Post-COVID Abnormal Sleep is Common, With Potential Impacts on Cognition


Among patients with post-acute sequelae from COVID-19 infection, self-reported cognitive symptoms were correlated with severity of fatigue, anxiety, and depression, but not subjective sleep disturbance.

Kathryn J. Reid, PhD, research professor of neurology, Northwestern Feinberg School of Medicine

Kathryn J. Reid, PhD

Findings from a small-scale study of patients previously infected by COVID-19 showed that most individuals had numerous neurological post-acute sequelae (PASC), including abnormal cognitive performance and sleep. Investigators concluded that interventions to improve sleep could benefit cognitive performance.

Among a cohort of 39 individuals recruited from the Neuro-COVID-19 Clinic at Northwestern Memorial Hospital, the median number of discrete neurologic symptoms attributed to PASC was 6, with 87% of patients reporting at least 4 neurologic symptoms. Presented at the 2023 SLEEP Annual Meeting, held June 3-7, in Indianapolis, Indiana, patients with abnormal sleep characteristics, which included wake-onset sleep onset (WASO), sleep efficiency, and sleep latency, demonstrated impaired objective attention and executive function.

Led by Kathryn J. Reid, PhD, research professor of neurology, Northwestern Feinberg School of Medicine, patients used National Institutes of Health Toolbox modules of processing speed, attention, executive function, and working memory, to assess cognition. In addition, these patients completed 7 days of wrist actigraphy with a sleep log and Patient Reported Outcomes for Symptom Severity (PROMIS) that covered cognitive function, fatigue, sleep disturbance, anxiety, and depression. Similar to previous studies, fatigue, insomnia, and depression were all common, with around 70% of patients reporting each.

Compared with population normative data, patients reported significant symptom burden in all PROMIS domains, and had measurably worse attention function along with borderline executive function (all P <.001; executive cognition, P = .056). These self-reported cognitive symptoms were found to be correlated with severity of fatigue (P <.001), anxiety (P = .05), and depression (P <.01), but not subjective sleep disturbance. Of note, there was no association between actigraphy-measured sleep or rest-activity characteristics and self-reported symptoms.

READ MORE: Post-COVID Abnormal Sleep is Common, With Potential Impacts on Cognition

The literature on the correlation between COVID-19 and sleep disturbances has steadily grown since the beginning of the pandemic. In one of the first studies of its kind presented at SLEEP 2022, findings showed a high prevalence of moderate-to-severe sleep disturbances in individuals who had PASC of COVID-19, including 3-fold higher odds for Black individuals. Of the cohort assessed, 682 patients completed the PROMIS Sleep Disturbance questionnaire with average T-scores of 57.7 (±8.1).

Findings showed that 41.2% of the cohort had T-scores greater than 60, indicating at least moderate disturbance. Additionally, 7.3% of patients reported severe sleep disturbances, indicated by scores of at least 70. The average PROMIS fatigue T-score was 63.0 (±9.2), with 68.6% of patients reporting at least moderate fatigue and 22.6% who reported severe fatigue. The data also revealed that a higher body mass index was associated with more moderate-to-severe sleep disturbances compared with normal-to-mild (32.3 [±8.7] vs 30.9 [±7.5]; P = .049).

Patients who’ve had a diagnosis of obstructive sleep apnea have also been associated with an increased risk of long-term symptoms suggestive of long COVID. A recently published study of electronic health records from more than 2.2 million Americans infected with COVID-19 showed a 1.41-3.93 times greater probability of PASC among those with a preexisting OSA diagnosis. The association was attenuated yet still elevated after successfully adjusting for demographic factors, hospitalization, obesity, and comorbidities.

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1. Reid K, Ingram L, Jimenez M, et al. Associations between sleep and cognitive function in patients with neurological post-acute sequelae of SARS-CoV-2 infection. Presented at: 2023 SLEEP Annual Meeting; June 3-7; Indianapolis, Indiana. Abstract 0301.
2. Pena Orbea C, Lapin B, Katzan I, Englund K, Folvary-Schaefer N, Mehra R. Sleep disturbances in post-acute sequelae of COVID-19 (PASC). Presented at: SLEEP Annual Meeting, 2022; June 4-8; Charlotte, NC. Abstract 0735
3. Mandel HL, Colleen G, Abedian S, et al. Risk of post-acute sequalae of SARS-CoV-2 infection associated with pre-coronavirus disease obstructive sleep apnea diagnoses: an electronic health record-based analysis from the RECOVER initiative. Sleep. Published online May 11, 2023. doi:10.1093/sleep/zsad126
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