SLEEP DISORDERS - GENERAL

Sleepiness and Sleep Disorders in Shift Workers: A Study on a Group of Italian

Police Officers
Sergio Garbarino;1 Fabrizio De Carli;2 Lino Nobili;3 Barbara Mascialino;3 Sandro Squarcia;4 Maria Antonietta Penco;4 Manolo Beelke;3 and Franco Ferrillo3
1Center

of Neurology and Medical Psychology, Health Service of the State Police, Department of the Interior, Italy; 2Center for Cerebral Neurophysiology, National Council of Research, Italy; 3Sleep Disorder Center, DISM, University of Genoa, Italy; 4Department of Physics, University of
Genoa, Italy.

Study objectives: evaluation of shift-work effect on sleepiness, sleep

disorders, and sleep-related accidents in a population of police officers.
Design: A questionnaire-based survey was used to gather information on
age and physical characteristics, working conditions, sleep problems, and
accidents. Sleepiness was measured by the Epworth Sleepiness Scale
(ESS) while the presence of sleep disorders was evaluated by a score
(SDS) drawn from indicators of insomnia, breathing disorders, periodic
limb movements and restless legs syndrome, and hypersomnia. The
effects of age, gender, body mass index, working conditions, and seniority on ESS, SD score, and accidents were analyzed by linear and logistic
regression.
Setting: The self-administered questionnaires were filled in by police officers in the district of Genoa (Italy).
Participants: 1,280 police officers: 611 shift workers (SW) and 669 nonshift workers (NSW).
Interventions: N/A.

Measurements and Results: The ESS score was not higher in SW than
in NSW, while the SDS was significantly influenced by shift-work conditions and seniority in shift work. The occurrence of sleep-ascribed accidents was significantly increased in the SW group and related to the presence of indicators of sleep disorders. There was evidence for sleep disorders in 35.7% of SW and in 26.3% of NSW.
Conclusions: Shift-work conditions and seniority may enhance sleep disorders and may favor sleep-related accidents, but they do not influence
ESS score. Stressful conditions could cause sleepiness to be underestimated, or else they might overcome sleepiness. However, our data should
alert occupational health physicians for the diagnosis and prevention of
possible undetected intrinsic sleep disorders, which could possibly worsen shift workers health and increase the risk of accidents.
Keywords: Sleep; sleep disorders; sleepiness; shift work; occupational
health; accidents

and sleep quality. There is little agreement among researchers as to

which type of shift work can create the problems.18-22
The International Classification of Sleep Disorders,23 includes the
shift work sleep disorder as one of the circadian rhythm sleep disorders, consisting of symptoms of insomnia or excessive sleepiness that
occur as transient phenomena in relation to work schedules. Insomnia
and sleepiness are generally associated with either sleep curtailment or
sleep fragmentation, which characterize various sleep disorders such as
obstructive sleep apnea syndrome (OSAS), periodic limb movement disorder (PLMD), restless legs syndrome (RLS), and psychophysiologic
insomnia.24-27 Shift work could interact with either the presence of or the
proneness to sleep disorders and could trigger long-term sleep disturbance and sleepiness.28
The aim of our work was to evaluate, with a self-administered questionnaire and a small sample of polysomnographic recordings, the
prevalence of excessive sleepiness and the possible relationship between
shift work and intrinsic sleep disorders in a population of Italian shiftworking police officers.

INTRODUCTION
SHIFT WORK, IN PARTICULAR NIGHT WORK, DISRUPTS THE
SLEEP-WAKE CYCLE AND ITS SYNCHRONY WITH THE LIGHTDARKNESS RHYTHM AND OTHER ENDOGENOUS BIOLOGIC
RHYTHMS, such as the circadian oscillation of body temperature. Furthermore, this working condition determines a phase shift between individual activities and the socioenvironmental synchronizing stimuli,1,2
which affect the alternation between alertness and sleep. Shift work
often has a negative impact on health and quality of life.3,4 Frequent
complaints concern disturbed sleep and excessive sleepiness.5,6 The latter is a major cause of accidents among shift workers, both during working hours and while driving to and from the workplace.7-9
Physiologic sleep is mainly regulated by circadian and homeostatic
factors,10 which also regulate the levels of alertness and sleepiness during wakening, especially during shift work.11,12
Individual characteristics acting through circadian and homeostatic
factors may facilitate either adaptation to shift work or the emergence of
sleep disturbances and excessive sleepiness.13-15 Other factors such as
age, sex, work seniority, sleep habits, and personality may affect both
the circadian adjustment process and sleep architecture.16,17 The duration
and type of shiftfor example, permanent shift or rotating shift, fast- or
slow-rotating shift, advancing or delaying shiftalso influence health

MATERIALS AND METHODS

Subjects
The self-administered questionnaire was submitted to all police officers in the district of Genoa (about 1800) and voluntarily completed. The
subjects enrolled in this study were informed of the objectives and methods used during the survey. Complete confidentiality was guaranteed,
and a contact telephone number was supplied for help in completing the
questionnaire. Each subject received the questionnaire and filled it in
during the morning of a rest day (Saturday for nonshift workers) in a
special room at the police district with no time limit. Subjects were also
informed that they could apply to the sleep medicine center of the University of Genoa in order to investigate the sleep disorders they reported.

Disclosure Statement
Nothing to disclose.
Submitted for publication September 2001
Accepted for publication May 2002
Address correspondence to: Dr. Franco Ferrillo, Centro di Medicina del Sonno.,
DISM. Universita di Genova, HSM Largo R. Benzi 10, I 16132 GENOVA
(ITALY); Tel: +39/0103537460; Fax: +39/0103537699;
E-mail: fifi@dism.unige.it
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642

Sleep Disorders in Shift WorkersGarbarino et al

Sleepiness was scored by the Epworth sleepiness scale (ESS)29 in its

Italian version.30 The scale measures the tendency to sleep in different
daily life situations. It has been validated in normal subjects and in
patients suffering from different diseases leading to daytime sleepiness;
the EES has shown a good discriminating sensitivity, and correlation
with the results obtained with objective neurophysiologic procedures.31
The values of ESS score greater than 10 were considered as indicative of
excessive sleepiness.

The study included 1280 subjects (71% of police officers of the district of Genoa), including 611 SW (47.7% of the sample), 93 women and
518 men, whose mean age was 29.7 years (SD, 5.6) and 669 NSW
(52.3%), 127 women and 542 men, with a mean age of 34.3 years (SD,
7.2). The age distribution of SW and NSW largely overlapped, although
SW were significantly younger than NSW. The sample of SW consisted
of staff employed in psychologically stressful and risky tasks (armed
escort, patrol service, flying squad, etc.). They were all working on fastrotating shifts organized according to the following schedule: First
evening, 19:00-01:00 h; Second afternoon, 13:00-19:00 h; Third morning, 07:00-13:00 h; Fourth night, 01:00-07:00 h; Fifth rest. Furthermore,
special operational requirements could entail overtime work without an
immediate recovery. On the other hand, NSW policemen mostly performed office tasks.

Data Analysis
Data concerning various items in the questionnaire were extensively
explored comparing the group of SW with the one of NSW.
The hypothesis that statistically significant influences on the ESS
score and on the SDS could be exerted by such factors as age, gender,
body mass index (BMI), working conditions (shift work or not), police
seniority, and shift-work seniority has been tested by means of multiple
regression analysis. The hypothesis that these factors could exert a significant influence on the occurrence of accidents and, in particular, of
sleep-related accidents, has been tested by means of multiple logistic
regression.
Considering that multiple statistical tests have been performed, the
threshold for the rejection of the null hypothesis has been set to .005.
Apart from the hypothesis tested by the regression analysis, the nominal
significant levels are used for descriptive purposes to illustrate other
comparisons between SW and NSW.

Questionnaire
The questionnaire recorded the following information
- age, sex, weight and height, marital status, and number of children
- working conditions, in particular role and seniority in police, and in
shift work (years and months worked for the police department and,
in particular, the number of years and months working rotating
shifts in the police department)
- sleep habits and problems related to sleep and sleepiness
- the occurrence of accidents at home, while on duty, during driving,
and their possible relationship with sleepiness
In the questionnaire the term accident refers to
- events that occurred after joining the police force and during the
last 3 years
- events that had caused injuries requiring medical intervention (particularly for home accidents) or material damage and police intervention (for car accidents) or job suspension (for accidents while on
duty)
- events for which the subject was partially or totally responsible
No further information about either the type or seriousness of accidents was reported in the questionnaire.
A group of 14 sleep-related items aimed to detect indicators of
insomnia (four questions regarding difficulties in initiating and maintaining sleep and advanced awakening), obstructive sleep apnea (three
questions regarding snoring, early morning headache, nycturia), RLS or
PLMD (two questions concerning limb paresthesias and periodic movements), and hypersomnia (five questions regarding the presence of daily
sleepiness, irresistible sleep attacks during rest or activity, sleep paralysis, and hypnagogic hallucinations).
These questions were organized into four ordinal levels NEVER,
RARELY, SOMETIMES, OFTEN, to which a numeric value of
0, 1, 3, 5, respectively, was associated. In order to score each subject and
type of disorder, the mean of the numeric values of relevant items was
computed. A global sleep disorder score (SDS) was evaluated for each
subject by averaging the numeric values associated with all the 14 items
suggesting the presence of sleep disorders. A schematic criterion was
used to classify subjects featuring indicators of a specific sleep disorder,
whose score was greater than a cutoff value, that could be reasonably
fixed as a value greater than 1 (RARELY) and lower than 3 (SOMETIMES). This cutoff value was selected after three sleep medicine
experts examined a number of different sets of answers in order to spot
possible patterns peculiar to sleep disturbances. Their answers were used
as the gold standard for an analysis of sensitivity versus specificity as
function of the cutoff value, as expected, the specificity increased when
the cutoff value was increased, while the sensitivity decreased. The analysis of the trend of sensitivity versus specificity enabled the choice of a
good cutoff at the value of 2.5 for specific sleep disturbances, corresponding to 80% sensitivity and 75% specificity. The global score was
used to identify subjects presenting indicators for a generic sleep disturbance. In this case the cutoff was lowered to the value of 2.0 in order to
detect cases in which answers suggested disorders (SOMETIMES or
OFTEN) for a significant subgroup of items.
SLEEP, Vol. 25, No. 6, 2002

Polysomnography
Subjects who spontaneously applied to the sleep medicine center
underwent a clinical examination, followed by an overnight polysomnogram. Data were acquired by a digital polygraph recording two electroencephalographic derivations (F4-C4 and C4-O2), two electrooculographic derivations (bipolar montage: right ocular cantus/left ocular cantus); the submental and tibial electromyogram (EMG), the electrocardiogram, the respiratory effort evaluated by thoracic and abdominal
strain gauges, the airflow by thermistors placed in front of each nostril
and the mouth, the snoring noise by a microphone, and the arterial oxyhemoglobin (HbSaO2) using a pulse oximeter with finger probe.
RESULTS
Sleepiness as evaluated by ESS score in the scale 0-24 resulted in a
mean value of 5.85 (SD: 3.23) in SW and 6.34 (SD: 3.06) in NSW. A
condition of excessive sleepiness (ESS score > 10) was found in 61 SW
(10.0%) and in 60 NSW (9.0%). The difference between mean values
was just significant at the .005 level in the regression analysis, in which
no other factor affected ESS score.
The score for sleep disorders, in the scale 0-5, resulted in a mean
value of 1.28 (SD: 0.73) in SW and 1.10 (SD: 0.61) in NSW (see Figure
1). Such factors as shift working condition, seniority in police, female
gender and BMI increased the SD score with high statistical significance, (Table 1), while age did not. When the regression analysis was
performed separately for different working conditions, the SD score in
NSWs was influenced by seniority, gender and BMI, while in SWs only
seniority in shift work showed a significant influence (p<0.002, see Figure 2). The difference in SD score between SW and NSW was further
explored by looking for values greater than 2 (cutoff value). Eighty
Eight SW (14.4%) and 48 NSW (7.2%) exceeded this value.
Details about the different types of sleep disorders are reported in
Table 2 and in Table 3, in which the cutoff value of 2.5 has been applied
for each type of sleep disorder. Shift workers revealed a prevalence of
insomnia (25.9% SW vs 15.8% NSW), hypersomnia (4.9% SW vs 2.2%
NSW and PLMD-RLS (8.5% SW vs 4.2% NSW). Signs of breathingrelated disorders were evenly distributed in the two groups (13.3% SW
vs. 11.7% NSW).
When the regression analysis was repeated for each type of sleep dis643

Sleep Disorders in Shift WorkersGarbarino et al

Table 1Factors affecting sleep disorder score evaluated by linear regression analysis
Sleep disorders score
Whole model
Source
Age
Body mass index
Gender (0,female/1,male)
Seniority
Shift work (0:no/1:yes)
Seniority

Total
F=23.62
Relationship
+
+
+

<.0001
P value
0.5
0.003
0.0004
0.0002
<0.0001

Shift workers
F=11.2
<.0001
Relationship
P value
+
0.8
+
0.32
0.12
0.95
+

Non-shift workers
F=17.31
Relationship
+
+

<.0001
P value
0.25
0.001
0.0005
0.0023

0.002

The analysis has been performed for the whole group and then repeated for the two subgroups. The first row reports the result for the whole model and shows the F-statistic. The other rows indicate the influence of each factor and report both the type of the relationship (positive or negative correlation) and the significant level resulting from
the t-statistic. The significant effects with the threshold set at p<0.005, are highlighted in bold.

Table 2Prevalence of sleep disorders in the sample

Type of sleep disorder

Insomnia
Breathing d.
Limb movements
Hypersomnia

Shift workers

Non-shift workers

#
158
81
52
30

#
106
78
28
15

%
25.9
13.3
8.5
4.9

%
15.8
11.7
4.2
2.2

Total
#
264
159
80
45

Hypersomnia
%
20.6
12.4
6.3
3.5

#
24
21
12

%
1.9
1.6
0.9

Limb
movements
#
41
35

%
3.2
2.7

Breathing
disorders
#
%
65
5.1

The presence of indicators of a particular type of sleep disorder (insomnia/ breathing disorders/ limb movements / hypersomnia) was assessed by setting a threshold on the
sleep-disorder scoringas described in the text. Left: Prevalence of each type of sleep disorder: comparison between shift workers and non-shift workers. The difference as evaluated by chi-squared test - was significant for insomnia (p<0.0001), limb movements (p<0.005) and hypersomnia (p<0.02) but not significant for breathing disorders.
Right: association of sleep disorder types in the whole group: counts of simultaneous presence of each pair. The percent values are all relevant to the whole group.

order, the shift-working condition turned out to influence all types of disorders (p<.0005). Seniority and gender had a fair influence on insomnia,
PLMD-RLS, and breathing disorders (p<.01) with greater scores in
females than in males, while BMI was highly significant only for breathing disorders (p<.0001). A remarkable influence of shift-work seniority
in SW was found for insomnia and PLMD-RLS (p<.001), while no other
significant factor was found for hypersomnia.
The relationship between SDS and ESS score has been evaluated by
means of the Pearson correlation coefficient, which was 0.50 for SW and
0.40 for NSW, with a global value of 0.44. All these values are associated with highly significant correlations (p<.0001).
Nearly half of the subjects, 309 SW (50.6%) and 294 NSW (43.9%),
reported accidents at home or while working or driving. Among these
subjects, 69 SW (11.1%) and 36 NSW (5.4%) declared that the accident
could be ascribed to sleepiness. The logistic regression analysis showed
a significant relationship between occurrence of an accident and age,
with younger people having a higher probability of having an accident
(p<.003, odds ratio = 0.94). A stronger relationship was found between
the occurrence of a sleep-ascribed accident and the shift-working condition with SW having higher probability of having a sleep-related accident (p<.0005, odds ratio = 2.24). When the regression analysis was
repeated after replacing previous regressors with ESS score and SDS, no
influence was detected on general accidents, while a strong influence of
SDS was detected for sleep-ascribed accidents (p<.0001). In fact, when
we classified the subjects according to signs of sleep disorders (SDS >
2) or excessive sleepiness (ESS score > 10), we could not find significant differences in the global occurrence of accidents, but we did find a
significant increase in the occurrence of sleep-ascribed accidents, in particular associated with the presence of sleep disorders (see Table 4).
Among workers participating in the survey, 8 SWs (6 males and 2
females, mean age 35.5 years, SD: 4.3) applied to the center for sleep
medicine, while no NSW applied spontaneously to the center. In all SW,
the clinical examination suggested the presence of sleep disorders. They
were evaluated again by the ESS, which indicated high values of daytime sleepiness (ESS score > 12). The analysis of polygraphic data
revealed the presence of obstructive sleep apnea in 4 subjects (males)
with a number of apneas or hypopneas per hour ranging from 20 to 50.
Two subjects (one male and one female) showed a long sleep latency
(more than 40 minutes) with a lot of lower-limb movements before sleep
onset and repetitive and stereotyped periodic lower-limb movements
SLEEP, Vol. 25, No. 6, 2002

during sleep (number of movements/hour higher than 25) without

breathing disturbances. In 2 subjects (one male and one female) long
sleep latency, frequent awakenings, and low sleep efficiency (total sleep
time/total recording time under 75%) were found without evidence of
either breathing disorders or periodic movements.
DISCUSSION
When measured by ESS score, the prevalence of excessive sleepiness
in the group of police officers analyzed in this study was approximately
9%-10% and was close to the values found in other groups of workers.32,33 Contrary to our expectations, we did not find higher values of
ESS score in SW than in NSW. Nevertheless, the score evaluating the
presence of sleep disorders was significantly higher in SW and strongly
influenced by seniority in shift work. The correlation between ESS score
and SDS was statistically highly significant, but the correlation coefficient was not high, thus indicating that only a small part of the variance
was common to the two measures. The fact that SW reported sleepascribed accidents more frequently than NSW suggests that ESS score
could have underestimated sleepiness in this group of subjects. The role
of ESS score in the evaluation of excessive daytime sleepiness is subject
to dispute.34-37 The main criticism to ESS scoring concerns its subjectivity; the ESS score would be an evaluation of the subjective complaint of
feeling sleepy more than a reliable measure of sleepiness and could be
influenced by confounding factors, including gender, psychologic factors and subjective perception of tiredness.35,38 In this sample of SW, particularly stressful work and responsibility might induce police officers to
underestimate the possibility of falling asleep, or perhaps it might actually help them maintain a high level of vigilance in many conditions.
Their tasks may also make policemen less willing to report sleepiness,
although subjects remained anonymous. More importantly, police officers may be less willing than most to report accidents. However, our data
report many cases of sleep disorders in SW and suggest that irregular
sleep-wake schedules, associated with stress, may produce sleep disorders and also cause latent intrinsic sleep disturbances to emerge. In this
way, sleepiness, either underestimated or overcome by stress, might
reappear as a result of prolonged sleep disorders and cause sleepascribed accidents.
The set of items for the evaluation of sleep disorders was not considered as a diagnostic tool in the same way as are other - more extensive
644

Sleep Disorders in Shift WorkersGarbarino et al

Table 3Distribution of subjects by number of sleep-disorder types simultaneously present (Num. of sd)

Num. of sd
0
1
2
3
4

Shift
Workers
#
393
144
50
19
5

%
64.3
23.6
8.2
3.1
0.8

Non-Shift
Workers
#
493
133
37
4
2

Total
%
73.7
19.8
5.5
0.6
0.3

Hypersomnia

#
886
277
87
23
7

%
69.2
21.6
6.8
1.8
0.6

#
13
14
11
7

%
1.0
1.1
0.9
0.6

Limb
Movements
#
%
22
1.7
35
2.7
16
1.3
7
0.6

Breathing
Disorders
#
73
58
21
7

Insomnia
%
5.7
4.5
1.6
0.6

#
169
67
21
7

%
13.2
5.2
1.6
0.6

Left: comparison between shift workers (SW) and non-shift workers (NSW). The difference between SW and NSW - as evaluated by the chi-square test applied to the 2x5
contingency table - was significant (p<.0002); Right: prevalence of each sleep-disorder type (insomnia/ breathing disorders/ limb movement / hypersomnia) by the number of
sleep-disorder types simultaneously present. The percent values are relevant to the whole group.
Table 4Number of generic and sleep-ascribed accidents in police officers
Generic accidents
ESS
Low
High
p>2

539
64

Sleep-ascribed accidents
ESS
86
7.5 %
18
14.9 %
.005

SDS
46.5 %
52.9 %

528
75

.18

46.2 %
55.2 %
.05

SDS
67
37

5.9 %
27.2 %
<.0001

The accidents are classified by the Epworth Sleepiness Scale (ESS) and the Sleep Disorder Score (SDS). The selected thresholds were > 10 for the ESS and > 2 for the
SDS. The nominal significant levels are reported for descriptive purposes. The percent values are relevant to the high/low score group.

Sleep disorders in shift workers

Shiftworkers

Non-shiftworkers

25

% Frequency

20
15
10

5
0
0.25

0.50 0.75

1.00 1.25 1.50 1.75 2.00 2.25 2.50

sleep disorders score

2.75 3.00 >3.0

Figure 1Percent distribution of sleep disorder score in shift workers (black) and non-shift workers (white). Lower scores are more frequently present in non-shift
workers and higher scores in shift workers. The difference between SW and NSW as evaluated by the Kolmogorov-Smirnov two-sample test was significant
(p<.002).
questionnaires, like the Sleep Disorders Questionnaire.39 The SDS supplied a quantitative evaluation of the presence of signs of sleep disorders
enabling intersubject comparisons. Following this approach, the a-priori
thresholds, set for global and specific sleep disorders, do not discriminate definite pathologic conditions but select subjects in whom some
signs of sleep disorders could be important, both as a general sleep disruption and for each particular type of disorder. Our results indicated that
this SDS and the following classification into sleep-disorder types could
highlight some important effects of shift working on sleep.
A remarkable presence of indicators of sleep disorders, associated
with seniority, was also found in NSW, although it was less extensive
than in SW. We have considered the hypothesis that these disorders
could be partially associated with a past experience in shift working, in
a substantial portion of NSW. Unfortunately, individual data about past
experience were not collected in this survey. However, other studies support the hypothesis that shift-work experience has a prolonged effect on
sleep.17 This past shift-work experience, along with more monotonous
tasks and a self-selection process, could also contribute to the slightly
SLEEP, Vol. 25, No. 6, 2002

higher values of mean ESS score in NSW than in SW.

Previous studies that analyzed data from a large and heterogeneous
group of French workers17,40 pointed out the increase of sleep disorders
in relation to age, female gender, and shift working. However, they did
not find a significant relationship with shift-work duration. On the contrary, we have found a significant influence of working and particularly
shift-working seniority that hid the effect of age. We suppose that this
effect was related to the homogeneity of our sample, in which age and
seniority are strongly correlated, but seniority includes the additional
effect of stressing work and fast-rotating shifts that progressively disrupt
sleep. The small variations of age within a fixed seniority did not show
significant effects, while small variations in seniority within a fixed age
did. In such situations seniority seemed to explain totally time-dependent increase of sleep disorders, probably absorbing the effect of age.
As to sleep disorders, indicators of insomnia prevailed and were significantly influenced by shift-work condition and seniority; the same
factors affected the presence of signs of PLMD-RLS, which were less
frequent, and also the presence of signs of hypersomnia, which were
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Sleep Disorders in Shift WorkersGarbarino et al

Trend of sleep disorders score in shiftworkers

2

SD-score

1.75
1.5
1.25
1
0.75
0.5
0

10
15
Shiftwork seniority (years)

20

25

Figure 2 Mean values of sleep disorder score are plotted across shift-work seniority in shift workers. Subjects were sorted by seniority and grouped in 5% quantiles: the data points represent the mean value of sleep disorders score for every quantile and the vertical bar indicates the pooled standard error.

rarely found. Breathing disorders were rather frequent and, as expected,

they were significantly influenced by BMI, though their presence
increased in connection with shift-working condition and seniority. In
fact, these relationships were also conditioned by the fact that in many
cases different types of sleep disorders were detected simultaneously.
Though signs of insomnia were mostly detected alone, they were sometimes associated with other sleep disorders. Signs of hypersomnia and
PLMD-RLS were mostly detected in association with other types of disorders and suggested the presence of an extensive sleep-wake disturbance.
The recordings from the small group of subjects who applied spontaneously to our sleep medicine center could not be directly related to the
questionnaires as these latter were anonymous. However, at the clinical
investigation, all these subjects reported sleep disorders and daytime
sleepiness according to the ESS. All these subjects were SW and in all
cases polygraphic recordings confirmed the presence of intrinsic sleep
disorders. This was a limited and possibly biased check, which however
confirmed the presence of objectively important sleep disorders in SW.
Our data showed a remarkable presence of sleep-ascribed accidents,
which was significantly higher in SW and was in association with higher SDS. This fact suggests that sleep disorders, and probably also an
insufficient awareness of potential sleepiness of SW, could be an important risk factor for sleep-related accidents. Further information about the
actual type, seriousness, and timing of accidents is not available in this
survey, but it could be useful. Yet, the relevant point in our data is the
relation between vigilance level and accidents in SW, while the actual
consequences of such accidents may depend on various external factors.
Nevertheless, as in the case of sleep-related vehicle crashes,41 the
seriousness of sleep-related accidents may well be greater than that for
accidents caused by non-sleep factors.
The risk of accidents at work is much more relevant for SW like
police officers who, in order to guarantee community safety, must
engage in tasks that feature high levels of performance and stressful
working conditions.
Our research study should alert occupational health physicians of
possible undetected intrinsic sleep disorders that worsen health problems
and increase the risk of accidents in SW.

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Sleep Disorders in Shift WorkersGarbarino et al