Get Some Rest: A Brief Guide for Those on the COVID-19 Front Lines

By Michael A. Grandner PhD MTR DBSM
Director, Sleep and Health Research Program
Director, Behavioral Sleep Medicine Clinic
Associate Professor of Psychiatry
University of Arizona College of Medicine 

This article was originally posted on Medium

As a sleep researcher and psychologist, I have had a lot of conversations over the past several weeks about COVID-19. My work focuses on real-world impacts of sleep health and insomnia, and how these relate to mental and physical health. So in these conversations, I’ve talked about how sleep impacts immunity and mental health, how our sleep patterns have changed, and how we can make the most of our sleep. But one issue that keeps coming up as I talk with friends and colleagues about the impacts of COVID-19 are current and future impacts of the pandemic on the healthcare workers themselves.

Fortunately, I don’t need to be on the front lines. My research lab has moved completely online, my students are all working remotely, and even my sleep clinic is 100% virtual visits for now. But many of us are– or will soon be – faced with long hours, stress, and fear.

This article is written to the nurses, doctors, other healthcare workers, logistics personnel, and all of the others out on the front lines, fighting COVID-19. You are working tirelessly (and tiredly) to keep the rest of us safe and healthy. You need and deserve to be able to keep yourself safe and healthy as well. 

We need you to be as well-rested as possible.

Sleep is important for both the brain and body. It is intricately involved in the immune system as well. Compelling scientific evidence exists that describes these connections at the molecular level, as well as at the population level. Sleep deprivation is a pro-inflammatory state, can weaken the immune system, and can increase viral infections.

Healthy sleep not only supports immune health, but it supports cardiovascular and metabolic health. For example, poor sleep can cause aberrations in insulin secretion and glucose homeostasis in just a few days among healthy people. This is important since cardiovascular disease and diabetes seem to be risk factors for COVID-19 complications.

Perhaps most importantly, sleep plays critical roles in mental and physical functioning. Lack of sleep -- even in the short term but especially when extended over days or weeks – can lead to an increase in errors of omission (things missed) or commission (mistakes made) for tasks that people are usually doing well. It also impairs judgment and decision-making capacity. It decreases attention, impairs an individual’s ability to maintain focus, and increases attentional lapses. 

Get some sleep if you can.

The ideal sleep schedule is one that is regular, where you set aside plenty of time for sleep, at around the same time each day. Keeping a regular schedule can help leverage clock time as a circadian signal and help prepare the mind and body for sleep at the night time. If you can keep your sleep schedule somewhat regular, even if it is not ideal, that may help you maximize the amount and quality of sleep available.

For many people right now, this is not an option. If your schedule is erratic or unpredictable, or if you are working interminable shifts and having difficulty figuring out when to sleep, consider the advice commonly given to another group of people suddenly thrust into a situation of long hours, high stakes, and round-the-clock needs: new moms.

Get as much of your sleep at night as you can, but also take naps. If you are not getting enough sleep, take it where you can get it. Naps can be restorative, reduce fatigue, improve brain function, and reduce the impact of sleep loss. In this trying (and temporary!) time, take naps when you can. A short nap of 15-30 minutes might help get you through a shift.

There is also some evidence that melatonin may help. Melatonin may not be a very effective treatment for insomnia disorder, but it can promote healthy sleep and may also help people sleep at times that are outside their normal schedule. There is also a little bit of evidence that it can improve immune function, though it is not clear how it might help in this situation. Melatonin timing and dosage can be tricky. About 5mg within 30-60 minutes of bedtime might be helpful. Higher doses (6-10mg) might have more immune benefits but might also produce more grogginess or other side effects.

Many people are turning to heavier sleep aids, including over-the-counter antihistamines and prescription sleeping pills. These might be helpful short-term sleep aids, but they can also lead to significant side effects – especially in the domains of physical and mental performance. Be wary of decrements in these areas, especially in situations when you have to alert quickly and perform. Also, sleep medications should only be used if you can set aside 8 or so hours for sleep, so they probably should not be used prior to a nap. 

Protect the sleep you get.

When you are able to carve out some time for sleep, insulate that sleep from external disturbances as much as you can. One way to do this is to have a place that you can go to sleep where you will be undisturbed for a set amount of time. At home, this could be a bedroom or spare room or den or office (with a place to lie down). If you’re not at home, this could be a break room or nap room specially set aside for this purpose. Either way, lock the door or at least let everyone know not to disturb you. Consider putting up a simple sign to let people know you are sleeping.

Other ways to protect your sleep might work by decreasing sensory input. This means that where you sleep should be dark, quiet, cool, and comfortable. The darkness will help to create a night-like environment, even if you are sleeping during the day. It will also decrease the sensory input to your eyes, even through closed eyelids, which may make sleep more shallow and wake you up. A simple eye mask can really be effective in these situations.

Enhancing the quietness of the environment is paramount. This can be easily and cheaply accomplished through earplugs. Other approaches, like noise machines and fans, may also help. Whether you opt for an approach that reduces the noise or masks it (like with white noise), keeping disruptive sounds away will be key.

If possible, making the place where you sleep cool and comfortable will also help to protect your sleep. Tactile and temperature inputs that signal discomfort may make sleep more difficult, so try to get comfortable if you can.

Another important way to protect your sleep is to prepare your mind and body. It can be difficult to go right to sleep at night after a long and stressful day, especially if that day is concluded by immersing yourself in the news and data about the epidemic. Plan on having enough lead-in time (perhaps 30 minutes) without adding new things to worry about. Turn off the news and stop checking emails and social media, in order to set you up to be able to sleep.

Protect the sleep of others, too.

If a colleague is sleeping and you don’t need to wake them, don’t. And if a patient is sleeping and you don’t need to wake them, don’t. Sleep is an important part of the process of healing and recovery. Also consider the sleep of your family or others that live with you. If you’re coming home late, let them sleep.

Many adults usually don’t sleep alone. They usually sleep with a partner or spouse in the same bed. Some people will sleep with other family members or children in the bed as well. Cultural and practical issues aside, there are reasons why you may want to sleep in a separate room for a while.

And there is a growing concern about sleep apnea. This is a condition that is highly prevalent in the population and is often treated with Positive Airway Pressure (PAP) therapy. Unfortunately, for those infected with the virus, there is a concern that the PAP machine may inadvertently aerosolize the virus in the room. So if you or a partner are using a PAP machine (CPAP or otherwise), this may influence the discussion about sleeping somewhere else. 

If you can’t sleep, don’t keep trying.

Worries, anxieties, and fears may interact with irregular schedules, excess caffeine, and altered rhythms to make sleep difficult. Developing a chronic insomnia disorder would make this situation much worse. Fortunately, there are some things you can do that will prevent this temporary sleeplessness from blossoming into a chronic insomnia.

The first and most important thing to remember is to get out of bed if you cannot sleep. If you are laying in bed for more than 20-30 minutes unable to sleep – either at the beginning of the night or after waking up – it is important to get out of bed. This will prevent a “conditioned arousal” to the bed, where you will inadvertently program your mind and body to be awake as it is desiring to fall asleep. Decades of research in insomnia has shown that chronic insomnia is often a problem of conditioned arousal, where an individual loses sleep for one reason or another but spends so much time in bed awake that they inadvertently train themselves to be awake in bed. So, if you are in bed and unable to sleep, get up and do something else for a little while and then try again.

This rule applies for any situation, including naps. The amount of time you have to spend out of bed (or wherever you are trying to sleep) can depend on the situation, but you should only try to sleep if you think that either sleep is imminent or at least possible. 

Stay awake when you have no other choice.

Sometimes, sleep is not possible. There may be times where you have to perform procedures, make judgments, conduct interviews, and do other work when you are very tired. Obvious signs of sleepiness include excessive blinking, rolling eyes, and head-bobbing. Know that in these situations you are prone to errors of omission or commission, poor judgment, emotional dysregulation, and impaired attention and ability to maintain focus. This is likely inevitable and, hopefully, will be countered by skill, experience, and support systems.

There are a number of things that you can do when you must be awake and cannot nap, but might also be impaired. Caffeine is probably the most used psychoactive substance in the world. Caffeine will take about 30 minutes to reach peak effects and it may be able to prolong wakefulness for 4-6 hours after consumption. Caffeine can also decrease fatigue and increase ability to maintain attention. Unfortunately, it will not rescue poor decision-making, though. Bright light and movement can also help, to a degree.

Other safeguards can be structural. Double and triple check anything that has high stakes. Maybe get a second set of eyes on particularly important documents, orders, or procedures. Providers and staff should serve as each other’s safety net, catching any errors and quickly (and non-judgmentally) redirecting. And if you’ve been working more than 18 hours in a row, please do not drive home. Get a ride from someone else or a ride-sharing service. Even if your work performance has not noticeably declined, your driving ability is likely to still be impaired.

Remember these take-home points.

Sleep in the time of coronavirus can be a stressful and unpredictable endeavor. During this stressful time, remember these take-home points:

  1. Remember that sleep can be a powerful ally in promoting your own health, immune function, and cognitive abilities.
  2. Get sleep when you can. Even brief naps may help, especially in the short term.
  3. Protect your sleep with eye masks, ear plugs, white noise, darkness, and other environmental safeguards.
  4. Protect the sleep of others, to promote their health and well-being.
  5. Avoid spending excessive amounts of time laying in bed trying to sleep. Get up.
  6. Employ countermeasures to maintain wakefulness and alertness, including structural supports.

It is highly likely that your sleep will be compromised during this time. Keep these ideas in mind as you navigate this stressful situation, and do what you can. Stay safe!

Special thanks to Victoria Bliznak and Anna Maltby for providing helpful ideas and feedback.