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| REVIEW ARTICLE |
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| Year : 2021 | Volume
: 69
| Issue : 1 | Page : 26-31 |
Sleep and Covid-19
Karuna Datta1, Manjari Tripathi2
1 Department of Sports Medicine, Armed Forces Medical College, Pune, India
2 Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| Date of Submission | 26-Aug-2020 |
| Date of Decision | 26-Aug-2020 |
| Date of Acceptance | 18-Jan-2021 |
| Date of Web Publication | 24-Feb-2021 |
Correspondence Address:
Manjari Tripathi
Department of Neurology, All India Institute of Medical Sciences, New Delhi
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0028-3886.310073
Background: COVID-19 pandemic has affected the world globally causing widespread repercussions on individuals' physical, mental and emotional well-being. In such times, sleep is likely to be affected.
Objective: The aim of this study was to present the available literature on sleep and also the foresight as to the future national strategy to mitigate the effects of this pandemic.
Materials and Methods: An extensive literature search on PubMed, Google Scholar, Epistemonikos database (https://www.epistemonikos.org), PsycINFO for available literature on the prevalence of sleep problem on COVID-19 was done. Cross-citation search was also conducted to increase relevance of the review. The key words used were- (((((((((((insomnia)) OR (sleep)) OR (sleepiness)) OR (“sleep quality”)) OR (OSA)) OR (“obstructive sleep apnoea”)) OR (“obstructive sleep apnea”)) OR ((“sleep problem”)) AND “covid-19” OR covid19* OR “COVID-19” OR “2019-nCoV” OR cv19* OR “cv-19” OR “cv 19” OR “n-cov” OR ncov* OR “sars-cov-2” OR “sars-cov2” OR “2019-ncov” OR “SARS-Coronavirus-2” OR “SARS-Coronavirus2” OR (wuhan* AND (virus OR viruses OR viral)) OR (covid* AND (virus OR viruses OR viral)) OR “covid-19-related” OR “SARS-CoV-2-related” OR “SARS-CoV2-related” OR “2019-nCoV-related” OR “cv-19-related” OR “n-cov-related”). Inclusion criteria consisted of articles in English, published from Jan 2020 till 19 Apr 2020. Two reviewers independently screened each research study for inclusion and eligibility.
Results and Conclusion: Sleep is affected during COVID-19 pandemic in patients, their families, health-care workers and their families, population in isolation, and quarantine and as such in public. Limited literature exists with subjective data and no objective criteria were found to study sleep in COVID-19 pandemic. OSA was found to be a frequent baseline characteristic of COVID-19 patients. A need to follow guidelines is of paramount importance and strategies to better sleep in the population needs to be addressed.
Keywords: Covid-19, insomnia, OSA, sleep lab, sleep, systematic review
Key Message: Subjective sleep was disrupted during COVID-19 pandemic. Increased anxiety, stress, post-traumatic stress symptoms reported and correlated with bad sleep. OSA was a comorbidity in COVID-19 patients. Increased focus on improvement of sleep for better mental health of the population.
How to cite this article:
Datta K, Tripathi M. Sleep and Covid-19. Neurol India 2021;69:26-31 |
COVID-19 pandemic has caused widespread implications to physical and mental health. It has not only affected the patients per se, but also lives of their family members, contacts of these patients in isolation, quarantine and the attending healthcare workers. The population was in lockdown and was following social distancing to prevent spread of the disease further. Effects on sleep were documented during earlier such infectious diseases of SARS or MERS in patients, suspect cases, and health-care workers.[1],[2],[3] COVID-19 is likely to cause similar effects adding anxiety of contracting the illness associated with fear in the population too. Mental health of patients, health-care workers, and population at large is important at this stage. This review was undertaken to understand the prevalence of the sleep problems during COVID-19 and gain foresight as to the future national strategy to mitigate the effects of this pandemic.
| » Methodology | |  |
A systematic methodology was used for literature search. Inclusion criteria consisted of articles in English, published from Jan 2020 till 19 Apr 2020. An extensive literature search on Pubmed, Google scholar, Epistemonikos database (https://www.epistemonikos.org), PsycINFO for available literature on the prevalence of sleep problem on COVID-19 was done. Cross-citation search was also conducted to increase relevance of the review. The key words used for Pubmed was- (((((((((((insomnia)) OR (sleep)) OR (sleepiness)) OR (“sleep quality”)) OR (OSA)) OR (“obstructive sleep apnoea”)) OR (“obstructive sleep apnea”)) OR ((“sleep problem”)) AND “covid-19” OR covid19* OR “COVID-19” OR “2019-nCoV” OR cv19* OR “cv-19” OR “cv 19” OR “n-cov” OR ncov* OR “sars-cov-2” OR “sars-cov2” OR “2019-ncov” OR “SARS-Coronavirus-2” OR “SARS-Coronavirus2” OR (wuhan* AND (virus OR viruses OR viral)) OR (covid* AND (virus OR viruses OR viral)) OR “covid-19-related” OR “SARS-CoV-2-related” OR “SARS-CoV2-related” OR “2019-nCoV-related” OR “cv-19-related” OR “n-cov-related”).
Similar strategy was adapted for other databases. In Google Scholar the search results with the key words as mentioned were sorted as per relevance and first 200 references were taken for the review.[4] Two reviewers independently screened each research study for inclusion and eligibility. The authors were contacted, in case full-text articles were not available. Full text articles and literature were screened and eligible search items included.
| » Results | | |
The PRISMA[5] flow diagram for the review is shown in [Figure 1]. [Table 1] describes the types of articles finally included in the review. The original study articles and case series can be divided into primarily three types i.e., on patients, healthcare workers and their families and population at large. Details of the studies are given in [Supplementary Table 1]. The studies on patients showed Obstructive Sleep Apnoea as a frequent pre-existing comorbidity in COVID-19 patients[6],[7],[8],[9] and a case series of five cases also reported that the patient with OSA had complement associated microvascular injury.[10] Insomnia was found to be a major symptom in COVID-19 patients in a drug trial using favipiravir and arbidol.[11] On the other hand, another study commented that hydroxychloroquine given as treatment might have caused insomnia.[12] There was a study done by Liu et al. on patients. He subjectively analyzed sleep after giving progressive muscular relaxation (PMR) in the experimental group and the study reported a significant reduction in anxiety and sleep as compared to the control group.[13]
Health-care workers reported excessive fatigue and increased sleepiness[14] to as much as 9.3% and female nurses were found to be more prone.[15] Insomnia prevalence was also found to be 34% amongst health-care in a study using Insomnia severity index (ISI), prevalence being higher in frontline health-care workers as compared to tertiary hospitals.[16] In the same study, prevalence of depression and anxiety of 50.4% and 44.6%, respectively, was found. The prevalence of insomnia was found to be higher in healthcare workers (38.4%) as compared to non-healthcare workers (30.5%).[17] Worry about being getting infected themselves, low educational level and perceived unhelpfulness of psychological support were found to be risk factors for insomnia in a study on medical staff, and an insomnia prevalence of 36.1% was found in them.[18] Self-rating scales used to assess anxiety and stress increased scores[19],[20] and some also reported that this decreased sleep quality[20] and it was thought that anxiety and stress was due to bad sleep.[21] Anxiety and stress as also found in family members of healthcare workers.[22]
Several studies have been reported on the population while in isolation, quarantine or otherwise while at home during a lockdown. Anxiety, stress and bad sleep remained an important concern.[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] Anxiety as high as 69% was reported in quarantined population.[23] In a study done in population by Rossi et al. reported a prevalence of 20.8% for anxiety, 17.3% had depression and 7.3% reported insomnia using ISI.[24] Web-based population survey using Pittsburgh Sleep Quality Index (PSQI reported a prevalence of 18.2% reporting poor sleep quality.[25] In a study conducted by Liu et al. using PSQI, 20.7% had bad sleep quality and 8.4% were unable to sleep for more than 30 minutes for more than two times a week and 13% woke up during the night more than three times a week.[27]
Another web-based survey using ISI reported an overall of 33.9% prevalence and health-care workers were found to be more affected than non-healthcare workers.[17]
Post-traumatic symptom scores (PTSS) of 37% were found[24] and a significantly higher prevalence of posttraumatic symptom scores was found in respondents who had poorer sleep.[25] Similarly higher anxiety and depression scores correlated with bad sleep.[31] An interesting report on Japanese citizens showed the population strategies including taking adequate sleep being advocated officially[33] and a scale made for 'fear of COVID-19' includes a question related to not able to sleep and worry about getting the disease.[34]
| » Discussion | | |
Literature search showed that most of the data pertaining to sleep or to prevalence of sleep problem related to COVID-19 pandemic are studies which have used self-rating scales, questionnaires, or just a few questions on sleep. It suggests that there is a high prevalence of sleep problems during COVID-19 pandemic.[11],[16],[17],[25]
Many studies found that poor sleep correlated with anxiety, depression, stress and posttraumatic stress symptoms increasing a likelihood or post-traumatic stress disorder.[24],[27],[35],[36],[37] Studies also report that increase in anxiety may lead to impairment in sleep.[30],[31],[38] Increased anxiety has been reported in healthcare workers, their families, patients, population in isolation and in quarantine and while working from home due to which improving anxiety and sleep in them may help.[19],[21],[39],[40]
A need to address sleep exists in the present times for healthcare workers, patients and population as such.[38],[41],[42],[43],[44],[45] Good sleep and diet were advocated in the government strategies sent out to public regarding COVID as mentioned in paper by Muto et al.[26] and if followed can better physical and mental health outcomes.
Getting adequate sleep has been advocated for school children.[46] It has been emphasized that screen time should be regulated during the social distancing and work from home scenario. Since the schools are closed, role of parents in regulating the child's sleep hygiene and sleep health becomes important.[47],[48],[49] Elderly also are required to take care of their sleep.[34],[50],[51]
Across the globe, there is a felt need to address sleep by advocating good sleep practices, ensuring adequate amount of time at night[52] and looking after mental and emotional health[53],[54],[55] by developing online platforms to promote good sleep and also for psychological consultations.[56],[57],[58],[59] Social support system has been found to be important to prevent psychological problems. Psychological crisis prevention during these testing times is therefore vital.[28],[60],[61] Increased misinformation to healthcare workers needs to be dealt with.[62] Leadership positions at hospitals and healthcare systems should ensure mitigation of such misinformation. They should also ensure that adequate time is given to healthcare workers to rest and sleep[63],[64],[65] to prevent burnout and fatigue.[14],[66],[67] Also health strategies for prevention and treatment should be devised for them.[68] Adequate sleep and preventing sleep disruption can prevent collaborative delirium prevention in COVID-19 patients.[69] Castro et al. communicated that psychological symptoms should be addressed and should not be missed out.[70] Nonpharmacological approaches like CBTI,[71] progressive muscular relaxation[13] and indigenous solutions using yoga nidra can also be tried[72],[73] to improve sleep. These are also important to help in special situations like the homeless, for whom space may be provided to sleep, in pregnancy,[74] in mental illness patients,[75] etc., It is important to make people understand that individualized strategy works the best and the individual should identify his own strategy to better his sleep.[76]
A few case series have brought out that OSA[6],[7],[8],[9],[10] did remain an important and frequent baseline characteristic in COVID-19 patients. Various societies have issued guidelines e.g., American academy of Sleep Medicine regarding sleep lab protocols.[77] Infectious Disease Society of America guidelines regarding the infection prevention of COVID-19[78] and disinfection and sterilization guidelines from Centres for Disease Control and Prevention.[79] It is required for us to follow recommended guidelines[80] regarding sleep studies in the lab or home monitoring. Guidelines for attending to patients with OSA in a sleep lab and sleep consultations also has been clearly spelt out and must be followed primarily because of the fear of spread of COVID infected OSA patients.[81]
All sleep labs must follow the recommendations[79],[80],[81] of which few salient ones are- Adequate postage regarding the pandemic must be put in the sleep clinic and lab and as per the recommended infection control procedures routine cleaning followed by disinfection done. Personal protective equipment (PPE) must be procured in adequate amount. Telemedicine consults are preferred and in high endemic areas, it is recommended not to perform non-invasive ventilation. If the patient is critical, a prior screening for COVID-19 is mandatory. Clinicians to wear mask at all times in clinics and sleep technologists and sleep lab staff should wear PPE. In patients where aerosol generation is likely e.g., positive airway titration, N95 mask, face shields and gloves must be worn by technologists and staff. They should also be in a long-sleeved gown and cap.
Home portable systems, auto PAP adjusting machines are preferred for OSA patients to be considered. In case home sleep apnea testing is performed, devices should be disinfected and be used for the next patient preferably only after 72 hours. Disposable nasal pressure transducers, ventilator tube to be used and all the sensors and equipment should be carefully cleaned and disinfected with non-corrosive chlorine-containing disinfectant or 75% ethanol between each patient use. Restart of the lab should be only done after taking due consideration of the local epidemic situation following the guidelines for consult and screening carefully.
There are a few limitations of this review. Due to the increased availability of literature, only first 200 publications in Google scholar after sorting for relevance were taken which is though a recommended method and was done to exclude irrelevant numbers. Secondly some preprints or non-peer-reviewed literature have also been included to make the literature more representative of the available research. The strategies to find out prevalence of sleep problems were very variant, with only a very few studies which used standard questionnaires, making it difficult to do statistical analysis.
There is a need to conduct RCT with objective sleep parameters to identify possible solutions. Considering an impending sleep problem in the times to come, a dedicated work force to develop population-based strategies to better sleep may be required.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1]
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