Sleep and somnolence
Because deranged sleep can contribute to any psychiatric illness, the quantity and quality of Trump's sleep should have occupied a central role in his medical care. This seems not to have been the case. As described and discussed in detail SEE BELOW, he experienced overt daytime somnolence while in office that included sleeping during a G7 meeting in 2018 1. This is not surprising, given the numerous factors that threatened his sleep health:
Time in BedBefore becoming president, Trump issued several tweets denigrating sleep and trumpeting the little time he devotes to it ("about four hours") 2. While campaigning, he again mentioned the four-hour figure 3. He has also said three to four hours 4. During the first four months of his presidency, the timing of his tweets suggests he normally -- but not always -- sleeps from midnight to six a.m. 2 (of course, tweeting is only an indirect measure of sleep/wake state). Journalistic accounts describe him waking around 5:30 am, after 5 to 6 hours of sleep, watching television, tweeting, then going to work 5. "Trump normally set his own schedule on when to start the day and often had flexibility when he returned to the residence" 6a. "During Trump's first six months in the White House ... [he] didn't show up for work until 11:00 in the morning" 6b. His chief of staff tried, "with only modest success," to "accelerate the start of [Trump's] workday" to arrive in the office by 9:00 or 9:30 am 5. His nightly dinner in the White House residence begins at 6:30 or 7 p.m. 5, though he prefers by that time to be in bed with a cheeseburger 7. Before the presidency: "he goes to bed late, gets up early" 8.
Sleep QualityThere is little description of his sleep quality. As a mark of bravado, he said "I slept like a rock" the day after a long practice session preparing for an interview with the Mueller investigators 6c (the interview never occurred). One source of sleep disruption can be ruled out: Trump and his wife maintain separate rooms in the White House -- the first presidential couple since the Kennedys to do so 7.
Daytime SomnolenceWithout deliberately searching, Dr. Zebra has encountered several descriptions of overt daytime somnolence in Trump:
Physician IgnoranceAlthough his physician had sought fit to give Trump a sleeping aid (pill) during travel across time zones 9, as of early 2018 he had not taken a sleep history at all, was unaware of even the most basic sleep parameters of the President, and based his medical judgments on speculation. When asked in January 2018 how much Trump sleeps, Dr. Jackson replied 9:
He doesn't sleep much. I mean, I would say that — you know, this is just my guess based on being around him. I didn't ask him this question, so I could be wrong on this, but I would say he sleeps four to five hours a night. And I think he’s probably been that way his whole life. That’s probably one of the reasons why he’s been successful, I don't know. ... But he’s just one of those people, I think, that just does not require a lot of sleep.The report of the 2019 physical examination 10 does not mention sleep either.
Extended DiscussionComment: As the saying goes, this is 10 kinds of bad.
The patient sleeps 5 hours a day and, although he calls it "garbage," drinks 12 servings of Diet Coke a day because he likes the caffeine "boost." He has even rigged a system where he can get the drug "stat." All of this should have prompted the physician to take a sleep history, not the least because the patient's caffeine consumption is approaching toxic levels, and, indeed, may already be having a toxic effect (the caffeine may be causing the short sleep time). Instead, the physician assumes that the patient has always been this way -- which is not the question at hand.
(Note: it is unlikely that the President is a physiological short sleeper. Although many people in the USA now sleep less than six hours nightly, historical records show that this is a recent development, i.e. it is due to population sleep-habit changes, not biology. Most so-called "short-sleepers" are, therefore, really just "brief-bedders" because of work pressure, and statistically Trump is more likely to fall into that category.)
But even if we assume that Trump's inborn physiology truly does need only 4-5 sleep hours per night, why does he need so much caffeine and why does he doze in public meetings? He is assuredly not ok with public dozing. This president cares greatly for anything that might connote weakness, and he knows that daytime somnolence caught on camera would lead to snide remarks about Grandpa, age 73, needing a blankie for his afternoon nap.
The possibility must be considered that he has a sleep disorder such as obstructive sleep apnea (OSA). He is a set-up for it. He is a thick-necked older man with truncal obesity who, on the basis of his caffeine intake, appears to be fighting somnolence every day, all day. (Does he snore? That would be a reason his wife sleeps separately.) Though OSA patients typically like to spend more time in bed, it is easy to posit a hyperactive Trump willing himself not to do that. Or, he may actually be spending far more than 5 hours daily in bed: He spends lots of time in the residence, and reportedly likes to be in bed by 6:30 with a cheeseburger 7.
Trump's apparent high-energy conduct does not rule out OSA. Dr. Zebra has seen strikingly high-energy people with severe sleep apnea, who burn the energy as a way to counter the sleepiness 11 12, much as a tired child becomes frenetic.
Overall, therefore, no matter how it's dissected, there are so many abnormal factors at play in Trump's sleep physiology that a mere sleep history is unlikely to fully clarify his clinical state. Therefore, he should be tested for a sleep disorder, which we know had not happened as of January 2018. Although national guidelines do not recommend screening the general adult population for OSA, those guidelines apply only to asymptomatic patients. As we have seen, with even the limited data available now, it can easily be construed that he is symptomatically somnolent. Moreover, his actions that some observers call "dementia" are more likely signs of sleep deprivation, as well could be some negative aspects of his personality.
Regardless of who is in office, sleep should always be among the top clinical considerations for the President's physician. One presidency has already been destroyed by sleep apnea. Presidential physicians should receive enhanced training in sleep medicine. They need to know that OSA is an insidious attacker of anyone involved in daily brain-work -- so subtle that it was not even discovered as a disease until the 1970s. Now everyone knows someone who has it. Why not the President? If Trump does have a sleep disorder -- or if he has bad sleep habits, or if caffeine is disrupting his sleep -- treatment is likely to be successful, and it can be life-changing (for the better).
It is even odds that this patient, if asked by the press about his sleep, will say he is the best sleeper in the history of mankind. Only the President's physician, sitting down with the patient in a confidential setting and building on the patient's confidence in their relationship, can obtain the information to help this man -- who may not even know he needs help.
Dr. Zebra also notes a dire scenario which could have come to pass, but did not: excessive caffeine + untreated sleep apnea --> intermittent atrial fibrillation (which may escape diagnosis) --> embolic stroke --> Crisis over the 25th Amendment, section 4.
a p.266 b p.299 c p.333
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