Sleep Management User's Guide

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SLEEP MANAGEMENT USER'S GUIDEFOR SPECIAL OPERA TIONS PERSONNEL

DTICELECTEAUGJ,0 19931

P. NaitohT. L. Kelly

IIReport No. 92-28

93-18338Approve(d for public release distributiol) knlilililiitid

NAVAL HEALTH RESEARCH CENTERP.O_BO X 85122

SA N DIEGO, CALIFORNIA 92186-5122NAVAL MEDICAL RESEARCH AN D DEVELOPMENT COMMANDBETHESDA, MARYLAND


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Sleep Management User's Guidefor Special Operations Personnel

Paul NaitohTamein Lisa Kelly

iRaval Health Research CenterPhysiological Performance and

Operational Medicine DepartmentSpecial operations Division

P.O. Box 85122-_ __San Diego, CA 92186-5122 (Cll! oNTIS CR&

AvdPCIdld

o'rIC QUALITY IN'SPECT~ED 3Report No. 92-28, slupported by the Naval Medical Research and DevelopmentCommand, Department of the Navy, under work unit 62233N MM33P30.002-6005. Theviews expresoed iLn thio article are those of the authors and do not reflect theofficial policy or position of the Department of the Navy, the D~rep3a-- nent ofDefense, or the U.S. Government. Approved for public release; distribu..'ion isunlimited.


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Table of ContentsPage

SUMMARY ............................... ................................ 3SLEEP MANAGERS' QUICK REFERENCE --- KE Y FACTS AN D RECOMMENDATIONS.... 4SECTION 1 BACKGROUND AN D PURPOSE .................. ................... 7SECTION 2 SLEEP AN D SLEEP DEPRIVATION ............... ................ 8SECTION 3 SUSTAINED OPERATIONS AN D SLEEP MANAGEMENT ..... ......... 11SECTION 4 PERFORMANCE DEGRADATION ............... .................. 14SECTION 5 SLEEP MANAGEMENT IN FIELD TRAINING ........ ............. 19SECTION 6 SLEEP TRAINING .................... ....................... 25SECTION 7 DRUGS .......................... ........................... 26SECTION 8 THE EFFECTS OF LIGHT ............... .................... 29SECTION 9 CONCLUSIONS/SUMMARY ................. .................... 30

APPENDICESAPPENDIX 1 - SLEEP LO G ....................... ........................ A-IAPPENDIX 2 - NAVHLIHRSCHCEN MOOD SCALE ............. ................ A-3APPENDIX 3 - PLUS 7 TASK TABLE ................. .................... A-5APPENDIX 4 - SLEEP QUESTIONNAIRE ................. ................... A--7APPENDIX 5 - MISSION EXAMPLE ................... ..................... A-i1

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Summary

Sleep management is th e study of sleep, its effects on personnel, and methods tosatisfy sleep requirements under demanding work schedules. Sleep logistics isth e application of sleep management to military operations. The objective ofsleep logistics is to ensure that fighting men and women at all levels obtainsufficient sleep to maintain combat effectiveness. In the past, major battlesusually occurred during th e day due to th e limitations of night visibility andunreliable equipment (which inhibit target detection and classif icationcapabili t ies). Technological advances diminish these obstacles, such that combatcan occur both day and night. Sleep loss can result, making sleep logistics animportant issue. Special warfare missions frequently involve night work andarduous o'>_rational schedules. This user 's guide explains selected sleepmanagement techniques for use during military operations, with particularemphasis on special operations missions. The guide will assist field commandersin using sleep logistics to prevent compromise of mission accomplishment due tosleep deprivation. It also provides basic information about th e need for sleepand consequences to behavior and mood when that need goes unsatisfied.Additionally, the guide provides techniques for assessing severity of sleep debtand compensating fo r its ill effects. The maost important steps to be taken foreffective sleep management are to : a) prepare a work/rest-sleep plan to meetsleep needs; and b) employ self-diagnostic techniques to detect and compensatefor the effects of sleep debt. Key facts and recommendations fo r sleepmanagement ar e l is ted, along with countermeasures to the effects of sleep loss.

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SLEEP MANAGERS' QUICK REFERENCF -- KE Y FACTS AND RECOMMENDATIONS

Degrading effects of sleep loss on performance, moous, andmotivation to work are felt most strongly during th e daily circadiantrough, as detined by body temperature. The circadian trough occursbetween 0200 and 0600 of th e time zone to which th e body is adapted.There is a significant loss of performance efficiency when anoperation demands a longer-than-24-hour continuous work episode(CWE). After a CWE of 36 hours, target detection is 70% anddecoding is 50% of baseline.Uninteresting and complex tasks are more seriously affected by sleeploss than interesting and/or simple tasks.Critical bu t routine tasks are often skipped, since sleep lossreduces overall willingness to respond.Physical work feels much heavier with sleep loss because ofexaggerated perceptions of physical exertion.Short-term memory is seriously affected. Poor short-term memory andlapses in attention work against effective communication. Sleeploss can cause a listener to forget what was recently said in aconversation. A listener may fill the information gap byinaccurately restruccuring the conversation.The ability to initiate action decreases with increasing sleep debt.This decrease in initiative includes all interactions among teammembers.Sleep-deprived individuals tend to overestimate their ability toperform tasks. They lose insight as to how well they are performingtheir assigned tasks.

Sleep loss causes deterioration of personal hygiene.* Often, higher ranking personnel are more likely to go without sleep

because they feel their duties are th e most critical and cannot befulfilled by others. Paradoxically, this sense of duty can resultin performance impairment, compromising th e very goals they soughtto achieve by denying themselves sleep.Sleep loss can be measured by the use of sleep logs to quantitatethe amount and timing of sleep and by th e use of a mood scale andthe plus 7 task to quantitate the impact of sleep loss.Uninterrupted sleep is more restorative. Avoid interruptions (e.g.,employ bladder prior to attempting to sleep).Optimize your circadian rhythms by following a regular scheduleevery day.* loep can bo improved by: following a regular nighttime routine,avoiding caffeine to r several hours before bed, avoiding excessive


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alcohol, avoiding tobacco, not becoming dependent on sleepingmedications, using muscle relaxation techniques, developing apositive att i tude about sleep and doing your worrying somewhereother than bed.

Suggestions to limit sleep deprivation during an operation are listedbelow:* Resting i! no t sleeping. It is th e amount of actual sleep that

counts.* Partial sleep deprivation over multiple days has a cumulative

effect .* We may be able to store up a little extra sleep taken ahead of time.

certainly, do no t begin a prolonged operation already sleep-deprived. However, sleep periods of over 10 hours should beavoided.

* Taking naps can interfere with nighttime sleep. However, naps arebeneficial when insufficient sleep is othierwise not available.

* Physical signs of serious sleep loss are: vacant stare, "glazed"eyes; pale skin; body sways upon standing, sudden dropping of chinupon sitting; intermittent lose of hand grip strength; walking intoobstacles and ditches; poor personal hygiene; very slow heart rate;loss of interest in surroundings; slurred speech.

* Train to be an effective sleeper and learn techniques to help inducesleep under unusual and stressful conditions.

Get as much sleep as possible before an operation. Avoid incurringa sleep debt before th e start of an operation when sleep may belimited.

* Try to sleep at least four to five hours in a single, unbrokenperiod each 24 hours. This amount of sleep should be adequate tomaintain maximum performance fo r a month or longer.

* During military operations where sleep is limited, use everyopportunity to take naps (preferably greater than 20 minutes).Napping is usually beneficial in maintaining task performance.However, be aware that awakening from naps may be accompanied bysleep inertia . Allow enough time (five to ten minutes) to overcomethis before beginning activities.

S IUse diagnostic aids, such as a sleep/activity diary, a mood scale,and th e Plus / Task, to obtain a realistic measure of sleep debtseverity.

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If sleep deprivation cannot be avoided, be aware of and plan fo r itseffects:* Know th e individual sleep loss tolerances of th e personnel under

your command.* Realize that self-observation deteriorates with sleep loss. Combatunit members may be unaware of significant impairment, so

insti tution of countermeasures should be based on th e known degreeof sleep deprivation, no t on whether people feel they need them.

* Allow more time than usual fo r completion of all activities.* Assign th e most sleep deprived individuals to self-paced,

interesting, and/or easy jobs. Critical activit ies may require increased numbers of personnel.* Effective communication will require increased effort . Alwaysconfirm orders by repeating them aloud, and as sleep loss

progresses, write orders down.* Be aware of circadian rhythms. All sleep loss effects will be worst

during the early morning hours (of th e time zone to which you areadapted).

* Physical activity may temporarily counteract sleepiness, butactivities will seem more difficult than usual, and sleepiness andfatigue will be increased afterwards.

* Sleep may be stored to some extent, thus longer than usual sleepperiods (but less than ten hours) may be beneficial.

* Early bedtimes produce better results than la ter rising to increasesleep period.

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SECTION 1 BACKGROUND AND PURPOSEThis user's guide explains the principals and applications ot sleep

management.

1.0 Background and ProblemsSleep management fo r military personnel (sleep logistics) was developed

roughly 30 years ago by Lieutenant Colonel Harold Williams of th e Walter ReedArmy Insti tute of Research. Sleep logistics, which includes work/rest-sleepplanning, is of serious concern when personnel must work without sleep for morethan 24 hours under conditions of decreased or disrupted sleep, particularly atnight.

All levels of military personnel may be subjected to such stressful workschedules: those on th e front line, those involved in resupplying the frontline, and those participating in special missions. Historically, major battleswere often limited to daylight hours because of poor night visibility andunreliable equipment. With improved technology, these problems have decreased;as a result , personnel may be required to fight both day and night.

Behavioral problems associated with sleep loss during military operationsare well documented. George E. Marshall 's observation during th e NormandyOperation in World War II accurately describes these problems: disorientation,overwhelming sleepiness, and inability to give and receive orders due touncontrollable lapses in attention and poor memory. Sleep logistics has beenproposed as a means of preventing these problems by way of work/rest-sleepplanning.1.1 Purpose

The purpose of this user 's guide is to provide basic information fo r fieldcomunanders about th e need fo r sleep and consequences to behavior and mood whenthat need goes unsatisfied. The user 's guide outlines the best availabletechniques fo r preventing excessive sleep loss, determining th e severity ofsleep debt, and countering th e ill effects of sleep loss so that militaryobjectives can be achieved. This user 's guide is based upon two decades of sleepresearch conducted by the Naval Health Research Center (NAVHLTHRSCHCEN), SanDiego, California.

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SECTION 2 SLEEP AND SLEEP DEPRIVATIONSection 2 describes th e normal sleep/wake cycle of human beings and reviews

th e effects of various disruptions to this cycle.2.0 Circadian Rhythms

Humans evolved as diurnal creatures. That is, people are designed to beactive during th e day &nd to sleep fo r a continuous seven- to eight-hour periodeach nint. Every aspect of each individual (physical and mental performance,mood, body temperature, blood pressure, pulse, etc.) shows a characterist icvariation over a 24-hour cycle. These 24-hour variations are called "circadianrhythms."

Generally, a person will work most effectively in th e afternoon and evening(1400 to 2000), although memory processes may peak somewhat earlier; this iscalled th e "circadian peak." The time of least effective work is in th e earlymorning hours (0200 to 0600), or th e "circadian trough." Figure 1 representsspeed and performance accuracy for a mental task over two days and nights withoutsleep. The subjects were Basic Underwater Demolition/Sea, Air, Land (BUD/SEAL)students who had successfully completed Phase 1 training. The physicalcharacteristics of this population closely resemble those of SEALs (Beckett etal., 1989). Fo r accuracy (percent correct), higher numbers represent betterperformance. Speed (reaction time) is presented as th e inverse (1/sec), so thathigher numbers represent better performance fo r this measure as well.

FIGURE 1

The data in Figure 1 illustrate two important points. First, performancevaries across th e day, with th e worst performances occurring during th e earlymorning hours (the usual sleep period). As subjects continue to work into th emorning and afternoon of th e second and third day, perforr~iances improves relativeto the preceding night, despite th e fact that sleep deprivation continues toprogress. Second, performance deter iorates as sleep deprivation continues. Whenperformance at th e same time on th e second day is compared to that of th e firstday, th e second-day performance is always worse. The worst performance occursduring the second late-night work period, when detrimental effects of workingduring the usual sleep period are compounded by effects of accumulated sleepdeprivation. In summary, people work best during daytime hours and w-st lateat night (between 0200 and 0600); both daytime and nightt ime performance can bedegraded when preceded by sleep deprivation.

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1130-1445- (n c i1730-2045 C C_

S1130- .

2330-TWU 0245- m 00530-0845-

1130

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17/30 (n

2045- ..1130 b

Speed (1/sec)

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2. 1 S leep___pr ivat ionSleep deprivation can be totol or partial. Total sleep deprivation

involves n1o sleep fo r 24 hours or more. In military operations, this can occurduring prolonged, intense operations. Often, higher rankinq personnel are morelikely to go without sleep because they feel their duties ac'e th e most criticaland cannot be fulfilled by others. Par.adoxically, this sense of duty can resultinl perfor-mance impairment, compromising th e very goals they sought to achieve bydenying themselves sleep.

Part ial sleep deprivation involves anything less than th e "usual" amountof sleep a given individual requires. Sleep requirements vary from person toperson, bu t th e average ideal sleep period is seven to eight hours each night.Must people can] restrict sleep to four to five hours per night fo r weeks (or evenmon~ths) without major effects on cognitive, physical, and motor performance,although mood and motivation may suffer. As sleep is cut back beyond this ,performance usually suffers. With special prolonged training, seone people havelearned to maintain performance on only three hours of sleep a day, divided intoseveral nap periods. Whether or no t this can be accomplished without prolongedtraini~ng has no t ye t been fully researched.

Sleep deprivation is cumulative. A little deprivation over many days ranadd up. A detailed description of signs and symptoms of sleep depr.ivation ispresented in Section 4.0.2.2 Np

Circadian rhythms apply to sleep as well as performance. Just as workper-formance is wor:st at night, sleep is least effective during th e day. That is,a given amount of sleep taken during th e day will probably be less recuperativethan th e same amount during th e night. Sleep is most effective when taken in asingle, continuous period rather than manly short naps; however, nap sleep can bevaluable. When total sleep deprivation is reduced to part-ial sleep deprivationvi~a naps, th e [ike.]. ihooo of improving performance, and therefore operationssucc~ess, is increased. There i~s evidence that people can, learn to napeffectively with pr'actice. It is important to be aware that "resting" is no t th esame as sleeping. Onl~y act~ual sleep can satisfy the body's need fo r sleep andr~everse thle effects of sleep deprivation. Merely resting, even in bed with eyesc:]osed, does nu t Lu I I.] the riced fo r sleep.2.3 Sleep_ Inire:t i. :

In daily rout in e , most peaopl.e do not: per form cr it ical opertat~ions uponawikeni ng . The body and mind ar'e aiccustomed to awakening gradual ly , eas ingj intothie day s act ivities. When people are requ Lred to perform act~ivities immediatelyupon aiwa ken inrg, there i.s of te i a le r iod of con fusion, sI.uqggi shnes s, and 1aw'k ofcuoordilnat.ioni. "'fh is po. t--sleep st. ate, usua Ily last i.ng ab~out: tivye mi nutesr, i s


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called "sleep inertia." Currently, no convincing evidence exists to indicatethat sleep inertia worsens at any part icular point in th e circadian cycle.Therefore, sleep inertia should no t impact on th e time of day a person sleeps.However , individuals who have already accumulated a degree of sleep deprivationmay show more severe or prolonged sleep inertia. Also, unusually pr'olonged sleepperiods (more than 10 hours) may be followed by a period of severe sleep inertia.

Unlike most civilian environments, combat may requirte part icipat ion incomplex and important behaviors immediately upon awakening. The possibility ofsleep inertia mast be taken into account in deciding when and fo r how longpersonnel may sleep. It must also be a determinant in assigning activities topersonnel who have just awakened (awake less than five to ten minutes).2.4 Jet Lag

The circadian rhythm of th e sleep/wake cycle attunes to the part of theworld where a person lives. When a person travels to a new time zone, his or herLnternai clock is out of synchronization with local time. For example, if aperson t ravels east from Los Angeles to Germany, the body clock (still on homebase time) will be nine hours out of synchronization with German time. Workingbetween 1100 and 1500 German time (normally an ideal time to work) means th e bodyand mind are working at 0200 to 0600 Los Angeles time (the circadian troughperiod and th e worst time to work). Under these circumstances, optimalperformances and moods cannot be expected. Adjustment to a new time zone isgradual, requiring a week or two fo r large shifts. Until adjustment is complete,signs and symptoms of jet lag will persist . During a period of jet lag, aperson may experience low energy, bleepiness during the day, irritability, andmoodiness. Reaction time and other aspects of performance may not measure up tousual levels. Headaches, intestinal upset, arnd difficulty in sleeping are likelyto occur. The latter caii, in turn, further aggravate jet la g symptomr.

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SECTION 3 SUSTAINED OPERATIONS AND SLEEP MANAGEMENTSection 3 defines sustained operations and aleep management.

3.0 0perational RelevanceMilitary operations can be prolonged. Short military operations may be

closely spaced, with little recovw!y time in-between. Participants in onemission or operation may have to assist in subsequent missions or operations,thus limiting their opportunity fo r rest and recovery. Tw o terms used whendiscussing such si tuat ions are "continuous work episodes" (CWE) and "sustainedoperations" (S[,SOPS). A CWE is a time period during which one works withoutpause fo r rest/s leep. Sustained operations contain one or more CWEs, and lastfo r more than 24 hours. Three primary factors have limited th e duration of CWEsin th e past: a) limited vision at night; b) equipment unreliability; and c)limited endurance. With improved technology, th e duration of CWEs is determinedprimarily by endurance, which is l imited primarily by th e need fo r sleep. Inotner words, th e duration of SUSOPS is determined by th e combat unit's endurance,no t by weapon or target reliability, weather, or darkness.

Along with one or more CWEs, most prolonged operations include relativelyquiet periods. Various levels of intensity characterize a battlefieldenvironment. Dist inct phases include movement to contact enemy forces, fighting,consolidation, regrouping, and resupply. Periods of intense, continuousfighting, with no chance fo r rest/s leep, are CWEs. Even on th e front l ine,where relatively quiet periods with opportunities fo r short periods of rest canoccur, one must always be ready to quickly resume fighting. A series of closely-spaced missions with intensive pre-mission planning and pi paration requirementscan approach a SUSOPS-type situation.3.1 Sleep Management

Sleep management pertains to techniques fo r optimizing sleep fo r those wh omust work under demanding shifts or continuous schedules. Its purpose i.,prevention of and compensation fo r deteriorating performance, moods, andmotivation caused by lack of sleep. Researchers in tho area of sleep managementare investigating new psychological, physiological, pharmacological, nutri t ional,and biochemical methods to remedy and counteract th e effects of sleep loss.

Sleep logistics is th e application of sleep management to militaryoperatLons -- ustablishing and requiring compliance to a work/rest-sleepschedule. Sleep logistics plans times and places fo r sleep in operations orclosely-spaced missions lasting a total of 24 hours or more. The objective ofsleep logistics is straightforward: fighting men and women, at all levels, musthave sufficient periods of quality sleep. They must be able to recuperate fromth e fatigue and stress of CWEs and maintain, both as individuals and as afighting unit , combat effectiveness during SUSOPS and other stressful schedules.

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3.2 Sleep Manaaement RecommendationsSleep management provides ways to reduce sleepiness and th e accumulation

of fatigue during CWEs. Using mission scenario operatiur. guidelines, periods ofavailable sleep and total number of possible sleep hours must be determined.Since changes in operational requirements are inevitable, it is recommended thatseveral work/rest-sleep plans be prepared fo r all phases of an operation; th ebest plan can be adopted fo r altered requirements.

Predeployment Phase. Many people tend to live under conditions of mildsleep deprivation, never getting quite as much sleep as they really need. Datasuggest sleep may be stored to some extent. Thus, th e week before a period ofintense work is no t th e time fo r personnel to put in late nights, either fo r workor fo r fun. Instead, longer-than-usual sleep periods (no more than 10 hours)would be beneficial . Early bedtimes produce better results than later risingt mes.

Also, personnel must become familiar with the surroundings and condit ionsunder which they will sleep. For example, some people may have to sleep inchemical-protective garments. If sleep in such unusual conditions is anticipatedin forthcoming operations, sleep management requires that personnel practicesleeping under these conditions during th e predeployment phase. Similarly, goodsleep managers wil l tr y out anticipated work/rest-sleep schedules before anoperation. Fo r example, if personnel will be working predominantly at nightduring a mission, it may be helpful to convert to a night-work/day-slaep cycle(relative to your destination time zone) for a period preceding deployment.

Deployment Phase. During th e deployment phase, sleep quality can bereduced by time pressures, traveling in uncomfortable vehicles, and changes intime zone and climate. Preplanned work/rest-sleep schedules should be adoptedand followed as closely as possible so that combat unit members may be fullycombat effective.

Pre-combat Phase. As discussed in Sections 2.0 and 2.4, th e body has acircadian rhythm associated with th e time zone to which it is adapted. Ifdeployment involves rapid transfer across more than one or two time zones, somedegree of jet lag will occur. When there is a week or more delay between combatzone arrival and actual combat, personnel cart adjust to th e new time zone.However, when there is no delay, it may be best to stay with th e work/rest-sleeppattern of th e home base. In that case, combat unit members wil l not tr y tc'adjust their circadian rhythms to local time. Possible techniques foraccelerating circadian adjustments will be discussed later in this manual.

Physiological and mental efficiency are influenced by th e degree ofadjustment or lack of adjustment to the local day/night cycle. For example,combat unit members working in th e afternoon by local time may physiologicallybe working at 0200 to 0600 hours by home base time. Thus, witho L adjustment to

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local time, daytime performance would be poor, since 0200 to 0600 hours is th ecircadian low point in performance efficiency. Leaders should be aware of thisinefficiency and plan th e workload accordingly.

Combat Phase. By using a work/rest-sleep plan, th e sleep manager canavoid a situation where all personnel are physically and mentally exhausted atthe same time. However, operational demands may prevent adoption of optimalwork/rest-sleep and shift-work plans, and personnel will often experiencesignificant sleep loss. Counterdegradation measures can help under thesecircumstances.

If th e operation requirements make sufficient sleep impossible, personnelshould take advantage of any lull in combat to nap. Effective napping meanssleeping, no t just resting.

Uninterrupted sleep fo r as little as 10 minutes may partially recoveralertness and help maintain job performance. However, th e risk of sleep inertiawith naps of less than ten minutes (sor. Section 2.3) must be acknowledged,especially during th e combat phase. The sleep manager must balance the negativeeffects of sleep (lost man-hours and sleep inertia), and th e positive effect(improved ability to perform a job after sleep).

Post-combat Phase. Immediately following an operation, combat unit membersshould be allowed to sleep for up to 10 hours. Longer periods of sleep are notdesirable, as they tend to cause severe sleep inertia (see Section 2.3) and delaygetting back to normal schedules. Sleep lost during th e operation need no t bereplaced hour-for-hour. After one or two long recovery sleep periods, durationshould be within the normal range fo r subsequent sleep periods. The sleepmanager should be aware that sleep inertia lasting longer than five minutes, andincreased susceptibility to naps may occur during th e week following SUSOPS.

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SECTION 4 PERFORMANCE DEGRADATIONSleep management will: (a) prevent degradat ion in performance, mood, and

work motivat ion by devising the best work/rest-sleep plan fo r any operation; (b)identify th e symptoms of sleep deprivation and increase combat unit awareness ofthose symptoms; an d (c) overcome degradat ion by reallocation of jobs an d useperformance aids.4.0 Identifying Signs and Symptoms of Performance Dearadation

The signs and symptoms of sleep loss are variable. Different people havedifferent susceptibilities, and manifestations may be intermittent. However, assleep debt accumulates, signs and symptoms will be more prevalent and willpersist . When these may appear in a given person depends no t only on th eaccumulated hours of wakefulness, bu t also on individual tolerance to sleep loss,types of tasks to be peLformed, severity of th e physical workload, and time ofday (o r point in th e circadian cycle).

Mood and Motivational Changes. Early symptoms of insufficient sleepinclude mood changes and decreased willingness to work. Combat unit members mayfeel less energetic, less alert, less cheerful, more irritable, increasinglynegative, and sleepy. Individuals who regard sleepiness an-4 mood changes assigns of weakness often deny negative moods and t iredness, but may admit todecreased positive mood. After prolonged sleep loss, combat unit members willpass from increased irritability and negativism to a sense of dullness andweariness.

Impaired Attention. With progressive sleep loss, attention span becomesshortened. Sleep-deprived individuals cannot concentrate on a job fo r longperiods of time. Intermittent, dreamlike, irrelevant thoughts or even brief"micro-sleeps" cause lapses of attention.Short-term Memory Loss. A common sign of sleep loss is th e inability torecall what one just saw, heard, or read. Memory loss is limited to recentevents or to short-term memory. A sleep-deprived individual often remainsconfident about retaining messages, events, or data, only to find later thatthese have been forgotten.

Variable and Slowed Responses. Under high work demands, th e best responsetime combat unit members can manage is affected only slightly by sleep loss. Theeffect of sleep loss on response time appears no t as a slowing down of allresponses, bu t as increased unevenness in response time. Some responses remainfast , while others become very slow. The danger of sleep loss is th eunpredictable failure or slowing down of appropriate responses.

Vision Il lusion/Hallucination. After more than 24 hours without sleep,some combat unit members may experience visual hallucinations. The prevalenceof these hallucinations varies; some people never develop these symptoms.Auditory i l lusions or hallucinations are rarely experienced.

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Failure to Complete Routines. Sleep loss causes carelessness toward suchroutines as drying feet, changing socks, or filling up canteens whenever waterbecomes available. Confirmation of verbal orders by repeating them aloud (thestandard operating procedure) becomes automatic, without effect , and eventuallydisappears altogether.

Impaired Task Performance. Effectiveness in performing assigned tasks issignif icantly lowered when CWEs exceed 24 hours. For example, after a 36-hourCWE, a combat unit may be able to perform only 50% of th e average messagecoding/decoding work output expected in a normal workday. Similarly, members ofa combat unit may be able to detect only 70% of incoming signals. Taskperformance is degraded due to impaired short-term memory; decreased ability toconcentrate; and intrusive, irrelevant, dream-like thoughts. Performance errorsmost frequently result from failure to respond to task demands (errors ofomission); however, inaccurate responses to task demands (errors of commission)also occur. Speed of reading written documents slows down. Comprehension isgood after sleep loss; however, combat unit members may experience difficulty inremembering th e directives in documents. Impaired performance follows acircadian rhythm. The worst performances occur during early morning hours of th etime zone to which th e person is adjusted.

Physical Exertion. Physical work performance is accompanied by asubjective feeling of physical exertion ranging from very l ight to verystrenuous. The perception of exertion also follows a circadian pattern. In th eearly morning hours, combat unit members may feel that more effort is requiredto work at th e same physical workload than if it were performed later in th e day.Sleep loss exaggerates this phenomenon so that combat unit members may want tostop work because of the increased sensation of physical exertion. However, onecan continue working without causing physical harm.Lack of Insight. In th e ordinary, non-sleep-deprived state, insights intoour own behavior coincide fairly closely with th e perceptions of others. If th einadequate performance of a combat unit member is corrected, that person willquickly remedy th e problem because he recognizes it. However, with sleep loss,th e power of self-observation deteriorates so that combat uni t members becomeunaware of performance problems and may no t even r(,cognize them when pointed out.

Failed Verbal Communication. Failed verbal communication is caused byattention lapses combined with impaired short-term memory. Serious consequencescan occur when field commanders are afflicted.

Since sleep-deprived individuals fail to remain continuously attentive toongoing discussions, their conversation may become fragmented, wander, andcontain repetitive phrases and ideas. Impatience and/or weariness due to sleeploss makes verb.il communication very difficult and tends to result inmisinterpretation. Members of th e combat unit are less likely to havemisunderstandings if they are asked questions with th e answers cross-checked.

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Failed verbal communications can cause orders to be ignored. A sense ofnumbness, omission of routines, arid impaired short-term memory can alsocontribute to ignoring of orders.

Bickering is a manifestation of irritability caused by sleep loss.However, bickering has one positive aspect: it shows that sleep-deprivedindividuals are still talking to each other, exchanging orders and messages. Thefrequency of bickering increases with increased sleep loss, up tc a point. Itdecreases when sleep-deprived individuals begin to have difficulty continuing totalk. As long as bickering continues, sleep-loss effects are no t severe. Asubsequent decline in overall message exchanges and th e amount of bickering isa symptom of serious sleep loss. When bickering decreases, especially after aperiod of increased bickering, individuals may be in a state of mentalxhaustion.

Signs of Jet Lag. As previously discussed, je t lag is commonly experiencedafter rapidly crossing three or more time zones. The physiological, performance,mood, and sleep effects of jet lag can compound th e effects of sleep deprivation.The presence or absence of jet lag must be considered when assessing th e statusof combat unit members.

Signs of shift-work Fatigue. Some work/rest-sleep schedules causeperformance degradations similar to those caused by sleep loss and jet lag. A"normal" work/rest-sleep schedule calls fo r an 8-hours-on/16-hours-off schedule(i.e., 8 hours on duty, 16 hours off duty, with about 7 to 8 hours of continuoussleep).

It is often necessary to use shift-work in a military operation, as th eavailable manpower pool is relatively fixed. Usually, th e simplest way to planfo r shift-work is to divide available manpower into two or three teams, whereeach team includes the supervision, skill-mix, and number of people necessary toaccomplish th e task. These teams rotate, providing workers around th e clock.With three teams, a basic 8-hours-on/16-hours-off schedule can be established.If only two teams can be formed, th e workload per team will go up (i.e., a 12--hours-on/12-hours-off schedule), and th e length of rest periods will be shortenedcorrespondingly. occasionally, non-24-hour cycles (e.g., 8-hours-on/8-hours-off)are necessary. However, such schedules can produce more stress and fatigue thanlonger shifts with sleep available at th e same time of day during each 24-hourcycle. The work/rest-sleep plan must balance th e demands of th e task to beaccomplished against th e fatigue (and resulting performance impairment.) expectedto accumulate. The physical signs of serious sleep loss are:

* Vacant stare - "glazed" eyes* Blood-shot eyes Pale skin Body sways upon standing; sudden dropping of chin upon sitting

Intermit tent loss of hand grip strength16


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* Walking into obstacles and ditches* Poor personal hygiene* Very slow heart rate* Loss of interest in surroundings Slurred speech

4.1 Preventing Performance DegradationSleep debt reduction best prevents fatigue-related performance degradation.

This requires a properly established work/rest-sleep schedule. If possible, atleast four to five hours of sleep (in a single, unbroken period) should occur per24 hours in a single, unbroken period. This is enough sleep to preventperformance impairment fo r over a month in th e average person.

There are large, stable, individual differences in tolerance to sleep loss.If one ranks a group of individuals in terms of tolerance to sleep loss (orability to work without sleep) from the highest to the lowest, this ranking willremain stable across various sleep-restricting operations.

Tiring easily is no t a personality weakness; th e abili ty to do withoutsleep is no t a learned trick. Some individuals are born as long-sleepers andothers as short-sleepers. Short-sleepers tolerate sleep loss well; long-sleepersdo not.

It is important fo r combat unit members to know their sleep loss tolerance.Some people may be overwhelmed by th e loss of one night 's sleep; some can takesleep loss in stride. The work/rest-sleep schedule will set an optimal patternfo r 'he average person. If a person is sensitive to sleep loss, they shouldsleep more frequently (nap), or fo r a longer period of time to lower th e rate ofsleep-debt accumulation. If a person is tolerant to sleep loss, they can remainawake a b it longer than the average person. However, everyone should be carefulof overconfidence in their abili ty to tolerate sleep loss. People succumb quitesuddenly to sleepiness when sleep loss continues beyond their tolerance,certainly when it exceeds 72 hours. Being aware of this prevents th ecatastrophic failure in job performance often seen among people who areoverconfident in their ability to ward off sleepiness.

Combat unit leaders are responsible to examine th e operation scenario anddetermine when and fo r ho w long combat unit members may be able to sleep.Leaders must ensure that enough of th e rest period entails actual sleep, sinceonly sleep can prevent sleep debt from increasing. Leaders must no t only knowtheir own tolerance to sleep loss, bu t that of all others ii-, their command.Combat unit members will suffer from imposed inaction and situational insomniawhen told to sleep when they a-e no t sleepy. Their restlessness may disturb th esleep of others in th e unit.

Usually,. in extended combat, involuntarily fall ing asleep is a more seriousproblem than situational insomnia or inability to sleep. However, field

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commanders should be prepared to deal with some individuals who cannot sleepduring th e pre-miss on and mission phases. Individuals who are poor sleepers ingeneral will have worse sleeping problems under the increased stress anddisruption before and during a military operation. Effective use of sleeptraining techniques can improve sleep under all circumstances. Sleep trainingtechniques are discussed in Section 6.4.2 Overcoming Performance Degradation

When signs of performance degradation begin to appear among members of acombat unit during SUSOPS, several preventive measures can be taken, such assetting aside time fo r naps, changing routines, or rotating jobs, if persornnelare cross-trained.The most sleep-loss--affected member should be allowed to do a task that canbe accomplished at a pace set by th e worker, no t by th e job. Sleep loss has lessimpact on self-paced jobs. Everyone should be encouraged to write down work tobe done or messages received, and have others check what has been written forclarity and legibility.

It is unlikely that two members of a combat unit will become incapacitatedby sleepiness at exactly th e same time. Teaming up to do a job, or creating th ebuddy system, is as valid a concept in SUSOPS as in SCUBA diving. The possibleuse of pharmacological agents is discussed in Section 7.

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SECTION 5 SLEEP MANAGEMENT IN FIELD TRAININGSleep management is just on e of many problems a field commander faces. As

th e unit goes through predeployment, deployment, and combat phases, sleepmanagement may appear to have a low priority when compared with other tasks.However, it is th e responsibi l i ty of th e field commander to se e that combat unitmembers comply with sleep management recommendations. If th e field commander isnon--compliant with sleep discipl ine, sleepiness and sluggishness may result inhazards to th e combat unit. The best wdy to remain alert and responsive tochanging tactical environments is to plan fo r sleep. Taking naps during SUSOPSis no t a sign of low fighting spirit or weakness; rather, it indicates foresight.5.0 The Work/Rest-Sleep Plan

The work/rest-sleep plan should ensure that sufficient hours of sleep areavailable to everyone during all phases of a mission (see Section 2.1). Sleepmanagement is part icular ly important during the predeployment or pre-missionphase, which tends to involve a heavy workload lasting over many days and weeks.Reduction of sleep to four to five hours per 24 hours does not cause seriousdegradation in cognitive task performances. Ideally, sleep mianagement shouldseek to provide a minimum of four to five hours per day fo r all unit members.If total sleep per 24-hour period must be reduced from a normal seven to eighthours to less than four to five hours, careful sleep management is needed.Anyone who sleeps less than four to five hours per day over an extended periodof time becomes more vulnerable to th e effects of circadian rhythms and t irednessafter eating. Irritability and mood changes may occur, and communication withothers may deteriorate. Jobs involving hard physical work wil l amplify th eundesirable effects of sleep loss.

During a deployment phase, it is important to provide environments whichfacilitate maximal sleep during rest periods. Sleep is facilitated by quiet,dark environments. Social interaction should be restricted, but reading with asmall lamp is acceptable. Sleep loss is cumulative. If personnel are able tosleep only two hours or less one day, quality sleep time should be made up bysleeping five hours or more th e next day; a key factor in sleep management is toavoid accumulation of a large sleep deficit.

In pre-combat and combat phases of an operation, it is unrealistic toexpect that four to five hours of unbroken sleep per 24-hour period will beavailable. If necessary, sleep can be ,aken in short periods of .0 to 30minutes. This method, however, is less recuperative than long blocks of sleep,so th e longest feasible periods should be allotted. If sleep must be broken intomany short periods, a longer total amount of sleep will be needed to achieve thesame degree of benefit.

Sleep management is usually no t considered necessary for the post-combat/post-mission phase, but plays a signif icant part in regaining combat

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readiness. This is especially important when another comhat mission phase isexpected to follow shortly. The first post-combat/post-mission sleep periodshould be allowed to extend either to spontaneous awakening or fo r 10 hours(whichever comes first). This first recovery sleep should be arranged so thatthere will be an awake period of 12 hours or longer before the next sleep period.Inadequate sleep management will delay re-adjustment to a routin3 work/rest-sleepschedule.5.1 Signs of Degradation

Review Section 4.05.2 Tolerance to Sleep Loss

Review Section 4.15.3 The Ability to sleep

There are many factors in th e field which tend to prohibit sleep.Sometimes combat unit members may no t want to sleep so as not to miss excitingevents. However, distractions must no t cause sleep to be shortened to less thanfour hours pe r 24-hour period. Combat unit members must be disciplined to takenaps. Napping is no t a time-wasting luxury, bu t is mandatory fo r maintainingperformance under conditions where opportunity for sleep is limited.5.4 Aids to Measure Sleep Loss

Three aids that can help a field commander apply sleep management duringa field exercise are: a) a sleep log; b) a mood scale; and c) th e "Plus 7 Task."

Sleep Lo . The best way to manage sleep in th e field is to keep a sleeplog. From th e predeployment phase to th e post-deployment phase, records of allsleep and nap periods should be kept. A record of total hours of sleepaccumulated over th e operation period should be included. Such a record willhelp to ensure that combat unit members are sleeping at leant four to five hourspar 24-hour period. If a sleep log shows that total hours of sleep (includingnap periods) are less than four hours per 24-hour period, the first availablelong rest period must be used for sleep.

If combat unit members have no t slept fo r 48 or inure hours, a sleep periodshould be two hours or longer, if at all possible. While any sleep isphysiologically better than none, sleep inertia may be worse after shorter napsin such sleep-deprived individuals. Also, the psychological difficulty of havingto awaken so soon can impact motivation negatively. This is especially importantif th e sleep period should fall from 0200 to 0600, th e circadian rhythm trough.The combined effects of a deeper circadian low (caused by sleep loss) and th esleep time being too short may cause personnel to feel they cannot go on.

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A sleep log can be very simple. Sleep managers can write down the lengthof time combat unit members have slept, or th e time sleep begins and the time ofawakening. It should also be indicated whether or no t combat unit members didmoderate or heavy physical work.

An example of a convenient sleep log is included in Appendix 1. The upperand lower parts of th e page represent th e front and back of a 5" x 8" index card.By adding up th e number of 30-minute boxes marked with a line to indicate sleep,it is possible to calculate the approximate amount of sleep that occurred in th egiven 24-hour period. If a sleep log card is filled out each day during anoperation, th e degree of accumulated sleep debt can be estimated at any time(Total Sleep/Number of Days = Sleep per Day; this should be at least 4 hours perday). Yo u should probably consider a given sleep debt more severe if th emajority of sleep has been taken in many small segments rather than a singlesleep period per 24 hours.

The questions on the front of th e card are phrased to fit a single sleeppe r 24-hour pattern, which may well no t be the case under operational conlitions.However, they indicate general types of information that may be valuable to sleepmanagers in making sleep logistics decisions.

Knowing how long it takes a person to fall asleep and whether that sleepis uninterrupted gives you a picture of how efficiently a given sleep period isbeing used. If someone has a two-hour period for sleep, bu t one hour is usedwaiting to fall asleep with repeated awakenings, then half th e possible sleeptime is wasted. In such a situation, the sleep environment should be improvedif possible. Also, the individual might conbider specifically training his sleephabits when he is ou t of the operational situation, to prevent such problemsduring future operations.

How rested a person feels, and whether there is a perceived need fo r moresleep, relate both to how restful sleep is, and th e severity of th e accumulatedsleep debt. The mood scale serves as an abbreviated estimate of th e more complexmood scale, should that no t be available. Hours of work in the last 24 hoursprovides an indication of how much sleep limitation is based on workload, and howmuch leeway there might be fo r additional sleep. The "Remarks" section can beused for recording the presence and quantity of physical exertion.

The sleepiness scale on the back of the card (lower portion of the page)measures sleepiness subjectively. The way we feel during the late morning andafternoon of a day following a good night 's sleep with no sleep deprivation inthe recent past, is represented by response (1). The way we feel in the middleof the night after many days without sleep is represented by response (7).Subjective sleepiness can be very helpful in assessing th e impact of sleepdeprivation. However, military personnel (perhaps particularly elite groups suchas SEALs) nviy be reluctant to admit feeling sleepy, considering it evidence ofweakness. Thi- caxi make the subjective sleepiness measure worthless. Sleep

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managers need to convince those under their commands of th e importance ofanswering this sleepiness scale objectively and honestly. With accurate answers,this scale can help assess whether a sleep plan is adequately fulfilling th esleep needs of personnel.

Mood Scale. A field commander should watch th e moods of combat unitmembers for early signs of accumulating sleep debt. Since leaders know thesepeople, they will probably be aware when their moods change from positive andenergetic to negative, jittery, and defiant.

A more objective means of determining how rapidly combat unit members'moods are changing is a mood scale, such as th e NAVHLTHRSCHCEN Mood Scale(Append.x 2). The NAVHLTHRSCHCEN Mood Scale consists of 19 positive and 10negative adjectives describing moods.

Once personnel become familiar with th e mood scale questionnaire, it willtake less than a minute to score positive and negative changes in mood. Thequestionnaire should be administered to combat unit members before an operationbegins, as well as while it is in progress. This enables th e field commander todetect subsequent increases in negative mood, and decreases in positive moods,by comparing with th e baseline phase.

Plus 7 Task. The effects of inadequate sleep can sometimes be masked whenpersonnel put forth extra effort toward their assigned tasks. This is laudableevidence of professionalism. However, this masking may be misleading and ma yprevent appropriate preventive measures. It may appear that sleep loss is notaffecting personnel; yet a short time later, combat unit members may show seriousperformance degradation.

Moderate physical work and excitement may also mask performancedegradation. However, during the post-physical-work period, combat unit memberswill show greater deterioration of cognitive performance. The combined effectsof physical work and sleep loss cause increased fatigue and sleepiness once th ephysical activation ind excitement wear off.

The best, way to detect early degradation in mental task performance,despite such masking, is to have combat unit members do an over-learned task ofa rather boring nature, such as th e "Plus 7 Task". The Plus 7 Task tests short-term memory, which is affected by sleep loss. It reliably detects mentaldegradation.

The Plus 7 Task consists of continuous additions. A random number betweenb and 9 (for example, 9) is picked. A short mental calculation is performed byadding 7 to th e number (9 f 7 -- 16). The calculation is performed again usingth e previous sum (16 A7 = 23). These additions are all done in th e head,remembering th e sum and calculating th e new sum by adding 7. When combat unitmembers can continue to do the Plus 7 Task correctly fo r one minute or longerwithout long pauses, they do not have severe sleep loss effects. If a part icularindividual is to be tested, th e individual should say thie sum aloud as it i.s

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calculated . The sleep manager should note how steady an d accurate thisindividual is in performing the task. Check the accuracy of the answers with atable listing a sequence of the correct sums (Appendix 3). However, moreimportant than accuracy is whether a person can do repeated additions withoutlong pauses. A few minutes of the Plus 7 Task, preferably with eyes closed, willreveal any mental degradation due to sleep loss.

As with th e mood scale, the Plus 7 Task must be administered prior to thestart of the operation to assess baseline performance. Testing shouldsubsequently be given at least once each 24-hour period, preferably several timesa day. A substantial decrease in th e total number of additions completed, aswell as increased number of long pauses or inaccurate additions, indicatesdeterioration.5.5 Sleep Facts

A combat unit field commander/sleep manager needs to understand sleep.Following are some basic facts about sleep:

* Resting on a bed is not th e same as sleep. During th e deploymentphase, many soldiers may be resting, bu t not sleeping, due toexcitement. Make certain that people are asleep, no t merelyresting.

* People typically become sleepy at least twice a day: once in th eafternoon and once during th e habitual sleep time.* There is evidence that a small amount of extra sleep can be stored

in our bodies. Sleeping a little longer than th e normal seven toeight hours (achieved by going to bed early rather than sleepinglate) before deployment may increase tolerance to subsequent sleeploss. However, th e important thing is no t to begin a prolongedoperation already sleep-deprived. Most people live in a chronicstate of mild sleep deprivation; therefore, th e main benefit ofsleeping a little longer during predeployment may be to counterexisting sleep deprivation.

* Excessively prolonged sleep periods (more than 10 hours) should beavoided, as they may cause exaggerated sleep inertia and aparadoxically increased feeling of sleepiness.

* To aid uninterrupted sleep, the bladder should be emptied beforeattempting to sleep. Waking up to urinate interrupts sleep, andgetting in and ou t of : bed can di~sturb others trying to sleep.

* During daytine or early morning naps, many people experience vividdreams an they afall asleep, often waking up frightened. To somesoldiers, th e dreamns may have a component of situational anxiety.Members of the combat unit should be reassured that vivid dreams arequite cnimuon in daytime slI eep.

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There are several stages of sleep: stages 1, 2, 3, 4, and rapid eyemovement (REM). Many Studies have shown that th e total amount ofsleep, not th e amount in a specific stage, is most important. Thebody will take care of th e type of sleep obtained, if sleep time isavailable.

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SECTION 6 SLEEP TRAINING

6.0 Sleep TrainingMany behaviors affect sleep. Most people will experience some degree of

sleep impairment when required to sleep under less-than-optimal conditions (e.g.,wrong time of day, noisy or uncomfortable environment, presence of emotionalstress). Anybody who starts out with poor sleep under ideal conditions is likelyto sleep especially badly under difficult conditions.

In a young, healthy population such as Navy SEALs, a normal sleeper canfall asleep within 20 minutes, sleep seven to eight hours without any sleepdisruption, and awaken in th e morning feeling refreshed and alert. If a personhas difficulty falling or staying asleep, or awakens in th e morning feelingpoorly rested, he or she is a poor sleeper and may suffer greater performanceimpairment during intense sleep-restr icting operations. All military teammembers should train themselves fo r optimum sleep. A questionnaire to determinecombat unit members, habits is included in Appendix 4.

Using sleep training techniques can improve sleep in general, and helpensure that individuals are well-rested with no sleep debt prior to deployment.In addition, th e sleeping skills developed through sleep training will enablepersonnel to use th e limited time that may be available fo r sleep during militaryoperations most efficiently. If th e sleep questionnaire indicates any sleepproblems, th e following tips will be helpful.6.1 Summary of Good Sleep Techniques

* Optimize your circadian rhythms by: getting up, eating meals,exercising, and going to bed at th e same time every day.

0 Use th e bed only fo r sleeping.0 Do th e same thing every night before bed. This should be a short

sequence of behaviors, starting before going to bed, and ending witha relaxing image to clear alerting thoughts from th e mind.

0 Establish a time and place for worrying other than at bedtime, anduse it every day.

0 Except during prolonged operations or before night Missions, do notnap. It is best to sleep fo r a set duration (ideally, seven oreight hours) at th e same time each night.0 Do not lie down during th e day. Do no t lie awake in bed fo r longperiods. Get up and do something boring to bring on drowsiness.

0 Avoid stimulants (coffee, caffeinated soft drinks, tea) after earlyafternoon. Avoid excessive alcohol. Avoid sleep-induclngmedications. Avoid tobacco produc"-s.

6 Learn a muscle relaxation technique.* Have a positive att i tude about sleep. Sleep is not just somemysterious event that happens to us; it is a behavior that can be

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SECTION 7 DRUGS7.0 Stimulants: Non-operational Us e

CaffeLne is a very potent stimulant drug. People who drink caffeinatedbeverages late in the day, after dinner, or close to bedtime generally haveimpaired sleep. They may have difficulty going to sleep or awaken easily duringthe night. They are often able to go to sleep, bu t the sleep is lightened by thestimulant. in this case, the person may no t be aware of a sleep problem, bu t maynot feel rested in the morning or may tend to get tired early in th e evening.If more caffeine is used to counter this fatigue, there will be further impairedsleep. It is important to remember that coffee is no t the only source ofcaffeine. Most soft drinks and te a contain caffeine, and even chocolate containsa stimulating caffeine-like drug called theobromine. Many medications alsocontain caffeine. A number of over-the-counter pain killers contain caffeine.All of these products should be avoided after early afternoon when working astandard daytime-work/nighttime-sleep schedule.7.1 Stimulants: Operational L'-e

When working under an unusual or SUSOPS--type schedule, it is no t unusualto use stimulant medications to tr y to counter the effects of sleep deprivationor circadian rhythms on alertness and performance. Such use should be controlledand carefully monitored. Most stimulants affect performance in a pattern knownas an inverted "U"-shaped curve. This means that they appear to improveperformance with increasing doses up to a point. But as th e dose is increasedfurther, p:lerformance starts to deteriorate and may even drop below baseline.Thus, drin'king 20 cups of coffee a day to tr y to counter sleep deprivationeffects may ',irther hinder performance because of jitters and nervousness.Another fa -, o consider is that many drugs hi ve less effect if consumedregularly. '..-utinely consuming large amounts of caffeine-containing products ma ydecrease the effects of caffeine when really needed.

There are stronger stimulants than caffeine available by prescription. Invery special limited circumstances, such medications might be used during amilitary operation. The most likely agents to be prescribed would beamphetamines, pemoline, or methylphenidate. It is no t ye t known which is th ebest agent. Pemoline has the advantage of being nonaddictive. In any case,medications should only be used under a doctor's direction.

If a stimulant (especially a strong one) must be used, a counteringmedication may be required later. For example, air crews who used stimulants toward off fatigue when returning from distant missions, have reported greatdifficulty sleeping afterwards. Interference with recovery sleep could impairperformance on subsequent missions. Thus, use of a stimulant may requiresubsequent use of a sedative -again, only under a doctor's direction,

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7.2 SedativesUnder most circumstances, sleeping pills are not recommended fo r military

personnel. In an operational situation, the risk of impairing criticalperformance is high. People are basically useless for the first four to sixhours after taking a sleeping pill. Some sleeping pills impair activity th efollowing day or even longer. Also, many sleeping pills suppress dreaming,causing less restorative sleep.

Even under non-operational circumstances, sleeping pills are notrecommended. Using sleeping pills over an extended period can cause dependency.Additionally, sleeping pills can decrease effectiveness of the sleep trainingtechniques discussed in Section 6.

One possible circumstance where sleeping pills might be appropriate formilitary use is with rapid transport, across multiple time zones. When personnelar e deployed to a distant location and need no t engage in critical work soonafter arrival, use of a sleeping pill to facilitate sleep during transfer, orpromote sleep synchronized with the new time zone after transfer, might decreasethe fatigue-related effects of je t lag. If effectiveness is demonstrated inscientific tests, new products may later become available to facilitate sleepwithout the side effects of sleeping pills.

Another possible situation where sedatives might be used is to allow sleepafter stimulant ingestion, as was discussed in the preceding section.7.3 Other Medications

Although nicotine is not an effective stimulant in general, those who ar eaddicted to it may perform less well when deprived of it. Also, when a smoker(or a smokeless tobacco user) is asleep, his body starts to go into nicotinewithdrawal. This often causes smokers to wake up during the night. Nicotine hasa very broad range of effects on the body, including the cardiovascular system.It is possible that some of these effects could interact in a negative or evendangerous manner with the effects of some military activities (e.g., diving).Addit ional ly, tobacco products, including smokeless tobacco, have well-established negative effects on health.

Alcohol can also cause sleep problems. First, as with any depressant drug,there is a n ,ed fo r more and more alcohol to induce sleep. Second, alcohol ismetabolized very rapidly. A few hours after consuming alcohol, the body beginsto withdraw from the effects, causing light,- sleep and a tendency to wake up.Third, alcohol suppresses dreamin9. Dreaming is a very important aspect ofsleep. Heavy alcohol users show chronic abnormalities in sleep. The deepesttype of sleep is lost, as is observed in th e very old, and a given period ofsleep will be less restorative. Once these changes have occurred, they ma ypersist, even after -1cohol is no longer being used.

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Most cold and allergy medications can affect either alertr.ess or sleep.Many antihistamines tend to cause sleepiness. There are antihiztamines that donot affect the brain (for example terfenadine or Seldane), but they are notcurrently available over the counter. If an antihistamine is needed, a physicianshould prescribe a non-sedating product. Most decongestants can prodiuce astimulant effect. If taken near bedtime, decongestants may impair sleep. Whenuncertain whether a particular product contains an antihistamine or adecongestant, consult a pharmacist.

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SECTION 8 THE EFFECTS OF LIGHTLight has two effects on alertness and sleep. First, there is a direct

alertino or energizing effect. When personnel are sleep-deprived, wcrking in abrightly lit area, preferably in sunlight, will help maintain maximumperformance.The second effect of l ight is indirect, via adjustment of circadianrhythms. Normally, everyone has a slight adjustment to his or her circadianrhythm each day. Curiously, the natural cycle of the internal circadjan clockis not actually 24 hours; it is closer to 25 hours. Therefore, withoutadjustment, people would gradually slide in and out of phase with th e world,experiencing periods of jet lag without going anywhere. However, various stimuliadvance the clock each day to keep the body cycling at 24 hours. One of th e mostimportant stimuli is bright-l ight exposure in th e morning, which can be employedwhen th e circadian rhythm needs more extensive adjustment, as in je t lag. Forexample, if you have flown eastward across six time zones, you now need to bewaking earlier and going to sleep earl ier relative to your previous time zone.Bright-light exposure during th e time period corresponding to morning in youroriginal time zone will tend to push your rhythm forward. With a six-hour shift ,this would correspond to th e early afternoon period (i.e., 0700 to 1000 in youroriginal time zone would correspond to 1300 to 1600 in your new time zone). Thisis th e time when one should get bright-l ight exposure to assist in adjusting toth e new time zone. Bright-light exposure during th e time period correspondingto evening in your original time zone, has th e reverse effect. Bright-light atth e wrong time tends to cause you to go to sleep and awaken later. Therefore,after an eastward f l ight, you would want to avoid evening light. After awestward f l ight, you should avoid morning light and seek evening l ight (again,remember, "morning" and "evening" are defined by your original time zone).Special artificial lights are becoming available to facilitate correctly timedbright-l ight exposure under conditions when natural sunlight is unavailable.Light visors and light masks to provide controlled, individual light exposure arecurrently being tested and may be helpful during transport, bu t we need moredefinitive studies.

Controlled light exposure can also be used to shift a person's circadianrhythm deliberately out of phase with local time. For example, someone who needsto work th e night shift might want to be as much as 12 hours ou t of phase withlocal time. This is possible with timed bright-l ight exposure. However, itrequires careful protection from bright-l ight exposure at the wrong time of dayand conformance to th e new sleep-wake cycle (i.e., you can't work the night shiftduring the week, play by day on th e weekend, and expect your body to be in phasewith your work schedule). Under controlled military conditions, this may bepossible. Exposure to artificial bright light could be used first to shift thecircadian rhythm to the new work/rest schedule and then continued (with dailytreatment during th e morning) to maintain synchronization with that schedule.

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Sleep research at th e Naval Health Research Center (and many other researchcenters), has concluded that:

1. A total sleep duration of four to five hours per 24-hour period isth e minimum amount required to maintain an acceptable level ofperformance (but with poor mood, fatigue, lowered motivation, andgeneral malaise).

2. A ll sleep stages contribute equally to recovery from sleep loss.That is, one sleep stage is as effective as another in removing th eundesirable effects of sleep loss.

3. It is preferable to sleep fo r a single, uninterrupted period ratherthan to take many short sleep episodes. However, short naps (20 to40 minutes) are better than no sleep at all.

4. The body and its functions are influenced by circadian rhythms.Sustained operations cause varying degrees of sleep debt, leading to

decreased combat effectiveness and hidden cost in manpower resources. Theprocess of removing sleep debt is quite similar to that for removing hunger.Hunger is eliminated by eating food; food logistics work scientifically to reducehunger. Similarly, sleep logistics (management) wil l work to reduce sleep debt.Sleep management guidelines can help evaluate and prevent th e degrading effectsof sleep loss on performance, moods, and motivation to work.

The most important steps to be taken in a non-pharmacologic approach tosleep management are summarized below:

* First , and most important, prepare a work/rest-sleep plan to meetsleep needs. Sleep needs are satisfied only by sleeping.

* Second, utilize appropriate self-diagnostic techniques andperformance aids to detect and compensate fo r sleep loss (sleepdebt).

Third, make sure personnel have good sleep skills that facilitateoptimum us e of opportunities fo r sleep before, during, and after anoperation.

Important points to remember about effects of pharmacological agents insleep management are summarized below:

* Any drug that helps keep you awake may prevent you from sleepingwhen you need to , and any drug that helps you to sleep may havehangover effects on performance.

* If a drug like caffeine is used repeatedly, it may have less effectthan if used only once.

0 Nicotine withdrawal can impair th e sleep of tobacco users.

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FURTHER READINGS


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NOTE: For ease of readability fo r users of this manual, references used inpreparing this manual are cited only in th e bibliography, and no t in th etext. Please contact th e authors at th e address given fo r furtherinformation about specific reference citations.

Beckett, M.B., Goforth, H.W., & Hodgdon, J.A. Physical fitness of U.S. Navyspecial forces team members and trainees. 1989. Technical Report No . 89-29.Available from: Naval Health Research Center, San Diego, California.Borbely, A. Secrets of Sleep. Basic Books, Ne w York, 1986.Bourke, D.H. The Sleep Management Plan. Harper, San Francisco, 1990.Coleman, R.M. Wide Awake at 3:00 A.M.: By Choice or by Chance. W.H. Freeman,Ne w York, 1986.Dinges, D. , and Broughton, R, , Eds. Sleep an d Alertness: Chronobiological,Behavioral, and Medical Aspects of Napping. Raven Press, 1989.Dotto, L. Losing Sleep: How Your Sleeping Habits Affect Your Life. WilliamMorrow, Ne w York, 1990.Horne, J. Why We Sleep: The Functions of Sleep in Humans and Other Mammals.Oxford University Press, Oxford, 1988.Meddis, R. The Sleep Instincts. Routledge & Kagan Paul, London and Boston,1977.Office of Technology Assessment. Biological Rhythms: Implications fo r th eWorker. Office of Technology Assessment, Congress of th e United States. OTA-BA-463, Washington, D.C.: U.S. Government Printing Office, September 1991.Scott, A.J., Ed. State of the Art Reviews Occupational Medicine: Shiftwork.Hanley and Belfus, Philadelphia, 1990.

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i , I II I I i, , .


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APPENDIX ISLEEP LOG

A-1

I, .nnnonpn'cn i, 'yhiltiiipduo 1...T no-!ni - i in l I -,nrinrC


35/47

[).,y I MlILI........ 77TIIIIY iLJ I..1!2hJ I'... 1..... .. in-,Ti.did yoh h 9.-9 In siey Iasi nigti Tr It(loll uslet' 3 nt y times do y.,, i.~a I

NONE ]l IGriT A' " FR 'T ii-'iI I Al tLF uiNltTt ,.hl"Ho rePoted do tii, feel' S Co nv leel that you coujid hate

uiied m~ore sleep""IWELLr)IUD .. DIRAT[ILt R51(U t N.) I A I Lt I Y-I SL. Y(. : 1 '_ I ', ode,'s Mood 1 d,--, e-le Ho,.,I -iIa

VLRY PL07P POOR AY( RAG[ .j -.OLX ...........

SE'.ErP LOG 1iNO.COM-6520/i (REV. 4.74) NANPRU (11-70l

Choose one of the sever stotements below whch best describes your present feelings. How you feel right now.

(1) Feeling active and vilOl, alert, wide awake.(2) Functioning of a high leel, but not at peolk, able to concfntrate,(3) Relaxed; owoke, responsive, but not ot lull alertness.(4) A little foggy, let down, nor at peak.(5) Foggy, slowed iu'wn. beginnirg to lose iterest in remaoning awake.(6) Sleepy, waooty prefer to be lying down, lighting sleep.(7) Almost in reverie; sleep onset soon, losing struggle to rieman awake.

T-2ANI P' LPINI SCAI IA-2


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NAVAL HEALTH RESEARCH CENTER


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MOOD QUESTIONNAIREThis 29 item quest ionnaire (NHRC MQ) uses a four point Likert type response scale (not atall = 0; a little 1 quite a bit = 2; extremely = 3) . There are two scales reflectingth e bi-factor theory of moods. These scales were derived using th e principle componentssolution on l imited data samples. The i tems in these scales an d th e scale ranges are:

Ngative Scale: annoyed, defiant, drowsy, dull, grouchy, jittery, sleopy, sluggish,tense , tired(simple sum of 10 item scale responses; range 0 - 30)Positive Scale: active, alert, carefree, cheerful, able to communicate, considerate,dependable, efficient , friendly, full of pep, good-natured, happy, kind, lively,pleasant, relaxed, sat isfied, able to think clearly, able to work hard(simple sum of 19 item scale responses; range 0 - 57)

Moses, J.M., Lubin, A., Naitoh, P. & Johnson, L.C. (1974). Subjective evaluat ion of th eeffects of sleep loss: The NHRC Mood Scales. Technical Report 74-24, Naval Health ResearchCenter, San Diego, CA .NPRU MOOD SCALE1IND-COM-6520/2 (5-73) Instructions: For each i tem, choose on e of th e four answersthat best descr ibes how yo u feel now. Then put an "X" in thatbox.NAME AGE SEX DATEITEM NOT AT ALL A LITTLE QUITE A BIT EXTREMELYACTIVEALERTANNOYEDCAREFREECHEERFULABLE TO CONCENTRATECONSIDERATEDEFIANTDEPENDABLEDROWSYDULLEFFICIENTFRIENDLYFULL OF PEPGOOD-NATUREDGROUCHYHAPPYJITTERYKINDLIVELY

A-4


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APPENDIX 3PLUS 7 TASK TABLE

A-5

PLUS 7 TASK TABLE

1 2 3 4 5 6 7 8 98 9 10 11 12 13 14 15 1615 16 .17 18 19 20 21 22 23


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22 23 24 25 26 2 7 28 29 3029 30 3] 32 33 34 35 36 3736 37 38 39 40 41 42 43 4443 44 45 46 47 48 49 50 5150 51 52 53 54 55 56 57 5857 58 59 60 61 62 6:3 64 6564 65 66 67 68 69 70 71 7271 72 73 74 75 76 77 78 7978 79 80 81 82 83 84 85 8685 86 87 88 89 90 91 92 9392 93 94 95 96 97 98 99 10099 100 101 102 103 104 105 106 107106 107 108 109 110 111 112 113 114113 114 115 116 117 118 119 120 121120 121 122 123 124 125 126 127 128127 128 129 130 131 132 133 134 135134 135 136 137 138 139 140 141 142141 142 143 144 145 146 147 148 149148 149 150 151 152 153 154 155 156155 156 157 1.58 159 160 161 162 163162 163 164 165 166 167 168 169 170169 170 171 172 173 174 175 176 177176 17"7 178 179 180 181 182 183 184183 184 185 186 187 188 189 190 191190 191 192 193 194 195 196 197 19819/ 198 199 200 201 202 203 204 205204 205 206 207 208 209 210 211 212211 212 213 214 215 216 217 218 21921 8 219 22 0 22 1 22 2 22 3 22 4 22 5 22 6225 226 227 228 229 230 231 232 233232 233 234 235 236 237 238 239 240239 240 241 242 243 244 245 246 247246 247 248 249 250 251 252 253 254253 254 255 256 25"7 258 259 260 261260 261 262 263 264 265 266 267 268267 26 8 269 270 271 272 273 274 275274 275 276 277 278 279 28 0 281 282281 282 2833 284 285 286 287 2838 289288 289 290 291 292 293 294 295 296295 296 297 298 299 300 301 302 303302 303 304 305 306 307 308 309 310309 310 311 :312 313 3.14 315 316 317316 317 318 319 320 321 322 323 324323 324 325 326 327 328 329 330 331330 331 332 333 334 335 336 337 338337 338 ]39 340 341 342 343 344 345344 345 346 347 348 349 350 351 352351 352 :353 354 356 357 358 359 360:358 359 360 361 362 363 :364 365 366365 366 36"7 368 369 370 371 372 3'/3372 373 374 375 376 3'17 378 379 380379 380 381 382 383 384 385 386 387386 387 388 389 390 391 392 393 394393 394 395 396 397" 398 399 400 40]40 0 401. 402 403 404 405 406 407 408407 408 409 410 411 412 413 414 415414 415 416 417 418 419 420 421 422

A-6


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APPENDIX 4SLEEP QUESTIONNAIRE

A.-7

NHRC SLEEP QUESTIONNAIRE(8/15/78)


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Page 1 Today 's DateNAME RANK/RATE RATINGSEX SOC SEC # DATE OF BIRTH AG ECURRENT DUTY STATION DATE ASSIGNEDInstructions: Please fill in th e blanks or circle th e answer that bestapplies to you. The completion of this questionnaire is voluntary. Thisinformation will. be used for research only, and will not become a par t ofyour permanent service record. TH E QUESTIONS BELOW AR E ABOUT YOUR USUALSLEEP NOW.For question~s 1 and 2, please use 24-hour clock times:1) At what clock time do you usually 7) If you have trouble falling asleep,go to bed on workdays? what is it that keeps you awake?On days off? 1. Thoughts running through my mind2. Aches and pains2) At what clock time do you usually 3. Too much noisewake up on workdays? 4. List any other

On days off?5. Does not apply to me3) On workdays, do you go to bed andget up at fixed, regular times? 8) If you have trouble falling asleep,1. Always or almost always do you:2. Often 1. Just lie in bed3. Sometimes 2. Turn on th e light and read4. Never or almost never 3. Get up" List an y other4) Ho w long does it usually take yo uto fall asleep after l ights-out? 5. Does not apply to me

;Hours . .. Minutes 9) Do you take anything to help you5) Do you ever have trouble falling fall asleep?asleep? 1. Never or almost neverI. Never or almost never 2. Sometimes2. Sometimes 3. Often3. Often 4. Always or almost always4. Always or almost always10) If you take something to help you6) If you OIo have trouble falling you fall asleep, what is it?asleep, how often docs this happen? I. Medicine prescribed by a doctor1. Less than once a year 2. Non-prescribed medicine2. Less than once a month 3. Lis t any other3. About once a month 4. Does not apply to me4. 1 or 2 times per week5- 3 or 4 times per week

6. 5 ( , more t imes per week7. Does not apply to me

A-8

11) How many times during your 17) How long do you usually sleep


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usual sleep period do you wake during your naps?up by yourself and then go back 1. Between 10 and 30 minutesto sleep? 2. Between 30 and 60 minutes1. Rarely or never 3. Between 1 and 2 hours2. 1 or 2 times 4. More than 2 hours3. 3 or 4 times 5. Does not apply to me4. 5 or 6 times5. 7 or 8 times 18) Do you have disturbing dreams or6. 9 times or more nightmares?1. Never or almost never12) On how many days per week does 2. Sometimesthis happen? 3. Often1. 1 or 2 days per week 4. Always or almost always2. 3 or 4 days per week3. 5 or more days per week 19) Overall, what kind of sleeper are4. Does not apply to me you?

1. Very good13) When you wake up during your 2. Goodusual sleep period, how long 3. Averagedoes it usually take to go 4. Poorback .o sleep? 5. Very Poor1. 10 minutes or less2. 10 to 20 minutes 20) If you are a poor or very poor3. 20 to 30 minutes sleeper, is this because you4. 30 minutes to an hour (mark most important)5. More than an hour 1. Have trouble falling asleep6. Does not apply to me 2. Wake up and have trouble goingback to sleep14) Do you wake up too early and find 3. Have disturbing dreams oryou cannot go back to sleep? nightmares1. Never or almost never 4. Are awakened frequently by noise2. Sometimes 5. Wake up too early (early morning3. Often awakening)4. Always or almost always 6. Wake up tired7. Other15) On how many days per week does 8. Does not apply to methis happen?1. 1 or 2 days per week 21) If you are a poor or very poor2. 3 or 4 days per week sleeper, ho w long have you had a3. 5 or more days per week sleep problem?4. Does not apply to me 1. 1 to 6 months

2. 6 months to 1 year16) How often do you take naps.? 3. 1 to 2 years1. Parely or never 4. 3 to 5 years2. Less than once a month 5. 5 to 10 years3. About once a month 6. As long as I can remember4. 1 or 2 times per week 7. Does not apply to me5. 3 or 4 times per week6. 5 or more times per week 22) Were (or are) any members of your7. More than once a day family poor sleepers, that is,have sleep problems?Yes 1 No 2

A-9

23) If yes to #22, which family 29) How much do you smoke each day?


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member, or members, if more 1. Nonethan one? 2. Less than 1 pack1. Father 3. 1 pack2. Mother 4. 2 packs3. Brother 5. More than 2 packs per day4. Sister5. Does no t apply to me 30) How much coffee, tea, or coke doyou drink per day? (if coke, circle24) Do you usually feel well-rested coke)after you wake up and first get 1. Noneout of bed? 2. 1 cup or 1 coke1. Always or almost always 3. 2 to 3 cups or 2 to 3 cokes2. Often 4. 3 to 5 cups or 3 to 5 cokes3. Sometimes 5. More than 5 cups or 5 cokes4. Never or almost never

25) Which choice below best describeshow you usually feel for the first2 or 3 hours after you wake up fromyour normal sleep period on workdays?1. Alert, wide awake2. High level, but not at peak3. Awake, but relaxed4. A little foggy, le t down5. Slowed down, sleepy6. Fighting sleep7. Almost asleep

26) Which choice below best describes howyou usually feel in the afternoon,between 1500 and 1700?1. Alert, wide awake2. High level, but not at peak3. Awake, but relaxed4. A little foggy, let down5. Slowed down, sleepy6. Fighting sleep7. Almost asleep

27 ) Do you ever fall asleep even thoughyou are trying hard to stay awake?1. Never or almost never2. Sometimes3. Often4. Always or almost always

28) Are you easily awakened by noises?1. Never or almost never2. Sometimes3. Often4. Always or almost always

A-1O

APPENDIX 5MISSION EXAMPLE


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Figures A--I and A-2 show the sleep/wake patterns of participants in a SEALtraining exercise. Sleep periods fo r each individual across th e eight days ofthe exercise ar e marked by lines. The normal sleep periods (2200 to 0600) aremarked by the shaded areas. The graph shows reduced amounts of sleep, with shortfragmented sleep periods often occurring outside of the ideal sleep time.Participants in th e exercise accumulated serious sleep debts. The men in thisexercise felt this was a very difficult schedule and reported that theyexperienced extreme fatigue. This is an example of a mission where applicationof sleep management might have improved th e alertness, mood, and generalperformance of th e participants.

A-II

ZT-V


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t AVG -

A\NY

Ii I L' 1v1 1 10"%~ ~0%p%0%0% 0 %0 N0%0fC4- a W- a N0 aI0 0 a o a -V-W-q- - -T-W-4Vw\\ . w ~ ~ ~ x w aw\z > x nv . -a'

w --a an_ 2U GO SIAVN i.ir


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Fonn ApprovedREPORT DOCUMENTATION PAGE OMBNo.071W0INPubhc rporr,,g burden for ha *Wkt~ionof informatlon is eanhnated to vseie I hour per response, nlding the ornieor avwmtng Inamietiona. serchungexianlg dam source, gaitheuing ard mantanirng tOe d*M neded, And crxnj'ering ed mvwa.g &he oln of linowrwTmon. Send ommwwenm regarding tiburden eslnmai or any odtwhae of fa miection of Informlon, inruding suggeboCna for rdung this burden, o Waahington Headquanaira Semoma,Directorai for InformagOn Operalonz " Repons, 1215 Jefferorln Dvis Highway. S&ite 1204, Mrltngton, VA 22202-4302, and to fe Office of Lbuagernent


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and Budget, Paperworkl educon Properc (0704.-0188), Wainglon. DC 20503.,1.AGENCY US E ONLY (Leave blank) 2. REPORT DATE 3. REPORT TYPE AND DATE COVEREDL_ , il]y 1992 FI NA ,4. TITLE AND SUBTITLE 5. FUNDING NUMBERS. ],..' Ma J ,( ant- U i.- 5: tu i ,Cl r P .)rogram Ele m2e1t: 6223 IN

Special Operations Personnel Work Unit Number:6. AUTHOR(S) MM33P30.002-6005Paul Naitoh and Tamaln Kelly

7. PERFORMING ORGANIZATION NAME(S) AND ADDRESS(ES) 8. PERFORMING ORGANIZATIONNaval Health Research Center Report No . 92-28P. 0. Box 85122San Diego, CA 92186-5122

9. SPONSORING/MONITORING AGENCY NAME(S) AND ADDRESS(ES) 10. SPONSORING/MONITORINGNaval Medical Research and Development Command AGENCY REPORT NUMBERNational Naval Medical CenterBuilding 1, Tower 2Bethoqria. MD ) 20H9-___44

11, SUPPLEMENTARY NOTES

12a. DISTRIBUTIONJAVAILABI LT Y STATEMENT 12b. DISTRIBUTION CODEApproved for public release; distribution isunlimited.

13. ABSTRACT (Maximum 200 words)The objective of sleep logist~ics is Lo ensure that fiqhting men an d womenat all levels obtain sufficient sleep to maintain combat. effertLiveriessSpecial warfare miss3ions frequently involve night work an d ardnous operot ioana.schedni s. Th.is UnE_r-'. C;uide expain a - selected sleep marnaqemncnt ,clmi uiafo r u.e; du r Lrii miliLar-y op)erat ions, witl) partL cular emplhasi.s on spr c .i.a1.ope rat-ianr* mii.in. [Thle Guido will at. flie d coirunandera in using I ee}locti.,' ic s to )rEI,'eilt c"npromiqe oft J 3 In ccompli-shimcnt dhin to .1 t',[)depr i va ti on. In additiLon, it pr ovides.- tr.chn, us fo r as ;ean;111(1 :;ev er/ ty of1001) dbt and a'omipon.-sat.inq f.or it i, 1 1 ec ts .

14. SUBJECTTERMS 15. NUMBER OF PAGESSleep Management Sleep Logiticsr4SI ee) Joss 16. PRICE CODE

17 SECURITY CLASSIFICA- 18. SECURITY CLASSIFICA- 19. SECURITY CLASSIFICA- 20. LIMITATION OF ABSTRACTTION OF REPORT TION OF THIS PAGE "IONOF ABSTRACT

I nc I ass I f I v d lina I as:,s i f Ied lric I amus i I i e, 1in1 nm t cdNSN 7540-01-280-5500 Standard Form 298 (Rev. 2-89)Proscribedby ANSI SOd. Z39- 18

298-102

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Sleep Management User's Guide