●Individuals who work night shifts commonly experience difficulties with both sleep and alertness at desired times, and shift work is increasingly recognized as a risk factor for a variety of adverse health outcomes, including diabetes, cancer, and cardiovascular disease. (See 'Introduction' above.)
●While some shift workers show circadian adjustment to their work schedule, most do not. Up to one-third of shift workers report regular, persistent complaints of insomnia and/or excessive sleepiness that meet formal criteria for shift work disorder (SWD). (See 'Diagnostic criteria' above.)
●Shift workers generally have severely reduced total sleep time over a 24-hour period compared with non-shift workers, and they commonly report difficulty with sleep initiation and maintenance. Disturbances during wakefulness include excessive sleepiness, impaired cognitive function, decreased psychomotor functioning, and altered social and emotional functioning, leading to an increased risk for accidents. (See 'Clinical spectrum' above.)
●The evaluation of shift workers who complain of sleep or wake disturbances includes a comprehensive sleep history, risk assessment, and objective assessment of sleep-wake patterns. Sleep logs and actigraphy are the primary tools used to objectively determine sleep-wake patterns over an extended period (ideally two weeks). (See 'Evaluation and diagnosis' above.)
●Minimum measures to improve sleep after a night shift include a regular sleep schedule (ie, anchor sleep), light-blocking shades, and ambient noise control. If family or social responsibilities prohibit one seven- to nine-hour sleep period, a regularized three- to four-hour morning "anchor" sleep with a second variably timed sleep period is recommended. (See 'Sleep scheduling' above and 'Improving daytime sleep' above.)
●Pharmacological interventions for sleep include short-acting benzodiazepine receptor agonists and melatonin. The newer orexin receptor antagonists may also be considered. Risks of carry-over sedation should be discussed and monitored when any hypnotic is used. Importantly, optimizing daytime sleep does not eliminate sleepiness during the night shift, and additional measures are needed to mitigate the risk for accidents, particularly in patients with circadian misalignment. (See 'Hypnotics' above and 'Exogenous melatonin' above.)
●Behavioral strategies to improve sleep in shift workers include sleep scheduling (including naps) and cognitive behavioral therapy. (See 'Cognitive behavioral therapy for insomnia' above.)
●Naps (less than one hour) before and during the night shift can improve alertness; caffeine intake during the shift can also help. (See 'Naps' above and 'Caffeine' above.)
●For individuals with excessive sleepiness during night shifts who desire pharmacotherapy, we suggest armodafinil or modafinil (Grade 2B). The observed benefits in randomized trials have been modest, however, and side effects may outweigh benefits in some patients. (See 'Wake-promoting agents' above.)
●Shift workers are at greatest risk of accidents during night and early morning shifts when circadian alertness is minimal. These and other safety issues should be reviewed with patients regularly. (See 'Safety issues' above.)