Sleep Assessment in Long COVID Clinics

Recent studies suggest that a significant proportion of individuals who had a COVID-19 infection developed 1 or more sequelae including fatigue, brain fog, depression, anxiety, breathlessness, and sleep disturbance.¹ Symptoms may range from mild to debilitating. A collection of these symptoms is referred to as “long COVID” or postacute sequelae of SARS-CoV-2 infection.

Many health care facilities across the world are seeing an increasing number of patients with long COVID. Numerous post-COVID clinics have been established, usually headed by neurology, pulmonary, or physical medicine and rehabilitation clinicians. On behalf of the COVID-19 Task Force of the American Academy of Sleep Medicine, we applaud their efforts and suggest collaboration with sleep medicine clinicians. Thus far, in our collective experience, sleep disturbances and fatigue, often significant enough to continue to impair daytime functioning for weeks or months after initial infection, seem to be a prominent feature in patients with long COVID; yet a formal sleep assessment does not seem to be a routine part of the post-COVID clinic protocols.² We submit that because sleep disturbances are such a common feature of long COVID, clinicians should routinely ask post-COVID patients about their sleep and screen for sleep complaints. A sleep medicine evaluation may uncover a disorder amenable to treatment that may hasten symptom improvement or resolution. Similarly, sleep medicine clinicians may wish to query patients routinely regarding whether they have recovered from COVID-19 if sleep complaints continue to persist beyond resolution of acute illness or if new symptoms have arisen or evolved since the time of initial infection.

Recent studies have shown that patients with obesity and obstructive sleep apnea (OSA) have worse clinical outcomes when hospitalized with COVID-19.^3,-,5 It is quite plausible that a proportion of patients with long COVID have undiagnosed OSA. Patients with lung damage from acute COVID–related pneumonia may have ongoing pulmonary insufficiency as well and an abnormal alveolar-arterial O₂ gradient, which can exacerbate the risk for nocturnal desaturation or sleep apnea. In these cases, OSA should be considered even if traditional risk factors are absent when evaluating a patient with new fatigue. Although OSA has not been classified by the Centers for Disease Control and Prevention as an independent risk factor for the acquisition of COVID-19, there are data demonstrating worse COVID outcomes in patients with nocturnal hypoxia and sleep apnea.⁶ Identifying and treating OSA early may be fruitful, and creating an inpatient sleep program and/or screening for OSA during hospitalization should be considered.

In addition to OSA, sleep fragmentation may present as insomnia in the form of both sleep-onset and sleep-maintenance difficulties and/or nonrestorative sleep. Persistent sleep disturbance may lead to chronic insomnia. Hypersomnia disorders should be considered if a significant degree of daytime fatigue or sleepiness is present. In these cases, further testing with in-laboratory polysomnography, actigraphy, sleep logs, or multiple sleep latency testing may be necessary. Circadian rhythm misalignment also may contribute to symptoms of long COVID.

Moving forward, we propose including sleep medicine clinicians as part of long COVID multidisciplinary clinics. We recognize that not all facilities have a sleep clinician on site and propose that standard screening tools such as the STOP-Bang or PROMIS assessment tools be deployed. In patients who report falling asleep during the daytime, the Epworth Sleepiness Scale score can be helpful, with a score >10 indicating pathologic sleepiness.⁷ Those who screen positive on any of these scales may be referred for further evaluation to a sleep clinician.

We also encourage sleep medicine clinicians to ask about a history of COVID-19 infection and about long COVID symptoms. We applaud the efforts of the NIH to identify and fund high-priority research areas to study sleep disorders and disturbance in long COVID—the role of sleep and sleep and circadian rhythm disorders; the prevalence of such disorders in long COVID; and whether treatment of sleep disorders affects long-term outcomes.⁸ These concerted efforts in the clinical and scientific domains may help our patients, yield useful information about the interaction between sleep and COVID-related outcomes, and boost our preparedness for future pandemics.

Appendix Authors

• Received March 28, 2022.
• Accepted August 11, 2022.

• © 2023 American Academy of Neurology