Dr. Thorpy is a Professor of Neurology at Albert Einstein College of Medicine and Director of the Sleep-Wake Disorders Center in the Department of Neurology at Montefiore Medical Center, both in New York. In addition to treating patients with sleep disorders, he conducts research in narcolepsy, insomnia, and sleep apnea.
Born in New Zealand, Dr. Thorpy earned his medical degree from the University of Otago Medical School. After receiving postgraduate training in Dunedin, New Zealand; Bombay, India; and London, England, he completed his residency in neurology at the State University of New York in Syracuse and a neuroendocrinology fellowship at Albert Einstein College of Medicine and Montefiore Medical Center. Dr. Thorpy is board certified in sleep disorders medicine.
Sleep Foundation (SF): Thank you for participating, Dr. Thorpy.
Last year SleepFoundation.org released sleep guidelines at the beginning of the pandemic. As time has worn on, however, we’re in a different state. We’re now 11 months in, broaching on a year for the U.S. Many of the things we wrote about didn’t anticipate the length and consequences of social isolation, as well as the school closures, job loss, and this anxiety.
So let’s start with this: now that we’re 11 months into this pandemic, what has surprised you as you look back?
MT: Being in New York City, we were involved with this pandemic pretty early on. A lot of what we were seeing initially was confusion and lack of understanding about what was going to happen with regards to the virus. Many of our patients expressed a lot of anxiety — there weren’t formal guidelines as to how to manage patients who had sleep disorders, or to conduct sleep disorder evaluations or sleep studies. We were making up on the fly what we needed to do to keep our staff safe, as well as our patients safe.
So there was a lot of anxiety from patients because they weren’t quite sure exactly how COVID, if it affected them, how it would affect their underlying illness, particularly the obstructive sleep apnea syndrome in patients.
We actually published an article on our experience in dealing with obstructive sleep apnea syndrome in New York City at the beginning of the pandemic. We got a feel for patients about their stressors that they were undergoing, and the concerns they might have about interaction of the virus with their underlying medical illness.
The other thing that was happening at this time, was that the places were beginning to get shut down and this affected patients in terms of medication treatment. Many of our patients who were getting medication from their local pharmacy suddenly found their pharmacies were closed and they couldn’t get their medication.
So there’s a lot of anxiety in patients and as a result, we tended to see more patients presenting with insomnia. Or patients who had other medical sleep disorders such as sleep apnea or narcolepsy who developed more sleep disruption because of the stress that they were undergoing.
So initially, until it became clear where things were going, the main thing was a lot of confusion about how to handle it. Of course, telehealth was set up pretty early. That was actually one of the good things that came out of this. Telehealth has been really a great advantage for many patients and reduced a lot of stress that they otherwise would have had. Telehealth gives them the ability to communicate with their physician without having to put themselves in an environment where they may be exposed to the virus.
SF: That’s an excellent point. If that had not happened, think of the massive dislocation and access to healthcare that would have occurred — it would have compounded this in so many ways.
With respect to some of these general trends, are you aware of any difference between presenting issues you found from patients living in major urban centers versus more rural areas?
MT: The only difference that we noticed was the fact that a lot of our patients travel a long distance to get to us, and it often involves a bus or trains and a lot of transportation. So for our patient population, the ability to be able to contact the physician through telehealth, without having to physically make that trip where they might be more exposed to the virus was a big thing for the urban part of the study. So that may be quite different from somebody who’s in a more rural environment.
“The fact that our patients don’t have to commute to cut themselves short of sleep at night — which they were doing prior to the pandemic — has made a big difference”
SF: Sleep opportunity has been one of the main educational awareness focuses of sleep in the last 15 years. We know that societal pressures — artificial societal, policy-caused pressures — have unfortunately resulted in volitional voluntary sleep deprivation. Have you seen anything that is promising about what we can take away from that? Have they become more in-touch with how valuable sleep is as a result of increased opportunity?
MT: The fact that our patients don’t have to commute to cut themselves short of sleep at night — which they were doing prior to the pandemic — has made a big difference. So of course commute times can be very long in New York and many patients have multiple jobs. The pandemic, of course, has forced them to spend far more time at home.
But what I’m finding is that sleep-wake scheduling has been probably a little worse overall. I find that patients tend to go to bed a lot later because they’re up watching a lot of reruns and things on television. They’re watching a lot of the series late into the night, but then they are napping more during the day because they have more flexibility to do that.
So although the total amount of sleep is probably more than they were getting before the pandemic, rather than being very a rigorous, 11:00 PM to 6:00 AM in the past, now it’s 1:00am or 2:00am going to bed, getting up at 9:00am, and then taking a nap for an hour or two in the afternoon. It’s more of a disrupted sleep wake schedule.
As others have said, we’ve also certainly seen an increase in alcohol use in adults. But stress is the overwhelming issue, and some people are actually under greater pressure and have less flexibility in terms of their schedule and have more work. A number of people, because certain staff members are out due to COVID, the pressure is being put on others. So people are having to work longer and longer hours and have less time off.
We even have some physicians that are presenting because of insomnia and stress, because they’re being asked to do far more work than they normally were able to do. Particularly older physicians, too, who normally would have a more relaxed schedule are being forced into doing a schedule similar to a younger resident. This is causing a lot of stress and anxiety. So I think a lot of first responders, particularly, are probably working more and have less time for sleep compared with a younger population that may have a little more flexibility in their sleep patterns.
SF: There have been a lot of reports of nightmares and some other unusual sleep problems emerging from the anxiety and stress of the pandemic. Do you see that in your practice?
MT: We’ve seen a little bit more in patients reporting about dreams and disturbing dreams. Actually I’ve also seen it in people who are post-COVID, too, that makes you wonder whether that may play a part in that as well. But I think largely, obviously, it’s the stress that may be contributing to it. But we are getting a few more reports of abnormal dream content, unpleasant dreams, than we had previously.
SF: And it’s not over, right? There’s likely going to be increasing pressure over the vaccine.
MT: Initially, we sort of saw a relief that there was going to be a vaccine. But now we’re having patients… and what comes to mind is an elderly 80-year-old that I was talking to the other day, who is very infirm and uses a walker. She went for her vaccine appointment and was told that the vaccine’s all run out. So of course this caused her enormous stress because she was unable to get the vaccine.
We’re now seeing people that are getting concerned about getting the vaccine, and there’s a lot of anxiety around the effect that they can’t get it or make an appointment. I don’t know about those in the rest of the country, but in New York, it can be very difficult to make an appointment to get a vaccine.
“You need to strengthen the sleep at night so that there’s less time awake. But also, the time of awakening is so important to control our circadian rhythms”
SF: There is a strong body of evidence that suggests that fairly consistent sleep schedules and routines are a very powerful part of our circadian rhythms. Is there something we could take away from this pandemic to modify or strengthen those recommendations? Or anything that we’ve learned from this that might point us back to learning about circadian rhythms?
MT: I totally agree with you that stability of sleep-wake patterns is extremely important. And I regard this one of the most important things in patients that I see no matter what their underlying sleep disorder might be. So maintaining a regular time of going to bed or regular time of getting up in the morning is absolutely essential.
But it’s not just that, and often people will tend to sort of leave it at that. But the most important part I think is the amount of time between going to bed and getting up in the morning. And for people with insomnia, for example, that is extremely important. They need to have seven and a half to eight hours — and no more than eight hours in bed — if they’re trying to deal with insomnia.
One of the principles we’re great believers in is that the more time you spend in bed awake, the more likely you are to become conditioned to being awake at night. You need to strengthen the sleep at night so that there’s less time awake. But also the time of awakening is so important to control our circadian rhythms; that time is tied to our body temperature, or cortisol, and many other hormonal and biochemical parameters.
So maintaining a regular time of going to bed, but most important, the regular time of getting up in the morning and being in bed for an appropriate amount of time I think are crucial elements that every patient or every individual needs to really understand.
SF: There’s an enormous market for meditation tapes and self-help guides like Headspace and Calm. Tracking your sleep is also now widely available and relatively inexpensive or even free. They have come a long way in terms of technology, but some sleep doctors are opposed as they don’t want their patients to obsess over the data. What do you tell your patients?
MT: For some of those devices, I think that they actually can be counterproductive. And I’m thinking here particularly about Fitbits. I’ve had patients who have become so focused on the Fitbit — and the fact that they’re arousing and have brief arousals at night — that they’ve become quite obsessed by it. And really, their treatment has been to remove the Fitbit altogether so that they’re not focused on it. And that’s been more helpful than their knowing what’s going on with their actual sleep.
SF: We know there is excessive sleepiness that is presenting in sleep labs as a result of the pandemic. Is it possible that narcolepsy is getting diagnosed quicker?
Michael Thorpy: I’m not too sure to what extent the pandemic has played a part in this. I think there is a general recognition more about sleep and sleepiness, and so that there is a greater awareness about hypersomnia and excessive sleepiness. Maybe in these times of pandemic, because of telehealth, people can actually approach a physician a little easier than having to make appointments, and travel, and take a significant amount of time away from work.
It’s possibly having a beneficial effect on these people who have sleepiness and presenting to a clinician to get an evaluation. I mean, they have their own unique sort of issues, patients that have excessive sleepiness. And of course, once they present, I mean, typically in order to reach an adequate diagnosis, you require sleep testing. And in this environment, it may be quite difficult, particularly if it involves a multiple sleep latency test or a daytime sleepiness test. That would require somebody to have to go to a hospital or a sleep center in order to have that, and that poses some difficulties.
But yeah, I think we certainly are seeing a lot of patients that have complaints of excessive sleepiness, and we have a constant stream of patients that are currently being diagnosed with narcolepsy.
“We strongly encourage patients to get exposed as they can to natural bright light during the day and full activity during the daytime”
SF: COVID has impacted all of us in so many different ways. If you had to give one sleep recommendation, what would it be?
MT: I’d like to re-emphasize the fact that the timing of going to bed, the timing of getting up in the morning and the amount of time a person spends in bed are the most crucial elements. But I’d also agree with what Helene was saying about taking some exercise during the daytime. We strongly encourage patients to get exposed as they can to natural bright light during the day and full activity during the daytime. I think just those factors alone can greatly strengthen the sleep-wake patterns.
There’s an important element with regard to COVID. People tend to think about this as being a pneumonia and a lung disease, but really it’s more than that. In fact, it’s probably more of a neurological disease and a pulmonary disease. So I think there are a lot of neurological consequences to COVID, and we just don’t know what’s going to happen in the long-term.
Of course, we’re all aware in the narcolepsy arena that viral infections can precipitate narcolepsy as can vaccinations of certain types. So we don’t know what’s going to happen with regard to COVID. Are we going to see more people with disorders of hypersomnia subsequently because of the neurological consequences of this disorder or disease or not? We’re not yet able to answer that question.
I’ve had quite a number of patients with narcolepsy who have asked me whether they should have the vaccine or not. It’s become a very common question by patients with narcolepsy. My answer of course, is that they definitely should have it because I think the consequences of the disease are far greater than any very remote chance that there could be any complication from the vaccine.
SF: This has been such a rich conversation. One final question: How have you personally seen your sleep impacted? Do you find that it’s different from some of the presenting issues in your clinics? Just as an expert in the field who is experiencing all of this, how have you tried to guard against many of the disruptions that you’ve spoken about?
Michael Thorpy: I’ve kept a pretty solid schedule. So work-wise, it’s been pretty solid, regular days. That hasn’t changed too much from that point of view.
The thing that really I find has been very rewarding is that you can have a greater interaction with patients through telemedicine. Because of being in New York and long travel times for patients, I have been inclined to see patients much less frequently than I would have liked. With telemedicine now, the moment a patient calls up and expresses any concern, we can do a telemedicine call and address it. So I’m dealing with patients’ problems a lot more quickly, and I think more efficiently than I had been able to do prior to the pandemic.