Article In Brief
Sleep neurologists are reporting increased sleep disturbances and the misuse of sleep medications in people recovering from COVID-19 and people whose lives have been beset by fear and social isolation.
Neurologists who specialize in sleep disorders are seeing an increase in sleep disorders associated with COVID-19, a surge they're terming “COVID-somnia.”
From insomnia to hypersomnia, night terrors to the misuse of sleep medications, the phenomenon is being reported and treated not only in people recovering from COVID-19, but in the far larger number of people whose lives have been turned upside down by fear and social isolation.
“All our patients are suffering from shifts in their sleep patterns due to their fears about getting the virus, concerns about loved ones, not being able to go to work, not having social contact with others,” said Rachel Marie E. Salas, MD, FAAN, associate professor of neurology at the Johns Hopkins Center for Sleep.
“Some of them now meet the diagnostic criteria for chronic insomnia: not being able to fall asleep within 30 minutes more than three times a week for more than three months,” Dr. Salas said. “They get into bed, the brain kicks in, they start worrying if they're going to lose their job, if their family member is going to survive, and they literally cannot fall asleep.”
Conscious fears of the contagion and its economic impacts are but one cause of the condition, neurologists told Neurology Today. Dissolution of daily schedules, reduced exposure to sunlight (particularly in the morning), excessive daytime napping and excessive use of electronic media (particularly near bedtime) all contribute to disrupted sleep patterns.
“Sunlight is our biggest zeitgeber—literally ‘time giver,’” said Daniel A. Barone, MD, FAASM, FAAN, associate medical director of the Weill Cornell Center for Sleep Medicine. “If people aren't leaving their homes because of fear of COVID-19, if they're not going to work as they once did, then they aren't getting that daily exposure to sunlight in the morning. That can disrupt their internal clock.”
One early measure of how quickly COVID-somnia took hold across the United States came from a report on April 16 from Express Scripts, the pharmacy benefits manager. Between February 16 and March 15 of this year, well before the peak of the outbreak, the number of prescriptions filled for sleep disorders had already increased by 14.8 percent compared with the same period in 2019.
Sleep-promoting medicines, however, are generally reserved for only fleeting cases of insomnia, and then prescribed for no more than two weeks. Sleep disorders specialists said there are far more effective approaches to treating COVID-somnia.
Studies and Clinical Observations
Physicians and others who treated COVID-19 patients during the peak of the outbreak have suffered sleeping difficulties of their own. On May 23, Chinese researchers published the results of their survey of 801 front-line medical workers in Hubei Province who treated COVID-19 compared to 505 non-front-line medical workers. On the Pittsburgh Sleep Quality Index, they found that these workers had significantly higher scores, indicating worse quality of sleep (p< 0.001). These medical workers likewise scored significantly worse on the Athens Insomnia Scale, (p< 0.001).
Loss of sleep affects not only mood and attention but the body's immune functioning and its ability to fight infections. For a 2015 paper published in the journal Sleep, researchers administered nasal drops containing the rhinovirus to 164 healthy men and women whose sleep duration and continuity were assessed by wrist actigraphy and sleep diaries. Those sleeping less than five hours per night, the study found, were 4.5 times more likely to develop a cold following rhinovirus exposure compared to those sleeping seven hours per night (95% CI, 1.08-18.69). Those sleeping between five to six hours per night were likewise at significantly increased risk of developing cold symptoms (OR = 4.24, 95% CI, 1.08-16.71).
Not all patients are experiencing sleep loss, of course.
“There is a subset of the population who are actually sleeping better, because they don't have to get up as early for work and may experience less stress from not having to commute,” said Dr. Barone.
Even for those whose sleep is adversely affected, insomnia is not the only way in which the disorder manifests.
“The proportion of our patients who have complaints of insomnia and hypersomnia has increased dramatically since the beginning of this pandemic,” said Alon Y. Avidan, MD, MPH, FAAN, professor and vice chair in the department of neurology at the David Geffen School of Medicine at UCLA, and director of the UCLA Sleep Disorders Center. “It's both.”
Abnormal dreams and disruptive nightmares are another type of sleep disturbance that can be triggered by events such as this pandemic, which has had a profound impact on the psychological and mental well-being of individuals across society. Dr. Avidan described one of his patients who had previously developed night terrors following the Fukishima earthquake and tsunami of 2011, while living in Japan.
“COVID-19 has reignited the patient's recurrent nightmares,” Dr. Avidan said. “The same effect is often seen in people who survived other tragic crises, including 9/11 in New York.”
For sleep apnea patients who are positive for COVID-19, concern has arisen over the potential for a continuous positive airway pressure (CPAP) device to spread the SARS-CoV-2 virus to a sleeping partner.
The best recommendation is for patients to continue to use their CPAP but to have their partner sleep in another room, according to Charlene E. Gamaldo, MD, FAAN, FAASM, medical director of the Johns Hopkins Center for Sleep at Howard County General Hospital.
“I've had patients who contacted me to say they were told to go off their CPAP,” Dr. Gamaldo said. “CPAP can actually help them to breathe better and recover sooner.”
For complaints of insomnia, writing a prescription for zolpidem or one of the benzodiazepines may be the quickest way for a neurologist to respond, but those who specialize in sleep medicine say their use should generally be limited to no more than a couple weeks, and are inappropriate for patients whose condition has become chronic.
“In the long-term, they affect your sleep quality and your cognition,” said Mark Boulos, MD, assistant professor of neurology at the University of Toronto. “They also reduce slow-wave sleep.”
A double-blind, placebo-controlled trial, the results of which were published in the Journal of Psychopharmacology in 2015, found that both temazepam and zolpidem significantly reduced slow-wave sleep, the deepest phase of non-rapid-eye-movement sleep and one critical to memory consolidation. The same trial found that the hormone melatonin, however, had no such effect.
“Melatonin is typically not a good sleeping pill, but it can be very helpful for anchoring the circadian rhythm,” said Dr. Salas. “Many of us recommend taking it two hours before the desired bedtime.”
Setting a regular daily schedule also promotes sleep, Dr. Salas said. “The more consistent your schedule is, the better,” she said. “If one night you go to bed at midnight, and another at 10, your brain is like, ‘What are we doing?’ Not being consistent can be just as bad or worse than sleep deprivation.”
Dr. Avidan said he, too, emphasizes the importance of daily routines.
“Sleep-wake patterns can quickly erode if people are spending their days indoors, socially and physically isolated, participating in video meetings and watching television at night,” he said. “The lack of circadian cues from the sun during the morning and abnormal exposure to blue light from electronics at night severely disrupts their circadian rhythms.”
“We generally recommend that people try to preserve their normal routines, even if they work remotely,” Dr. Avidan said.
“They should wake up at the same time, dress up as if going to work, eat breakfast and begin working as they would at the same time as they did before the pandemic. Then they should ideally preserve time for exercise and have dinner at the same time they used to.”
“They should avoid watching anxiety-provoking news programs before bedtime as this would heighten anxiety and perpetuate insomnia, while the blue light from the screen would stimulate the circadian clock delaying sleep. The best thing is to maintain normal daily routines, maximize activities that promote alertness during the daytime and avoid behaviors that promote arousal at bedtime.”
Part of that routine should include exposure to bright sunlight in the morning and avoidance of so-called “blue” light at night, Dr. Barone said.
“At night, I tell patients, give yourself 30 to 60 minutes without watching TV or anything with a backlit screen,” he said. “This specific frequency of light has the ability to disrupt your sleep.”
For patients whose chronic sleep disturbances do not respond to the neurologist's treatments, referral is warranted to a cognitive-behavioral therapist with specialized training in insomnia (CBTi).
“CBTi therapists can easily be treated by a cognitive behavior therapist who can focus on sleep retraining, relaxation techniques, and modifying their fears and worries about the inability to sleep,” Dr. Avidan said. “Many folks with insomnia have developed poor habits, associations, misconceptions and behavioral patterns that are amenable to CBTi.”
Dr. Avidon recommended that neurologists check the website for the Society of Behavioral Sleep Medicine, which offers a listing of trained therapists in every state.