Integrative support for unconventional sleep patterns

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By Catherine Darley, ND

While society has largely adapted to the conveniences of a 24-hour lifestyle, there are tremendous implications to human health. Patients who commute work unconventional hours that interfere with a natural sleep cycle may struggle maintaining a normal schedule, and as a result present with numerous health concerns. Integrative practitioners are uniquely positioned to address sleep as part of a larger whole-person protocol for these patients.  

Many so-called “shift workers,” who keep the world running around the clock, have difficulty sleeping during the day in the work week then transitioning to nighttime sleep on the weekend. In addition, shift workers experience higher cancer rates, digestive issues, heart disease, and social discord. These disorders stem from being out of sync with the solar day and night light cycle. When shift workers are given strategies to reduce this de-synchrony, their sleep improves, as do other symptoms and concerns.

Roughly 16 percent of employees do some type of shift work. As an integrative provider, it’s important to acknowledge the individual’s natural circadian phase preference, which may change depending on the person. For example, a 6 a.m. start time, which would not be shift work for an older person who wakes on their own at 5 a.m., may constitute shift work for a young person who doesn’t wake naturally until 9 a.m.

There are many types of shift-based schedules that I keep in mind as a practitioner: daytime, swing shift or approximately 3 p.m. to 12 p.m., and night shift or approximately 11 p.m. to 8 a.m. Shift workers may also have rotating shifts with an advancing or delaying pattern, and extended shifts are more often involved than for day workers.

For some professions, such as healthcare workers and first responders, extended shifts can last up to 72 hours, with unpredictable sleep opportunities. To maintain social connections, most shift workers try to sleep on the same pattern as their loved ones on days off and catch sleep irregularly on workdays. Strategies that include precisely timed sleep hours, light and dark exposure, melatonin, and other behavioral strategies have been shown to improve sleep, alertness, and social function.

Of key importance is finding a three- to four-hour block of time for sleep that is consistent across the entire week, regardless of whether it’s a workday or off day. An example would be a sleep block from 8:30 a.m. to noon daily. On days off, the sleep period could be extended earlier in the evening, so 3 a.m. to noon. On work nights, sleep could extend later in the day, for a sleep period 8:30 a.m. to 3:30 p.m. This allows for sufficient rest every night of the week. More importantly, this consistent sleep block, combined with appropriate light exposure, shifts the circadian rhythm so that the core body temperature minimum is experienced later in the morning, thereby sleep quality improves, as well as alertness during wake time.

Another approach practitioners may consider is to control light and dark exposure. Light exposure before the core body temperature minimum, which is typically experienced at about 4 a.m., will cause the circadian rhythm to shift later. On the other hand, light after the core body temperature minimum will cause the circadian rhythm to shift earlier. Shift workers usually get light exposure on both sides of their core body temperature minimum, causing it to stay around 4 a.m. At their core body temperature minimum, people are the sleepiest, and have the most difficulty with concentration and motivation.

Core body temperature takes days to shift. A general rule of thumb is that the circadian rhythm can shift about an hour a day. The goal is to have the core body temperature minimum during the main sleep period, whenever that may be.

In the hours before bedtime, darkness allows the natural melatonin levels to rise, increasing drowsiness and sleep quality. This physiologic darkness can be achieved by using high quality blue light blocking goggles from the end of the shift until the worker is in bed with lights out. Signaling the beginning of the wake period with 20 to 30 minutes of afternoon light helps entrain the circadian rhythm to daytime sleep and night wakefulness.

A third component of an integrative sleep strategy is to use various melatonin preparations. A low dose of 0.3 to 0.5 milligrams of melatonin can be taken six hours before bedtime on nights off, shifting the circadian rhythm earlier and allowing the shift worker to fall asleep hours earlier than on workdays. A 3 milligram dose of regular or time release melatonin can be taken at morning bedtime as a hypnotic to aid in either sleep initiation or sleep maintenance, whichever is needed.

Case Study

Melissa is a 32-year-old single woman who works as an intensive care unit (ICU) nurse. Her work schedule is 7 p.m. to 7:30 a.m., three to four nights per week on a variable schedule. She lives in a two-bedroom apartment with a roommate, commuting between work and home via a 15-minute bike ride. On days off, she enjoys high intensity skiing with her boyfriend, and socializing with friends and family.

The patient reported difficulty sleeping during the day, as well as anxiety and trouble concentrating at work in the middle of the night. She said she has difficulty falling asleep both during the nights and during the days.

Melissa gets about four to five hours of sleep on workdays. On her days off, she can’t fall asleep until late in the evening, and then wakes in the morning when her roommate rises. Her mind races at sleep time and she said she often ends up napping.

Over three visits, we were able to make significant improvements in all these complaints, with the following treatment plan:

• Sleep time on workdays from 8:30 a.m. to 4 p.m.
• Sleep time on days off from 3 a.m. to noon
• Melatonin 0.3 milligrams at 9 p.m. on days off, six hours before lights out
• Melatonin 3 milligrams upon arriving home about 7:45 a.m. on workdays, 30 to 45 minutes before lights out
• Blue light blocking goggles from end of shift until lights out on workdays
• Blue light blocking goggles from 1 a.m. until lights out on workdays

Melissa also reported feeling frustrated when trying to fall asleep. When people spend time awake in bed, it can lead to the habit of thinking things through in bed and worry about losing the ability to sleep. For Melissa, we implemented a journaling and thought stopping practice to make sure thoughts were processed in advance of bedtime every day. Examples of thought stopping practices may include:

• Meditation
• Muscle isolation
• Verbal interruption: stop thoughts by saying, “stop,” “enough,” or “not now,” either verbally or in your head.
• Positive self-talk: restructure negative thoughts into positive thoughts that empower you.
• Scattered counting: start with any number and jump around (example, 3, 49, 37, 43, etc.)

Another difficulty shift workers experience is feeling disconnected from their loved ones, as their schedule is out of sync with social norms. Sleeping until noon or 4 p.m. and staying up late, as this treatment plan requires, can further worsen that disconnect unless it is addressed. I worked with Melissa to identify what socializing she could do on this plan, and likewise what activities she could enjoy on her own late at night. This is a critical step to make the plan actionable.

References

Rivera, A.S., Akanbi, M., O’Dwyer, L.C., and McHugh, M. (2020) Shift work and long work hours and their association with chronic health conditions: A systematic review of systematic reviews with meta-analyses. PLoS One. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/32240254/

Smith, M.R. and Eastman, C.I. (2012) Shift work: health, performance and safety problems, traditional countermeasures, and innovative management strategies to reduce circadian misalignment. Nature and Science of Sleep. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/23620685/

U.S. Bureau of Labor Statistics. (2019) Job flexibilities and work schedules summary. Retrieved from: https://www.bls.gov/news.release/flex2.nr0.htm

About the Author

Catherine Darley, ND, is the leader in natural sleep medicine. She combines her knowledge of sleep disorders with her training as a naturopathic physician to bridge these two fields. As a naturopath, her expertise lies in providing natural and effective treatments for sleep problems. She treats people of all ages and especially enjoys working with teens and their families. She founded The Institute of Naturopathic Sleep Medicine Inc. in Seattle, which is dedicated to patient care, public education about sleep health, and consultation with high-risk populations such as first responders. Darley regularly writes articles and trains healthcare providers in the treatment of sleep disorders. She has served as adjunct faculty at Bastyr University and the National University of Natural Medicine.