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Fatigue
Learning Objectives
1. Describe symptoms of fatigue
2. Identify self‐assessment strategies to monitor fatigue and tools for client assessment
3. Examine fatigue and sleep management E
i f i
d l 26th Annual Southwestern Regional NP Symposium
Susan Phillips MSN, RN, PMHCNS‐BC, PMHNP‐BC
Carol Moffett Ph.D, FNP‐BC, CDE, FAANP
Arizona Nurses Association Chapter 9
methodologies including countermeasures to promote health and safety 1
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Fatigue
Fatigue
Introduction
 Approximately 38% of the U.S. workforce is fatigued  40 million Americans suffer from a sleep disorder
•insomnia
•sleep apnea
•restless legs syndrome
•circadian rhythm sleep‐wake disorders •narcolepsy
•shift work sleep disorders
 Fatigue results in:  ‐ slower reaction time
 ‐ trouble concentrating and remembering  ‐ difficulty communicating with others
 ‐ falling asleep on the job or while driving
 ‐ risk for making a safety‐critical error
 ‐deterioration in health (increases in obesity, diabetes and cancer)
 Fatigue leads to a variety of adverse medical outcomes, burnout, errors, and client dissatisfaction
Zhou et al., (2011). Mismatch subjective alertness objective performance, Sleep Research.
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Fatigue
Fatigue
Signs of Excessive Fatigue
Emotional
 More quiet or withdrawn than usual
 Lack of energy
 Lacking the motivation to perform tasks
Awareness is the first and most important step in fatigue management
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www.eheandme.com
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Fatigue
Fatigue
Signs of Excessive Fatigue
Signs of Excessive Fatigue
Mental
Physical  Difficulty concentrating on tasks
 Yawning
 Lapses in attention
 Drooping eyelids
p g y
 Difficulty remembering tasks being performed
 Rubbing of eyes
 Failing to communicate important information
 Head dropping
 Failing to anticipate events or actions
 Microsleep
 Accidentally doing the wrong thing
 Digestive problems  Accidentally not doing the right thing
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Fatigue
INDIVIDUAL FATIGUE LIKELIHOOD
ASSESSMENT
BACK
FRONT
Lack of Sleep May Lead to Junk Food Binging
Food Binging
A Swedish Study of 16 normal weight young men found:
Lack of sleep can lead to:
• eating larger portions of high‐calorie foods • increasing food intake regardless of whether
feeling full
• increasing long‐term risk of weight gain
Individual Fatigue Likelihood Assessment
Individual Fatigue Likelihood Assessment
Step 1. Sleep in prior 24 hours
Sleep < 2h 3h 4h 5+h
Points 12 8 4 0
S
Step 2. Sleep in prior 48 hours
Sl
i i 8 h
Sleep <8h 9h 10h 12+h
Points 8 6 4 0
Step 3. Hours of wake since last sleep
Add one point per hour awake greater
than sleep in step 2.
Step 4. Add all points together to determine your score.
http://www.tc.gc.ca/eng/civilaviation/standards/standards‐3922.htm
Uppsala University, news release, Feb. 20, 2013 http://consumer.healthday.com/Article.asp?AID=673758
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NP Fatigue Survey
Work Schedule and Hours Time of Day usually worked
Demographics
Respondents
134
10
93% Female
Age
Day
76%
Day & or Eve.
23%
20‐30
3%
8‐10
38%
31‐40
17%
10‐12
28%
41‐50
20%
12‐16
13%
51‐60
45%
>16
2%
61‐70
61
70
14%
71‐80
1%
3 days/wk
13 %
Masters
76%
DNP
10%
PhD
7%
RN prior to NP 67% > 10 yrs
As NP
50% >10 yrs
Hrs/Day in clinical practice
# Days/wk in clinical practice
Education
4 days/wk
21%
5 days/wk
47%
7 days/wk
3%
Hrs/wk in clinical practice
Years 11
<48 hrs
75%
>56 hrs
16%
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NP Survey Results
NP Survey Results
Client Load, Time per Client, and Positions
Sleep
# Clients/day usually seen
Hrs/night of sleep
<10
16%
<4
10‐15
31%
4‐5
12%
16‐20
26%
6‐7
65.5%
21‐25
18%
8‐9
18%
>26
10%
>9
3%
No restrictions
25%
Seriously
14%
10‐20 min
38%
Moderate
35%
20‐30 min
24%
Mildly
32%
>30 min
13%
Not at all
18%
/
# Minutes/ client 1.4%
Concern re: quality of sleep
# Of Positions of Employment
How often Relaxed at HS
1 position
65%
Not at all
8%
2 or more
35%
Some of time
41%
At least ½ of time
30%
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Sleep Cycle
Sleep Pressure—Increases with time
•After ‐Awake for 24 hours‐‐
sleep happens quickly with inactivity
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Eppworth Sleepiness Scale
Human Biological Clock
Score of 8 Borderline 10 Abnormal
Situation
http://upload.wikimedia.org/wikipedia/commons/thumb/3/30/Biological_clock_human.svg/2000px‐
Biological clock human.svg.png
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Would Never Doze
Slight Chance of Dozing
Moderat
e Chance
of Dozing
High Chance of Dozing
Sitting & Reading
0
1
2
3
Watching TV
0
1
2
3
Sitting, inactive in public place (ie, theater or meeting)
(i th t ti )
0
1
2
3
Passenger in car for an hour without break
0
1
2
3
Lying down to rest in afternoon
0
1
2
3
Sitting quietly after lunch without alcohol
0
1
2
3
In a car while stopped for a few minutes in traffic
0
1
2
3
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Common Sleep Disorders
Obstructive Sleep Apnea Loud disruptive snoring
Other Sleep Questionnaires & Tools
Idiopathic Daytime Hypersomnia
Excessive daytime sleepiness
Narcolepsy
Excessive sleepiness, sleep paralysis (briefly unable to move when awakening), hypnogogic hallucinations, cataplexy (sudden loss of muscle strength triggered by emotion or laughter)
Insomnia
Sleep onset difficulties, awakenings with trouble falling asleep
Delayed Sleep Phase
Syndrome
Unconventional timing of sleep/wake schedule
Restless Leg Syndrome
Uncomfortable leg sensations accompanied by urge to move or adjust legs or arms
Periodic Limb Movements of Sleep
Semi rhythmic contractions of the limb accompanied by limb jerks usually of the feet
 On line quiz found on National Sleep Foundation Site
REM Sleep Behavioral Disorder (RSBD)
Dream enacted behaviors– can include yelling, screaming, punching, running
 National Sleep Foundation Site offers many tools
Parasomnias
Abnormal behaviors –such as night terrors, sleep walking, sleep talking
Nocturnal Eating
Uncontrolled episodes of eating—person may not be aware of
 Children's Sleep Habits Questionnaire (abbreviated)
 Book to assist parents
 School Sleep Habits Survey
 8 page survey for use with TEENS
 Teens require 8½ hours—and on average 9¼ hours of uninterrupted sleep
 National Sleep Foundation Sleepiness Test ( 6 items)
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Fatigue
Sleep Hygiene
1. Allow enough time for sleep. ‐‐‐‐Most people need 7‐9 hours of sleep each day
2. Avoid heavy meals and alcohol before sleep. 3. Reduce intake of caffeine and other stimulants several hours before bedtime
4. Arrange a sleep environment that is very dark, comfortable, quiet, & cool to facilitate falling asleep quickly and staying asleep.
4. Avoid TV beds and other media‐furniture.
5. Follow an exercise routine (but not within 3 hours before bedtime). ‐‐‐Daily physical activity improves sleep‐helps with stress management, and promotes general health
6. Seek assistance from healthcare providers for continuing difficulties with sleep, since specific sleep disorders may require special treatments.
NP Survey Results
Food and Drink to Promote Sleep
Sleep Aids
Report using meds to help sleep 1. No caffeine 4‐6 hours before bed
2. No alcohol at least 3 hours before bed (affects REM sleep)
3 No heavy meals before bed
3.
N h
l b f
b d
• Foods to eat:
• Oatmeal
• Almonds
• Whole grain bread
• Hummus
40%
Freq of med use for the 40% who reported use
Report using Alcohol to assist with sleep
Freq of Alcohol use for the 17% who reported use
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5‐7 x/wk
50%%
5‐7x/wk
42%
17%
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Melatonin OTC‐ & Prescriptive Cousins
OTC Sleep Aids (Antihistamines)
Medication
Uses
Diphenhydramine (Benadryl)
Nyquil Cold & Flu
Promote Sleep Initiation Adverse Effect
Allergy symptoms, Insomnia
acetaminophen – decreases fever/pain
chlorphreniramine –
antihistamine for relieving allergic rhinitis, sneezing, itchy/watery eyes, itchy nose/ throat
dextromethorpan – antitussive
for suppressing cough •Caution with CNS depressants (e.g. ETOH).
due to additive sedative effect.
•Common reactions : dizziness, drowsiness, impaired coordination, blurred vision, hypotension, i i h
i photosensitivity
•Abuse potential
•Caution with CNS depressants (e.g. ETOH).
due to additive sedative effect
•Common reactions
Blurred vision, diplopia, fatigue, hypotension, agranulocytosis
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Medication Uses
Adverse Effects
Melatonin (dietary supplement)
3 mg/hs
•Insomnia,
•treatment of jet lag, •some anti‐inflammatory affect,
•circadian rhythm sleep disorders,
Use with caution with benzodiazepines (potentiates anxiolytic effect )and CNS depressants (increases the sedative effect)
Avoid cerebral stimulants – work y g
y
synergistically and exacerbate insomnia
Prolonged Release p
p
prescriptive version approved in Europe
2 Prescription Melatonin Receptor Agonists approved by FDA
1. Tasimelteon
2. Ramelteon
(Roserem) ‐8mg & 16mg doses
•Tasimelteon –only for use in blind adults tx 24hr sleep cycle disturbances
•Ramelteon‐ tx. Delayed sleep onset (decreased time to fall asleep and duration of sleep by40min)
•Ramelteon‐ (6% report) somnolence, dizziness, nausea, fatigue, headache, and insomnia
•Skidmore‐Roth, L. (2006). Mosby’s handbook of herbs& natural supplements (3rd ed.). St. Louis, MO: Elsevier. Epocrates
Online.
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•http://en.wikipedia.org/wiki/Melatonin
Prescription Sleep Medications
Prescription Sleep Medications
Promote Sleep Initiation
Medication
Benefit
Adverse Effect
Zolpidem
(Ambien)
Short‐term use for insomnia (3 months)—sleep initiation
Short acting hypnotic
•Short half life 2‐3 hours
Serious Reactions ‐ depression exacerbation, SI, aggressive behavior, complex sleep‐related behavior, hallucinations, amnesia, withdrawal if abrupt d/c
Caution in Elderly‐ fall risk
Common Reactions – drowsiness
(extending more than 8 hours with g
increased MVA especially in women), dizziness, lightheadedness, lethargy, drugged feeling 5 & 10 mg dosing
2013 FDA –advised
Women‐ 5 mg dose
Insomnia – onset and maintenance
•Half life 6 hours
Schedule IV
5/2014 FDA warning starting dose decreased to 1 mg‐ men and women
Serious Reactions – similar to Ambien
Common Reactions – somnolence, depression, anxiety, confusion, hallucinations, abnormal dreams
Impairments–impaired driving noted 11 hours after dose (men =women), memory and coordination impairments
•Triazolam (Halcion) Insomnia
•Zaleplon (Sonata)
Both can be habit forming—properties similar to benzodiazipines
Eszopiclone
(Lunesta)
Medications Hydroxyzine
(Vistaril)
Antihistamine
Uses Adverse Effects
Anxiety, pruritis, sedation, nausea and vomiting, insomnia
½ life 3 hours
•Caution with CNS depressants (e.g. ETOH)due to additive sedative effect. May impair thinking and reactions, slurred speech, driving impairment p
g p
caution
Anxiety, short‐term treatment of insomnia, pre‐op sedation
•Dependency/Addiction
•Serious Reactions –
respiratory depression, apnea, respiratory depression, dependency, abuse, SI, avoid abrupt withdrawal
•Common Reactions –
sedation, dizziness, fatigue, amnesia, confusion 25‐100 mg 5
g
Lorazepam (Ativan)
Benzodiazepine
2‐4 mg at bedtime (adult)
1‐2 mg (elderly)
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Prescription Sleep Medications
Sleep Initiation &Return to Sleep –Tricyclic Anti Depressants
Insomnia
Drug
Use
Adverse Effects
Doxepin (Silenor)
Insomnia (early morning awakening and returning to sleep), depression
Few side effects at low dose. Good safety and efficacy in elderly with low dose CNS depression at higher dose
Depression, chronic pain, insomnia
Avoid sudden withdrawal, use caution with ETOH abuse, contraindication with St. John’s Wort
Serious Reactions ‐ QT prolongation, orthostatic hypotension, syncope, ventricular arrhythmias, hallucinations, psychosis
Common Reactions –
drowsiness, dizziness, blurred vision , impaired coordination, confusion, anxiety, agitation See above
See above
***3mg‐6 mg
Imipramine
(Tofranil)
10‐20 mg
FDA Black Box Warning – suicidality risk
Amitriptyline (low dose) 10‐25 mg‐‐ 2 hrs prior to HS
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Cognitive Behavior Therapy to Treat Insomnia
Goodnight Mind: Turn off Your Noisy Thoughts & Get a Good Night’s Rest 30
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Fatigue
Cognitive Behavioral Therapy for Insomnia App– VA sponsored
5 of 10 Best Insomnia Apps iPhone ‐ 4.5 stars $0.99
Insomnia Cure –
Sleep Now –
with Max Kirsten
iPhone ‐ 4 stars ‐
4 stars $2.99
$2 99
Sleep
iPhone ‐ 4.5 stars ‐ $0.99
Yoga for Insomnia
iPhone ‐ 4.5 stars ‐ $2.99
Sleep Cycle alarm clock
Deep Sleep with
Andrew Johnson
iPhone & Android –
4 ‐4.4 stars ‐ $2.99
CBT‐i Coach –collaborative ‐‐between VA’s National Center for PTSD, Stanford School of Medicine, and DoD’s National Center for Telehealth and Technology.
http://www.healthline.com/health‐slideshow/top‐insomnia‐iphone‐android‐apps
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NP Survey Results
Fatigue
Perceived Fatigue related Problems
Concern re : errors due to fatigue
Seriously
11%
Moderately
18%
Mildly
39%
Not at all 32%
All or most of time
8%
Some of time
65%
Never
27%
Most of time
14%
Some of time
49%
Never
37%
Commuting
 One of the most dangerous activities is Driving While g
Ability to concentrate affected
Fatigued
DWF
 Danger increases when driving at times your body wants to Feel Drowsy Driving after work
sleep
 Nightshift workers are 4 to 7 times more likely to have an accident while driving home 33
NP Survey Results
NP Survey Results
a little more most of the a moderate at least How often do not at all– some of the time– amount of half of the than half of time–
you feel?–
not at all– some of a at least half a little most of the the time– moderate of the more than time–
amount of time–
half of the time–
time–
–
10.14%
31.88%
23.19%
9.42%
13.04%
12.32%
14
44
32
13
18
17
....distresse
d about work?
How often
do you
feel?–
–....dread about waking up to another day of work?
–....like quitting your job?
28.68%
39
33.33%
46
41.18%
56
31.16%
43
9.56%
13
10.87%
15
7.35%
10
6.52%
9
6.62%
9
8.70%
12
34
6.62%
9
9.42%
13
time–
–....like your mind is foggy and inattentive at time–
the time–
31.65%
44
46.76%
65
10.79%
15
4.32%
6
2.88%
4
3.60%
5
20.86%
29
20.86%
29
45.32%
63
29.50%
41
13.67%
19
19.42%
27
6.47%
9
4.32%
6
7.19%
10
11.51%
16
6
6.47%
9
14.39%
20
17.52%
24
21.90%
30
16.79%
23
7.30%
10
13.14%
18
23.36%
32
7.41%
10
31.11%
42
12.59%
17
11.85%
16
20.00%
27
17.04%
23
work?
–....exhausted at work?
–....that too much is h i expected of you at work?
–....that your work life takes all of your energy?
–....mentally or physically exhausted after work?
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NP Survey Results
How often do
you feel?–
....you have difficulty recovering your energy not at all– some of the time–
14.39%
20
43.17%
60
NP Survey Results
a moderate at least half a little more most of amount of of the time– than half of the time–
time–
the time–
15.11%
21
7.19%
10
9.35%
13
How often do
you feel?
–
10.79%
15
–....you have lots of energy to give family and friends?
–....you have between work shifts?
....you do not get enough time between work shifts not at all–
22.30%
31
41.73%
58
14.39%
20
6.47%
9
6.47%
9
energy for
f your hobbies/relaxing
activities in your 8.63%
12
some of the time–
a moderate amount of time–
a little at least most of more half of than half the the time
of the time–
time–
16.18%
22
53.68%
73
13.24%
18
6.62%
9
7.35%
10
2.94%
4
22.46%
31
48.55%
67
15.22%
21
5.80%
8
5.07%
7
2.90%
4
25.90%
36
38.85%
54
18.71%
26
4.32%
6
7.19%
10
5.04%
7
spare time?
–....you have energy for physical exercise?
to recover your energy fully?
...fully rested at the start of each work day/shift?
15.11%
21
43.17%
60
17.99%
25
4.32
%
6
8.63%
12
37
10.79
%
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Fatigue
Countermeasures
Managing Fatigue Beasts
Lighting the Work Environment
Stimulatory effects of 750‐1000 lux Illumination
Reverses normal fall in alertness related to night shift
Adverse health effects
 Widespread neuroendocrine effects
 Melatonin suppression
 Elevation of cortisol
 Increases heart rate
 Hypertension
 Hyperglycemia
 Decrease in appetite regulating hormone leptin
 Increased risk of cancer
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Fatigue
Sleep Pressure
Interventions
Warm temperature
 Reduced social stimulation and interaction
 Dim lighting
 Minimal physical activity
 Low noise levels
 Passive monitoring type work
Awake for 24 hours‐‐sleep happens quickly with inactivity
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Countering Sleep Pressure
Metro Nap Energy Pod
1.
2.
3.
4.
– Cool temperature
– Increased social stimulation and interaction
Ergonomic
Sound control
Light control
Timer Rents for about Rents
for about
$700/month
– Bright lighting
– Increased physical activity
– Loud noise levels
– Active work
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Coffee: The Civil War
Soldier’s Secret Weapon
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Positive
Caffeine
Negative
“The power of the soldiers to endure the fatigue
of the march and keep their places in the ranks was greatly enhanced by an opportunity to brew a cup of coffee by the wayside.”
Uncommon Grounds: The History of Coffee and How It Transformed Our World By Mark Pendergrast
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Strategic Use of Caffeine
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Hydrate
1:30(am or pm)
7:30(am or pm)
200 mg dose ‐ onset of action 15‐45 minutes
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Fatigue
Fatigue Management
1. Symptoms of fatigue
•
•
•
Emotional‐quiet, withdrawn, lack of energy and motivation
Physical‐ yawning, eye rub, head droop, digestive problems
Mental‐cognitive impairment, lapses in communication, 2. Self‐assessment strategies to monitor fatigue
•
•
•
Awareness of symptoms
f
Fatigue assessment tool (Canadian), Eppworth Sleepiness Scale
3. Fatigue and sleep management methodologies
• Anticipate fatigue generating situations
• Improve sleep quantity and quality (appropriately diagnose and treat sleep problems)
• Strategically use lighting, caffeine, and naps
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Susan A. Phillips
[email protected]
Carol Moffett [email protected]
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