Recognize "sleepy" workers by asking the right questions early in the rehabilitation process.

Recognize "Sleepy" Workers by Asking the Right Questions Early in the Rehabilitation Process

The impact of sleepiness upon job performance has smoldered as a neglected issue for many years. In fact, only disastrous events, particularly involving nuclear power and the aviation industry, have succeeded in bringing the problem to the attention of both the general public and regulatory agencies. At present, obvious aggravating factors--external to, yet imposed upon the worker (such as shift work and "jet lag") are under intense scrutiny. However, a major dilemma remains.

Essentially, we have tripped over the razor-sharp tip of a massive iceberg. There are many employees inherently incapable of maintaining adequate alertness for job performance, irrespective of hours and work conditions.

For example, the leading cause of severe sleepiness encountered by sleep medicine specialists is sleep apnea. This syndrome is characterized by repeated cessation of breathing during sleep. Individuals may struggle violently to overcome closure of the upper airway hundreds of times each night. Their consequent exhaustion may be compounded further by the serious drops in blood oxygen levels that many of them demonstrate. Potential complications, aside from incapacitating sleepiness, include heart failure, hypertension, and risk of sleep-related heart attacks, seizures, strokes and sudden death. It seems incredible that such a dramatic condition in fact is common--occurring in approximately one out of every fifty adult men.

Narcolepsy, an often inherited disorder that appears due to neurochemical imbalances in the brain, was first described over 100 years ago and had been thought rare. We now recognize that it has a prevalence of roughly 1:1000 or greater, such that it is at least as prevalent as multiple sclerosis. A large number of additional men and women are diagnosed as having idiopathic central nervous system hypersomnolence: likely due to yet other perturbations in brain chemistry, that eventuate in severe sleepiness without classic narcolepsy. A variety of other physical causes of impaired wakefulness similarly abound.

In short, we now realize that the magnitude of the population affected by these disorders is immense. No less striking is the severity of job impairment experienced by this group.

Narcolepsy has been most thoroughly studied in this latter regard. Broughton and co-workers (1984) contrasted life effects of narcolepsy and epilepsy and found that although a higher percentage of people with narcolepsy currently were working (73.3 vs 55.0), people with narcolepsy more often reported reduced work performance due to the underlying condition: 61.4 vs 30.3. Narcolepsy also was reported as having led to a variety of specific problems: reduction in earnings in 31.8%, prevention of promotion in 22.7%, fear of job loss in 45.5%, and actual job loss in 23.3%. A more recent and somewhat larger survey (Alaia, 1988) cited reduced job performance in 84.6%, resulting job change in 57.1%, failure to receive promotion in 37.9%, and accidents on the job in 18.9%, with narcolepsy stated to have influenced initial job choice in 42.9%.

At the same time, workers whose impairment derives from excessive sleepiness tend to be excellent rehabilitation candidates. For example, nearly all sleep apnea patients are restored to full alertness if their nocturnal breathing abnormality is corrected, now possible in the vast majority due to the advent of newer treatment approaches.

Recognition: The Challenge

Two obvious questions arise. First, if the prevalence of these disorders is so great, "where have they been"? Second, if effective treatment indeed is possible, why might individuals with sleep disorders still present for rehabilitation?

Odds would favor many rehabilitation counselors already having seen workers unemployed as a direct consequence of excessive sleepiness--without ever knowing that such was the basic problem. Tragically, individuals with impaired ability to maintain wakefulness often remain completely unaware of their tendency to doze off uncontrollably! They instead may sense that they begun to experience difficulties with confusion, memory loss and irritability. they often are intensely frustrated by their inability to think clearly and quickly. Many will admit fears of Alzheimer's dementia. Yet they surprisingly do not seem to be able to perceive the very sleepiness that accounts for their deteriorating mental capabilities.

Furthermore, sleep is that part of our existence during which we are unable to observe what happens to us. For example, one might expect to "know it", if he stopped breathing six hundred times per night, for up to two minutes or so at a time. Actually, most patients with sleep apnea do not realize that they have this condition--unless informed of such by a worried bed-partner.

The tragic tendency for these disorders to elude detection is compounded further by the fact that their detrimental effects on performance are likely to be interpreted in a moral, rather than a medical light. The sluggish, sleepy employee frequently inspires anger rather than concern on the part of employers: who may well dismiss the problem (and the employee) on the grounds that laziness, apathy, stupidity or substance abuse probably were responsible. Such would seem especially likely if the employee was never stated reasons for termination may not mention "sleeping on the job" but instead, emotional misinterpretations of sluggish, substandard performance.

It also is helpful to understand a rather common scenario which can render identification of sleep apnea even more challenging. While narcolepsy most often commences relatively early in life (particularly in adolescence and the early 20s), sleep Apnea is apt to develop progressively with advancing age. Symptoms are especially likely to begin in the fourth through sixth decades: such that many of those who have sleep apnea already will have established themselves in a career. Their insidiously worsening ability to function on the job, coupled with the irritability and malaise arising from hypoxemia as well as fears that younger "up and coming" employees might usurp their position, can produce a very understandable posture of hostile, angry denial and defensiveness.

Obviously, people most often receive medical attention when they desire it, and patients with sleep disorders often have no idea that they have a physical problem. A large percentage ultimately receive care only because of the efforts of family members or enlightened employers. In many instances, the concerns voiced by spouses are ignored for years. The very individual with the impairment simply cannot sense nor believe it.

The final, tragic irony occurs when such severely impaired individuals finally relent to the demands of others and go to a doctor; who, if not familiar with sleep pathologies, may tell the patient that he is sleep-deprived, depressed or "just fine."

In short, this population is particularly likely to present to the rehabilitation counselor in an undiagnosed state, and clues to the underlying problem often will not be volunteered by the person with the problem. If diagnosis and treatment already had been provided, a good percentage in fact still would be working in their former position, potentially without need for rehabilitation services. In other instances, of course, skilled rehabilitation and counselling still would prove necessary--particularly in cases whose treatment was only partially effective.

The rehabilitation specialist, simply by learning how and when to suspect impaired wakefulness in his or her clients, can succeed in preventing ongoing socioeconomic ruin. Moreover, in the large percentage who suffer from sleep apnea, the risk of cardiovascular disability and even death can be prevented as a direct result of the rehabilitation counselor's acumen. Few exercises in basic detective work could offer more richly rewarding results.

Intervention

After indications of a disorder of excessive sleepiness are brought to light, the obvious next step involves definitive diagnosis and institution of treatment. Even if clear-cut narcolepsy is present, per an incontrovertible history of cataplexy, overnight sleep laboratory monitoring usually still is warranted, due to the high prevalence of sleep apnea: even as an aggravating factor that could render treatment for narcolepsy less efficacious. Information on referral sources is available from the American Narcolepsy Association as well as the American Sleep Disorders Association.

Following institution of treatment, the nature and degree of rehabilitative services will be predicated in part upon the extent to which impaired wakefulness has been controlled.

Career planning ideally should be based upon considerations related to time and activity. The ideal job for a client prone to excessive sleepiness would permit that employee to retain some degree of control over his or her time. for example, most people with narcolepsy derive immense benefit from brief (e.g., 20 minute) naps, if they have the liberty to take them. Moreover, lengthy workdays, frequent overtime and shift changes--difficult for normal subjects--can prove disastrous to workers with sleep disorders. The optimal shift for each client may vary, as many of the afflicted note particular times of day that they are most likely to "fight uphill". It is worthwhile asking the client about this point. A particularly suboptimal circumstance would involve a long work shift ending after dark: which could render the employee less capable of remaining alert during the drive home.

The nature of the job tasks is critical. A "desk job", without freedom to get up and move about, clearly is a problem for many with incompletely controlled symptoms. In a similar vein, occupations that involve prolonged driving, piloting of aircraft, and repetitive tasks (e.g., assembly line work) are inadvisable. When good medical control proves impossible, activities in which sleepiness could result in injury to self or others should be avoided. Enthusiasm and the reward of being able to participate creatively in job tasks can facilitate maintenance of wakefulness. In short, the ideal position for many clients with impaired ability to maintain vigilance would involve positive stimulation, without overload and consequent exhaustion.

While these conditions are physical, not psychiatric disorders, psychological counseling is of major potential benefit in many instances. Inability to function due to impaired wakefulness is a horribly defeating experience, leading to a sense of being overwhelmed by events for which one lacks the energy to respond in a competent manner. Severe depression, low self-esteem and pervasive anxiety over possible future failures are understandably frequent and not surprisingly, such "low moods" may secondarily worsen the degree of sleepiness, sometimes despite treatment that otherwise would have been successful.

Many people with narcolepsy in particular never have known anything but repeated failures, due to frequent onset of the condition early in life. Allaying fears about possible dementia, when sleepiness was the sole cause of impaired intellectual functioning, is important. Formal psychometric testing (best performed after full alertness is restored) may be required to erase lingering doubts on the part of the client. Patients' suspicions of Alzheimer's often go unvoiced and tragically persist.

Finally, sleep apnea, although occasionally occurring in thin subjects, typically progresses particularly in the presence of obesity. Concurrently, it can worsen with age. Hence, even if the obese patient does not gain additional weight, he or she is at risk of gradual worsening, potentially with loss of treatment responsiveness, if the passage of time is not counteracted by reduction in weight. Significantly obese sleep apnea patients usually require nutritional counselling. In severe or refractory cases, referral to an ethical formal weight loss program may be warranted.

In summary, the rehabilitation counselor, via learning simple keys to the detection of disorders of impaired wakefulness, will be able to unlock those doors that tragically concealed the source of progressive deterioration--socioeconomic, psychosocial, intellectual and physical--for many. The experience of seeing previously devastated victims undergo a dramatic return to a functional, capable, and enthusiastic state with a future is immensely gratifying.

One such patient, whose severe, disabling sleep apnea was essentially abolished via a simple mechanical device (nasal continous positive airway pressure or "CPAP") wrote a note, describing his CPAP machine as better than a 10-lb bass, a 20-point buck, winning a million-dollar lottery and partaking in the world's most wonderful sexual experience! He admitted that he had felt that he was dying before treatment, but he had no idea why. He now is back on the job, fully productive, simply because he was asked the right questions.