In this episode Sleep Disturbance as experienced by Long Covid sufferers. The causes, specific treatments and general management will be discussed.
I am Dr Tim Robinson, formerly a GP for 30 years, retired as planned at the start of the Covid pandemic. Since then I have become involved in the world of Long Covid. Currently I am GP clinical lead for Long Covid NHS in South West England, as well as GP lead for three NHS Long Covid Services – Dorset, Bristol and South Devon. I am also Clinical Lead for Hope for the Community CIC. I have research involvement as co-investigator in a study on breathlessness in Long Covid, University of Bristol.
Long Covid Doctor is an educational series for Long Covid sufferers; each talk covers the many aspects of Long Covid, the symptoms, causes, treatments, management and expected outcomes.
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Disclaimer: Long Covid Doctor is an educational series. Any advice, diagnosis, treatments mentioned should only be considered after discussion with your own GP or qualified professional health provider.
References, links, resources:
NICE Covid-19 rapid guideline: https://www.nice.org.uk/guidance/ng188
How to manage post viral fatigue after Covid-19: www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19-0 (http://www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19-0)
Your Covid Recovery: NHS England – self-help patient resource for symptoms, information and self-management of Long Covid: www.yourcovidrecovery.com (http://www.yourcovidrecovery.com/)
Welcome to Long covid doctor an educational series for sufferers of long covid I’m Dr Tim Robinson formerly a GP for 30 years now GP lead for three NHS long covid clinics and clinical lead for long covid across the southwest of England this episode is on sleep disturbance and long
Covid I will be talking about the symptoms the uh treatments and management of sleep disturbance in Long covid references links and resources are in the show notes below any treatments that I mention should only be considered after discussion with your own GP Health provider and so here we go sleep disturbance and long
Covid sleep disturbance and long covid uh certainly in my experience in my working in my long covid clinics is an extremely common problem in uh patients who are suffering from long covid it’s important to understand for a number of reasons to find out the causes for it to understand why it occurs in
Long covid to find out any ways to help to resolve it and uh sleep really as we all know is an important part of the recovery from long covid so first of all uh what what is normal sleep what is deemed as normal sleep sleep is the state of reduced mental and physical
Activity uh uh in which this sort of Consciousness is altered but not you’re not unconscious motor activity the sort of movement of Limbs Etc is altered vol untary activity is turned off but involuntary activity so the heart rate the the breathing Etc is left on sensory activity is in is sort of
Turned down it’s inhibited so while we sleep we go through various sleep cycles alternating between two types of sleep the very deep deep sort of slow wave sleep it’s called slow wave sleep s SWS slow wave sleep nonr I’ll come on to that RM in a minute
And then there’s fast wave sleep shallow dreaming sleep the remm sleep now remm stands for rapid eye movement it’s called rapid eye movement as your eyes flicker whilst you’re asleep during this dream phase okay so basically most people sleep between 7 and 8 hours uh a night that’s
The normal sort of P pattern and it’s divided into phases you’ve got the Deep phases and the shallow phases the Deep phases mostly sort of five or six of those through the night bursts with bursts of of of RM in between those phases the dream rapid eye movement
Phases so what is the function of sleep uh basically it’s to restore and repair basically as we all know the old saying go sleep is a great tonic sleep is the great healer all the systems in the body the immune system the endocrine system the nervous system muscular sceletal all the
Organs in the body um all these cells throughout the body are repaired and restored during sleep breakdown products of metabolism are removed if you like a spring clean every night the repair of damage and replacement of worn out cells worn out Parts occurs during this during um night time during
Sleep um just as importantly sleep is necessary for all things that is happening sort of in the brain the maintenance of your thinking functions your cognitive function your memory your mood sleep as we all know occurs at night uh when it’s dark which brings me on to the day night cycle the so-called
Circadian rhythm this is important for all those rest and restore functions it is also governs the release of s of the hormones of certain hormones uh with the day night cycle there’s growth hormone the tissue repair hormone that is mostly secreted at night there’s melatonin the natural sleeping hormone sleep hormone sedating
Hormone that we all produce is released at night cortisol um is produced at the end of the night and the early morning that helps us get up and go and sort of gear up for the day and face the day so a day night cycle release of hormones is
Really important for all these reasons um so what happens if we don’t get a a regular good night sleep if you have sleep disturbance as we are finding in Long covid patients so obviously all those rest restorative repair process are not working optimally therefore they’re not working most efficiently and therefore
At their best capacity this is not ideal while we’re trying to recover from long covid adverse effects are seen in the immune system that’s impaired and studies show that cognitive function your sort of thought processes concentration alertness memory are all impaired if your sleep deprived or impaired mental well-being again that’s
Affected um if you have sleep disturbance um there’s an effect on the mood and irritability that leads to you know clinical conditions s such as anxiety and depression so what are our patients our long covid patients telling us um with regard to their sleep disturbance how how is sleep disturbance presenting with
With them and how in what way is it disturbing them um they’re telling us that all sorts of things they’re telling us that they have insomnia they have difficulty getting off to sleep taking time to get to sleep this is so-called sleep latency there’s interrupted sleep this
Is sort of waking repeatedly through the night maybe hourly patients are also telling us that they’re waking in the early hours for no reason or other things like you know excessive dreaming Vivid or even distressing dreaming um they they’re also telling us that they’re waking feeling completely
Unrefreshed even after a 7 8 hours sleep or even longer some patients are sleeping for 12 14 hours and still waking up feeling pretty Dopey um so why are our long covid patients getting sleep disturbance you know what’s the explanation behind this you know particularly I mean patients
Are asking this who previously prior to covid have had normal normal restful SLE sleep every hour every every night 7 eight hours but now since having covid they’ve got sleep disturbance why is this well you know first and foremost as I’ve said before in previous podcast that basically long covid is complexed
And complicated with multiple causes disregulation disregulation and dysfunctions so all symptoms in Long Co result from many any possible causes and explanations not just one cause one explanation unfortunately so I mean so therefore this applies to long covid sleep disturbance also so what are the possible causes for sleep disturbance in
Long covid so on the simplest level um you know patients who are unwell are not getting tired physically or mentally due to because they’re unwell they’ve been less active than usual hence they’ve burnt up less energy uh got less tired and less in need of sleep as a consequence maybe long covid patients
Have given into a long daytime nap um you know understandably and so therefore if they’ve had a long nap in the daytime they won’t be so tired at bedtime therefore they can’t get to sleep then they get into a sort of if you like a chaotic sleep routine and even even a
Sort of reversed sleep pattern awake all night and sleep all day or maybe it’s due to other long covid symptoms that the patient might be experiencing at the same time as their sleep disturbance so they may have sleep disregulation again this is a common symptom in our long covid patients they
They’re they’re sort of their they they’ve got sort of disregulation of their temperature control they either feel hot and sweaty and flushing at night or chilly cold or alternating patients may have tinitus and tinitus is ringing in the ears is always more more noticeable at night when everything else is quiet around
You and a lot of our long covid patients have muscle aches joint aches and pains just can’t get comfortable again along covid problems or maybe another explanation for the Sleep disturbances gut the gut disbiosis what do we mean by that they the friendly Flora the the friendly
Bacteria bugs in your or in your gut in your intestin are Disturbed we see this and this is well documented and studied in Long covid patients um as a consequence of this is the the the gut Flora is not not ideal it’s you know what we call disbiosis sort of um and so
Therefore the normal functions of the gut Flora are not as good as they could be so um one of the functions is secretion of um neurotransmitters such as serotonin the happy hormone 90% of that is is produced in the intestinal cells um Gaba um the calm hormone is also produced in the
Large large bowel both are reduced and this may contribute to a tendency for anxiety and depression which in themselves have sleep disturbance associated with them so G the biosis in long covid can be a contributing factor to sleep disturbance and finally um and I think most interestingly the long covid
Effects on the brain overall the central nervous system we know that long covid disrupts the balance of the sympathetic and the parasympathetic nervous systems the patients are stuck in their fight or flight mode adrenaline charged we know that the the HPA axis the hypothalamopituitary adrenal axis is
Disturbed and so the the the cortisol release um from the from the adrenal glands is disrupted we we know that the levels of cortisol are reduced we see this interestingly enough in mecfs as well um the neural Pathways between the hypothalamus and the pineal gland are probably Disturbed as well remember
That’s the pineal gland is where the natural the Melatonin comes from our own bodies Our body’s own natural sleeping pill is is produced and secreted from long covid can mess up that process and that nerve nerve uh pathway and so you don’t have your own natural melatonin being
Produced uh there’s the disruption of the lyic system the part of the autonomic nervous system for emotional processing and memory memory foundation and hence a a as a consequence of this there’s there’s anxiety and memory disfunction and that contributes to brain fog all these things and then
Finally uh we know that long covid in interrupts the the various um nuclei that’s collection of of of nerve cells in the brain stem the the dorsal brain stem that that look after and deal with nausea and pain and sickness Behavior response and sleep function are all
Going to be disturbed in long covid so there are multiple reasons for um the these processes to be occurring and again I’ve talked in previous podcasts about the sort of what we call pathophysiology the causes behind long covid in general um but these can all apply um throughout the body and
Particularly in the brain the excessive inflammation the sort of blood micro micro thrombi the inflammation of the blood vessels the the myelin loss the nerve cells how they the nerve cells affected all this you know we I could go on forever and ever um all this contributes to sleep
Disturbance and finally I mean I don’t think we should we shouldn’t shouldn’t go un unnoted that one of the other consequences of long covid is the effect on the person overall not just sort of the person who’s not not just not getting better the effects on on the patient who has
Had their Co for a long time and the effects that therefore the KnockOn effects on their family their relationships their friendships they can’t work the financial effects life robbed hopes and dreams smashed all totally understandable worries and stresses and fears may lead to sort of anxiety and depression which
Of course like I’ve said before all contribute to sleep disturbance so that’s a very long long answer to that question what are the possible causes for sleep disturbance in long covid I mean the the short answer is there are tons of reasons for sleep disturbance in Long
Covid Le this leads on therefore if we’ve got this problem how are we going to how are we going to help with sleep disturbance in our long covid patients so firstly we need to rule out other causes for non long covid causes for sleep disturbance so just to make sure
Simple things really make sure the patient isn’t taking too much caffeine coffee tea energy drinks alcohol can disturb your sleep some medication can disturb your sleep steroids for example make sure that the patient not got sleep disturbance because of joint pains because of arthritis or night sweats because of menopausal night
Sweats or um reflux heartburn um uh and sort of nighttime cough due to acid coming up from the stomach or sleep apnea um uh make sure that you know people aren’t having those periods of sleep periods of of um absences in their breathing whilst they’re asleep restless
Leg syndrome heart failure these are all sort of like I’ve said nonong covid causes for sleep disturbance and they all need to be thought about and excluded and addressed um in order to you know help with sleep disturbance and then see what we’re left with to see whether the sleep
Disturbance persists and therefore can be attributed to do the long covid having ruled out all those Co causes what advice would we be giving for long covid sleep disturbance well first and foremost let’s think about the non pharmacological um approaches um we’ve got to think about sleep hygiene and I’m sure that everyone
Sort of thought about and and sort of tried to optimize their sleep hygiene naturally anyway but you know obviously you know environment you know the bedroom needs to be quiet and warmish bed needs to be comfortable um noise well you know if there’s noise in the house or else
Outside Etc there’s always air plugs dark like I’ve talked about the sort of day night cycle you know it’s important to have a dark environment to be sleeping in so line curtains or wear eye visors why not to maximize the the secretion of your own natural melatonin from your Pine pineal
Bland there’s a lot mentioned about sort of no mobile phone or tablet screen viewing sort of the hour before going to sleep why because they emit so-called blue light light in the blue wavelength band of the light spectrum that’s and again I know this because I’ve looked it up it’s 400
Nanometers um that part of the electromagnetic spectrum and that inhibits melatonin release our own natural melatonin release and and a studies shown that you know blue light is more stimulating it’s s of in it sort of brings about the arousal response rather than red light which in the 70 nanometer band bandwidth is
Sedating so no tablets and phones an hour before going to bed very important um structured bedtime I think this is really important as sort of the bedtime routine you really should be going to bed um at the same time every night be strict be disciplined preferably after a
Relaxing bath or a hot a mug of hot chocolate settle down to a nice t Reed you know a Jane Austin not a Stephen King novel um you need as well as a sort of structured bedtime you need a structured get up time in the morning this is also
Important to have a routine to avoid sleeping in over sleeping in the daytime may you know it that basically means that you won’t be sleepy when you when you get to nighttime if you’ve overslept in the in the morning uh and had had a lazy lion um and this also applies to the
Daytime nuts okay I talked about daytime nuts and you know if you if you’ve given into a really long daytime nap because you just can’t function you’ve you’ve given into a daytime n I’m not averse to or against a daytime nap I myself enjoy a 15minute
Daytime nap uh after lunch um but you know make sure it’s it’s not not longer than 20 minutes and the reason for this is that at 30 minutes um you descend into the level three sleep I you remember at the start I talked about the different stages and phases of sleep
Okay and I talked about the Deep Sleep the slow way of sleep um if you wake from this and studies uh demonstrate this very clearly if you wake from deep sleep you feel rubbish groggy spaced out and often disorientated this is known as it’s got its own label it’s called Sleep inertia
Okay studies also show that a 20 minute power nap soal increased is alertness and thought process cognitive performance and learning abilities and motor skills that’s a 20 minute pound that okay and like I said you know I enjoy a 15 minute sleep after lunch and
I after which I you know set an alarm for it uh but I wake up feeling utterly refreshed and lot of zing and zest um and you know I can just get back to work can feel really charged up highly recommended it I use a mindfulness technique to get me off to
Sleep really quickly with practice you can do this even if I can’t get off to sleep because you know thoughts keep popping into my mind um the timeout the brain rest makes me feel refreshed and great almost as good as actually getting that 15minute power nap so I highly recommend
It so all this advice is very general everyone has different requirements some long covid patients sleep for 12 to 14 hours and can’t help it um they have to give into it but regardless of this I think it’s really important to to introduce a sort of structured
Timing of when you get up get an alarm clock and um hopefully you know a structure timing when you turn the the light off at night okay and remember those sleep enhancing um Jane noston novels so what about treatments for sleep disturbance you know treatments so supplements sedatives sleeping tablets
What’s on offer and mean how long to use them for and what are their benefits and what are their risks right so first of all I’ll talk about supp um there’s magnesium so 500 mgrs at night Studies have shown that it reduces sleep latency I um time it takes to get
Off to sleep uh reduces in sleep interruptions and it increases the duration of sleep so there are studies worth trying from the health food shop 500 milligrams that’s what the study used don’t don’t exceed that why not try it also in the health food shop you’ll come across Herbal Remedies of course okay
There’s Rescue Remedy which is a combination of flower essences there’s nitl herbal um which contains herbs which are said to have sleep enhancing properties Hops and valarian and passion flow but note um NL herbal not nightl original or nightl one a night that’s 25 or 50 milligrams these um don’t contain
The herbs they contain an antihistamine called dienamine Dien hydramine big a pardon another antihistamine that can be tried would be the the ancient um first generation sedating H1 antihistamine Pon chlorphenamine 4 mg which you can buy um off the shelf over the counter uh in the
Chemist um not not for not to be used not recommended in pregnancy or breastfeeding um certainly worth trying 4 milligrams at bedtime why not the next is melatonin okay well melatonin keeps coming up doesn’t it um as I explained earlier melatonin is our natural hormone uh sleeping if you like
Our sleeping Tablet S sleeping supplement natural hormone secreted each night by our pineal gland in our brain um and melatonin has as a hormone has sedating effects as well as the other functions such as it’s an anti antioxidant so it dampens un inflammation but it aids restful um restorative
Sleep there’s a synthetic form of melatonin uh that can be taken to add to our own natural melatonin it’s used to get you to sleep quicker with less interruptions and for longer it takes one to two hours to work so take it a few hours before going to
Bed in the UK it is a prescription only medicine for the over 55s or for patients with learning difficulties or for one on for a short period of time jet lags some P some countries it is overthe counter you can get it um a lot of European countries
You can get it over the counter it’s also available online but you know as always beware of online medicines if you just want to have a quick sort of Refresh on that go to the NHS website nhs.uk website um and look for dangers of buying medicines online online gives
You a lot of common sense advice on what to look out for and what to be wary of there’s one reliable source as recommended some by some pediatricians who treat um kids with ADHD um and that is bio.com B IO V A.C I’ll put that in the in the
Description and the CA in the show notes below um uh and for long covid purposes choose the slow release form the 2 mgram um which is uh labeled as cadan which is very popular um look up cad.com What are the side effects of this synthetic melatonin well there of course there are some side effects the most common ones listed are headache and nausea and vivid dreams it shouldn’t be taken along with other hermal remedies uh and if taken if if if you’re taking other prescribed medicines especially
Those acting on the brain check with your GP first it shouldn’t be taken with coffee alcohol or smoking because its effect won’t be so good it shouldn’t be taken during pregnancy as we don’t know enough about it safety it’s only okay to be it’s but however it is okay to be
Taken um with breastfeeding Beware with driving if it makes you feel drowsy obvious obvious Common Sense advice you may be asking why is it prescription for on prescription for you know 55 patients 55 and over sounds a bit sort of random doesn’t it basically it’s because there was a research study done
On melatonin synthetic melatonin on a group of patients patients who were 55 plus and it showed benefits um that I’ve listed above why did they choose 55 as the age they chose it because uh natural melatonin uh starts falling at that age and so they obviously then based this
Policy decision on how to license melatonin um on on that study incidentally there’s another study that that that demonstrates um both both efficacy and safety of melatonin done on patients between age between 20 and 80 given melatonin and they were reviewed at 6 months and 12 months after starting
The study and they indeed found that it was effective and safe so like I said if you want to know more go to the website cadi.com as I mentioned above where there’s some excellent resources on um melatonin synthetic melatonin and Caden so those are sort of first for those those are some
Prescription um uh medications for sleep disturbance other prescriptions uh it’s obviously issued by uh a doctor U benzo diine group of drugs so the common one was was diazapam but this can lead to dependence and its effect wears off after you’ve used it for a period of time and so then
To get the same effect you have to give higher Doses and higher Doses and then you become addicted to it we want to avoid that at all costs other sleeping tablets that are prescribed are non benzoin the So-Cal Zed drugs zopiclone zadam these are less dependency lead to less
Dependency um they can be used in the short term for mild to moderate insomnia that’s what they’re licensed for so the question is you know if you are prescribed sleeping tablets how long for you short duration is the answer only a few selected nights per week what
Are the benefits well for peace of mind really that you know piece of mind that you’ve got something there if you should need it and you become desperate so for example night for an exam or the driving test um or if you’ve had a bad run of of nights um to reset a
Disturbed reverse sleep pattern what are the risks well as I’ve said before you can get addicted to them and then dependent on them they can Clash with other of them medicines they can lead to nonrestorative uh non-restorative sleep um and they can have side effects and hangover and dry mouth and vivid
Dreams um there dangers with driving and operating Machinery um another another approach is to use uh an anti-depressant um not you know obviously if a patient has depression and reactive due to circumstances or endogenous depression as diagnosed by the GP but also in absence of diagnosis of depression an ancient anti-depressant
Is used a tricyclic anti-depressant called amalin is used for its sleep enhancing properties not its anti-depressant properties it’s not addictive it’s also common use for commonly used outside of of this you know for migraine prevention and for chronic pain syndromes so as I say it’s tried and tested it’s been around for
Years it is prescribed for other things but it has sleep enhancing properties and so I think it’s very reasonable and I used to prescribe it um in place of Zed drugs in in general practice so that concludes if you like again quite a long section on the treatments for long covid sleep
Disturbance both the sort of the over their counter herbal the supplements but also the prescription only medicines I think it’s also important just to touch on um you know other things to consider to help with long covid sleep disturbance I think we shouldn’t forget the sort of more holistic whole person approaches and
Strategies that I’ve talked about before for in other podcasts just as important as as the overall management of long Co covid you know so we’ve got to think about you know and incorporate all these other um um strategies so dietary strategies and how to tackle anxiety and
Uh so diet for example you know we’ve got to think about that mix balanced that Mediterranean diet um that produ that provides all those minerals and vitamins those polyphenols um the spectrum of vegetables and and and fruit um that also contain prei pre Prebiotic fiber for our microbiota there
The healthy friendly bacteria you know um oily fish Omega-3 for immune support vitamin D all this is so important to consider as as part of the whole long covid package if you like so important I’ve touched on you know the effects on on the on the person and
Their sort of if you like their mental um their mood and mental well-being Etc and being stuck in the flight and fright um uh the sympathetic adrenaline uh Dynamo brain um effects of of the long covid can have on any of us and the benefits of thinking about sort
Of other strategies such as um the sort of the Mind Body techniques so mindfulness and and yoga and taii you know just to help incorporate and focus uh breath control and coordination and and and and sort of ways to allay stress and and and and reduce anxiety Etc all
These things again like I said all part and parcel of the whole package for helping with long covid so there we are that’s it um that concludes my talk on sleep disturbance uh with long covid um I hope you found it helpful um as I mentioned at the
Start you know any treatments that I mention in this series and and in this and and in this talk on sleep disturbance and on Co should only be considered after discussion with your own GP Health provider so in the meantime my very best wishes uh for your long covid recovery cheerio