on measures of alertness and attention. In addition, SWS enhancement during sleep restriction appears to result in a reduced homeostatic response to sleep loss.
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Affiliation(s)
- James K Walsh
- Sleep Medicine and Research Center, St. Luke's Hospital, Chesterfield, MO 63017, USA.
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138
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Buxton OM, Pavlova M, Reid EW, Wang W, Simonson DC, Adler GK. Sleep restriction for 1 week reduces insulin sensitivity in healthy men. Diabetes 2010; 59:2126-33. [PMID: 20585000 PMCID: PMC2927933 DOI: 10.2337/db09-0699] [Citation(s) in RCA: 405] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2009] [Accepted: 06/18/2010] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Short sleep duration is associated with impaired glucose tolerance and an increased risk of diabetes. The effects of sleep restriction on insulin sensitivity have not been established. This study tests the hypothesis that decreasing nighttime sleep duration reduces insulin sensitivity and assesses the effects of a drug, modafinil, that increases alertness during wakefulness. RESEARCH DESIGN AND METHODS This 12-day inpatient General Clinical Research Center study included 20 healthy men (age 20-35 years and BMI 20-30 kg/m(2)). Subjects spent 10 h/night in bed for >or=8 nights including three inpatient nights (sleep-replete condition), followed by 5 h/night in bed for 7 nights (sleep-restricted condition). Subjects received 300 mg/day modafinil or placebo during sleep restriction. Diet and activity were controlled. On the last 2 days of each condition, we assessed glucose metabolism by intravenous glucose tolerance test (IVGTT) and euglycemic-hyperinsulinemic clamp. Salivary cortisol, 24-h urinary catecholamines, and neurobehavioral performance were measured. RESULTS IVGTT-derived insulin sensitivity was reduced by (means +/- SD) 20 +/- 24% after sleep restriction (P = 0.001), without significant alterations in the insulin secretory response. Similarly, insulin sensitivity assessed by clamp was reduced by 11 +/- 5.5% (P < 0.04) after sleep restriction. Glucose tolerance and the disposition index were reduced by sleep restriction. These outcomes were not affected by modafinil treatment. Changes in insulin sensitivity did not correlate with changes in salivary cortisol (increase of 51 +/- 8% with sleep restriction, P < 0.02), urinary catecholamines, or slow wave sleep. CONCLUSIONS Sleep restriction (5 h/night) for 1 week significantly reduces insulin sensitivity, raising concerns about effects of chronic insufficient sleep on disease processes associated with insulin resistance.
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Affiliation(s)
- Orfeu M Buxton
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA.
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139
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Abstract
Because there is insufficient cellular energy for organisms to perform their functions at the same constant rate and at the same time, all biologic processes show rhythmicity, each with its own unique frequency, amplitude, and phase. Optimal sleep and wakefulness requires proper timing and alignment of desired sleep-wake schedules and circadian rhythm-related periods of alertness. Persistent or recurrent mismatch between endogenous circadian rhythms and the conventional sleep-wake schedules of the environmental day can give rise to several circadian rhythm sleep disorders. Evaluation of suspected circadian rhythm sleep disorders requires proper monitoring of sleep diaries, often over several days to weeks. This article discusses the disorders of the circadian sleep-wake cycle and the therapeutic measures to correct the same.
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Affiliation(s)
- Naveen Kanathur
- Division of Sleep Medicine, Department of Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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Shy BD, Portelli I, Nelson LS. Emergency medicine residents' use of psychostimulants and sedatives to aid in shift work. Am J Emerg Med 2010; 29:1034-6.e1. [PMID: 20708878 DOI: 10.1016/j.ajem.2010.06.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2010] [Revised: 06/11/2010] [Accepted: 06/15/2010] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES We evaluated the frequency that emergency medicine house staff report use of stimulants and sedatives to aid in shift work and circadian transitions. METHODS We surveyed residents from 12 regional emergency medicine programs inviting them to complete a voluntary, anonymous electronic questionnaire regarding their use of stimulants and sedatives. RESULTS Out of 485 eligible residents invited to participate in the survey, 226 responded (47% response frequency). The reported use of prescription stimulants for shift work is uncommon (3.1% of respondents.) In contrast, 201 residents (89%) report use of caffeine during night shifts, including 118 residents (52%) who use this substance every night shift. Eighty-six residents (38%) reported using sedative agents to sleep following shift work with the most common agents being anti-histamines (31%), nonbenzodiazepine hypnotics such as zolpidem (14%), melatonin (10%), and benzodiazepines (9%). CONCLUSION Emergency medicine residents report substantial use of several classes of hypnotics to aid in shift work. Despite anecdotal reports, use of prescription stimulants appears rare, and is notably less common than use of sedatives and non-prescription stimulants.
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Affiliation(s)
- Bradley D Shy
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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141
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Grady S, Aeschbach D, Wright KP, Czeisler CA. Effect of modafinil on impairments in neurobehavioral performance and learning associated with extended wakefulness and circadian misalignment. Neuropsychopharmacology 2010; 35:1910-20. [PMID: 20505660 PMCID: PMC2904872 DOI: 10.1038/npp.2010.63] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2009] [Revised: 03/05/2010] [Accepted: 03/26/2010] [Indexed: 11/08/2022]
Abstract
Although worldwide millions of people work prolonged hours, at adverse circadian phases, evidence suggests that cognitive function is impaired under these conditions with important societal consequences. In a double-blind placebo-controlled laboratory-based study, we investigated the effect of the wakefulness-promoting drug modafinil as a countermeasure against such neurobehavioral impairments induced by both prolonged wakefulness and circadian misalignment. Neurobehavioral performance, alertness, and sleep were studied in young healthy participants (N=18) who underwent a 25-day forced desynchrony protocol in which the period of the sleep-wakefulness cycle was scheduled to be 42.85 h (duration of each wakefulness episode: 28.57 h; sleep/rest episode: 14.28 h). Each waking day, participants were treated with either 400 mg modafinil, divided into three doses, or placebo, according to a randomized, parallel-group design. Treatment with modafinil significantly attenuated the performance decrements seen for several parameters including cognitive-psychomotor speed, visual attention and reaction times both with progressive hours awake and when working at adverse circadian phases. Subjective alertness and sleep parameters were similar between treatment groups, but modafinil-treated participants had fewer bouts of inadvertent sleep during scheduled waking. Modafinil reduced the neurobehavioral impairment associated with work, both during prolonged wakefulness and at adverse circadian phases, without adversely affecting subjective alertness or subsequent sleep. These features suggest that modafinil might be a particularly relevant countermeasure against the deleterious effects of prolonged work hours, shift work, and transmeridian travel.
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Affiliation(s)
- Scott Grady
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Aeschbach
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kenneth P Wright
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Sleep and Chronobiology Laboratory, Department of Integrative Physiology, University of Colorado, Boulder, CO, USA
| | - Charles A Czeisler
- Division of Sleep Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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142
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Abstract
Excessive sleepiness (ES) is a widespread condition, commonly the result of a sleep/ wake disorder such as obstructive sleep apnea (OSA), shift-work disorder (SWD), or narcolepsy. ES poses significant health and safety concerns in patients. Numerous interventions are available to treat the underlying causes of ES and ES itself, including behavioral measures, mechanical devices, and pharmacologic agents. This review explores the evidence supporting the use of armodafinil to treat ES associated with OSA, SWD, and narcolepsy. Armodafinil is an oral non-amphetamine wake-promoting agent, the R-isomer of racemic modafinil. Armodafinil and modafinil share many clinical and pharmacologic properties and are distinct from central nervous system stimulants; however, the mechanisms of action of modafinil and armodafinil are poorly characterized. Compared with modafinil, the wake-promoting effects of armodafinil persist later in the day. It is for this reason that armodafinil may be a particularly appropriate therapy for patients with persistent ES due to OSA, SWD, or narcolepsy.
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Affiliation(s)
| | - Richard Bogan
- SleepMed of South Carolina, Columbia, South Carolina, USA
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143
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Schwartz JRL, Roth T. Neurophysiology of sleep and wakefulness: basic science and clinical implications. Curr Neuropharmacol 2010; 6:367-78. [PMID: 19587857 PMCID: PMC2701283 DOI: 10.2174/157015908787386050] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2007] [Revised: 07/31/2008] [Accepted: 09/19/2008] [Indexed: 11/25/2022] Open
Abstract
Increased attention to the prevalence of excessive sleepiness has led to a clear need to treat this symptom, thus reinforcing the need for a greater understanding of the neurobiology of sleep and wakefulness. Although the physiological mechanisms of sleep and wakefulness are highly interrelated, recent research reveals that there are distinct differences in the active brain processing and the specific neurochemical systems involved in the two states. In this review, we will examine the specific neuronal pathways, transmitters, and receptors composing the ascending arousal system that flow from the brainstem through the thalamus, hypothalamus, and basal forebrain to the cerebral cortex. We will also discuss the mutually inhibitory interaction between the core neuronal components of this arousal system and the sleep-active neurons in the ventrolateral preoptic nucleus, which serves as a brainstem-switch, regulating the stability of the sleep-wake states. In addition, we will review the role of homeostatic and circadian processes in the sleep-wake cycle, including the influence of the suprachiasmatic nucleus on coordination of sleep-wake systems. Finally, we will summarize how the above processes are reflected in disorders of sleep and wakefulness, including insomnia, narcolepsy, disorders associated with fragmented sleep, circadian rhythm sleep disorders, and primary neurological disorders such as Parkinson’s and Alzheimer’s diseases.
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Affiliation(s)
- Jonathan R L Schwartz
- Integris Sleep Disorders Center of Oklahoma, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
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144
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Black W, Hoey P, Mayze T. Modafinil use in patients with a primary psychiatric illness. Aust N Z J Psychiatry 2010; 44:583-4. [PMID: 20482418 DOI: 10.1080/00048671003636448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
| | - Peter Hoey
- Consultant Psychiatrist, Roseville, New South Wales, Australia
| | - Thomas Mayze
- The Brisbane Clinic, Cleveland Queensland, Australia
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145
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Modafinil zur Behandlung exzessiver Schläfrigkeit bei Patienten mit Schichtarbeitersyndrom. SOMNOLOGIE 2010. [DOI: 10.1007/s11818-010-0477-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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146
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147
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148
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Morgan PT, Pace-Schott E, Pittman B, Stickgold R, Malison RT. Normalizing effects of modafinil on sleep in chronic cocaine users. Am J Psychiatry 2010; 167:331-40. [PMID: 20080983 PMCID: PMC5857958 DOI: 10.1176/appi.ajp.2009.09050613] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The purpose of the present study was to determine the effect of morning-dosed modafinil on sleep and daytime sleepiness in chronic cocaine users. METHOD Twenty cocaine-dependent participants were randomly assigned to receive modafinil, 400 mg (N=10), or placebo (N=10) every morning at 7:30 a.m. for 16 days in an inpatient, double-blind randomized trial. Participants underwent polysomnographic sleep recordings on days 1 to 3, 7 to 9, and 14 to 16 (first, second, and third weeks of abstinence). The Multiple Sleep Latency Test was performed at 11:30 a.m., 2:00 p.m., and 4:30 p.m. on days 2, 8, and 15. For comparison of sleep architecture variables, 12 healthy comparison participants underwent a single night of experimental polysomnography that followed 1 night of accommodation polysomnography. RESULTS Progressive abstinence from cocaine was associated with worsening of all measured polysomnographic sleep outcomes. Compared with placebo, modafinil decreased nighttime sleep latency and increased slow-wave sleep time in cocaine-dependent participants. The effect of modafinil interacted with the abstinence week and was associated with longer total sleep time and shorter REM sleep latency in the third week of abstinence. Comparison of slow-wave sleep time, total sleep time, and sleep latency in cocaine-dependent and healthy participants revealed a normalizing effect of modafinil in cocaine-dependent participants. Modafinil was associated with increased daytime sleep latency, as measured by the Multiple Sleep Latency Test, and a nearly significant decrease in subjective daytime sleepiness. CONCLUSIONS Morning-dosed modafinil promotes nocturnal sleep, normalizes sleep architecture, and decreases daytime sleepiness in abstinent cocaine users. These effects may be relevant in the treatment of cocaine dependence.
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149
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Bittencourt LRA, Santos-Silva R, de Mello MT, Andersen ML, Tufik S. Chronobiological disorders: current and prevalent conditions. JOURNAL OF OCCUPATIONAL REHABILITATION 2010; 20:21-32. [PMID: 19898779 DOI: 10.1007/s10926-009-9213-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
In recent decades, the hectic lifestyle of industrialized societies has wrought its effects on the quality of sleep, and these effects are evidenced by a profusion of sleep-related disorders. Regular exposure to artificial light, coupled with social and economic pressures have shortened the time spent asleep. Otherwise, Circadian Rhythm Sleep Disorders are characterized by desynchronization between the intrinsic circadian clock and the extrinsic cycles of light/dark and social activities. This desynchronization produces excessive sleepiness and insomnia. The International Classification of Sleep Disorders describes nine sleep disorders under the category of Circadian Rhythm Sleep Disorders. Currently, this diagnosis is made based on the patient's history, a sleep log alone, or the sleep logs and actigraphy conducted for at least 7 days. This review contains an overview of current treatment options, including chronotherapy, timed bright light exposure, and administration of exogenous melatonin.
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Affiliation(s)
- Lia R A Bittencourt
- Department of Psychobiology, Universidade Federal de Sao Paulo (UNIFESP), Rua Napoleão de Barros, São Paulo, SP, Brazil
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Smith MR, Fogg LF, Eastman CI. A compromise circadian phase position for permanent night work improves mood, fatigue, and performance. Sleep 2010; 32:1481-9. [PMID: 19928387 DOI: 10.1093/sleep/32.11.1481] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
STUDY OBJECTIVE To assess night shift improvements in mood, fatigue, and performance when the misalignment between circadian rhythms and a night shift, day sleep schedule is reduced. DESIGN Blocks of simulated night shifts alternated with days off. Experimental subjects had interventions to delay their circadian clocks to partially align with a night shift schedule. Control subjects had no interventions. Subjects were categorized according to the degree of circadian realignment independent of whether they were in the experimental or control groups. Twelve subjects were categorized as not re-entrained, 21 as partially re-entrained, and 6 as completely re-entrained. SETTING Home sleep and laboratory night shifts. PARTICIPANTS Young healthy adults. INTERVENTIONS Experimental subjects had intermittent bright light pulses during night shifts, wore dark sunglasses outside, and had scheduled sleep episodes in darkness. MEASUREMENTS AND RESULTS A computerized test battery was administered every 2 hours during day and night shifts. After about one week on the night shift schedule, which included a weekend off, the partially and completely re-entrained groups had markedly improved mood, fatigue, and performance compared to the group that was not re-entrained. The completely and partially re-entrained groups were similar to each other and had levels of mood, fatigue, and performance that were close to daytime levels. CONCLUSIONS Partial re-entrainment to a permanent night shift schedule, which can be produced by feasible, inexpensive interventions, is associated with greatly reduced impairments during night shifts.
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Affiliation(s)
- Mark R Smith
- Biological Rhythms Research Laboratory, Department of Behavioral Science, Rush University Medical Center, Chicago, IL 60612, USA
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