Developing a successful treatment for co-morbid insomnia and sleep apnoea

Clinical Characteristics and Treatment Efficacy for Co-Morbid Insomnia and Sleep Apnea (COMISA): Evidence from Qualitative and Quantitative Analysis

OBJECTIVES

A multitude of physical and mental challenges are being faced in the population with Co-morbid Insomnia and Sleep Apnea (COMISA). Unfortunately, research about clinical characteristics and management of COMISA based on quantitative evidence is lacking.

METHOD

Standard procedures for literature retrieval, selection and quality assessment, data extraction, analysis, and interpretation were conducted step by step. For studying the sleep characteristics, common complications and widely recognized treatment options for COMISA, Weighted Mean Difference (WMD) and Odds Ratio (OR) were applied to assess the mean and risk differences between compared groups. Outcomes included sleep health parameters and secondary impairments in physical and mental well-being.

RESULTS

COMISA showed worse sleep quality than OSA only by PSQI (WMD = 3.38 point) and heavier sleep fragmentation (WMD = 11.46 min) than insomnia only. Besides, COMISA patients showed a higher risk for depression (OR [95%CI] = 5.03[2.31, 10.93]) and PTSD (OR [95%CI] = 3.96[1.85, 8.46]) in comparison with OSA alone. Compared to insomnia alone, COMISA patients suffered from more than two times higher risk of cardiovascular diseases, hypertension, and diabetes. In treating COMISA patients, combining CBTI with PAP treatment can enhance the improvement of insomnia severity (ISI, WMD [95%CI] =-3.26[-4.51, -2.00] point) and sleep efficiency (WMD [95%CI] = 6.39[1.97, 10.81] %) compared to PAP alone.

CONCLUSIONS

Impaired sleep domains in COMISA cover sleep quality and sleep structure. Also, COMISA has a higher risk for cardiometabolic diseases and mental disorders. Combining CBTI with PAP can be a recommended treatment to relieve sleep impairments for COMISA.

Co-morbid Insomnia and Sleep Apnea (COMISA) in a large sample of Iranian: prevalence and associations in a sleep clinic population

BACKGROUND

Sleep apnea (SA) and insomnia (INS) are prevalent sleep disorders among referrals to sleep clinics. People with comorbid insomnia and sleep apnea (COMISA) suffer both disorders simultaneously. The epidemiology of COMISA is not well known in the Middle East including Iran. We hypothesized that COMISA is prevalent in metropolitan sleep clinic cohorts in Iran.

METHOD

The records of patients aged < 95 years referred to sleep disorders centers in four large metropolitan areas including Kermanshah, Tabriz, Shiraz, and Ahvaz were examined. Polysomnography (PSG) was performed in all these patients in specialized centers and the results were scored by a trained technician and interpreted by a sleep specialist. SA was defined as an Apnea-Hypopnea Index (AHI ≥ 5), INS was defined by psychiatrists according to self-report and clinical interviews, and COMISA was defined if both disorders were present. Participants with neither condition were included in as comparator group. One-way ANOVAs, correlation, and linear/logistic regression analyses were used.

RESULTS

This study included 1807 patients (Mean age 49.3, SE ± 13.7; 38.8% Female). Comparator, INS, SA and COMISA made up 7.2%, 16%, 50.2% and 26.6% of the sample, respectively. Logistic regression analyses showed that male gender, older age, and increasing neck circumference, but not BMI, were associated with COMISA. Epworth Sleepiness Scale scores were lower in INS (5.39 ± 5.78) compared to the other three groups.

CONCLUSION

COMISA is a prevalent condition in metropolitan sleep centers in Iran among participants referred to sleep centers. The data showed that male gender and age were associated significantly with COMISA.

Direct to psychology for sleep disorders: Innovating models of care in the hospital and health service

A 'Direct to Psychology Insomnia' pathway was developed for implementation within a multidisciplinary sleep disorders service in a tertiary hospital in Brisbane, Australia. The project was informed by implementation science principles and methodology to re-design the model of care (MoC). A consensus group workshop using the Nominal Group Technique (NGT) with 12 multidisciplinary staff was undertaken to develop the new MoC. The workshop explored inclusion and exclusion criteria for a Direct to Psychology pathway including patient flow and enablers. The team endorsed a MoC that was acceptable to stakeholders and addressed service-level imperatives. The findings highlighted that patient inclusion or exclusion should be overseen by the Sleep Physician team and an Advanced Psychologist with behavioural sleep medicine expertise. Continuum of care for patients referred via primary care providers was considered. Barriers and risks to the MoC changes were identified which informed the refinement of the MoC.

Decisional Needs of Veterans With Mild Traumatic Brain Injury Initiating Treatment for Insomnia Disorder and Obstructive Sleep Apnea

OBJECTIVE

We sought to elicit key informant (KI) perspectives regarding decisional needs of Veterans with mild traumatic brain injury (mTBI) who are initiating insomnia disorder and obstructive sleep apnea (OSA) treatment within the Veterans Health Administration (VHA) Polytrauma/TBI System of Care (PSC). Specifically, we sought to understand: (1) information regarding treatment options that Veterans with mTBI require in order to make an informed decision; and (2) values used to guide decision-making (ie, personally meaningful aspects of the decision used to compare treatment options).

SETTING

Nationwide VHA PSC sites.

PARTICIPANTS

Clinicians included VHA providers and policymakers involved in the management of mTBI and/or sleep disorders in the VHA PSC (n = 29). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or OSA within the past year (n = 20).

DESIGN

Semi-structured interviews with the 49 KIs were recorded and transcribed verbatim. Themes were identified using a descriptive and interpretive approach to qualitative analysis.

MAIN MEASURES

Not applicable.

RESULTS

Informational needs identified by both KI groups included information regarding outcomes and downsides of treatment, accessible delivery, treatment candidates, description of diagnosis, and level of commitment. Values used to guide decision-making for both insomnia disorder and OSA treatment included benefits, downsides, and availability of treatments. Values used to decide on insomnia treatments alone included time commitment, intrinsic management of sleep, beliefs regarding mental health treatment, and time course of benefit. Values used to decide on OSA treatment alone included intrusiveness of the treatment, appearance, and impact on bed partners.

CONCLUSIONS

The current study revealed the decisional needs of Veterans with mTBI who are initiating sleep disorder treatment. Findings can inform the development of decision aids and other efforts aimed at promoting patient-centered management of comorbid mTBI and sleep disorders, thereby improving care quality and clinical outcomes.

Prevalence of co-morbid insomnia and obstructive sleep apnoea

INTRODUCTION

The coexistence of insomnia and obstructive sleep apnea (OSA) poses a complex and challenging clinical scenario, commonly referred to as comorbid insomnia and OSA (COMISA). The bidirectional relationship between these two sleep disorders is explored, illuminating how the presence of one can exacerbate the severity and manifestations of the other. We under took this study to understand the prevalence of COMISA in Indians which is never studied.

AIM

To study the prevalence of COMISA in tertiary hospital in India.

METHODS

All OSA patients diagnosed with polysomnography were interviewed with insomnia severity index. Patients having score of more than 15 were considered to have insomnia. Demographic factors, clinical and physical examination and polysomnography values were noted.

RESULTS

25% of 64 patients were diagnosed to have COMISA. Female gender, BMI, and STOP BANG score had positive association with COMISA, whereas age was not associated with increased risk.

CONCLUSION

COMISA can be more complex to diagnose and manage than insomnia or OSA alone. The symptoms and mechanisms of each condition have synergistic effect and is a barrier to treating COMISA.

The PAP-RES algorithm: Defining who, why and how to use positive airway pressure therapy for OSA

Obstructive sleep apnea (OSA) is a common condition that is increasing in prevalence worldwide. Untreated OSA has a negative impact on health-related quality of life and is an independent risk factor for cardiovascular diseases. Despite available data suggesting that cardiovascular risk might differ according to clinical phenotypes and comorbidities, current approaches to OSA treatment usually take a "one size fits all" approach. Identification of cardiovascular vulnerability biomarkers and clinical phenotypes associated with response to positive airway pressure (PAP) therapy could help to redefine the standard treatment paradigm. The new PAP-RES (PAP-RESponsive) algorithm is based on the identification of OSA phenotypes that are likely to impact therapeutic goals and modalities. The paradigm shift is to propose a simplified approach that defines therapeutic goals based on OSA phenotype: from a predominantly "symptomatic phenotype" (individuals with high symptom burden that negatively impacts on daily life and/or accident risk or clinically significant insomnia) to a "vulnerable cardiovascular phenotype" (individuals with comorbidities [serious cardiovascular or respiratory disease or obesity] that have a negative impact on cardiovascular prognosis or a biomarker of hypoxic burden and/or autonomic nervous system dysfunction). Each phenotype requires a different PAP therapy care pathway based on differing health issues and treatment objectives.

Comorbid Insomnia and Sleep Apnea: Challenges and Treatments

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Therapy can be challenging as treatment of 1 disease may worsen the other. Cognitive behavioral therapy for insomnia is the first-line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA), such as mandibular advancement devices or emerging pharmacotherapies. Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA. Otolaryngologists must be cognizant of the common presentation of COMISA in patients seeking surgical treatment and utilize a multidisciplinary approach to the treatment of these complex patients.

Sleep Bruxism and Sleep Structure in Comorbid Insomnia and Obstructive Sleep Apnea (COMISA) Syndrome: A Polysomnographic Study

Introduction: Comorbid insomnia and obstructive sleep apnea (COMISA) is not a well-identified sleep disorder, despite having a significant impact on health. This study investigates the relationship between sleep bruxism (SB) and sleep architecture in patients with COMISA, obstructive sleep apnea (OSA), and in those without any sleep disorders. Methods: 119 patients were included in the study and divided into three groups: OSA, COMISA, and a control group. Polysomnographic (PSG) examination provided parameters related to sleep architecture, OSA, and characteristics of SB. Results: The bruxism episode index (BEI) and other SB parameters were not found to be statistically different between the three groups (p > 0.05). There was no statistical difference in measured sleep architecture between the COMISA and OSA groups (p > 0.05). In comparison to the control group, participants in the COMISA group were found to have an increased apnea-hypopnea index (AHI), oxygen desaturation index (ODI), respiratory disturbance index (RDI), all arousals (AA), and respiratory arousals (RA) (p < 0.05). Among COMISA patients, AA and RA were shown to have a positive linear correlation with the number of bradycardia events per hour (r = 0.49, r = 0.48, p < 0.05). Conclusions: SB does not occur in patients with COMISA more frequently than in patients with OSA or those without any sleep disorders. PSG parameters are not specific for COMISA; therefore, in order to differentiate this disorder from OSA alone, a comprehensive patient assessment has to be performed.

Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury

STUDY OBJECTIVES

We elicited perspectives of clinical stakeholders and Veterans regarding barriers and facilitators to implementing shared decision-making (SDM) for comorbid mild traumatic brain injury (mTBI) and sleep disorders in the Veterans Health Administration. We also compared the perspectives of clinical stakeholders and Veterans regarding determinants of SDM.

METHODS

Semistructured interviews were conducted with 29 clinical stakeholders and 20 Veterans (n = 49). Clinical stakeholders included Veterans Health Administration providers and policymakers involved in the management of mTBI and/or sleep disorders (insomnia disorder, obstructive sleep apnea). Veterans included those with a clinician-confirmed mTBI who received care for insomnia disorder and/or obstructive sleep apnea within the past year. Themes were identified using a descriptive and interpretive approach to qualitative analysis. We compared results across clinical stakeholders and Veterans.

RESULTS

Barriers to implementing SDM were identified by both groups at the patient (eg, mTBI sequalae), provider (eg, deprioritization of Veteran preferences), encounter (eg, time constraints), and facility levels (eg, reduced care access). Similarly, both groups identified facilitators at the patient (eg, enhanced trust), provider (eg, effective communication), encounter (eg, decision support), and facility levels (eg, mitigating access barriers). Integrated services and provider discontinuity were factors identified by clinical stakeholders and Veterans alone, respectively.

CONCLUSIONS

Our study revealed factors shaping the implementation of SDM at the levels of the patient, provider, encounter, and facility. Findings can inform the development of strategies aimed at implementing SDM for comorbid mTBI and sleep disorders, promoting patient-centered care and enhancing clinical outcomes.

CITATION

Kinney AR, Brenner LA, Nance M, et al. Factors influencing shared decision-making for insomnia and obstructive sleep apnea treatment among Veterans with mild traumatic brain injury. J Clin Sleep Med. 2024;20(5):801-812.

Multi-night home assessment of sleep structure in OSA with and without insomnia

OBJECTIVE

To explore sleep structure in participants with obstructive sleep apnea (OSA) and comorbid insomnia (COMISA) and participants with OSA without insomnia (OSA-only) using both single-night polysomnography and multi-night wrist-worn photoplethysmography/accelerometry.

METHODS

Multi-night 4-class sleep-staging was performed with a validated algorithm based on actigraphy and heart rate variability, in 67 COMISA (23 women, median age: 51 years) and 50 OSA-only (15 women, median age: 51) participants. Sleep statistics were compared using linear regression models and mixed-effects models. Multi-night variability was explored using a clustering approach and between- and within-participant analysis.

RESULTS

Polysomnographic parameters showed no significant group differences. Multi-night measurements, during 13.4 ± 5.2 nights per subject, demonstrated a longer sleep onset latency and lower sleep efficiency for the COMISA group. Detailed analysis of wake parameters revealed longer mean durations of awakenings in COMISA, as well as higher numbers of awakenings lasting 5 min and longer (WKN≥5min) and longer wake after sleep onset containing only awakenings of 5 min or longer. Within-participant variance was significantly larger in COMISA for sleep onset latency, sleep efficiency, mean duration of awakenings and WKN≥5min. Unsupervised clustering uncovered three clusters; participants with consistently high values for at least one of the wake parameters, participants with consistently low values, and participants displaying higher variability.

CONCLUSION

Patients with COMISA more often showed extended, and more variable periods of wakefulness. These observations were not discernible using single night polysomnography, highlighting the relevance of multi-night measurements to assess characteristics indicative for insomnia.

Positive Airway Pressure Therapy Compliance in Patients With Comorbid Insomnia and Sleep Apnea

OBJECTIVES

This study aimed to compare positive airway pressure (PAP) therapy compliance between patients with comorbid insomnia and sleep apnea (COMISA) and those with obstructive sleep apnea (OSA) alone. It also assessed the influence of insomnia clinic visits on PAP compliance.

METHODS

Patients diagnosed with OSA and initiated on PAP therapy between January 2012 and December 2021 were included. The COMISA group (n=43) comprised patients with insomnia, while the control group (n=86) consisted of OSA patients without insomnia, matched 1:2 based on age and sex. COMISA patients were further categorized into group A (n=20), with at least two insomnia clinic visits, and group B (n=23) with one or no visits. PAP compliance in each group was evaluated at 3 and 9 months.

RESULTS

No significant differences were observed in PAP compliance between the COMISA patients and OSA patients without insomnia. Within the COMISA group, the impact of insomnia clinic visits on PAP compliance was not significant. No significant difference was observed in daily PAP usage between the two groups at 3 months (265.5±145.9 minutes in group A vs. 236.3±152.3 minutes in group B, P=0.760) or 9 months (213.4±155.3 minutes in group A vs. 166.3±158.3 minutes in group B, P=0.538). The percentages of PAP users and nights with PAP use exceeding 4 hours also showed no significant differences at either time point.

CONCLUSION

This study demonstrated no significant disparity in PAP compliance between the COMISA and OSA groups at either 3 or 9 months. Furthermore, insomnia clinic visits did not significantly impact PAP compliance in COMISA patients during 3- and 9-month intervals.

Relationship of Nocturnal Insomnia Symptoms and Outcomes After Hypoglossal Nerve Stimulation

Objective

In patients undergoing hypoglossal nerve stimulation (HGNS), we examined the Insomnia Severity Index (ISI) to understand how baseline sleep onset insomnia (SOI), sleep maintenance insomnia (SMI), and early morning awakening (EMA) affected postsurgical outcomes.

Study Design

Observational.

Setting

Multicenter registry.

Methods

We included patients from the Adherence and Outcomes of Upper Airway Stimulation for Obstructive Sleep Apnea International Registry (ADHERE) with a baseline ISI from 2020 to 2023. Regression analysis examined the association of ISI question scores for SOI, SMI, and EMA and outcomes: Apnea-Hypopnea Index (AHI) reduction, device usage, changes in the Epworth Sleepiness Scale (ESS) and overall ISI score, final visit (FV) completion, and satisfaction.

Results

No relationship was noted between insomnia subtypes and AHI reduction or FV completion. In the subgroup of patients with baseline moderate/severe insomnia, patients with major impairment for SOI used their device 64 min/day longer than those with minimal impairment. Among all patients, those with baseline major impairment for SOI had a 2.3 points greater improvement in ISI from baseline to FV compared to patients with minimal impairment, while patients with baseline major impairment for SMI had a 2.0 and 3.5 points greater improvement in the ESS and ISI than those with minimal impairment. Patients with EMA and moderate/severe baseline insomnia had decreased odds of being satisfied after surgery.

Conclusion

In ADHERE, nocturnal symptoms of insomnia did not limit HGNS efficacy or therapy use. Conversely, those with worse insomnia subtype impairments at baseline had improved outcomes related to adherence, sleepiness, and insomnia at the FV.

Comorbid Insomnia and Sleep Apnea: Challenges and Treatments

Insomnia and obstructive sleep apnea (OSA) are 2 of the most prevalent sleep disorders and frequently co-occur. Cognitive behavioral therapy for insomnia is the first line treatment for insomnia and has been shown to improve compliance with positive airway pressure therapy. Other alternatives to OSA treatment may have higher acceptance in those with comorbid insomnia and sleep apnea (COMISA). Surgery, particularly hypoglossal nerve stimulation, appears to be well tolerated and may improve insomnia in those with COMISA. Otolaryngologists must be cognizant of the common presentation of COMISA in patients seeking surgical treatment and utilize a multidisciplinary approach.

Clinical usefulness of dual orexin receptor antagonism beyond insomnia: Neurological and psychiatric comorbidities

Orexin is a neurotransmitter produced by a small group of hypothalamic neurons. Besides its well-known role in the regulation of the sleep-wake cycle, the orexin system was shown to be relevant in several physiological functions including cognition, mood and emotion modulation, and energy homeostasis. Indeed, the implication of orexin neurotransmission in neurological and psychiatric diseases has been hypothesized via a direct effect exerted by the projections of orexin neurons to several brain areas, and via an indirect effect through orexin-mediated modulation of sleep and wake. Along with the growing evidence concerning the use of dual orexin receptor antagonists (DORAs) in the treatment of insomnia, studies assessing their efficacy in insomnia comorbid with psychiatric and neurological diseases have been set in order to investigate the potential impact of DORAs on both sleep-related symptoms and disease-specific manifestations. This narrative review aimed at summarizing the current evidence on the use of DORAs in neurological and psychiatric conditions comorbid with insomnia, also discussing the possible implication of modulating the orexin system for improving the burden of symptoms and the pathological mechanisms of these disorders. Target searches were performed on PubMed/MEDLINE and Scopus databases and ongoing studies registered on Clinicaltrials.gov were reviewed. Despite some contradictory findings, preclinical studies seemingly support the possible beneficial role of orexin antagonism in the management of the most common neurological and psychiatric diseases with sleep-related comorbidities. However, clinical research is still limited and further studies are needed for corroborating these promising preliminary results.

Prevalence and clinical aspects of obstructive sleep apnea in Parkinson disease: A meta-analysis

BACKGROUND AND PURPOSE

Obstructive sleep apnea (OSA) frequently occurs in Parkinson Disease (PD), probably caused by upper airway dysfunctions or shared pathogenetic mechanisms. OSA may precede PD diagnosis or worsen throughout its course, but its relationship with clinical features and dopaminergic medication remains unclear. This meta-analysis aimed to provide a reliable estimate of OSA prevalence in the PD population (PD-OSA) and to clarify its clinical associated factors to help clinicians in understanding the underlying pathophysiological mechanisms.

METHODS

A systematic literature search was performed up to April 2023 using the PubMed, Scopus, and PsycINFO databases. Articles were included if they provided data on PD patients with and without OSA. Pooled prevalence for PD-OSA was calculated using the proportions of PD participants diagnosed with OSA. Demographic and clinical features associated with PD-OSA were explored by comparing PD patients with and without OSA.

RESULTS

Seventeen studies were included in the meta-analysis. Pooled OSA prevalence was 45% of a total sample of 1448 PD patients and was associated with older age, male sex, higher body mass index (BMI), more severe motor disturbances and periodic limb movements, reduced risk of rapid eye movement sleep behavior disorder, intake of dopamine agonists, and worse excessive daytime sleepiness. No relationship emerged with cognitive functioning and neuropsychiatric manifestations.

CONCLUSIONS

OSA affects nearly half of PD patients as a secondary outcome of predisposing factors such as older age and higher BMI in addition to PD-related motor impairment. Future studies should focus on determining the impact of both clinical features and dopaminergic medication on the development of PD-OSA.

Heritability and genetic correlations for sleep apnea, insomnia, and hypersomnia in a large clinical biobank

RATIONALE

Comorbid insomnia and sleep apnea is reported to have worse outcomes than either condition alone. The local genetic correlations of these disorders are unknown.

OBJECTIVES

To identify local genomic regions with heritability for clinically diagnosed sleep apnea and insomnia, and to identify local genetic correlations between these disorders and/or hypersomnia.

METHODS

Fifty thousand two hundred seventeen patients of European ancestry were examined. Global and local heritability and genetic correlations for independent regions were calculated, adjusting for obesity and other covariates.

RESULTS

Sleep apnea and insomnia were significantly globally heritable and had 118 and 168 genetic regions with local heritability p-values <.05, respectively. One region had a significant genetic correlation for sleep apnea and hypersomnia (p-value = 9.85 × 10-4).

CONCLUSIONS

Clinically diagnosed sleep apnea and insomnia have minimal shared genetic architecture, supporting genetically distinct comorbid insomnia and sleep apnea components. However, additional correlated regions may be identified with additional sample size and methodological improvements.

Impact of Insomnia on Hypoglossal Nerve Stimulation Outcomes in the ADHERE Registry

OBJECTIVE

We aimed to determine the preoperative prevalence of insomnia in the Adherence and Outcomes of Upper Airway Stimulation for OSA International Registry (ADHERE) and to examine serial sleep-related data longitudinally, in particular the Insomnia Severity Index (ISI), to compare outcomes between patients with no/subthreshold insomnia (ISI < 15) and moderate/severe insomnia (ISI ≥ 15) at baseline.

METHODS

We analyzed observational data from ADHERE between March 2020 and September 2022. Baseline demographic and mental health (MH) data, apnea hypopnea index (AHI), ISI, and ESS (Epworth Sleepiness Scale) were recorded. At post-titration (PT) and final visits, AHI, ISI, ESS and nightly usage were compared between baseline ISI < 15 and ISI ≥ 15 subgroups.

RESULTS

A baseline ISI was obtained in 928 patients (62% with ISI ≥ 15). Of the 578 and 141 patients reaching the 12- and 24-month time periods to complete PT and final visits, 292 (50.5%) and 91 (64.5%) completed the ISI, respectively. Baseline MH conditions were higher with ISI ≥ 15 than ISI < 15 (p < 0.001). AHI reduction and adherence did not differ between patients with baseline ISI ≥ 15 and ISI < 15. Patients with ISI ≥ 15 experienced greater improvement in ESS than ISI < 15 at post-titration and final visits (p = 0.014, 0.025). All patients had improved nocturnal, daytime, and overall ISI scores at follow-up visits (p < 0.001), especially for those with baseline ISI ≥ 15 compared with ISI < 15 (p < 0.05).

CONCLUSION

HGNS therapy efficacy and adherence were similar between ISI severity subgroups at follow-up visits. Insomnia and sleepiness scores improved in all patients with HGNS therapy and to a greater degree in patients with baseline moderate/severe insomnia.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:471-479, 2024.

Screening for Comorbidity of Sleep Disorders in Career Firefighters

BACKGROUND

The purpose of this study was to assess the prevalence and sequelae of insomnia, obstructive sleep apnea (OSA), and comorbid OSA and insomnia (COMISA).

METHOD

In the morning, after a shift end, Midwest career firefighters ( N = 89) in a midsized city completed an electronic battery of questionnaire to screen for OSA, daytime sleepiness, insomnia, presleep arousal, nightmares, mental and physical health symptoms, and a one-night sleep diary.

RESULTS

Prevalence of firefighters exceeding screening thresholds: OSA: 54%; insomnia: 30%; COMISA: 17%; four or more nightmares per month: 15%. Firefighters who met criteria for COMISA had shorter total sleep time, less restful and worse sleep quality, higher depression and anxiety symptoms, and presleep arousal symptoms than firefighters without self-reported sleep problems.

CONCLUSIONS

Many firefighters are at elevated risk of individual behavioral sleep disorders, COMISA, and daytime dysfunction.

Multi-night measurement for diagnosis and simplified monitoring of obstructive sleep apnoea

Substantial night-to-night variability in obstructive sleep apnoea (OSA) severity has raised misdiagnosis and misdirected treatment concerns with the current prevailing single-night diagnostic approach. In-home, multi-night sleep monitoring technology may provide a feasible complimentary diagnostic pathway to improve both the speed and accuracy of OSA diagnosis and monitor treatment efficacy. This review describes the latest evidence on night-to-night variability in OSA severity, and its impact on OSA diagnostic misclassification. Emerging evidence for the potential impact of night-to-night variability in OSA severity to influence important health risk outcomes associated with OSA is considered. This review also characterises emerging diagnostic applications of wearable and non-wearable technologies that may provide an alternative, or complimentary, approach to traditional OSA diagnostic pathways. The required evidence to translate these devices into clinical care is also discussed. Appropriately sized randomised controlled trials are needed to determine the most appropriate and effective technologies for OSA diagnosis, as well as the optimal number of nights needed for accurate diagnosis and management. Potential risks versus benefits, patient perspectives, and cost-effectiveness of these novel approaches should be carefully considered in future trials.

The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis

Comorbid insomnia and sleep apnoea (COMISA) is a highly prevalent and debilitating sleep disorder. Cognitive behavioural therapy for insomnia (CBTi) may be an appropriate treatment for COMISA; however, no previous study has systematically reviewed and meta-analysed literature reporting on the effect of CBTi in people with COMISA. A systematic literature search was conducted across PsychINFO and PubMed (n = 295). In all, 27 full-text records were independently reviewed by at least two authors. Forward- and backward-chain referencing, and hand-searches were used to identify additional studies. Authors of potentially eligible studies were contacted to provide COMISA subgroup data. In total, 21 studies, including 14 independent samples of 1040 participants with COMISA were included. Downs and Black quality assessments were performed. A meta-analysis including nine primary studies measuring the Insomnia Severity Index indicated that CBTi is associated with a large improvement in insomnia severity (Hedges' g = -0.89, 95% confidence interval [CI] -1.35, -0.43). Subgroup meta-analyses indicated that CBTi is effective in samples with untreated obstructive sleep apnoea (OSA) (five studies, Hedges' g = -1.19, 95% CI -1.77, -0.61) and treated OSA (four studies, Hedges' g = -0.55, 95% CI -0.75, -0.35). Publication bias was evaluated by examining the Funnel plot (Egger's regression p = 0.78). Implementation programmes are required to embed COMISA management pathways in sleep clinics worldwide that currently specialise in the management of OSA alone. Future research should investigate and refine CBTi interventions in people with COMISA, including identifying the most effective CBTi components, adaptations, and developing personalised management approaches for this highly prevalent and debilitating condition.

Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions

PURPOSE OF REVIEW

Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions.

RECENT FINDINGS

People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches.

SUMMARY

It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.

Links between Sleep Apnoea and Insomnia in a British Cohort

Poor sleep is a major public health problem with implications for a wide range of critical health outcomes. Insomnia and sleep apnoea are the two most common causes of poor sleep, and recent studies have shown that these disorders frequently co-occur. Comorbid insomnia and sleep apnoea can substantially impair quality of life and increase the overall risk of mortality. However, the causal and physiological links between sleep apnoea and insomnia are unclear. It is also unknown whether having a higher risk for one condition can increase the risk of developing the other. Here, we investigated links between sleep apnoea and insomnia in a British population using a combination of self-reported questionnaires and causal inference. We found that 54.3% of the cohort had moderate insomnia, 9.4% had moderate sleep apnoea, and that 6.2% scored high for both conditions. Importantly, having a higher risk of sleep apnoea was associated with a higher risk of insomnia and vice versa. To determine the causal directionality between sleep apnoea and insomnia, we used Mendelian randomisation and found evidence that sleep apnoea could cause insomnia, but not the reverse. To elucidate how both sleep apnoea and insomnia were linked to each other, we looked at the behavioural markers of poor sleep. We found that feeling fatigued after sleeping and having noticeable sleep problems were linked to a higher burden of both sleep apnoea and insomnia. In conclusion, our results show that sleep apnoea increases the risk of developing insomnia, and both conditions can result in fatigue. We highlight the importance of considering and treating the symptoms of both conditions.

Pharmacological management of co-morbid obstructive sleep apnoea and insomnia

INTRODUCTION

Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.

AREAS COVERED

This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.

EXPERT OPINION

There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

Sleep structure in patients with COMISA compared to OSA and insomnia

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) and insomnia frequently co-occur, making diagnosis and treatment challenging. We investigated differences in sleep structure between patients with OSA, insomnia, and comorbid insomnia and sleep apnea (COMISA) to identify characteristics that can be used to improve the diagnosis of COMISA.

METHODS

We obtained polysomnography data of 326 patients from the Sleep and OSA Monitoring with Non-Invasive Applications database. The group included patients with OSA (n = 199), insomnia (n = 47), and COMISA (n = 80). We compared statistics related to sleep structure between the 3 patient groups.

RESULTS

Wake after sleep onset was significantly shorter for the OSA group (median: 60.0 minutes) compared to the COMISA (median: 83.3 minutes, P < .01) and the insomnia (median: 83.5 minutes, P = .01) groups. No significant differences were found in the total number of awakenings and the number of short (up to and including 2 minutes) and medium-length awakenings (2.5 up to and including 4.5 minutes). However, the number of long awakenings (5 minutes or longer) and wake after sleep onset containing only long awakenings was significantly lower for patients with OSA (median: 2 awakenings and 25.5 minutes) compared to patients with COMISA (median: 3 awakenings, P < .01 and 43.3 minutes, P < .001) or with insomnia (median: 3 awakenings, P < .01 and 56.0 minutes, P < .001). Total sleep time was significantly longer and sleep efficiency was significantly higher for the OSA group (median: 418.5 minutes and 84.4%) compared to both the COMISA (median: 391.5 minutes, P < .001 and 77.3%, P < .001) and the insomnia (median: 381.5 minutes, P < .001 and 78.2%, P < .001) groups. The number of sleep-stage transitions during the night for patients with COMISA (median: 194.0) was lower compared to that for patients with OSA (median: 218.0, P < .01) and higher compared to that for patients with insomnia (median: 156.0, P < .001). Other sleep architectural parameters were not discriminative between the groups.

CONCLUSIONS

Patients with COMISA show specific characteristics of insomnia, including prolonged awakenings. This variable is distinctive in comparison to patients with OSA. The combination of prolonged awakenings and the presence of sleep-disordered breathing leads to increased sleep disturbance compared to patients having only 1 of the sleep disorders.

CITATION

Wulterkens BM, Hermans LWA, Fonseca P, et al. Sleep structure in patients with COMISA compared to OSA and insomnia. J Clin Sleep Med. 2023;19(6):1051-1059.

Comorbid insomnia and sleep apnea in children: a preliminary explorative study

Insomnia and sleep-disordered breathing (SDB) are prevalent sleep disorders. These disorders can therefore be concurrently present - comorbid insomnia and sleep apnea (COMISA). The prevalence of COMISA in the paediatric age range is unclear. As such, phenotypic constructs should help better define this comorbid condition if it exists in children and improve both diagnostic sensitivity and ultimately clinical care outcomes. We aimed to evaluate the frequency of insomnia in children and adolescents referred for evaluation of sleep symptoms suggestive of SDB in one initial (Cohort#1) and verify such findings in an independent cohort (Cohort#2) using a retrospective cross-sectional approach in patients aged 9-19 years presenting at a sleep centre to be evaluated for symptoms of SDB. Cohort #1 comprised 50 consecutive children (58% males; mean [SD] age 13.6 [3.3] years; median [interquartile range, IQR] Epworth Sleepiness Scale score 10 [6-12]) who were evaluated using validated SDB and insomnia questionnaires. Cohort#2 was extracted from electronic medical records and included 384 polysomnographically evaluated children (mean [SD] age 12.9 [3.6] years; mean [SD] body mass index z score 1.27 [0.28]; median Epworth Sleepiness Scale score 9.7 [4-17]). In Cohort #1, 56% were at high risk of SDB, 36% had insomnia alone, and 18% were at high risk of COMISA. The prevalence of COMISA in Cohort #2 was 16%, 72% had SDB alone, and 12% had insomnia alone. In both cohorts, COMISA manifested as increased propensity for sleepiness and fatigue during both waking and daytime. Thus, the presence of COMISA is frequent in the paediatric age range and accompanied by a more prominent symptomatic phenotype.

A comprehensive evaluation of insomnia, obstructive sleep apnea and comorbid insomnia and obstructive sleep apnea in US military personnel

STUDY OBJECTIVES

The aim of this study was to characterize the sleep disorders of insomnia, obstructive sleep apnea (OSA), and comorbid insomnia and OSA (COMISA) in active duty military personnel.

METHODS

Prospective observational study of 309 military personnel with a mean age of 37.17 years (SD = 7.27). Participants served in four branches of the U.S. military (47.9% Air Force, 38.8% Army, 11.3% Navy, and 1.9% Marines). Sleep diagnoses were rendered after video-polysomnography and a clinical evaluation. Validated self-report measures assessed insomnia severity, excessive daytime sleepiness, sleep quality, disruptive nocturnal behaviors, nightmare disorder, shift work disorder (SWD), sleep impairment, fatigue, posttraumatic stress disorder (PTSD) symptoms, anxiety, depression, and traumatic brain injury (TBI). General linear models and Pearson chi-square tests were used for between-group differences in data analyses.

RESULTS

Insomnia was diagnosed in 32.7%, OSA in 30.4% and COMISA in 36.9%. Compared to military personnel with OSA alone, those with insomnia only and COMISA had significantly greater insomnia severity, disruptive nocturnal behaviors, sleep-related impairment, rates of nightmare disorder, and poorer sleep quality (all Ps < .05). They also reported greater symptoms of fatigue, PTSD, anxiety, and depression (all Ps < .05). There were no significant differences among the three sleep disorder diagnostic groups on sleepiness, SWD, or TBI.

CONCLUSIONS

Military personnel with insomnia only and COMISA overall report worsened symptoms of sleep disorders, sleep-related impairment, fatigue, and psychiatric disorders than those with OSA. Results highlight the importance of a comprehensive assessment for sleep-related impairment, sleep, and comorbid disorders in military personnel with clinically significant sleep disturbances.

Personalized Medicine and Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a common disease that is often under-diagnosed and under-treated in all ages. This is due to differences in morphology, diversity in clinical phenotypes, and differences in diagnosis and treatment of OSA in children and adults, even among individuals of the same age. Therefore, a personalized medicine approach to diagnosis and treatment of OSA is necessary for physicians in clinical practice. In children and adults without serious underlying medical conditions, polysomnography at sleep labs may be an inappropriate and inconvenient testing modality compared to home sleep apnea testing. In addition, the apnea-hypopnea index should not be considered as a single parameter for making treatment decisions. Thus, the treatment of OSA should be personalized and based on individual tolerance to sleep-quality-related parameters measured by the microarousal index, harmful effects of OSA on the cardiovascular system related to severe hypoxia, and patients' comorbidities. The current treatment options for OSA include lifestyle modification, continuous positive airway pressure (CPAP) therapy, oral appliance, surgery, and other alternative treatments. CPAP therapy has been recommended as a cornerstone treatment for moderate-to-severe OSA in adults. However, not all patients can afford or tolerate CPAP therapy. This narrative review seeks to describe the current concepts and relevant approaches towards personalized management of patients with OSA, according to pathophysiology, cluster analysis of clinical characteristics, adequate combined therapy, and the consideration of patients' expectations.

More than sleepiness: prevalence and relevance of nonclassical symptoms of obstructive sleep apnea

PURPOSE OF REVIEW

The purpose of this review is to describe the nonclassical symptoms and manifestations occurring in patients with obstructive sleep apnea (OSA), both from a standpoint of prevalence and in terms of clinical relevance. Particular emphasis will be given to nightmares, comorbid insomnia, restless legs syndrome and periodic limb movement disorder, bruxism, morning headache, nocturia, acid reflux, chronic cough and dysphagia.

RECENT FINDINGS

A review of the recent literature suggests that nonclassical symptoms have a high prevalence, are underestimated, and can interact with quality of life. Although these disturbances may occur together by mere coincidence, they may interact reciprocally. However, the degree of symptoms is not always correlated with OSA severity.

SUMMARY

OSA is a heterogeneous disease with variable clinical manifestations. This review highlights the need for detailed evaluation of patients with OSA to diagnose other important sleep disorders and clinical manifestations, given their frequent association.

Sleep architecture based on sleep depth and propensity: patterns in different demographics and sleep disorders and association with health outcomes

Study Objectives

Conventional metrics of sleep quantity/depth have serious shortcomings. Odds-Ratio-Product (ORP) is a continuous metric of sleep depth ranging from 0 (very deep sleep) to 2.5 (full-wakefulness). We describe an ORP-based approach that provides information on sleep disorders not apparent from traditional metrics.

Methods

We analyzed records from the Sleep-Heart-Health-Study and a study of performance deficit following sleep deprivation. ORP of all 30-second epochs in each PSG and percent of epochs in each decile of ORPs range were calculated. Percentage of epochs in deep sleep (ORP < 0.50) and in full-wakefulness (ORP > 2.25) were each assigned a rank, 1–3, representing first and second digits, respectively, of nine distinct types (“1,1”, “1,2” … ”3,3”). Prevalence of each type in clinical groups and their associations with demographics, sleepiness (Epworth-Sleepiness-Scale, ESS) and quality of life (QOL; Short-Form-Health-Survey-36) were determined.

Results

Three types (“1,1”, “1,2”, “1,3”) were prevalent in OSA and were associated with reduced QOL. Two (“1,3” and “2,3”) were prevalent in insomnia with short-sleep-duration (insomnia-SSD), but only “1,3” was associated with poor sleep depth and reduced QOL, suggesting two phenotypes in insomnia-SSD. ESS was high in types “1,1” and “1,2”, and low in “1,3” and “2,3”. Prevalence of some types increased with age while in others it decreased. Other types were either rare (“1,1” and “3,3”) or high (“2,2”) at all ages.

Conclusions

The proposed ORP histogram offers specific and unique information on the underlying neurophysiological characteristics of sleep disorders not captured by routine metrics, with potential of advancing diagnosis and management of these disorders.

Insomnia and Upper Airway Stimulation Therapy Benefit and Adherence: A Case Series

Obstructive sleep apnea (OSA) and insomnia are common sleep disorders that often occur concurrently. The presence of one of these disorders often negatively impacts the other, including affecting treatment benefit and adherence. While insomnia has been shown to adversely affect positive airway pressure therapy adherence, minimal data are currently available on the effects of insomnia on upper airway stimulation (UAS) therapy for the treatment of OSA. We present two cases that highlight the negative impact of insomnia on UAS therapy usage and OSA management as well as the benefits of insomnia treatment on overall outcomes. Screening for and treatment of insomnia prior to UAS implantation are recommended.

Sleep Deficiency: Epidemiology and Effects

Adequate sleep is an important pillar of physical and mental health. Sleep deficiency, resulting from short sleep or suboptimal sleep quality, is highly prevalent in modern society. Occupation, social demands, psychiatric disorders, physical disorders, and sleep disorders are some of the contributing factors to sleep deficiency. Some populations are at increased risk of sleep deficiency based on ethnicity, age, marital status, sex, and hospitalization. Sleep deficiency influences cognition, alertness, mood, behavior, diabetes, cardiovascular health, renal function, immune system, and respiratory physiology. This review summarizes the epidemiology and effects of sleep deficiency.

The association of co-morbid insomnia and sleep apnea with prevalent cardiovascular disease and incident cardiovascular events

Insomnia and obstructive sleep apnea commonly co-occur (co-morbid insomnia and sleep apnea), and their co-occurrence has been associated with worse cardiometabolic and mental health. However, it remains unknown if people with co-morbid insomnia and sleep apnea are at a heightened risk of incident cardiovascular events. This study used longitudinal data from the Sleep Heart Health Study (N = 5803) to investigate potential associations between co-morbid insomnia and sleep apnea and cardiovascular disease prevalence at baseline and cardiovascular event incidence over ~11 years follow-up. Insomnia was defined as self-reported difficulties initiating and/or maintaining sleep AND daytime impairment. Obstructive sleep apnea was defined as an apnea-hypopnea index ≥ 15 events per hr sleep. Co-morbid insomnia and sleep apnea was defined if both conditions were present. Data from 4160 participants were used for this analysis. The prevalence of no insomnia/obstructive sleep apnea, insomnia only, obstructive sleep apnea only and co-morbid insomnia and sleep apnea was 53.2%, 3.1%, 39.9% and 1.9%, respectively. Co-morbid insomnia and sleep apnea was associated with a 75% (odd ratios [95% confidence interval]; 1.75 [1.14, 2.67]) increase in likelihood of having cardiovascular disease at baseline after adjusting for pre-specified confounders. In the unadjusted model, co-morbid insomnia and sleep apnea was associated with a twofold increase (hazard ratio, 95% confidence interval: 2.00 [1.33, 2.99]) in risk of cardiovascular event incidence. However, after adjusting for pre-specified covariates, co-morbid insomnia and sleep apnea was not significantly associated with incident cardiovascular events (hazard ratio 1.38 [0.92, 2.07]). Comparable findings were obtained when an alternative definition of insomnia (difficulties initiating and/or maintaining sleep without daytime impairment) was used.

The Effect of Cognitive Behavioural Therapy for Insomnia (CBT-I) on Subjective–Objective Sleep Discrepancy in Individuals with Co-Morbid Insomnia and Sleep Apnoea: A Randomised Controlled Trial

People with insomnia frequently underestimate the duration of their sleep compared to objective polysomnography-measured sleep duration. Cognitive behavioural therapy for insomnia (CBT-I) is the most effective treatment for insomnia and also reduces the degree of sleep underestimation. Obstructive sleep apnoea (OSA) is a highly prevalent sleep disorder characterised by frequent narrowing (hypopnoea) and closure (apnoea) of the upper airway during sleep. Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating disorder. No study has investigated subjectively (sleep diary) versus objectively (polysomnography) measured sleep discrepancies (SOSD) in individuals with COMISA before or following CBT-I. This randomised waitlist-controlled trial investigated SOSD in 145 participants with COMISA before and 6-weeks after CBT-I (n = 72) versus control (n = 73). All participants were studied prior to continuous positive airway pressure treatment for sleep apnoea. At baseline, participants underestimated their total sleep time (mean ± SD −51.9 ± 94.1 min) and sleep efficiency (−9.6 ± 18.3%), and overestimated sleep onset latency (34.5 ± 86.1 min; all p = < 0.001). Mixed models indicated a main effect of time on reduction of SOSD in both groups, but no between-group difference in the reduction of any SOSD parameters. These findings may indicate that untreated OSA contributes to a discrepancy between perceived and objective sleep parameters in people with COMISA that is not amenable to CBT-I alone (ACTRN12613001178730).

All-Cause Mortality in People with Co-Occurring Insomnia Symptoms and Sleep Apnea: Analysis of the Wisconsin Sleep Cohort

PURPOSE

Insomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality.

PATIENTS AND METHODS

Wisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings "often" or "almost always", and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models.

RESULTS

Among 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00-2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk.

CONCLUSION

Co-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.

Differentiation Model for Insomnia Disorder and the Respiratory Arousal Threshold Phenotype in Obstructive Sleep Apnea in the Taiwanese Population Based on Oximetry and Anthropometric Features

Insomnia disorder (ID) and obstructive sleep apnea (OSA) with respiratory arousal threshold (ArTH) phenotypes often coexist in patients, presenting similar symptoms. However, the typical diagnosis examinations (in-laboratory polysomnography (lab-PSG) and other alternatives methods may therefore have limited differentiation capacities. Hence, this study established novel models to assist in the classification of ID and low- and high-ArTH OSA. Participants reporting insomnia as their chief complaint were enrolled. Their sleep parameters and body profile were accessed from the lab-PSG database. Based on the definition of low-ArTH OSA and ID, patients were divided into three groups, namely, the ID, low- and high-ArTH OSA groups. Various machine learning approaches, including logistic regression, k-nearest neighbors, naive Bayes, random forest (RF), and support vector machine, were trained using two types of features (Oximetry model, trained with oximetry parameters only; Combined model, trained with oximetry and anthropometric parameters). In the training stage, RF presented the highest cross-validation accuracy in both models compared with the other approaches. In the testing stage, the RF accuracy was 77.53% and 80.06% for the oximetry and combined models, respectively. The established models can be used to differentiate ID, low- and high-ArTH OSA in the population of Taiwan and those with similar craniofacial features.

Co-morbid insomnia and obstructive sleep apnoea is associated with all-cause mortality

STUDY OBJECTIVES

Increased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of co-morbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk.

METHODS

Insomnia was defined as difficulties falling asleep, maintaining sleep, and/or early morning awakenings from sleep ≥16 times a month and daytime impairment. OSA was defined as an apnoea-hypopnoea index ≥15 events/h sleep. COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazard models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up.

RESULTS

5236 participants were included. 2708 (52%) did not have insomnia/OSA (control), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone, and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (ORs [95%CI]; 2.00 [1.39, 2.90]) and cardiovascular disease compared to controls (1.70 [1.11, 2.61]). Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not cardiovascular disease compared to controls. Compared to controls, COMISA was associated with a 47% (HR, 95% CI; 1.47 (1.06, 2.07)) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia.

CONCLUSIONS

Co-morbid insomnia and sleep apnoea was associated with higher rates of hypertension and cardiovascular disease at baseline, and an increased risk of all-cause mortality compared to no insomnia/OSA.

Association of Hypoglossal Nerve Stimulation With Improvements in Long-term, Patient-Reported Outcomes and Comparison With Positive Airway Pressure for Patients With Obstructive Sleep Apnea

Importance

Hypoglossal nerve stimulation (HNS) and positive airway pressure (PAP) have been shown to improve patient-reported outcomes (PROs) in obstructive sleep apnea (OSA). However, to our knowledge, there are no data that compare change in PROs between HNS and PAP or that indicate whether HNS improves comorbid insomnia or depression in the long term.

Objectives

To determine whether HNS is associated with improvements in patient-reported sleepiness, insomnia, and depression in the long term and to compare the respective associations of HNS and PAP with improved PROs.

Design, Setting, and Participants

This retrospective cohort study used data from patients treated at the Cleveland Clinic for OSA. Participants received either HNS (referred sample) from November 1, 2015, to September 31, 2018, or PAP (previous cohort) from January 1, 2010, to December 31, 2014, for OSA. Patients were matched 3:1 for PAP:HNS based on age, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), sex, and apnea hypopnea index (AHI). Data were collected at baseline and at prespecified follow-up points. Data were analyzed from March 26, 2020, to September 9, 2021.

Exposures

Treatment with HNS vs PAP.

Main Outcomes and Measures

Data collected included AHI and Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Insomnia Severity Index (ISI), and Patient Health Questionnaire-9 (PHQ-9; depression) scores.

Results

Among 85 patients receiving HNS (mean [SD] age, 62.8 [9.5] years; 59 men [69.4%]; 77 White patients [90.6%]; mean [SD] BMI, 28.8 [3.1]), compared with 217 matched patients receiving PAP (mean [SD] age, 62.1 [9.9] years; 157 men [72.4%]; 173 White patients [81.2%]; mean [SD] BMI, 29.5 [3.1]) included in the analysis, significant improvements were seen in PHQ-9 scores for HNS vs PAP (least square means, -4.06 [95% CI, -5.34 to -2.79] vs -2.58 [95% CI, -3.35 to -1.82]; mean difference, -1.48 [95% CI, -2.78 to -0.19]) with comparable improvements in ESS, FOSQ, and ISI scores. Clinically meaningful differences were observed in 42 of 65 HNS group patients (64.6%) vs 118 PAP group patients (54.5%) for ESS scores, 29 of 49 HNS group patients (59.2%) vs 67 of 217 PAP group patients (30.9%) for FOSQ scores, 14 of 48 HNS group patients (29.2%) vs 53 of 217 PAP group patients (24.4%) for PHQ-9 scores, and 23 of 49 HNS group patients (46.9%) vs 79 of 217 PAP group patients (36.4%) for ISI scores. At the 1-year post-HNS assessment, meaningful improvements were seen in 17 of 28 patients (60.7%) for ESS scores, 11 of 20 patients (55.0%) for FOSQ scores, 7 of 23 patients (30.4%) for PHQ-9 scores, and 11 of 25 patients (44.0%) for ISI scores.

Conclusions and Relevance

In this cohort study of patients with OSA, sustained improvements in PROs were observed 1 year after HNS and were comparable to those for PAP at 3 months. These findings suggest that HNS is a viable treatment for improving insomnia and depression in patients with OSA.

Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders among the general population, and they may often coexist in patients with sleep-disordered breathing (SDB). The higher prevalence of insomnia symptoms in patients with OSA (40–60%) compared to that observed in the general population has thus led researchers to identify a new disorder named comorbid insomnia and OSA (COMISA), whose true burden has been so far largely underestimated. The combined treatment of COMISA patients with positive-airway pressure ventilation (PAP) with cognitive behavioral therapy for insomnia (CBTi) has shown a better patient outcome compared to that obtained with a single treatment. Furthermore, recent evidence has shown that an innovative patient-centered approach taking into consideration patient characteristics, treatment preferences and accessibility to treatment is recommended to optimize clinical management of COMISA patients. However, in this complex mosaic, many other sleep disorders may overlap with COMISA, so there is an urgent need for further research to fully understand the impact of these therapies on outcomes for OSA patients with comorbidity. In light of this need, this review focuses on the major sleep disorders comorbid with OSA and the recent advances in the management of these insomniac patients.

Co-occurring depression and insomnia in Australian primary care: recent scientific evidence

Depression and insomnia commonly co-occur, resulting in greater morbidity for patients, and difficult diagnostic and treatment decisions for clinicians. When patients report symptoms of both depression and insomnia, it is common for medical practitioners to conceptualise the insomnia as a secondary symptom of depression. This implies that there is little purpose in treating insomnia directly, and that management of depression will improve both the depression and insomnia symptoms. In this review, we present an overview of research investigating the comorbidity and treatment approaches for patients presenting with depression and insomnia in primary care. Evidence shows that clinicians should avoid routinely conceptualising insomnia as a secondary symptom of depression. This is because insomnia symptoms: (i) often occur before mood decline and are independently associated with increased risk of future depression; (ii) commonly remain unchanged following depression treatment; and (iii) predict relapse of depression after treatment for depression only. Furthermore, compared with control, cognitive behaviour therapy for insomnia improves symptoms of both depression and insomnia. It is critical that primary care clinicians dedicate specific diagnostic and treatment attention to the management of both depression (eg, psychotherapy, antidepressants) and insomnia (eg, cognitive behaviour therapy for insomnia administered by trained therapists or psychologists through a mental health treatment plan referral, by online programs, or by a general practitioner or nurse) when they co-occur. These treatments may be offered concurrently or sequentially (eg, insomnia treatment followed by depression treatment, or vice versa), depending on presenting symptoms, history, lifestyle factors and other comorbidities.

Effect of Continuous Positive Airway Pressure on Symptoms and Prevalence of Insomnia in Patients With Obstructive Sleep Apnea: A Longitudinal Study

Objective

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders. Continuous positive airway pressure (CPAP) is considered first-line treatment for OSA. In the present study, we assess the effect of CPAP on symptoms and prevalence of insomnia in patients with OSA. We hypothesized a decrease in insomnia symptoms from CPAP initiation to follow-up, and that this decrease would depend on CPAP adherence.

Materials and methods

The sample included 442 patients diagnosed with OSA [mean age 54.9 years (SD = 12.1), 74.4% males] who started treatment with CPAP at a university hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean apnea-hypopnea index (AHI) was 30.1 (SD = 21.1) at baseline. Insomnia was assessed prior to CPAP treatment (baseline) and at follow-up after a median of 19.9 weeks (range 6–52 weeks) with the Bergen Insomnia Scale (BIS). CPAP adherence was defined as an average use of ≥ 4 h per night, whereas non-adherence was defined as < 4 h per night.

Results

There was a significant decrease in BIS scores from baseline (mean = 18.8, SD = 9.8) to follow-up (mean = 12.9, SD = 9.9), p < 0.001. Cohen’s d(0.65) indicated a moderate effect size. The reduction in BIS scores was depending on CPAP adherence (interaction effect F(1,440) = 12.4, p < 0.001), with larger reduction in the adherent group than in the non-adherent group. The proportion of patients with chronic insomnia was significantly reduced from 51.1% at baseline to 33.0% at follow-up (p < 0.001).

Conclusion

Overall, there was a significant reduction in insomnia symptoms from baseline to follow-up. The improvement was significant in both adherence groups, but the degree of improvement was larger among patients who were adherent to CPAP. Furthermore, there was a significant reduction in the prevalence of chronic insomnia at follow-up compared to baseline. This suggests that CPAP effectively reduces both the presence of insomnia and the severity of insomnia symptoms in some patients with OSA.

Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum

Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.

Gender-related sleep duration perception in a Brazilian sleep clinic cohort

PURPOSE

This study aims to evaluate if gender influences the sleep duration perception in adults referred for polysomnography (PSG).

METHODS

A cross-sectional study was undertaken from December 2019 to January 2021. Total sleep time was objectively assessed from the overnight PSG and subjectively estimated. The sleep perception index (SPI) was defined by the ratio of subjective and objective values. Diagnosis of obstructive sleep apnea (OSA) was based on an apnea-hypopnea index ≥ 5.0/h. Insomnia was defined by the presence of one or more specific complaints: difficulty falling asleep, difficulty maintaining sleep, and/or waking up earlier than desired. The association between continuous variables and SPI was assessed by linear regression analysis.

RESULTS

This study enrolled 2,004 outpatients (56% men) who were grouped into four subsamples: controls (n = 139), insomnia (n = 154), OSA (n = 912), and insomnia comorbid with OSA [COMISA] (n = 799). In women, the median SPI differed among groups and ranged from 89 to 102% (p = 0.001); while in men, it ranged from 90% to 99% (p = 0.007). However, no gender-related SPI value differences emerged within each of the subgroups: controls (p = 0.907), insomnia (p = 0.830), OSA (p = 0.070), and COMISA (p = 0.547). The presence of insomnia (β, - 0.101, p < 0.001) or OSA (β, - 0.082, p = 0.001), but not gender (β, - 0.017, p = 0.612), were independent predictors of the SPI.

CONCLUSION

In a clinical referral cohort, no evidence of sex dimorphism emerged for SPI irrespective of the underlying sleep diagnosis.

Effect of the new dual orexin receptor antagonist daridorexant on nighttime respiratory function and sleep in patients with mild and moderate obstructive sleep apnea

In this randomized, double-blind, placebo-controlled, two-period crossover study, the effect of the dual orexin receptor antagonist daridorexant was evaluated on nighttime respiratory function and sleep in 28 patients with mild and moderate obstructive sleep apnea (OSA). In each period, 50 mg daridorexant or placebo was administered every evening for 5 days. The primary endpoint was apnea/hypopnea index (AHI) during total sleep time (TST) after the last dosing. Other endpoints included peripheral oxygen saturation (SpO2), sleep duration, latency to persistent sleep (LPS), wake after sleep onset (WASO), and sleep efficiency index (SEI). Pharmacokinetics, safety, and tolerability were also assessed. The mean treatment difference for AHI during TST (i.e. daridorexant - placebo) after the last dosing was 0.74 events/hour (90% confidence interval [CI]: -1.43, 2.92). The corresponding treatment difference for SpO2 during TST was 0.16% [90% CI: -0.21, 0.53]. Overall, there was no clinically relevant effect of daridorexant on AHI or SpO2-related data after single and repeated dosing irrespective of sleep phase (i.e. rapid eye movement [REM] vs non-REM). Moreover, after single and repeated dosing, daridorexant prolonged TST by 39.6 minutes (90% CI: 16.9, 62.3) and 38.8 minutes (19.7, 57.9), respectively, compared with placebo and favorably modulated other sleep-related endpoints (i.e. increased SEI, decreased WASO, and shortened LPS). It attained expected plasma concentrations and was well tolerated in patients with mild and moderate OSA. These results indicate that single and repeated doses of 50 mg daridorexant do not impair nighttime respiratory function and improve sleep in patients with mild and moderate OSA. Clinical Trial Registration: ClinicalTrials.gov NCT03765294. A study to investigate the effects of ACT-541468 on nighttime respiratory function in patients with mild to moderate obstructive sleep apnea. https://clinicaltrials.gov/ct2/show/ NCT03765294.