Abstract Introduction This guideline establishes recommendations for the treatment of shift work disorder (SWD). Methods The American Academy of Sleep Medicine (AASM) commissioned a task force of experts in sleep and circadian medicine to develop recommendations and assign strengths based on a systematic review of the literature and an assessment of the evidence using the GRADE process. The task force summarized the relevant literature and the quality of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations supporting the recommendations. The AASM Board of Directors approved the final recommendations. Results The following recommendations are intended as a guide for clinicians in choosing specific treatment(s) for symptoms of excessive sleepiness and/or insomnia, and for circadian adaptation in adults with SWD. Each recommendation statement is assigned a strength (e.g., “Strong” or “Conditional”). For SWD, there were only “conditional” recommendations for or against (i.e., “We suggest…”) and those requiring the clinician to use clinical knowledge and experience and consider the individual patient’s values and preferences to determine the best course of action. Interventions in recommendation statements were compared to no treatment. Conclusion Adults with SWD with symptoms of excessive sleepiness associated with work schedule: 1. In adults with SWD with excessive sleepiness, the AASM suggests the use of armodafinil or modafinil taken 30 to 60 minutes prior to the night shift over no armodafinil or modafinil (Conditional recommendation, moderate certainty evidence). 2. In adults with SWD with excessive sleepiness, the AASM suggests the use of bright light over no bright light during the night shift (Conditional recommendation, very low certainty evidence). Remark: Individuals with SWD who exhibit insomnia and daytime function impairments may also benefit from using bright light during their night shift. 3. In adults with SWD with excessive sleepiness, the AASM suggests the use of caffeine taken prior to and/or during the night shift over no caffeine (Conditional recommendation, very low certainty evidence). Remark: Caffeine intake close to bedtime can disrupt sleep onset and quality, which may exacerbate symptoms of shift work disorder. 4. In adults with SWD with excessive sleepiness, the AASM suggests the use of a clockwise rotating shift schedule over a counterclockwise rotating shift schedule (Conditional recommendation, very low certainty evidence). 5. In adults with SWD with excessive sleepiness, the AASM suggests taking a nap over no nap prior to the night shift (Conditional recommendation, very low certainty evidence). Remarks: Sleep inertia occurring soon after the nap may temporarily increase sleepiness, decrease cognitive performance, and increase accident risk. Allowing adequate time for resolution of sleep inertia prior to driving or performing other safety-sensitive behaviors may be needed to reduce these risks. 6. In adults with SWD with excessive sleepiness, the AASM suggests either not eating or eating a snack rather than eating a full meal during the night shift (Conditional recommendation, low certainty evidence). 7. In adults with SWD with excessive sleepiness, the AASM suggests the combination of caffeine and bright light over the combination of no caffeine and no bright light (Conditional recommendation, very low certainty evidence). Remark: Caffeine intake close to bedtime can disrupt sleep onset and quality, which may exacerbate symptoms of shift work disorder. 8. In adults with SWD with excessive sleepiness, the AASM suggests the combination of taking a nap and caffeine over the combination of no nap and no caffeine prior to the night shift (Conditional recommendation, very low certainty evidence). 9. In adults with SWD who are working either an 8-hour or 12-hour night shift, the AASM does not suggest working one shift duration over the other (Conditional recommendation, very low certainty evidence). Remark: This recommendation does not consider other shift durations, rotation, or the number of consecutive shifts. This guideline did not look at shifts over 12 hours. The total number of hours worked per week ranged from 36 to 52. Adults with SWD with sleep disturbance/insomnia: 10.9. In adults with SWD with daytime sleep disturbance/insomnia the AASM suggests the use of CBT-I over no CBT-I (Conditional recommendation, very low certainty evidence). 11.10. In adults with SWD with daytime sleep disturbance/insomnia following the night shift, the AASM suggests the use of melatonin over no melatonin (Conditional recommendation, very low certainty evidence). 12.11. In adults with SWD with sleep disturbance/insomnia, when transitioning from daytime to nighttime sleep, the AASM suggests the use of melatonin over no melatonin for night sleep following shift work (Conditional recommendation, low certainty evidence). 13.12. In adults with SWD who desire to take a nap prior to the first night shift, the AASM suggests the use of melatonin over no melatonin prior to the nap (Conditional recommendation, very low certainty evidence). Remarks: Melatonin may temporarily increase sleepiness, decrease cognitive performance, and increase accident risk. Allowing adequate time for resolution of sleepiness prior to driving, returning to work or performing other safety-sensitive behaviors may be needed to reduce these risks. 14.13. In adults with SWD with daytime sleep disturbance/insomnia, the AASM suggests the use of ramelteon or other melatonin receptor agonists over no melatonin receptor agonist (Conditional recommendation, low certainty evidence). 15.14. In adults with SWD with daytime sleep disturbance/insomnia, the AASM suggests the use of suvorexant or other dual orexin receptor antagonists over no dual orexin receptor antagonists (Conditional recommendation, low certainty evidence). 16.15. In adults with SWD with daytime sleep disturbance/insomnia, the AASM suggests against the use of triazolam and other benzodiazepines (conditional recommendation, very low certainty evidence). Adults with SWD seeking circadian adaptation 17.16. In adults with SWD seeking circadian adaptation to the night shift, the AASM suggests the use of bright light over no bright light during the night shift (Conditional recommendation, very low certainty). Remarks: For individuals who work rotating or frequently changing shifts, circadian adaptation is not a realistic goal of treatment and therefore they would not be expected to benefit from this intervention. The evidence supporting this recommendation came from studies in which individuals reached partial circadian adaptation to the night shift. 18.17. In adults with SWD seeking circadian adaptation to the night shift, the AASM suggests the combination of bright light at night and fixed daytime sleep timing over the combination of no bright light and no fixed sleep timing (Conditional recommendation, very low certainty evidence). Remarks: For individuals who work rotating or frequently changing shifts, circadian adaptation is not a realistic goal of treatment and therefore they would not be expected to benefit from this intervention. The evidence supporting this recommendation came from studies in which individuals reached partial circadian adaptation to the night shift. 19.18. In adults with SWD seeking circadian adaptation to the night shift, the AASM suggests the combination of bright light at night, fixed daytime sleep timing, and reduced-light-transmittance glasses in the morning over the combination of no bright light, no fixed sleep timing, and no reduced-light-transmittance glasses (Conditional recommendation, very low certainty evidence). Remark 1s : For individuals who work rotating or frequently changing shifts, circadian adaptation is not a realistic goal of treatment and therefore they would not be expected to benefit from this intervention. The evidence supporting this recommendation came from studies in which individuals reached partial circadian adaptation to the night shift. Remark 2: Attention to driving safety is important when wearing reduced-light-transmittance glasses Other considerations for Adults with SWD 19. In adults with SWD who are working either an 8-hour or 12-hour night shift, the AASM does not suggest working one shift duration over the other (Conditional recommendation, very low certainty evidence). Remark: This recommendation does not consider other shift durations, rotation, or the number of consecutive shifts. This guideline did not look at shift durations exceeding 12 hours. The total number of hours worked per week ranged from 36 to 52. Support (if any)
Wright et al. (Fri,) studied this question.