First Responders and Sleep Disorders
A public safety job is almost never 9:00 to 5:00. First responders are shift workers; they are needed 24/7. The nature of these jobs requires many law enforcement and corrections officers, firefighters, EMTs and other first responders to work odd hours, which means atypical sleep patterns.
Police1.com recently conducted two interesting polls relating to sleep:
Question: How much sleep do you average in a 24-hour period?
More than 8 hours 3% 7-8 hours 23% 6-7 hours 34% 5-6 hours 31% Less than 5 hours 10%
Question: How often have you used sleep aids or medications to help you fall or stay asleep over the past 30 days?
Every day 18% Most days 12% 6-7 hours 19% Some days 51%
It’s disturbing to learn the overwhelming majority of respondents typically slept fewer than eight hours per night (or per “night,” since many first responders work nights and sleep during the day). Also, almost half of those polled required sleep aids at least some of the time. Clearly, sleep is a pervasive, ongoing issue for police officers (and other first responders).
Journal of Global Health Study
The polls cited above are unscientific, but they point to a very real problem in the field of public safety. A recent study published in the Journal of Global Health sheds even more light on the issue of sleep and first responders.
In “Prevalence of Sleep Disorders Among First Responders for Medical Emergencies: A Meta-analysis,” the authors conducted a survey of 28 studies in four research databases, which covered a total of 101,080 first responders. The specific job categories in the meta-analysis included firefighters, police/law enforcement, EMTs, paramedics and other ambulance personnel. Surveys in the analysis came from North America (10), Asia (11), Europe (4) South America (2) and Africa (1). Study dates spanned two decades, running from 2002 to 2022.
In this multi-study analysis, the authors concluded the job requirements of first responders “have been associated with physical and psychological problems such as sleep disorders.” They go on to quantify the specific mental and physical issues as well as the sleep disorders that commonly accompany this type of work.
According to the authors, the four common (and two rare) sleep disturbances studied in the analyzed research caused a number of negative health impacts, including “poor alertness and concentration, fatigue, mood disturbances, cognitive impairment, and poor quality of life among first responders.” In addition, the authors noted “demographic factors (education, gender, age, smoking status, alcohol status, living habits and environment, marital status, mental disorders, and medical history) and occupational factors (irregular work schedules, type of work, profession, peer support, and awareness of support measures) have shown to have an impact on the occurrence of sleep disorders.”
After parsing the studies and their results, researchers estimated the following prevalence of sleep disorders among first responders:
CONDITION IMPACTED % IMPACTED Shift Work Disorder 31% Obstructive Sleep Apnea 30% Excessive Daytime Sleepiness 28% Insomnia 28% Restless leg syndrome 2% Narcolepsy 1%
We’ll go through the disorders one by one to see how common they are and what can be done to counter their effects.
Shift Work Disorder (SWD)
What Is SWD?
According to the DSM-5, Shift Work Disorder (SWD) is a “recurrent pattern of sleep disruption that is primarily due to alteration of the circadian system or to a misalignment between the endogenous circadian rhythm and the sleep-wake schedule required by an individual’s physical environment or social or professional schedule.” In other words, your job makes you lose sleep. People with SWD often have trouble falling asleep and staying asleep. It can create cascading problems in social and occupational environments.
According to the 2017 article, “Shift Work and Shift Work Sleep Disorder,” the medical impact of SWD can include “increased risk for cardiovascular disease, cerebrovascular events and stroke, obesity and metabolic disorders, GI complaints, poor sexual health (including reduced fertility and problems during pregnancy), and multiple forms of cancer.” Workers with SWD may also experience impaired mental health, including “more psychiatric disease and greater psychosocial distress, including depression, anxiety, alcohol abuse, and work stress spillover as well as poorer quality of life.” First responders may also experience attention and memory issues as a result of SWD.
Research indicates one of the common themes with shift workers experiencing SWD is that these individuals often try to go back to a more regular daytime/nighttime schedule on their days off. They do this to match the waking patterns of family and friends to synch up for social and family time, sporting events and other activities. According to experts, those suffering from SWD often find falling asleep easy; it’s the staying asleep that’s the difficult part. This is mostly due to disruptions in natural circadian rhythms.
How Is SWD Treated?
Shift Work Disorder is best treated under the care of a sleep psychologist or other sleep expert. However, there are lots of things people can do to help lessen the effects. Most of it comes down to practicing good sleep hygiene:
- Set and follow a structured bedtime routine, regardless of what time you go to bed from day to day.
- Start this routine between half an hour and an hour before you want to fall asleep.
- Take a warm, relaxing bath or shower before bed.
- Practice yoga, meditation or other techniques to relax your mind and body.
- Avoid alcohol and caffeine several hours before bedtime.
- Read a chapter from a book — a paper book, not a digital one — before going to sleep.
- Stay away from digital devices for at least an hour before you want to sleep.
You can also help alleviate SWD by making sure your bedroom environment is:
- Cool: Running a fan or air conditioner (or both) helps regulate the temperature and also provides “white noise.”
- Dark: Use blackout shades or curtains, and an eye mask if that helps.
- Quiet: Earplugs and white noise machines can help mask intrusive sounds.
- Uncluttered: Even if your eyes are closed, a messy room can sometimes contribute to anxiety that makes it more difficult to sleep.
If you do all of this and still have trouble falling asleep or staying asleep, talk to your doctor about other treatment options.
Obstructive Sleep Apnea (OSA)
What Is OSA?
According to Johns Hopkins Medicine, OSA occurs “when your breathing is interrupted during sleep, for longer than 10 seconds at least 5 times per hour (on average) throughout your sleep period.” If your breathing is restricted, resulting in not enough oxygen to your brain, that’s called “hypopnea.” If your breathing stops completely, that’s called “apnea.” Both hypopneas and apneas are caused by an obstruction in a person’s upper airway, usually from the positioning of the tongue, mouth/throat muscles, or other bodily tissues.
While some people with OSA might not have obvious symptoms, many experience feelings of daytime sleepiness even when they’ve supposedly had plenty of “sack time.” Some other symptoms include snoring (often interspersed with periods of quiet), morning headaches, feelings of irritation, depression and memory problems.
When left untreated, OSA can cause serious complications, including high blood pressure, cardiovascular issues (such as stroke, arrhythmia and heart failure), low oxygen levels, increased risk of diabetes (or worsening of symptoms) and mood disorders. Furthermore, when OSA is allowed to continue unchecked, it can cause dangerous accidents when sufferers fall asleep while driving or performing other critical tasks.
How Is OSA Treated?
There are several methods for treating the causes and symptoms of obstructive sleep apnea:
- Using a CPAP (continuous positive airway pressure) mask and machine can give an OSA sufferer a constant airflow, which helps maintain the airway.
- Oral appliances, which fit over your teeth like an orthodontic retainer, can also keep airways open for better breathing and sleep.
- Surgery for sleep apnea sufferers targets the root causes of OSA, removing extra tissue (such as adenoids and tonsils) or even reconstructing portions of a patient’s sinuses or facial structure for better breathing while asleep.
- A hypoglossal nerve stimulator, a specialized type of medical implant, stimulates the hypoglossal nerve. Stimulation automatically synchronizes with breathing to help reduce airway obstruction.
In addition to mechanical and surgical interventions, there several other things you can do to help reduce the impact of OSA:
- Lose weight: Dropping just 10 to 15% of your body weight can lower the severity of sleep apnea by as much as 50%, though it probably won’t cure it altogether.
- Reduce alcohol intake: Since alcohol depresses the nervous system, it can amplify the symptoms of OSA. Eliminating alcohol — especially before bedtime — can help reduce this effect.
- Reduce sedative use: Many sedatives, both over the counter and prescribed, impact the nervous system in the same way alcohol does.
Excessive Daytime Sleepiness (EDS)
What Is EDS?
According to the Mayo Clinic, Excessive Daytime Sleepiness — also known as hypersomnolence and hypersomnia — is characterized by “feelings of excessive sleepiness; episodes of inadvertently falling asleep, including sleep attacks (episodes of falling asleep without prodromal symptoms of drowsiness); a prolonged main sleep episode that is unrefreshing; recurrent naps in the same day; and sleep inertia (prolonged difficulty waking up, with irritability, automatic behavior or confusion).” EDS is sometimes a symptom of another medical or mental disorder.
It seems almost too obvious to mention, but the major cause of EDS is not getting enough sleep. Other triggers include disruptions in a person’s circadian rhythm (which is exacerbated by shift work), breathing problems such as sleep apnea, and other conditions like narcolepsy, idiopathic hypersomnia, and Kleine-Levin syndrome.
EDS can contribute to both physical and mental problems, including lack of focus, accidents (including vehicle crashes), errors in judgment and other mental lapses. When untreated, EDS can contribute to depression, mood swings, attention-deficit/hyperactivity disorder and other problems.
How Is EDS Treated?
Again, the obvious “fix” for Excessive Daytime Sleepiness is to get more sleep. First responders often think they can do everything, working overnight shifts and then spending the day with families and friends. So, the first solution is to set aside enough time for sleep, and then be diligent about dedicating that time. Good sleep hygiene and a sleeping area conducive to quality sleep (see above) can help tremendously.
If you’re getting the recommended hours in bed and still feeling drowsy at work, experts recommend:
- Exercise: Even just getting up and walking around can make you more alert when you’re feeling the effects of EDS.
- Scheduled naps: Taking short, measured naps during the workday (if you can work them into your schedule) can often reduce the cottony feeling of EDS.
- Chewing gum: Giving your mouth something to do seems to foster wakefulness.
- Medications: Your doctor might prescribe something for you to take before bed to help ensure that your sleep is restful. Be sure to ask about potential side effects and dependency.
If you try all this and still experience the symptoms of Excessive Daytime Sleepiness, talk to your doctor about conducting a sleep study and investigating other potential interventions.
What Is Insomnia?
Insomnia is a catch-all term for not sleeping enough or not sleeping well. According to the Cleveland Clinic, most people experience insomnia from time to time, but as much as 10% of the population suffers often enough for it to become problematic. Based on the Journal of Global Health survey cited above, first responders are as much as three times more likely to have insomnia than non-shift workers.
Insomnia may be chronic (long-term) or acute (short-term). It may be primary, which means it happens on its own, or it may be secondary, which means it’s triggered by another condition. Insomnia can also differ by when it’s experienced during the sleep cycle:
- Initial insomnia: When someone has trouble falling asleep.
- Middle insomnia: When someone wakes up in the middle of a sleep session but is able to eventually fall asleep again.
- Late insomnia: When someone wakes up late in a sleep session but can’t fall back asleep.
The causes of insomnia are varied:
- Disrupted Schedules: Shift work, or anything else that disturbs your body’s circadian rhythm, can cause insomnia.
- Genetics: Some people are predisposed to insomnia because of their family history.
- Medical Problems: Illnesses, injuries, digestive problems (like acid reflux), and other physical ailments can make it difficult to fall or remain asleep.
- Mental Health: People with depression, anxiety, and a variety of other mental disorders are more likely to experience insomnia.
- Life Changes: Changes to life patterns, including shift changes, jet lag, sleeping in unfamiliar surroundings, and a new baby can contribute to sleeplessness.
- Personal Habits: Alcohol and caffeine consumption, exercise, excessing napping, and even diet can cause or exacerbate insomnia.
- Stress: If your mind is focused on a looming problem, it can make it difficult to fall or stay asleep.
As with other sleep disorders, insomnia can cause fatigue, mood problems, confusion, difficulty concentrating, memory lapses, and slowed reflexes.
How Is Insomnia Treated?
If you’re having chronic insomnia, the first thing to do is examine your life and see if you’re doing something that’s directly contributing to it. Getting enough exercise, reducing your intake of alcohol and caffeine, and removing stressors from your life can often reduce the number of sleepless nights you experience. You should also check your sleep hygiene (see above) and make sure your habits and sleeping environment aren’t adding fuel to the fire.
Once you’ve done everything you can to help yourself, you may want to see a doctor. Your primary care physician may recommend a supplement such as melatonin or an over-the-counter or prescription medication to help you fall asleep and stay asleep. Many people find that seeing a therapist can help as well. It makes sense — if you’re not sleeping due to stress, anxiety or depression, then treating those conditions can help put you in a better mental state to give yourself over to sleep.
Restless Leg Syndrome (RLS)
Also known as Willis-Ekbom Disease, Restless Leg Syndrome is characterized by the urge to constantly move your legs. RLS may be accompanied by discomfort in the muscles of the legs that seems only to be alleviated by moving or shaking them. Though not technically a sleep disorder, RLS can interfere with sleep to the point where it becomes a problem.
RLS can be caused by sleep deprivation, overuse of substances such as alcohol, nicotine and caffeine, pregnancy, and nerve damage (neuropathy). Treatment options include changes in diet, supplements such as iron or potassium, and a variety of prescription medications. The following have also been shown to reduce the effects of Restless Leg Syndrome:
- Practice good sleep hygiene (see above)
- Engage in regular physical activity, including cardio and stretching
- Reduce alcohol, nicotine and caffeine intake
- Leg massages
- Warm baths
- Heating pads or ice packs
- Foot wraps and vibration pads
RLS has also been linked to Parkinson’s disease, kidney failure, and spinal cord lesions, so if you experience symptoms that don’t get better with self-care, see your doctor.
Narcolepsy is a serious condition that usually includes Excessive Daytime Sleepiness and may also include falling asleep involuntarily and without warning. According to the Sleep Foundation, narcolepsy is treatable but not curable. It is considered a life-long condition, and can be mitigated with medication, behavioral therapy and lifestyle changes. Falling asleep with no warning can be dangerous — especially while driving or performing various job-related duties. If you experience any symptoms, see a doctor immediately.
- “How much sleep do you average in a 24-hour period?” Police1 Poll. https://www.police1.com/polls/how-much-sleep-do-you-average-in-a-24-hour-period-2jtWUQBgIJjlLXWQ/
- “How often have you used sleep aids or medications to help you fall or stay asleep over the past 30 days?” Police1 Poll. https://www.police1.com/polls/how-often-have-you-used-sleep-aids-or-medications-to-help-you-fall-or-stay-asleep-over-the-past-30-days-61re7T5S3L3XZdoC/
- Huang G, Lee T, Band KJ, Pien L, Jen H, Chen R, Liu D, Hsiao SS, Chou K. “Prevalence of sleep disorders among first responders for medical emergencies: A meta-analysis.” Journal of Global Health 2022;12:04092. https://jogh.org/wp-content/uploads/2022/10/jogh-12-04092.pdf
- Emerson M. Wickwire, Jeanne Geiger-Brown, Steven M. Scharf, and Christopher L. Drake. “Shift Work and Shift Work Sleep Disorder.” Chest 2017 May; 151(5): 1156–1172. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6859247/
- Harvard Medical School. “Circadian Rhythms and the Brain.” Summer 2018. https://hms.harvard.edu/news-events/publications-archive/brain/circadian-rhythms-brain
- Hersh, Erica. “10 Healthy Sleep Hygiene Habits.” Healthline. https://www.healthline.com/health/sleep-hygiene
- Johns Hopkins Medicine. “Obstructive Sleep Apnea.” https://www.hopkinsmedicine.org/health/conditions-and-diseases/obstructive-sleep-apnea
- Kriti D. Gandhi, Meghna P. Mansukhani, Michael H. Silber, and Bhanu Prakash Kolla. “Excessive Daytime Sleepiness.” Mayo Clinic Proceedings, April 08, 2021. https://www.mayoclinicproceedings.org/article/S0025-6196(20)30984-8/fulltext
- The Cleveland Clinic. “Insomnia.” https://my.clevelandclinic.org/health/diseases/12119-insomnia
- National Institute of Neurological Disorders and Stroke (NIH). “Restless Legs Syndrome.” https://www.ninds.nih.gov/health-information/disorders/restless-legs-syndrome
- Sleep Foundation. “Narcolepsy Treatment.” June 10, 2022. https://www.sleepfoundation.org/narcolepsy/treatments