Sleep Problems during

The COVID-19 Pandemic

ZAMRONI AFIF
KELOMPOK STUDI GANGGUAN TIDUR
DEPARTEMEN NEUROLOGI
FKUB – RSSA MALANG

1
Introduction
• Global •Insomnia
pandemic •OSA
•EDS
•RLS
Sleep
Covid 19
disorder

Morbidity Immune
& Mortality system • Neuroinflammatory
• Therapy process
• Prognosis • Risk of Infection
disease

2
COVID-19
Acute respiratory
disease caused by a
novel coronavirus
(SARS-CoV-2, previously
known as 2019-nCoV)
The novel coronavirus
uses the same receptor,
angiotensin-converting
enzyme 2 (ACE2) as that
for SARS-CoV, and
mainly spreads through
the respiratory tract

Guo et al. Military Medical Research (2020) 7:11

3
4
 Sleep & Immunity
Cytokine
• IL-1β, IL-6, and TNFα involve as regulators of
sleep physiology
• IL-1 and TNFα are involved in an increase in
NREM sleep
• REM sleep is decreased during infection

Neurologic areas
• the hippocampus, hypothalamus, and
brainstem

Silva E de SM e, Ono BHVS, Souza JC. Sleep and immunity in times of COVID-19. Rev Assoc Med Bras. 2020;66(Suppl 2):143–7 5
 Lack of Covid-
sleep 19
↓expression of HLA-DR, IL-6 is an essential part
variations in CD4+ and during cytokine storm
CD8+ T lymphocytes, and correlated with Covid-
positive regulations of 19 severity symptoms
CD14+

The damage Inflammation and

mitogenic damage of CNS tissue
proliferation of
lymphocytes
Cytokine storms during
Lower activity of viral infection
natural killer cells
Decline in global sleep
Decreased T cells quality, quantity, and
circadian misalignment

Silva E de SM e, Ono BHVS, Souza JC. Sleep and immunity in times of COVID-19. Rev Assoc Med Bras. 2020;66(Suppl 2):143–7.
Imeri L, Opp MR. How (and why) the immune system makes us sleep. Nat Rev Neurosci. 2009;10(3):199–210. 6
Obstructive Sleep Apnea (OSA) & C0VID-19
Epidemiology
• Patients with OSA experienced about eight times more significant for Covid-19 risk
• OSA was found in 28% of patients with Covid-19
• OSA was correlated with a significant risk of hospitalization and an increase twice
respiratory failure risk

Comorbidity
• OSA is strongly correlated with significant comorbidities of Covid-19 such as
hypertension, diabetes, cardiovascular disease, and obesity
• OSA is associated with hypoxemia, sympathetic activation, and increased inflammatory
markers related to OSA comorbidities

Dysregulation of the RAS in OSA patients

• OSA was associated with higher angiotensin-converting enzyme (ACE) activity levels,
angiotensin II and aldosterone
• Risk factor and comorbidities for OSA related with negative Covid-19 outcome

Ekiz T, al. Obstructive sleep apnea, renin-angiotensin system, and COVID-19 : possible interactions. J Clin Sleep Med. 2020;16(8):1403–4.
Miller MA, Cappuccio FP. A systematic review of COVID-19 and obstructive sleep apnoea. Sleep Med Rev. 2021;55:1-9 7
Tufik S, et al. Does obstructive sleep apnea lead to increased risk of COVID-19 infection and severity ? J Clin Sleep Med. 2020;16(8):1425–6.
Miller, M.A., Cappuccio. F.P. Sleep Medicine Reviews 55 (2021) 101382 8
 Circadian Rhythm Sleep Disorders (CRSD) & COVID-19

Social
isolation

Susceptibility
of infection
Quarantine

CRSD
Alteration
Health
sleep
behavior quality

DSPD

Bryson WJ. Circadian rhythm sleep-wake disorders and the COVID-19 pandemic. J Clin Sleep Med. 2020;16(8):1423.
Salehinejad MA, et al., Negative Impact of COVID-19 Pandemic on Sleep Quantitative Parameters, Quality, and Circadian Alignment : Implications for Health and Psychological Wellbeing. EXCLI J. 9
2020;19:1297–308.
Narcolepsy related with COVID-19

damage the orexin

(OX) hypothalamic
disrupt the neurons
blood-brain
enter the barrier
hypothalamus

through the
olfactory bulb

Aguilar ACR, et al,. The effects of the COVID-19 pandemic on patients with narcolepsy. J Clin Sleep Med.
Schirinzi T, et al. COVID - 19 : dealing with a potential risk factor for chronic neurological disorders. J Neurol. 2020;1–12 10
Mori, I., The olfactory bulb: A link between environmental agents and narcolepsy. Medical Hypotheses 126 (2019)
Conclusion:
Cascade of events leading to OX system
and involving the diferent subsets of
immune cells (B cells, T CD4+and T
CD8+cells)
T cells seem to have direct and indirect
efects on OX neurons
Hypotheses : sleep medicine clinicians
and researches is to consider SARS-CoV2
infection as a possibly triggering event
leading to narcolepsy

11
Restless Leg Syndrome (RLS) & COVID-19

Upregulation of RLS
hepcidin
• production production •Hepcidin binds
Symptoms
of IL-6 • in the to ferroportin •CNS iron
choroid deficiency
plexus
Cytokine Decrease in
storm iron

Tony AA, Ae E, Ali SB, Ezzeldin AM, Mahmoud AA. COVID-19-associated sleep disorders : A case report. Neurobiol Sleep Circadian Rhythm. 2020;9:1-3.
12
Insomnia & COVID-19
Coffein &
Stressor anxiety alcohol
consumption

Decrease sleep Longer latency

quality of sleep

Javaheri S, Javaheri S. The impact of SARS-CoV-2 on sleep. J Clin Sleep Med. 2020;16(8):1413. 13
Characteristics of Insomnia Severity Index (ISI) Score in Indonesia on COVID-19
Pandemic Period : A Descriptive Study on February – March 2021
Zamroni Afif , Afiyf Kaysa Waafi , Septy Aulia Rahmy

Subjects' Gender Profile Insomnia Severity Index (ISI) Data

61
48
44
Laki-Laki
Perempuan 20
94 9

No Clinically Significant Subthreshold Insomnia Clinical Insomnia Clinical Insomnia

(0-7) (8-14) (Moderate 15-21) (Severe 22-28)

Insomnia Severity Index in Male Insomnia Severity Index in Female

Subjects Subjects

22
39
36

12
7 3 13 6

No Clinically Significant Subthreshold Insomnia Clinical Insomnia Clinical Insomnia No Clinically Subthreshold Clinical Insomnia Clinical Insomnia
(0-7) (8-14) (Moderate 15-21) (Severe 22-28) Significant (0-7) Insomnia (8-14) (Moderate 15-21) (Severe 22-28)

14
 Conclusion:
Healthcare workers, as the front line of
the fight against COVID-19, are more
vulnerable to the harmful effects of this
disease than other groups in society.
Increasing workplace stress increases
sleep disturbances in the medical staff,
especially nurses and physicians.
It is important for health policymakers
to provide solutions and interventions
to reduce the workplace stress and
pressures on medical staff.

Salari et al. Globalization and Health (2020) 16:92 15

Salari et al. Globalization and Health (2020) 16:92 16
 Results :
The prevalence of sleep
disturbances among nurses is
34.8% (95% CI: 24.8-46.4%)
The prevalence of sleep
disturbances in physicians was
reported 41.6% (95% CI: 27.7-
57%)

Salari et al. Globalization and Health (2020) 16:92

17
 Interpretation:
Early evidence suggests that a
considerable proportion of HCWs
experience mood and sleep
disturbances during this
outbreak, stressing the need to
establish ways to mitigate mental
health risks and adjust
interventions under pandemic
conditions.

Brain, Behavior, and Immunity 88 (2020) 901–907

18
Brain, Behavior, and Immunity 88 (2020) 901–907 19
Conclusion
▪ The COVID-19 pandemic is still a global health problem.
▪ One of the manifestations of COVID-19 related with neurology is sleep
disorders.
▪ More research is needed on the relationship between COVID-19 and sleep
disorders.
▪ Good quality of sleep for both patients and health workers is needed to
improve the immune system against COVID-19.

20
THANK YOU

21