SLEEP AND FATIGUE

Introduction to Sleep and Fatigue

Sleep is essential to human well-being. During a sleep
period the body is not only recuperating from the
physical activity of the day but it is also carrying out
essential organization of the mental processes. The
amount of sleep required varies according to age,
amount of physical and mental energy used prior to sleep
and individual differences. Sleep exhibits particular cycles
during each sleep period, varying from light dozing to
very deep sleep, with intervals of a unique type of sleep
in which vivid dreams occur. The duration of sleep and its
quality depends to a large extent on our internal body
rhythms, and it is well to consider these rhythms before
looking at sleep itself.
Aircrew’s Attitude to Sleep
Aircrew must not regard sleep as merely a
mechanism for recuperation from the previous
day’s activity. It is of fundamental importance
that aircrews’ attitude towards sleep is pro-
active and that sleep is actively planned in order
that flights are conducted at maximum physical
and mental efficiency.
BODY TEMPERATURE
Body Temperature and Sleep
There is a direct relationship between our body
temperature and sleep cycle. At the time of lowest body
temperature we find it hardest to stay awake. We will start
to feel sleepy at a time when the temperature is falling
and be at our most wide awake when the temperature is
rising. This relationship explains the difficulty we may have
of sleeping well for a few days after time zone crossings.
This is one of the symptoms of ‘jet lag’.
Body temperature variations throughout the day follow a
regular cycle. The highest temperature occurs around 1700
hours and the lowest at about 0500 hours, at which time
we are least efficient and the desire for sleep is at its peak.
Timing Planned Sleep
Time spent awake is important in determining readiness
for sleep but there is also a circadian rhythm of sleep.
This means that at certain times of the day even the
sleep-deprived individual may have difficulty in falling
asleep. It is the timing of sleep not the amount of time
awake that is the critical factor in determining sleep
duration. As indicated earlier, the duration of sleep is
linked to the body temperature cycle.
Sleep taken at times near the temperature peak or when
the temperature is falling will be longer and more
refreshing than sleep taken when body temperature is
rising. Aircrew attempting to sleep when the body
temperature is on the rise will have considerably more
difficulty getting to sleep, and if successful, will usually
awaken within a relatively short period of time.
TIME OF DAY AND PERFORMANCE
As well as the circadian rhythms of temperature and other
basic physiological processes, there are rhythms for more
complex behaviours. Performance of different tasks is
affected by the time of day. Simple tasks, requiring little
short-term memory input, follow the pattern of body
temperature. Performance improves as temperature
increases and declines as the temperature decreases.
Performance using short-term memory tasks declines
throughout the day. Verbal reasoning and mental arithmetic
skills peak around midday.
Accident statistics have been examined to detect a
correlation between time of day and accidents. It has been
found that driving accidents peak at certain times of the day,
for example 1500 hours, but other factors, such as traffic
density and road conditions will also affect the results.
MEASUREMENT AND PHASES OF SLEEP
Measurement
Laboratory experiments have revealed a great deal
about the various sleep phases. Volunteers have
undergone a number of measurements and observations
whilst they are asleep. The devices used include:
 Electroencephalogram (EEG) - to record the electrical
activity of the brain
 Electrooculogram (EOG) - to measure eye movement
within the eye socket
 Electromyogram (EMG) - to measure muscle tension or
relaxation
Stage 1
The sleeper is in a very light sleep. It is a transitional
phase between waking and sleeping; if woken at this
stage the volunteer may claim that he has not even been
asleep. In early sleep we pass through about 10 minutes
of Stage 1 before moving to the deeper Stage 2.
Stage 2
In early sleep we spend about 20 minutes in stage 2
before moving on to the deeper Stage 3 & 4. About 50%
of a normal sleep is spent in Stage 2
Stages 3 & 4
During Stage 3 & 4 sleep:
 The brain is semi-active emitting long slow waves
measured by EEG tracings and thus it is commonly
referred to as ‘Slow Wave’ or Orthodox sleep
 The eyes are stationary behind the eyelids.
 The muscles are relaxed.
 Choking or crushing dreams.
Function of Slow Wave Sleep (Orthodox Sleep)
Slow wave sleep refreshes the body and is necessary for
tissue restoration. After strenuous physical activity the
body will require more slow wave sleep
Rapid Eye Movement (REM) Sleep
 Superimposed on the above 4 stages is REM
(sometimes referred to as Paradoxical sleep) which is quite
different to orthodox sleep. In this phase:
 The brain is active and the EEG trace is similar to that of an
individual who is fully awake whilst the other
measurements show the person to be asleep.
 Rapid eye movement behind the eyelids are detected
 Whereas there is near total muscle paralysis (thought to
prevent the sleeper acting out dreams), there is frantic
movement of the muscles of the eye. This motor
activation occasionally breaks through resulting in
twitching of the limbs.
 Complex, bizarre, and emotionally-coloured dreams take
place.
Function of REM Sleep
REM sleep refreshes the brain. It strengthens and
organizes the memory. After a period of learning new
tasks or procedures REM sleep will increase. In addition,
REM sleep contributes significantly to emotional
equilibrium and good humour. Thus, irritability normally
follows a period of disrupted sleep.
Characteristics of Orthodox and Paradoxical
Sleep
Some characteristics of Orthodox and Paradoxical sleep
are:
Sleep Cycles
During any normal night’s sleep the pattern operates on
an approximately 90 minute cycle. Towards the end of
the first 90 minutes of falling asleep the first REM stage
occurs but this first REM experience lasts only 10 to 20
minutes before the person passes back into slow wave
sleep.
At the end of the second cycle of 90 minutes the
duration of REM sleep periods increases.
Sleep Profile
The individual stages will vary depending on the activities
prior to sleep. If a great deal of strenuous physical
activity has taken place then the sleep stages 3 and 4 will
be extended. Alternatively, if a lot of mental work has
been undertaken, such as learning new information or
procedures, then REM sleep will be increased.
Rebound Effect
Sleep deprivation experiments have shown that if a
person is deprived of either slow wave or REM sleep there
will be a ‘rebound’ effect in the next sleep period. That is
the individual will make up the deficit in either case. For
example if one is woken after 3 hours of a normal sleep
period then the body will have had all its required slow
wave sleep, but be deficient in REM sleep. In the next
sleep period it is found that REM sleep will occur earlier
and last longer than normal.
AGE AND SLEEP
Individuals differ in the amount of sleep they require. In a
survey of one million people the most frequently reported
sleep duration was between 8 and 9 hours. Some people
seem able to do with much less sleep and can manage
quite well on 3 to 4 hours per night.
 Ageing brings major changes in sleep requirements. New
born babies may sleep for up to 23 hours per day (of which
the majority is REM) and even as they grow older will
require much more sleep than adults. However as people
get older they sleep less but at the same time, become less
flexible about when sleep is taken. Shift work becomes
more difficult with age as it is much harder to re-
programme the body clock. Women tend to sleep longer
than men but report more sleep problems.
NAPS AND MICROSLEEPS
A nap is a short period of sleep taken at any hour. The time
of day, the duration of the nap and the sleep credit/deficit
of the individual will determine through which sleep stages
the individual will pass. The restorative properties of naps
will vary from one individual to another. Those who
habitually take naps appear to gain more benefit than non-
habitual nappers, who sometimes perform at a reduced
level for some time after awakening from the nap.
With the increase in extended flight times there is debate
about allowing a crew member to take 20 to 30 minute naps
in the seat in an effort to keep him/her fresh. There would
appear to be some benefit but pilots should be aware of the
pitfalls. It is not unknown for one of the pilots to be taking a
nap and the other pilot to fall asleep.
Pilots should also be aware that after napping it may take
some minutes to collect one’s thoughts and they will have
slow responses and reactions for up to 5 minutes after being
roused. The minimum duration for a nap to be restorative
appears to be not less than 10 minutes (Hawkins). It is
strongly recommended that pilots should plan to be fully
awake at least 1 hour before descent.
Microsleeps are very short periods of sleep lasting from a
fraction of a second to two to three seconds. Although their
existence can be confirmed by EEG readings, the individual
may be unaware of their occurrence which makes them
particularly dangerous. They occur most often in conditions
of fatigue but are of no assistance in reducing sleepiness.
SHIFT WORK
General
Sleep loss or partial sleep is an occupational hazard of
commercial aviation. There will be times when the pilot
has to work when he would rather be asleep, and other
times when he has to sleep when he would rather be
awake. At these times sleep problems may be
aggravated by circadian rhythms.
The sleep/wake cycle affects readiness for sleep, and the
timing of sleep relative to the body cycle of temperature
is critical in determining the duration of the sleep.
Planning Shift Work Sleep
As an example it is assumed that one is rostered for night
duty. The pilot will attempt to get some sleep during the
afternoon prior to reporting for duty. However, it will be
difficult to get any satisfactory sleep due to having a
good sleep credit assuming a normal night’s sleep had
been achieved the night before, plus an increasing body
temperature does not facilitate sleep.
There are basically two options in this case:
Firstly, one could go to bed early the previous night and
set the alarm for an early call so that, by the afternoon,
the body will be approaching sleep deficit and be ready
for sleep. The second alternative would be to go to bed
late the previous night, sleep late, relax in the afternoon
and still have a good sleep credit for the night duty
Both solutions have limitations, in the first case, having
gone to bed in the afternoon, sleep may be impossible
due to outside noise, daylight entering the room or, if in a
hotel, construction work or domestic work in the
corridors. In which case one may go on duty with an even
greater sleep deficit. The second solution will prove
useless if, having prepared oneself for five to six hours
duty, the trip is delayed for a few hours for technical,
weather, or air traffic reasons.
SLEEP HYGIENE
If your body really needs sleep it will sleep under almost
any condition. If one is attempting to sleep whilst still in
sleep credit or at a time of low circadian sleepiness then:
 Avoid drinks containing caffeine near bed time (coffee,
tea, cola and a number of “fizzy” soft drinks). Caffeine
effects both Stage 4 and REM sleep. When caffeine is
removed from a drink, the sleep-disturbing effect is also
removed. (Aspirin also contains caffeine).
 Avoid napping during the day
 Make sure the room and bed are comfortable, with any
daylight excluded, air conditioning working, and ensure
insects (especially the biting or stinging variety) are not
able to enter the room.
 Avoid excessive mental stimulation, emotional stress.
 A warm milky drink, light reading, or simple progressive
relaxation techniques will all help to promote sleep.
 Avoid alcohol and heavy meals.
SLEEP AND ALCOHOL
Alcohol is widely used by aircrew as an aid to sleep. It is
however a non-selective central nervous depressant. It
may induce sleep but the sleep pattern will not be normal
as REM sleep will be reduced considerably and early
waking is likely
SLEEP DISORDERS
Narcolepsy
An inability to stop falling asleep even when in sleep
credit. Specialists believe that this is associated with the
inability of the brain to distinguish between wakefulness
and REM sleep. This condition is clearly undesirable in
aircrew as the sufferer may go to sleep at any time, even in
a dangerous situation.
Sleepwalking (Somnambulism)
This condition, as well as talking in one’s sleep, is more
common in childhood, but does occur later in life. It may
happen more frequently in those operating irregular hours
or those under some stress. This condition should not
cause difficulty in healthy adults unless the sleep walker is
involved in an accident whilst away from his bed.
Insomnia
This is simply the term for difficulty in sleeping. It may be
divided into:
Clinical insomnia
This describes the condition when a person has difficulty
in sleeping under normal, regular conditions in phase
with the body rhythms. In other words, an inability to
sleep when the body’s systems are calling for sleep.
It must be understood that Clinical Insomnia is rarely a
disorder within itself. It is normally a symptom of another
disorder. For this reason the common and symptomatic
treatment with sleeping drugs or tranquillisers is
inappropriate unless treatment for the underlying cause
is also undertaken.
Situational insomnia
There is an inability to sleep due to disrupted work/rest
patterns, or circadian disrhythmia. This often occurs when
one is required to sleep but the brain and body are not in
the sleeping phase. This condition is the one most
frequently reported by aircrew.
DRUGS AND SLEEP MANAGEMENT
People’s tolerance to sleep disturbance varies and some
individuals may require the assistance of drugs to obtain
sleep or to stay awake. The commonest drug used to
delay sleepiness is caffeine, contained in tea or coffee,
and this will assist the user to stay awake.
Wide publicity has been given to Melatonin as a cure of
Jet Lag. Aircrew should not take this drug or any other
drug or medicine without first seeking advice from his/her
Aviation Medical Specialist.
FATIGUE
Introduction
Fatigue is deep tiredness and, similar to stress, it is
cumulative and can be caused by:
 A lack of restful sleep
 A lack of physical or mental fitness
 Excessive physical or mental stress and anxiety
 Desychronisation of the body cycles (Jet Lag)
Whereas tiredness is instantly recognizable by the sufferer
and is an acceptable social admission, fatigue is more
insidious. A pilot suffering from fatigue can be unaware of
his/her condition for a long period of time until a crisis forces
realization. Even if aware that fatigue is a problem, a pilot
will be hesitant to admit the fact openly. It appears to be
akin to an admission that he/she is not up to the job.
 Fatigue can be sub-divided into short and long-term
(chronic) fatigue.
Short-term Fatigue
As implied, this type of fatigue is akin to tiredness. It is
usually due to a lack of sleep, hard physical or mental
exertion, crew scheduling, a long duty period, lack of food
or Jet Lag. Shortterm fatigue is easily recognised and
remedied by not flying and sufficient rest.
Long-term (Chronic Fatigue)
Long-term fatigue is much more difficult to recognise and
admit. It can come from a number of different causes which
may include a lack of physical or mental fitness, a stressful
marriage coupled with problems at work, financial worries
and a high workload. It also can be subjective, one pilot
being able to tolerate more than the next before chronic
fatigue sets in. Anyone who suspects that they are suffering
from chronic fatigue must take themselves off flying.
The symptoms of fatigue can be:
 Lack of awareness
 Diminished motor skills
 Obvious tiredness
 Diminished vision
 Increased reaction time
 Short-term memory problems
 Channelled concentration
 Easily distracted
 Poor instrument flying
 Increased mistakes
 Irritability and/or abnormal mood swings
 Reversion to ‘old’ habits
 Decrease in communication
Delaying the onset of fatigue
Some of the actions that may be considered to avoid
fatigue:
 Accept that fatigue is a potential problem
 Plan sleep strategies pro-actively (plan sleep ahead of
the next day’s activities)
 Use exercise as part of the relaxation period and ensure
you are fit
 Avoid alcohol
 Eat a regular and balanced diet
 Have your emotional and psychological life under control
 Ensure cockpit comfort
 Ensure that food and drink are available for long flights
 Ensure your seat is properly adjusted