Evidence Report: Risk of Performance Decrements and Adverse Health Outcomes Resulting from Sleep Loss, Circadian Desynchronization, and Work Overload Human Research Program Behavioral Health and Performance Element Approved for Public Release: April 11, 2016 National Aeronautics and Space Administration Lyndon B. Johnson Space Center Houston, Texas 1 Current Contributing Authors: Erin Flynn-Evans, Ph.D NASA Ames Research Center Kevin Gregory, B.S. San Jose State University Research Foundation Lucia Arsintescu, M.A. San Jose State University Research Foundation Alexandra Whitmire, Ph.D. Wyle Science, Technology and Engineering Previous Contributing Authors: Laura Barger, Ph.D. Harvard Medical School and Brigham and Women’s Hospital George Brainard, Ph.D. Jefferson Medical College, Thomas Jefferson University David F. Dinges, Ph.D. University of Pennsylvania School of Medicine and Drexel University Elizabeth Klerman, MD, Ph.D. Harvard Medical School and Brigham and Women’s Hospital Lauren B. Leveton, Ph.D. NASA Johnson Space Center Camille Shea, Ph.D. Universities Space Research Association Alexandra Whitmire, Ph.D. Wyle Science, Technology and Engineering 2 Table of Contents I. PRD RISK TITLE: RISK OF PERFORMANCE DECREMENTS AND ADVERSE HEALTH OUTCOMES RESULTING FROM SLEEP LOSS, CICADIAN DESYNCHRONIZATION AND WORK OVERLOAD ............................................................................................................................... 7 II. EXECUTIVE SUMMARY ................................................................................................................... 4 III. INTRODUCTION .............................................................................................................................. 6 IV. EVIDENCE ....................................................................................................................................... 10 A. SpaCeflight EvidenCe ............................................................................................................................... 11 B. Ground-based evidenCe ......................................................................................................................... 24 V. COMPUTER-BASED MODELING AND SIMULATION ............................................................ 52 VI. RISK IN CONTEXT OF EXPLORATION MISSION OPERATIONAL SCENARIOS ............. 56 VII. GAPS ............................................................................................................................................... 58 VIII. CONCLUSION .............................................................................................................................. 59 IX. REFERENCES .................................................................................................................................. 61 X. TEAM ................................................................................................................................................. 78 XI. LIST OF ACRONYMS ..................................................................................................................... 79 APPENDIX A: MEASUREMENT OF SLEEP, CIRCADIAN PHASE AND WORKLOAD ........... 81 APPENDIX B: INTERNATIONAL SPACE STATION LIGHTING ................................................ 82 3 I. PRD RISK TITLE: Risk of Performance Decrements and Adverse Health Outcomes Resulting from Sleep Loss, Circadian Desynchronization and Work Overload. II. EXECUTIVE SUMMARY Sleep loss, circadian desynchronization, and work overload occur to some extent for ground and flight crews, prior to and during spaceflight missions. Ground evidence indicates that such risk factors may lead to performance decrements and adverse health outcomes, which could potentially compromise mission objectives. Efforts are needed to identify the environmental and mission conditions that interfere with sleep and circadian alignment, as well as individual differences in vulnerability and resiliency to sleep loss and circadian desynchronization. Specifically, this report highlights a collection of new evidence to better characterize the risk and reveals new gaps in this risk as follows: • Sleep loss is apparent during spaceflight. Astronauts consistently average less sleep during spaceflight relative to on the ground. The causes of this sleep loss remain unknown, however ground-based evidence suggests that the sleep duration of astronauts is likely to lead to performance impairment and short and long-term health consequences. Further research is needed in this area in order to develop screening tools to assess individual astronaut sleep need in order to quantify the magnitude of sleep loss during spaceflight; current and planned efforts in BHP’s research portfolio address this need. In addition, it is still unclear whether the conditions of spaceflight environment lead to sleep loss or whether other factors, such as work overload lead to the reduced sleep duration. Future data mining efforts and continued data collection on the ISS will help to further characterize factors contributing to sleep loss. • Sleep inertia has not been evaluated during spaceflight. Ground-based studies confirm that it takes two to four hours to achieve optimal performance after waking from a sleep episode. Sleep inertia has been associated with increased accidents and reduced performance in operational environments. Sleep inertia poses considerable risk during spaceflight when emergency situations necessitate that crewmembers wake from sleep and make quick decisions. A recently completed BHP investigation assesses the effects of sleep inertia upon abrupt awakening, with and without hypnotics currently used in spaceflight; results from this investigation will help to inform strategies relative to sleep inertia effects on performance. • Circadian desynchrony has been observed during spaceflight. Circadian desynchrony during spaceflight develops due to schedule constraints requiring non-24 operations or ‘slam-shifts’ and due to insufficient or mis-timed light exposure. In addition, circadian misalignment has been associated with reduced sleep duration and increased medication use. In ground-based studies, circadian desynchrony has been associated with significant performance impairment and increased risk of accidents when operations coincide with the circadian nadir. There is a great deal of information available on how to manage circadian misalignment, however, there are currently no easily collected biomarkers that 4 can be used during spaceflight to determine circadian phase. Current research efforts are addressing this gap. • Work overload has been documented during current spaceflight operations. NASA has established work hour guidelines that limit shift duration, however, schedule creep, where duty requirements necessitate working beyond scheduled work hours, has been reported. This observation warrants the documentation of actual work hours in order to improve planning and in order to ensure that astronauts receive adequate down time. In addition to concerns about work overload, ground based evidence suggests that work underload may be a concern during deep space missions, where torpor may develop and physically demanding workload will be exchanged for monitoring of autonomous systems. Given that increased automation is anticipated for exploration vehicles, fatigue effects in the context of such systems needs to be further understood. • Performance metrics are needed to evaluate fitness-for-duty during spaceflight. Although ground-based evidence supports the notion that sleep loss, circadian desynchronization and work overload lead to performance impairment, inconsistency in the measures used to evaluate performance during spaceflight make it difficult to evaluate the magnitude of performance impairment during spaceflight. Work is underway to standardize measures of performance evaluation during spaceflight. Once established, such performance indicators need to be correlated with operational performance. • Individual differences in sleep need and circadian preference, phase shifting ability and period have been documented in ground-based studies. Individual differences in response to sleep loss and circadian misalignment have also been documented and are presumed to be associated with genetic polymorphisms. No studies have systematically reported individual differences in sleep or circadian- related outcomes during spaceflight. More work is needed in this area in order to identify genetic or phenotypic biomarkers that predict resilience or vulnerability to sleep loss in order to personalize countermeasure strategies and mitigate performance impairment during spaceflight. Two laboratory and field investigations specific to this topic are currently ongoing; additional efforts, including an effort to mine existing biological data from spaceflight relative to sleep and circadian outcomes, are planned. • Sex differences in sleep need and circadian period and phase have been reported in ground-based studies. The impact of these sex differences on performance is unclear. Sex differences in sleep need and circadian rhythms have not been systematically studied during spaceflight, presumably due to the small number of women that have flown in space. More research is needed in this area to evaluate whether any of the observed sex differences in physiology lead to altered performance in spaceflight and on the ground. • Countermeasures to mitigate the impact of sleep loss, circadian desynchronization and