The prevalence of sleep disturbances among patients with COVID-19
Morteza Rahbar Taramsari 1, Robabeh
Soleimani 2*, Paniz Tavakol
3, Shokoufeh Mogharabi
Ostadkelayeh 4, Sakineh
Mazloom 5, Seyed Amirhossein Azimi Meybodi 6, Fatemeh
Karimi 6, Shahab Salimi Meidan Shahi 6, Mahdi Amirarshadi
7*
1 Department of
Forensic Medicine, School of Medicine, Guilan
University of Medical Sciences, Rasht, Iran
2 Psychiatry
Department, Kavosh Cognitive Behaviour
Sciences and Addiction Research Center, Shafa
educational - remedial Hospital, Guilan University of
Medical Sciences, Rasht, Iran
3 School of
medicine, Tehran Medical Sciences Islamic Azad University, Tehran, Iran
4 Faculty of
Nursing, Iranshahr Branch, Islamic Azad University, Iranshahr, Iran
5 Department of
Nursing, Zahedan Branch, Islamic Azad University, Zahedan, Iran
6 Shahid Sadoughi University of Medical University,Yazd, Iran
7 School of
Medicine, Guilan University of Medical Sciences,
Rasht, Iran
*Corresponding Authors: Mahdi Amirarshadi * Email: mahdiamirarshadi@gmail.com
Robabeh Soleimani * Email: Soleimani.dr@gmail.com
Abstract
Introduction: Due to
the importance of sleep disorders and the unknown effects that they may have on
the course of the disease in COVID-19 patients, in this study, we aimed to investigate
the factors affecting sleep disorders in these patients.
Materials and Methods: The
present research was a cross-sectional analytical study conducted in Razi
Hospital in Rasht. The study population included COVID-19 patients referred to
the corona clinic of Razi Hospital for follow-up. Information about age,
gender, body mass index (BMI), underlying disease, drugs used, a history of
using cigarette and opioids, duration
of hospitalization, and type of hospitalization (normal
ward or the intensive care unit (ICU)
ward) was extracted from patients’ files and recorded
in the data collection form. The Petersburg Sleep Quality Index (PSQI)
was used to assess sleep disorders. The collected data were entered into SPSS
software version 24. The significance level of the tests was considered P < 0.05.
Results: The mean age of the subjects in this study was
43.79 years. According to the results, 52 people were male (52.5%) and the rest
were female. Based on the results, it was found that age (p = 0.540), gender (p
= 0.141), BMI (p
=
0.464), cigarette use (p = 0.675), opium use (p = 0.757), underlying disease (p
= 0.430), drug use (p = 0.327), and duration of hospitalization (p = 0.203)
were not significantly associated with sleep disorders.
Conclusion: According to the findings of this study, sleep
in patients with COVID-19 is not associated with age, gender, cigarette use,
opium use, underlying disease, duration of hospitalization, and a history of
drug use.
Keywords:
Sleep
disorder, COVID-19, Petersburg Sleep Quality Index, Cigarette use, Opium use
Since
early December 2019, numerous cases of pneumonia due to an unknown etiology
were reported in Wuhan, Hubei Province, China (1–3). Most patients worked in
the seafood wholesale market (1–4). The cause of this disease was a new and
genetically modified virus from the family of coronaviruses called SARS-CoV-2,
which was named COVID-19. Unfortunately, due to its high transmissibility, the virus
spread rapidly throughout the world and infected almost all countries of the
world in a short time (less than 14 months) (5,6) .
According to official reports, more than 7 million people in the world have
been infected with the virus as of June 25, 2020, and the number of deaths due
to this virus has been reported to
more than 400,000 (7). Coronaviruses are a group of very diverse,
single-stranded RNA viruses. They cause
many diseases related to the respiratory, intestinal, hepatic, and nervous
systems with varying severity in humans and animals (8,9). COVID-19 is the
seventh recorded coronavirus that infects humans
and has 75%- 80% genomic resemblance to the
severe acute respiratory syndrome coronavirus (SARS-COV), 50% to the Middle
East respiratory syndrome coronavirus (MERS-COV), and 96% to bat coronavirus
(3). Therefore, current evidence strongly supports that the new coronavirus
(COVID-19) has been derived from bats, although its intermediate hosts are not
yet known (10). Studies have shown that, like the SARS coronavirus, the COVID-19 virus uses the receptor, the angiotensin II converting enzyme
(ACE2), to enter the cell (3,11). The most important clinical symptoms upon arrival of COVID-19 patients at the
hospital include fever, cough, sputum, headache, vomiting, diarrhea, fatigue,
rhinorrhea, and chest pain. Almost 80% of patients with the new coronavirus show mild symptoms and recover at home. In 14% of
cases, the sufferer shows severe symptoms, including pneumonia and shortness of
breath. In 5% of cases, the patient’s condition worsens, associated with
respiratory failure, infectious shock, and failure in other organs
of the body (11). Given the pathogenicity of the virus, its high rate
of spread, and its resulting mortality rate, this disease may affect
the mental health
status in different
strata of society as well as
the patients with this disease. Sleep disorder in COVID-19 patients is one of
the problems related to individuals’ mental health and well-being.
Patients
with this disease should be isolated which the patient’s isolation during the course of the disease
may exacerbate anxiety and sleep disorders (12,13).On
the other hand, sleep disorders can aggravate
psychological stress and increase stress and defective cycle, followed
by various changes in the body’s immune and hormonal
systems, which in turn intensify the destructive course of the disease.
For example, with increasing levels of cortisol in the
body, the mortality rate of patients with COVID-19 increases, showing the importance of the above-mentioned
cases and one of the ways through which sleep disorders affect the disease
(14). During sleep disorders, patients may also have to take soporific drugs, which these
drugs through sedative mechanisms and muscle relaxation, may affect respiratory
fatigue or other factors leading to exacerbating disease course and mortality.
Because of the importance of sleep disorders and the unknown effects that they
can have on the course of COVID-19, in this study, we aimed to investigate the
frequency of sleep disorders in COVID-19 patients.
The study population in this research included
COVID-
19
patients referred to the corona clinic of Razi Hospital for follow-up.
Inclusion criteria were all patients with COVID-19 whose disease had been
confirmed by computed tomography (CT) scan or polymerase chain reaction (PCR),
and after treatment and discharge from the hospital of origin, they had
referred to the corona clinic of Razi Hospital. Exclusion criteria were
patients with incomplete files or those who were not willing to participate in
this study.
The
present research was conducted as a cross- sectional analytical study.
Information about age, gender, body mass index (BMI), underlying disease, drugs
used, a history of using cigarette and opioids, duration of hospitalization,
and type of hospitalization (normal ward or the intensive care unit (ICU) ward)
were extracted from patients’ files and recorded in the data collection form.
The Petersburg Sleep Quality Index (PSQI) was used to assess sleep disorders.
This questionnaire is one of the best tools designed and developed to measure
sleep quality which was
developed
in 1989 by Dr. Boyce et al. at Pittsburgh Psychiatric Institute (15). To
exclude patients who had insomnia due to depression or anxiety (exclusion
criteria), the Hospital Anxiety and Depression Scale (HADS) was used. This
scale was designed by Zigmond et al. in 1983 to
measure patients’ risk of depression and anxiety (16).
In this
research, descriptive statistical methods such as frequency, percentage, mean,
and standard deviation were used to describe the obtained data. The Independent
Samples Test was used to examine the relations
of age and BMI to sleep disorders; the Pearson
Chi-square Test was used to examine the relations of gender, cigarette use,
underlying disease, and drug use to sleep disorders; the Fisher’s Exact Test
was used to examine the relationship between opium use and sleep disorders, and
the Mann-Whitney U Test was used to investigate the relationship between
duration of hospitalization and sleep disorders. The data analysis
was
performed using SPSS software version 24, and the significance level of all
tests was considered 0.05.
The mean age of the subjects in this study was
12.54 ±
43.79
years, among which 52 people were male (52.5%), and the rest were female. The
mean BMI of the subjects was 3.22 ± 26.83. Table 1 shows the frequency of the
type of underlying disease in the subjects.
According
to the results, 35 people (35.4%) had a history of drug use, 35 (35.4%) had a
history of cigarette use, and 15 (15.2%) had a history of opium use. The mean
duration of hospitalization of the study subjects was 2.84 ± 4.81 days.
Based on the results,
71 people (71.7%)
had mild sleep disorders. In addition, the analysis
of the data of this study showed that age, gender, BMI, cigarette use, opium
use, underlying disease, drug use, and duration of hospitalization were not
significantly associated with sleep disorders.
Table
1. Frequency of
subjects based on the underlying disease.
|
Disease |
Number |
Percent |
|
High
blood cholesterol |
4 |
12.12 |
|
High
blood pressure |
8 |
24.24 |
|
Diabetes |
4 |
12.12 |
|
Chronic
heart failure |
1 |
3.03 |
|
Chronic
kidney failure |
1 |
3.03 |
|
Hypothyroidism |
1 |
3.03 |
|
Osteoarthritis |
1 |
3.03 |
|
Fatty
Liver |
1 |
3.03 |
|
High blood pressure + high blood cholesterol |
4 |
12.12 |
|
High
blood pressure + chronic kidney failure |
1 |
3.03 |
|
High
blood pressure + prostate hypertrophy |
2 |
6.06 |
|
Diabetes
+ hypothyroidism |
1 |
3.03 |
|
High blood pressure + high blood cholesterol
+ diabetes |
2 |
6.06 |
|
High
blood pressure + diabetes |
1 |
3.03 |
|
High
blood pressure + chronic kidney failure + prostate hypertrophy |
1 |
3.03 |
|
Total |
33 |
100 |
The COVID-19
disease is unique because it has infected all countries of the world due to its
high transmissibility in less than a few months and creating a pandemic
situation (12,13). Currently, the number of patients infected with this disease
as well as the resulting mortality, is increasing rapidly worldwide (5,6).
Accordingly, and considering the current emergency situation of this disease,
it is predictable that some of the symptoms of psychological disorders will
appear in COVID-19 patients. In this regard, the results of numerous studies on
COVID-19 patients in China during the disease spread, some of these
psychological disorders, including anxiety, fear, depression, emotional changes,
insomnia, and post- traumatic stress disorder (PTSD) with a high prevalence have been reported
in these patients
(17,18). According to previous studies, COVID-19 patients have low
psychological tolerance, and due to the current state of the disease in the
world, these individuals are highly exposed to psychological disorders such as
anxiety, fear, depression, as well as negative
thoughts (19). Also, according to the results
of a study in China, the prevalence of low-quality sleep is 38.3%, the prevalence of problems
related to sleep onset is 29.8%, and the prevalence of insomnia is 29.1% in
patients with COVID-19 (20). In this study, the frequency of sleep disorders in
COVID-19 patients was investigated. Based on the results, there was no
significant relationship between age and sleep disorders. The results of a
study in Bangladesh in 2020 showed
that the prevalence of sleep disorders in COVID-19 patients in the age range of
31 to 40 years was much higher than in other age groups (21). The results of a
study on COVID-19 patients in China in 2020 showed that sleep disorders were
higher in patients older than 35 years (22). With increasing age, some changes
occur in the quantity and quality of sleep,
leading to sleep disorders and frequent complaints related to these disorders.
On the other hand, the incidence of physical diseases exacerbates the incidence
of sleep disorders in this age group. Elderly patients also experience issues such as retirement or the
death of a loved one (for example,
a spouse), leading
to emotional stress. For this reason,
they often have delays
in falling asleep as well as frequent awakenings during sleep. In addition, the elderly often
take medications to control and treat chronic diseases,
which these medications can affect
the quantity and quality of sleep.
The elderly are more likely to develop primary sleep
disorders such as obstructive sleep apnea, which may predispose them to chronic
sleep disorders (23). However, based on the results, sleep disorders are not
significantly associated with taking medication. The results of a study showed
that the use of muscle relaxants can be effective in improving sleep quality
and reducing anxiety in patients with COVID-19
(24).
In the
following, according to the results, it was found that sleep disorders were not
significantly related to gender. In line with the results of the present study,
a study on COVID-19 patients in China in 2020 showed that the rate of sleep
disorders was not related to patients’ gender (22). Contrary to the results of
the present study, a study in Bangladesh in 2020 showed that the prevalence of
sleep disorders in COVID-19 patients was higher in women than in men (21). The
results of another study in Bangladesh showed that the rate of generalized
anxiety and subsequent sleep disorders was higher in women with COVID-19
than in men (25). Differences
in the results of different studies
may be due to differences in the demographic characteristics of the subjects.
However, in previous studies, sleep disorders were generally associated with
gender. For example, Kijna et al. have mentioned
gender as one of the important effective factors in sleep disorders (26). and the study of
Trible has also shown that being a woman is a factor in sleep disorders (27). This
finding may be due to the home duties of women and their preoccupations at the
time of hospitalization because of not doing housework and the affairs related
to their children, which cause sleep disorders in them. Another reason which
can be raised is the issue of women’s menopause, which causes them to have
trouble sleeping compared to their youth because, during menopause, sleep onset is delayed
with frequent awakenings, and
sleep time is shortened. Also, based on the results, there was no significant
relationship between BMI and sleep disorders. Given the relationship between
the negative effects
of obesity and inactivity on sleep (28). it was
expected that patients with higher BMI would have higher rates of sleep
disorders, which was not the case. In line with the results of the present
study, a study on COVID-19 patients in China in 2020 showed that the rate of
sleep disorders was not related to patients’ BMI (22). Based on the results,
sleep disorders were not significantly associated with cigarette use.
Consistent with the results of the present study, a study on COVID-19 patients
in China in 2020 showed that the rate of sleep disorders was not related to
cigarette use (22). It seems that
the main factors in sleep disorders in COVID-19 patients are different from the
common causes of sleep disorders in
other individuals in the community. For example, it has been suggested that
sleep disorders in COVID-19 patients are more psychological and stem
from anxiety.
The results showed that sleep disorders were not significantly associated with
opium use. Given the high prevalence of depression in patients who use opium
and the role of depression in the development of sleep disorders (29). it was
expected that the rate of sleep disorders in patients who use opium was higher, which
was not the case. Also, based
on the results, sleep disorders were not significantly related to the underlying diseases. According to a study by Basedosky
et al., sleep disorders can lead to more activation of inflammatory processes
and changes in the cytokine system in individuals with underlying diseases, and
subsequently, these changes can exacerbate sleep disorders. The studies by Hung
et al. have also shown that the mortality rate is higher in septic patients
with sleep disorders. From the above articles, we can understand the possible
prevalence of insomnia in COVID-19
patients and the role it can play in
the prognosis of these patients
(30–32). Therefore, it was expected that in patients with
underlying diseases, due to higher levels of systemic inflammation, the rate of
sleep disorders would be higher, which was not the case. In the following,
based on the results, there was no significant relationship between the duration
of hospitalization and sleep disorders. According to the results of a study by Guo et al. in May 2020, the rate of sleep disorders is higher in coronary
patients due to isolation, hospitalization, and distance from family (33). According to a study
by Zhang et al. in June 2020, it was found that many patients with
insomnia were admitted to the ICU, but after investigating patients without sleep problems, it was found that none of them required ICU admission (34).
Therefore, it was expected that the rate of sleep disorders would increase
following increasing patients’ duration of hospitalization, which was not the case.
The
results of the present study showed that sleep disorders in COVID-19 patients
were not associated with age, gender, cigarette use, opium use, underlying
disease, duration of hospitalization, and a history of drug use.
MRT,
RS, MA wrote the manuscript ,revised and conducted
this study. PT, ShMO, SM, SAAM, FK and
ShSMSh contributed in some sections of the article.
All authors read the final edited version of the manuscript.
Compliance with ethical guidelines: IR.GUMS.REC.1399.273.
The
authors declare no potential conflicts of interest.
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