Shift work sleep disorder: symptoms, treatment

Remember pulling those all-nighters in high school or college to study for an exam or finish up a term paper? For millions of people, those all-nighters don’t stop with school but can continue throughout their careers.

Plenty of jobs are necessary around the clock, and shift workers (people who work shifts overnight) are the ones who fill those essential roles.

While many people love working the night shift, one common downside is something called shift work sleep disorder. Let’s explore the ins and outs of this disorder, along with possible solutions.

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About 20% of employed people in the U.S. do shift work. The term shift work is poorly defined, but it's generally when a portion of your work schedule falls between 7 PM and 6 AM, rather than the standard daytime workday (Wickwire, 2017). 

Shift work often occurs when a job must be done 24 hours a day, so people work at different times around the clock to make that happen. An example would be nurses in a hospital—patients need to be taken care of day and night, so one nurse might work 7 AM to 7 PM, while another takes over to work 7 PM to 7 AM.

Sometimes, shift workers have a set work schedule with regular shift times every day. Other types of shift work may have rotating shifts, switching between day and night shifts (Wickwire, 2017).

Almost all shift work is in essential service industries, including the military, food preparation/provision, and healthcare. Our lives depend on shift workers like pilots, police officers, firefighters, and nurses being productive and alert on their shifts, 24 hours a day, every day (Wickwire, 2017).

If you do shift work, you may be working at a time when you would usually sleep. You may feel exhausted when you're working. When this fatigue continues, you may experience shift work sleep disorder (SWSD). Shift work sleep disorder comes with excessive sleepiness and insomnia that becomes continual and interferes with your life. Shift work, especially night shift work, disturbs the natural wake-sleep cycle in some people (Wickwire, 2017).

The latest scientific research estimates that about one in four shift workers experiences shift work sleep disorder (Pallesen, 2021). 

The symptoms of shift work sleep disorder are all associated with lack of sleep. They include (Wickwire, 2017):

• Excessive tiredness

• Headaches

• Lack of focus or difficulty concentrating

• Low energy

• Difficulty staying or falling asleep 

Shift work sleep disorder can also be called a circadian rhythm sleep disorder. The circadian rhythm is regulated by the brain and is affected by light. Your eyes receive environmental light and send information about the quality and intensity of the light back to the brain. Your brain then modifies the circadian rhythm in reaction to the light it perceives. The circadian rhythm alerts your body to release melatonin as the environment gets darker (Reddy, 2020). 

Melatonin, also known as the sleep hormone, helps with sleeping. It tapers off at the end of the night. As melatonin winds down, cortisol ramps up in the early morning to give you energy for the day ahead. People with shift work sleep disorder have their melatonin and cortisol release misaligned. Their cortisol (energy) levels are raised during their sleep time, and their melatonin (sleepy) levels increase during their awake time (Reddy, 2020).

The circadian rhythm doesn’t just regulate your sleep-wake cycle. It also regulates body temperature, blood pressure, hormone levels, eating habits, and other vital bodily functions. Sleep disturbances or a disrupted circadian rhythm can have health consequences on the entire body  (Jehan, 2017).

People who work the night shift increase their risk of affecting the following bodily systems (Jehan, 2017):

• Cardiovascular: High blood pressure, heart disease, and high triglycerides

• Endocrine: Metabolic disorders, including obesity and diabetes

• Gastrointestinal: Obesity, gastric disturbances

• Immune: Increased white blood cells, lowered immune system, higher risk of cancer 

• Neurological: Increased risk of migraines, stroke

• Reproductive: Impaired fertility (becoming pregnant or staying pregnant), decreased sexual function, and menstrual problems 

• Skeletal: Lowered bone density and increased risk of bone fractures

Working night shifts also raises the risk of mental health disorders, especially anxiety and depression. People may misuse alcohol and other substances as a sleep aid. When people don't get enough sleep, it can affect the function of their brains and how they think and feel (Jehan, 2017).

Sleeplessness and exhaustion at work also increase the risk of making errors at work or causing car accidents when driving to or from your job. Research into workplace accidents shows that working day shifts leads to the lowest risk of mistakes. Error rates increase in the afternoon shift by almost 18% and by nearly 30% after 6 PM during the night shift. Evidence shows that workplace fatigue was a significant factor in the nuclear power plant meltdowns in Pennsylvania and Chernobyl (Caldwell, 2019). 

If all those effects on the body sound scary, don't worry. Not everyone who works night shifts or rotating shifts develops SWSD.

The people at highest risk for developing shift work sleep disorder are those with stress-related sleep issues and those who are more sensitive to their natural sleep-wake cycle (Kalmbach, 2018). 

People may also have a genetic predisposition for the morning (morning larks) or the night (night owls). So, if you know you're more of a morning person, it's a good idea to move your shifts to the daytime if you can. People with work shifts that conflict with their innate preferred time may be at greater risk of developing SWSD (Kalmbach, 2018).

Older adults (50 years and older) and women are also at higher risk for being diagnosed with shift work sleep disorder (Wickwire, 2017).

When people sleep at unusual times like during the day, their sleep quality may suffer because of external factors that are more common in the daytime. Outside noise, bright light from the sun, and family obligations during the hours when you need to sleep can all interrupt your attempts to fall and stay asleep. 

The main symptoms of shift work sleep disorder are excessive sleepiness and an inability to sleep when you have the opportunity to do so. To be considered shift work sleep disorder, these symptoms must be due to working when it's dark out and sleeping during daylight hours, not due to another medical condition. The American Academy of Sleep Medicine recommends at least seven hours of sleep for adults. Shift workers' total sleep time may be less than that amount, and their sleep quality is often poorer (Watson, 2015).

Your healthcare provider will also do a complete physical exam to see if your symptoms may be coming from an underlying physical or mental health problem, medication, or other factors. They may also check if you have another sleep disorder that mimics SWSD, like sleep apnea or narcolepsy (Wickwire, 2017).

Your healthcare provider will also do a complete physical exam to see if your symptoms are caused by an underlying physical or mental health problem, medication, or other factors. They may also check if you have another sleep disorder that mimics SWSD, like sleep apnea or narcolepsy (Wickwire, 2017).

They may ask you to keep a sleep diary—a recording of sleep, sleeplessness, and activity every day—for at least two weeks. They may order a sleep test where you will wear a tracking device on your wrist that measures your sleep and activity for two weeks or longer (Wickwire, 2017). 

If you suspect you might have shift work sleep disorder, that doesn’t mean you need to quit your job. There are treatments available to help you manage your symptoms and have a productive work and home life, despite a less-than-ideal sleep schedule. 

Bright light exposure

The circadian rhythm uses light and darkness to send messages to the brain for waking and sleeping. Artificial bright light can help people who work the night shift suppress their natural melatonin release once it gets dark (Olsen, 2020).

The bright light should be the strongest in the evening and weakest in the morning. You may want to wear sunglasses or special blue-light blocking glasses or goggles for your commute back home in the morning to help your brain get the message to wind down (Olsen, 2020).

Darkness helps to release melatonin and suppresses morning cortisol so you can get some sleep once you are home. Lamps for seasonal affective disorder or light boxes are appropriate for bright light treatment and can be obtained through your healthcare provider. People with eye diseases or light sensitivity should not do this treatment (Olsen, 2020).

Melatonin treatment

Melatonin is known as the sleep hormone because it is released at night and tapers off before the first morning light. Melatonin is sold as a supplement and typically comes in doses from 1 mg to 10 mg. Day shift workers can take additional melatonin at night. Night shift workers can employ dark therapy or light restriction like sunglasses or blue-light blocking goggles to keep their natural melatonin release times intact. 

Stimulants

The U.S. Food and Drug Administration (FDA) has approved two prescription medications, modafinil (Provigil) and armodafinil (Nuvigil), for excessive sleepiness from SWSD. These medications are non-amphetamine stimulants used to treat narcolepsy. Side effects of these medications can include headaches, anxiety, dizziness, and nausea. These medications do not replace restorative sleep or help you sleep; instead, they help keep workers alert when working the night shift (Wickwire, 2017).

Many night shift workers will use caffeine—usually in beverage form—to stay alert during their work hours. Caffeine and short naps can help with feeling awake. If you drink coffee or energy drinks at work, be sure to stop using them a few hours before your shift ends so you can fall asleep once you get home (Liira, 2014). 

Sleep medicine

Many people who work the night shift cannot get enough sleep during the day. Some healthcare providers will prescribe hypnotics or benzodiazepines to extend their sleeping hours when they can sleep. However, these medications can be addictive and potentially worsen other diagnosed sleep disorders (Liira, 2014).

Schedule consistency

Maintaining a consistent sleep-wake schedule—even on your days off—can be helpful. Switching back and forth between sleeping during the day and night causes you to lose sleep. If you have to work in rotating shifts, you may want to change your sleep times by small increments to help you adjust to your work schedule (Kalmbach, 2015).

Some people find that they sleep better if they split their sleep time. That means sleeping for several hours right when you come home, waking up for a few hours, and then taking a nap before going back to work (Kalmbach, 2015).

Lifestyle adjustments

There are several lifestyle modifications you can do to help reduce your symptoms and get some good sleep. 

• Keep it quiet and dark: It’s challenging to avoid light and noise during daylight hours. If you sleep during the day, try to schedule noisy activities and appointments later in the day. Put your phone on “do not disturb.” Make your bedroom as dark as possible with blackout curtains. You may want to use an eye mask to keep out any light. A fan can keep your room cool and add a “white noise” effect, which some people find soothing. You can also purchase a white noise machine or download an app on your phone.

• Take naps and catch up on sleep: If possible, napping for 30 minutes or less during your shift can help you stay more alert at work or on the drive back home. Shift workers who work more than 8-hour shifts and lose sleep create a sleep deficit. Napping at home or adding more sleep hours on your days off from work can help replenish your “sleep account” and fix that deficit (Vanttola, 2020).

• Move your body: Exercise helps keep your body healthy and promotes sleep. Doing exercise at different times of day can have different impacts on the body. Researchers are currently looking at which times of day exercising will most impact your circadian rhythm sleep-wake schedule (Saner, 2020).

• Eat a healthy diet: Sleep deprivation can make it harder to maintain a healthy weight and even lead to craving more unhealthy foods. You can combat this by reducing your added sugar and processed food intake, and increasing fruits, vegetables, and lean proteins (Potter, 2016).

• Improve your sleep hygiene: Use relaxation techniques like meditation, breathing exercises, or listen to soothing music or white noise. Stop using screens (phones, tablets, or television) 30–60 minutes before sleep. Try to go to sleep at a regular set time so your body gets used to a bedtime routine (Jehan, 2017).  

• Get support: Ask your family or friends to help you take care of appointments or tasks that need to be done during the day so you can sleep. You can even consider using a rideshare platform or asking a friend to drive you to and from work to decrease the risk of a traffic accident.  

Sometimes the jobs we love or just simply need to work can have an impact on our health. Shift work sleep disorder isn’t to be taken lightly, as it can potentially cause harm to yourself and others. 

If you’re a shift worker and find it challenging to stay awake when working or sleep well when it’s time to sleep, contact your healthcare provider. They can help you develop a plan to get the rest you need and improve your quality of life.

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Current version

June 10, 2021

Written by

Tobi Ash, MBA, RN, BSN

Fact checked by

Steve Silvestro, MD

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About the medical reviewer

Steve Silvestro, MD, Ro

Dr. Steve Silvestro is a board-certified pediatrician and Associate Director, Clinical Content & Education at Ro.