Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials

The Sleep Course: An inclusive trial examining the feasibility, acceptability, and preliminary efficacy of a digital sleep intervention for adults with self-reported sleep difficulties

Cognitive Behavioural Therapy for Insomnia (CBTi) is a well-established first-line treatment for insomnia and sleep difficulties, yet numerous barriers hinder its widespread adoption. One potential criticism of the existing evidence base for CBTi is that many trials exclude participants that would commonly be seen in in primary care, such as those aged over 65, with comorbid health conditions, or prescribed sleep medication. The current pilot study therefore aimed to assess the acceptability and efficacy of a brief, digitally delivered sleep intervention, the Sleep Course, using a broad range of participants. Participants (n = 74) completed the 6-week, 4-lesson intervention alongside measures of sleep disturbance, sleep-related impairment, depression, anxiety and sleep-wake patterns (via sleep diary). Generalized estimating equations analysis modelled change in participants' outcomes from pre- to post-treatment and 3-month follow-up, and subgroup analyses explored the role of possible moderators (e.g., age over 65, co-morbidities, and concurrent prescription medication use). The intervention was associated with good rates of satisfaction (79 %) and lesson completion (70 %). Results showed significant and large reductions in insomnia, sleep disturbance and associated symptoms (e.g., d = 1.06-1.37 change in insomnia symptoms). Evidence of high acceptability and clinical improvement was found irrespective of age, physical comorbidity, and sleep medication use. However, there was evidence of less improvement among those taking medications or having tried psychological treatment in the past. These results provide strong preliminary evidence for the intervention as an acceptable, efficacious and scalable treatment for a broad range of participants with sleep difficulties. Larger randomised controlled trials are needed.

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.

Exploring the link between comorbid insomnia and sleep apnea (COMISA) and erectile dysfunction: implications for male sexual health

INTRODUCTION

This review explores the interplay between comorbid insomnia and sleep apnea (COMISA) and erectile dysfunction (ED), 2 conditions that significantly impact men's health. COMISA, a recently recognized condition characterized by the coexistence of insomnia and obstructive sleep apnea, has been shown to disrupt sleep architecture and cause intermittent hypoxia. These disturbances are increasingly linked to the exacerbation of ED, a prevalent issue among men. Understanding the connection between COMISA and ED is crucial for developing integrated treatment approaches that address both sleep and sexual health.

OBJECTIVES

We aim to explore the epidemiological, physiological, and potential therapeutic intersections of COMISA and ED. This review sets out to develop a better understanding of the relationship between these conditions and to emphasize the need for an integrated diagnostic and therapeutic approach that addresses both sleep and sexual health.

METHODS

Through a comprehensive analysis, including a detailed examination of extant studies, we address the hormonal imbalances and alterations in neural pathways that collectively contribute to the complex pathophysiology of ED and how these are particularly susceptible to the concurrent presence of COMISA.

RESULTS

Our analysis indicates that disruptions in sleep architecture and intermittent hypoxia associated with COMISA can exacerbate ED. Hormonal imbalances, endothelial dysfunction, autonomic imbalance, and increased inflammation and oxidative stress are key mechanisms through which COMISA influences ED. These factors collectively impair vascular health, reduce testosterone levels, disrupt neural control of erections, and contribute to the severity of ED.

CONCLUSIONS

This review underscores the necessity for an integrated approach to diagnosis and therapy that considers both sleep and sexual health to improve overall outcomes. These insights should foster a deeper understanding of the relationship between COMISA and ED, encourage further research in this area, and potentially lead to the development of innovative treatment strategies to manage these closely intertwined health concerns.

Australasian Sleep Association 2024 guidelines for sleep studies in adults

Executive summary: This document is a consensus statement of a subcommittee of experienced sleep physicians and scientists, tasked to review the literature and formulate recommendations on the indications, performance, and reporting of sleep studies, to update clinical practice from the 2017 Australasian Sleep Association (ASA) guidelines for sleep studies in adults (Douglas JA, Chai-Coetzer CL, McEvoy D, et al. Guidelines for sleep studies in adults - a position statement of the Australasian Sleep Association. Sleep Med. 2017;36(Suppl 1):S2-S22. doi:10.1016/j.sleep.2017.03.019). This document moves the focus beyond important discussions outlined in the 2017 guidelines, particularly surrounding the sensitivity and specificity of validated questionnaires and home sleep studies. The 2024 guide outlines the performance of the broad range of sleep testing available for the investigations of sleep disorders in adults including indications, strengths, limitations, and reporting standards.

The Association between Suicidal Ideation and Subtypes of Comorbid Insomnia Disorder in Apneic Individuals

Background/Objectives: Given the existence of higher suicidality in apneic individuals, this study aimed to determine the potential role played by subtypes of the comorbid insomnia disorder (CID) in the occurrence of suicidal ideation for this specific subpopulation. Methods: To perform our analyses, 1488 apneic individuals were retrospectively extracted from the Sleep Laboratory hospitalization register. Only apneic individuals with suicidal ideation highlighted during the psychiatric interview and/or with a score ≥1 on item G of the Beck Depression Inventory confirmed during the clinical interview were included in the group with suicidal ideation. The likelihood of suicidal ideation associated with CID subtypes was investigated using logistic regression analyses. Results: The prevalence of suicidal ideation was 9.3% in our sample of apneic individuals. After hierarchically introducing the significant confounders for adjustment, multivariate logistic regression analyses demonstrated that unlike short sleep duration alone and CID without short sleep duration, the likelihood of suicidal ideation was only higher for CID with short sleep duration in apneic individuals. Conclusions: Thus, we highlighted in this study that CID with short sleep duration could play a major role in higher suicidality for apneic individuals, which seems to require systematic screening and appropriate treatment of this comorbid sleep disorder to enable better management of suicidal risk in this specific subpopulation.

Expanded gray matter atrophy with severity stages of adult comorbid insomnia and sleep apnea

OBJECTIVE

To investigate gray matter volume (GMV) changes in patients with comorbid insomnia and sleep apnea (COMISA) of differing severity and relationships between GMV alterations and clinical measures.

METHODS

Thirty-four COMISA patients and 24 healthy controls (HC) were recruited. All patients underwent structural MRI and completed measures related to respiration, sleep, mood, and cognition. COMISA patients were further divided into a mild and moderate COMISA (MC) and a severe COMISA (SC) group. Changes in GMV of COMISA patients were investigated via VBM. The voxel-wise differences in GMV were compared between HC group and COMISA group. Analysis of covariance (ANCOVA) was performed on individual GMV maps in MC, SC, and HC groups to further investigate effects of different stages of COMISA severity on GMV. Partial correlation analysis was then performed to analyze relationships between altered GMV and clinical measures.

RESULTS

GMV atrophy was mainly located in the temporal lobes and fusiform gyrus in COMISA group. The post-hoc analysis of the ANCOVA revealed temporal lobes and fusiform gyrus atrophy in MC and SC groups compared to HC and the temporal lobe atrophy was expanded in SC group based on cluster size. Moreover, the SC group showed GMV atrophy of the right amygdala compared to both MC and HC groups. Partial correlation analysis revealed positive relationships between the GMV and mood-and cognitive-related measures and negative correlation between GMV and respiration measure.

CONCLUSIONS

Our findings showed GMV atrophy expansion from temporal lobe to limbic system (right amygdala) as severity stages increase in COMISA patients. These findings contribute to our understanding of neurobiological mechanisms underlying different stages of severity in COMISA patients.

From guidelines to bedside - insomnia treatment practices in South Korea: a nationwide cohort study

Background

Insomnia is a prevalent disorder that impacts quality of life and leads to significant economic costs. Treatment includes both non-medication and pharmacological interventions, with international guidelines recommending cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment.

Objective

To describe current insomnia treatment practices in South Korea, focusing on pharmacological and non-medication treatments, and to identify gaps in guideline implementation.

Methods

This cohort study used data from the Korea National Health Insurance Service-National Sample Cohort (NHIS-NSC) from 2002 to 2019 and identified 18,003 patients newly diagnosed with insomnia between 2015 and 2019. This study analyzed treatment patterns and utilization rates.

Results

Of the 18,003 patients, 16,181 (89.9%) received pharmacological treatment, resulting in 35,638 prescriptions. Zolpidem (60%) and benzodiazepines (30-40%) were the most prescribed medications. Most patients were treated in clinics, with consistent dosages and increasing treatment lengths. Psychotherapy claims rose from 3.20% in 2015 to 9.14% in 2019, particularly in general hospitals (22.06% to 48.37%), but remained low in clinics (1.26% to 2.08%).

Conclusion

Pharmacological treatments dominate insomnia management in South Korea, with CBT-I being underutilized. Future efforts should focus on integrating non-pharmacological treatment into routine practice and exploring treatment risks and effectiveness based on patient demographics.

Obstructive sleep apnea comorbid with insomnia symptoms and objective short sleep duration is associated with clinical and preclinical cardiometabolic risk factors: Clinical implications

BACKGROUND

Insomnia with objective short sleep duration (ISSD) but not insomnia with normal sleep duration (INSD) is associated with cardiometabolic morbidity. It has been reported that sleep apnea comorbid with insomnia (COMISA) confers higher cardiovascular risk than each condition alone. We hypothesize that the association of COMISA with clinical (hypertension) and preclinical (inflammatory and metabolic) biomarkers is driven by the ISSD phenotype.

METHODS

A clinical sample of 101 adults with mild-to-moderate OSA (mmOSA) (5 ≤ AHI <30) and insomnia symptoms underwent polysomnography or home sleep apnea testing, blood pressure measures (BP), fasting blood glucose, insulin, CRP and IL-6 plasma levels. Insomnia was based on PSQI. Objective short sleep duration was based on the median total sleep time of the sample. Participants were classified into 2 groups based on objective sleep duration: mmOSA with ISSD vs. mmOSA with INSD. Analysis of covariance and logistic regression analysis were conducted controlling for confounders.

RESULTS

Systolic and diastolic BP were elevated in the ISSD group compared to INSD group (p = 0.039 and p = 0.004, respectively). Also, the risk of hypertension was significantly higher in the ISSD (OR = 3.88, 95%CI = 1.26-11.95, p < 0.05) compared to INSD group. Plasma IL-6 concentrations and insulin resistance as indexed by glucose/insulin ratio were significantly higher in the ISSD group compared to INSD group (both p < 0.05). CRP levels were not different between the two groups.

CONCLUSION

It appears that the additive adverse effects of COMISA on cardiometabolic risks are driven by the ISSD phenotype, a finding with potential implications for further phenotyping COMISA.

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.

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.

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.

Increased Risk of Postoperative Complications in Patients Who Have Obstructive Sleep Apnea Undergoing Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Obstructive sleep apnea (OSA) has been linked to multiple adverse health outcomes and postoperative complications. Despite the high prevalence of OSA in patients undergoing total joint arthroplasty (TJA), few studies have evaluated the postoperative course of OSA patients after joint arthroplasty surgery.

METHODS

PubMed (MEDLINE) and Scopus (EMBASE, MEDLINE, and COMPENDEX) were used to conduct a systematic review of articles from inception to July 2023. Primary studies comparing postoperative outcomes following TJA between patients who had and did not have OSA were included. Postoperative medical complications, utilization of critical care, hospital stay, and mortality data were extracted. Descriptive statistics and random-effects meta-analysis models were used to analyze the available data. Included studies were evaluated for methodological risks of bias using the risk of bias in non-randomized studies of interventions. This review was registered on the International Prospective Register of Systematic Reviews (ID: CRD42023447610).

RESULTS

There were 7 studies with a total of 20,977 patients (9,425 hip; 11,137 knee; 415 hip or knee) that were included. Pulmonary complications were most frequently studied, followed by thromboembolic events. Cardiac, gastrointestinal, hematologic, genitourinary, and delirium events were also reported across studies. Meta-analysis revealed that OSA patients had 4-fold increased odds of overall medical complications (OR [odds ratio], 4.23; 95% confidence interval (CI), 2.97 to 6.04; P < .001; I2 = 0%), 4-fold increased odds of pulmonary complications (OR, 4.31; 95% CI, 2.82 to 6.60; P < .001; I2 = 0%), 2-fold increased odds of thromboembolic complications (OR, 1.92; 95% CI, 1.22 to 3.03; P = .005; I2 = 9%), and 4-fold increased odds of delirium (OR, 3.94; 95% CI, 1.72 to 9.04; P = .001; I2 = 0%).

CONCLUSIONS

A significant association was found between OSA and overall medical, pulmonary, and thromboembolic complications. These patients also had a higher incidence of postoperative delirium. The present findings underscore the need for comprehensive perioperative strategies to mitigate these risks in OSA patients who elect to undergo TJA.

A Pilot Randomized Trial of Combined Cognitive-Behavioral Therapy and Exercise Training Versus Exercise Training Alone for the Management of Chronic Insomnia in Obstructive Sleep Apnea

Insomnia treatment among individuals with comorbid insomnia and obstructive sleep apnea is suboptimal. In a pilot randomized controlled trial, 19 individuals with comorbid insomnia and obstructive sleep apnea were allocated to one of two arms: EX + EX, consisting of two 8-week phases of exercise training (EX), or RE + CBTiEX, encompassing 8 weeks of relaxation training (RE) followed by 8 weeks of combined cognitive-behavioral therapy and exercise (CBTiEX). Outcomes included Insomnia Severity Index (ISI), polysomnography, and cardiorespiratory fitness measures. A mixed-model analysis of variance revealed a Group × Time interaction on peak oxygen consumption change, F(1, 14) = 10.1, p = .007, and EX increased peak oxygen consumption (p = .03, g' = -0.41) and reduced ISI (p = .001, g' = 0.82) compared with RE (p = .49, g = 0.16) post-8 weeks. Post-16 weeks, there was a significant Group × Time interaction (p = .014) driven by RE + CBTiEX yielding a larger improvement in ISI (p = .023, g' = 1.48) than EX + EX (p = .88, g' < 0.1). Objective sleep was unchanged. This study showed promising effects of regular EX alone and combined with cognitive-behavioral therapy for insomnia on ISI in comorbid insomnia and obstructive sleep apnea.

Insomnia

Sleep significantly impacts health. Insomnia, characterized by difficulty with sleep onset, maintenance, and subsequent daytime symptoms, is increasingly prevalent and increases the risk of other medical comorbidities. The pathophysiology involves hyperarousal during non-REM sleep and altered sleep homeostasis. The 3P model explains the development and persistence of insomnia. Assessment is primarily clinical and based on appropriate history while distinguishing from other sleep disorders. "Somnomics" suggests a personalized approach to management. Cognitive behavioral therapy for insomnia is the first-line treatment in addition to other nonpharmacological strategies. Medications are a secondary option with weak supporting evidence.

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.

Effect of melatonin on insomnia and daytime sleepiness, in patients with obstructive sleep apnea and insomnia (COMISA): A randomized double-blinded placebo-controlled trial

BACKGROUND

COMISA is a common disorder that results in nighttime awakenings ,daytime sleepiness and PAP intolerance. Cognitive behavioral therapy for insomnia is used to improve PAP adherence and no medication has been evaluated in such population yet. Melatonin with its chronobiotic and antioxidant effects may have potential benefits on COMISA consequences at the appropriate dose and time. This study aimed to evaluate the effect of melatonin on sleep quality, daytime sleepiness and PAP Compliance in patients with COMISA.

METHODS

This double-blind placebo trial randomly assigned eligible OSA patients who suffered from insomnia despite using PAP for over a month to receive either melatonin 10 mg or placebo. The primary outcomes were measured by changes in the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire (FOSQ-10) over one month. Adherence to PAP was measured by the results of the PAP device reports on the average length of time and number of nights that the device was used.

RESULTS

Thirty patients were enrolled in the study after randomization. The melatonin arm showed significant improvement in all four primary outcomes compared to the placebo arm. The PSQI score was 3.836±1.839 in the melatonin arm versus 10.522±3.626 in the placebo arm (Pvalue<0.001). The ISI score was 8.476±3.568 in the melatonin arm versus 14.47±4.50 in the placebo arm (Pvalue<0.001). The ESS score was 6.854±4.334 in the melatonin arm versus 13.298±5.119 in the placebo arm (Pvalue<0.001). The FOSQ-10 score was 24.93±5.02 in the melatonin arm versus 19.87±4.24 in the placebo arm (Pvalue= 0.006). Additionally, nighttime consequences such as sleep latency and awakenings showed significant improvement in the melatonin arm. PAP devices results revealed improvement in duration of PAP use overnight.  CONCLUSIONS: Administering melatonin has been shown to improve self-reported sleep quality and PAP adherence in patients with COMISA.

TRIAL REGISTRATION

Registration number IRCT20220105053635N1 was issued by the Iranian Registry of Clinical Trials (IRCT).

Quantitative validation of the suprasternal pressure signal to assess respiratory effort during sleep

Objective.Intra-esophageal pressure (Pes) measurement is the recommended gold standard to quantify respiratory effort during sleep, but used to limited extent in clinical practice due to multiple practical drawbacks. Respiratory inductance plethysmography belts (RIP) in conjunction with oronasal airflow are the accepted substitute in polysomnographic systems (PSG) thanks to a better usability, although they are partial views on tidal volume and flow rather than true respiratory effort and are often used without calibration. In their place, the pressure variations measured non-invasively at the suprasternal notch (SSP) may provide a better measure of effort. However, this type of sensor has been validated only for respiratory events in the context of obstructive sleep apnea syndrome (OSA). We aim to provide an extensive verification of the suprasternal pressure signal against RIP belts and Pes, covering both normal breathing and respiratory events.Approach.We simultaneously acquired suprasternal (207) and esophageal pressure (20) signals along with RIP belts during a clinical PSG of 207 participants. In each signal, we detected breaths with a custom algorithm, and evaluated the SSP in terms of detection quality, breathing rate estimation, and similarity of breathing patterns against RIP and Pes. Additionally, we examined how the SSP signal may diverge from RIP and Pes in presence of respiratory events scored by a sleep technician.Main results.The SSP signal proved to be a reliable substitute for both esophageal pressure (Pes) and respiratory inductance plethysmography (RIP) in terms of breath detection, with sensitivity and positive predictive value exceeding 75%, and low error in breathing rate estimation. The SSP was also consistent with Pes (correlation of 0.72, similarity 80.8%) in patterns of increasing pressure amplitude that are common in OSA.Significance.This work provides a quantitative analysis of suprasternal pressure sensors for respiratory effort measurements.

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.

A sleep stage estimation algorithm based on cardiorespiratory signals derived from a suprasternal pressure sensor

Automatic estimation of sleep structure is an important aspect in moving sleep monitoring from clinical laboratories to people's homes. However, the transition to more portable systems should not happen at the expense of important physiological signals, such as respiration. Here, we propose the use of cardiorespiratory signals obtained by a suprasternal pressure (SSP) sensor to estimate sleep stages. The sensor is already used for diagnosis of sleep-disordered breathing (SDB) conditions, but besides respiratory effort it can detect cardiac vibrations transmitted through the trachea. We collected the SSP sensor signal in 100 adults (57 male) undergoing clinical polysomnography for suspected sleep disorders, including sleep apnea syndrome, insomnia, and movement disorders. Here, we separate respiratory effort and cardiac activity related signals, then input these into a neural network trained to estimate sleep stages. Using the original mixed signal the results show a moderate agreement with manual scoring, with a Cohen's kappa of 0.53 in Wake/N1-N2/N3/rapid eye movement sleep discrimination and 0.62 in Wake/Sleep. We demonstrate that decoupling the two signals and using the cardiac signal to estimate the instantaneous heart rate improves the process considerably, reaching an agreement of 0.63 and 0.71. Our proposed method achieves high accuracy, specificity, and sensitivity across different sleep staging tasks. We also compare the total sleep time calculated with our method against manual scoring, with an average error of -1.83 min but a relatively large confidence interval of ±55 min. Compact systems that employ the SSP sensor information-rich signal may enable new ways of clinical assessments, such as night-to-night variability in obstructive sleep apnea and other sleep disorders.

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.

The obstructive sleep apnoea endotypes are similar in elderly trauma-exposed veterans with and without diagnosed PTSD

BACKGROUND

Approximately 60% of veterans living with posttraumatic stress disorder (PTSD) experience obstructive sleep apnoea (OSA). Why OSA is so prevalent in individuals with PTSD remains unknown, though PTSD may influence the underlying endotypes known to cause OSA. We examined whether these endotypes (upper airway collapsibility, muscle compensation, loop gain, and the arousal threshold) differ between those with comorbid OSA and PTSD relative to their counterparts with OSA-only.

METHODS

Using the ventilatory flow pattern from diagnostic polysomnography, the OSA endotypes were measured in a retrospective cohort of 21 OSA patients with PTSD and 27 OSA-only patients. All participants were trauma exposed elderly male Australian Vietnam War veterans with mild-to-severe OSA (median Apnoea-Hypopnea index: 20.2 vs. 23.6 events/h). Age and BMI were similar between groups (70.7 vs. 71.7 years, and 28.4 vs. 28.4 kg/m2).

RESULTS

There were no significant differences in the OSA endotype traits between PTSD + OSA and OSA-only patients for upper airway collapsibility (76.68 [71.53-83.56] vs. 78.35 [72.81-83.82] %Veupnea, median [IQR]), muscle compensation (4.27 [0.34-9.18] vs. 5.41 [1.83-7.21] %Veupnea), loop gain (0.56(0.17) vs. 0.60(0.14)), and arousal threshold (135.76 [126.59-147.54] vs. 146.95 [128.64-151.28] %Veupnea).

CONCLUSION

The OSA endotypes in veterans with PTSD were similar to their trauma exposed OSA-only counterparts. PTSD appears to exert little influence on the OSA endotypes beyond the effect that age and trauma exposure may have. The aetiology of increased prevalence of OSA in PTSD remains unclear. Further work examining OSA endotypes using larger and more diverse samples is needed before robust conclusions can be made.

Insomnia and sleep-disordered breathing in FKRP-related limb-girdle muscular dystrophy R9. The Norwegian LGMDR9 cohort study (2020)

Limb-girdle muscular dystrophy R9 (LGMDR9) is a progressive and disabling genetic muscle disease. Sleep is relevant in the patient care as it impacts on health, functioning, and well-being. LGMDR9 may potentially affect sleep by physical or emotional symptoms, myalgia, or sleep-disordered breathing (SDB) through cardiorespiratory involvement. The objective was to investigate the occurrence of insomnia and unrecognized or untreated SDB in LGMDR9, associated factors, and relationships with fatigue and health-related quality of life (HRQoL). All 90 adults in a Norwegian LGMDR9 cohort received questionnaires on sleep, fatigue, and HRQoL. Forty-nine of them underwent clinical assessments and 26 without mask-based therapy for respiration disorders additionally underwent polysomnography (PSG) and capnometry. Among 77 questionnaire respondents, 31% received mask-based therapy. The prevalence of insomnia was 32% of both those with and without such therapy but was significantly increased in fatigued respondents (54% vs 21%). Insomnia levels correlated inversely with mental HRQoL. Among 26 PSG candidates, an apnea-hypopnea index (AHI) ≥ 5/h was observed in 16/26 subjects (≥ 15/h in 8/26) with median 6.8 obstructive apneas and 0.2 central apneas per hour of sleep. The AHI was related to advancing age and an ejection fraction < 50%. Sleep-related hypoventilation was detected in one subject. Fatigue severity did not correlate with motor function or nocturnal metrics of respiration or sleep but with Maximal Inspiratory Pressure (r = - 0.46). The results indicate that insomnia and SDB are underrecognized comorbidities in LGMDR9 and associated with HRQoL impairment and heart failure, respectively. We propose an increased attention to insomnia and SDB in the interdisciplinary care of LGMDR9. Insomnia and pulmonary function should be examined in fatigued patients.

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.

A randomized, double-blind, placebo-controlled, crossover study of respiratory safety of lemborexant in moderate to severe obstructive sleep apnea

STUDY OBJECTIVES

To evaluate the respiratory safety of lemborexant among adults and older adults with moderate to severe obstructive sleep apnea (OSA).

METHODS

E2006-A001-113 (Study 113; NCT04647383) was a double-blind, two-period crossover, placebo-controlled study in adults (ages ≥ 45 to ≤ 90 years, n = 33) with moderate (apnea-hypopnea index [AHI] score ≥ 15 to < 30 events/h, n = 13) or severe (AHI ≥ 30 events/h, n = 20) OSA. Participants were randomized to lemborexant 10 mg (LEM10) or placebo (PBO) for two treatment periods of 8 nights with a ≥ 14-day washout period. AHI and peripheral oxygen saturation were evaluated after treatment on Day 1 (after a single dose) and Day 8 (after multiple doses).

RESULTS

No significant differences in AHI were observed after single and multiple doses of LEM10 compared with PBO in participants with moderate to severe OSA (least-squares mean: single-dose LEM10, 41.7; PBO, 44.8; multiple-dose LEM10, 44.9; PBO, 45.7). In addition, there were no significant differences between treatments in peripheral oxygen saturation (least-squares mean: single-dose LEM10, 93.0; PBO, 93.1; multiple-dose LEM10, 93.1; PBO, 93.4). Further, there were no significant differences between treatments in percentage of total sleep time with peripheral oxygen saturation < 90%, < 85%, or < 80%. No significant differences were observed between treatments when AHI and peripheral oxygen saturation outcomes were analyzed by OSA severity. Altogether, 6/33 (18.2%) participants receiving LEM10, vs 3/33 (9.1%) PBO, reported treatment-emergent adverse events, mostly mild in severity.

CONCLUSIONS

LEM10 demonstrated respiratory safety and was well tolerated with single-dose and multiple-dose administration in participants with moderate to severe OSA. This suggests that LEM may be a treatment option for patients with OSA and comorbid insomnia.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: A Study to Evaluate the Respiratory Safety of Lemborexant in Adult and Elderly Participants With Moderate to Severe Obstructive Sleep Apnea and in Adult and Elderly Participants With Moderate to Severe Chronic Obstructive Pulmonary Disease; URL: https://clinicaltrials.gov/ct2/show/NCT04647383; Identifier: NCT04647383.

CITATION

Cheng JY, Lorch D, Lowe AD, et al. A randomized, double-blind, placebo-controlled, crossover study of respiratory safety of lemborexant in moderate to severe obstructive sleep apnea. J Clin Sleep Med. 2024;20(1):57-65.

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.

Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea

STUDY OBJECTIVES

The aim of this study was to evaluate sex-related differences in symptoms of sleep disorders, sleep-related impairment, psychiatric symptoms, traumatic brain injury, and polysomnographic variables in treatment-seeking military personnel diagnosed with insomnia, obstructive sleep apnea (OSA), or comorbid insomnia and OSA (COMISA).

METHODS

Participants were 372 military personnel (46.2% women, 53.8% men) with an average age of 37.7 (standard deviation = 7.46) years and median body mass index of 28.4 (5.50) kg/m2. Based on clinical evaluation and video-polysomnography, participants were diagnosed with insomnia (n = 118), OSA (n = 118), or COMISA (n = 136). Insomnia severity, excessive daytime sleepiness, sleep quality, nightmare disorder, sleep impairment, fatigue, posttraumatic stress disorder, anxiety, depression symptoms, and traumatic brain injury were evaluated with validated self-report questionnaires. Descriptive statistics, parametric and nonparametric t-tests, and effect sizes were used to assess sex differences between men and women.

RESULTS

There were no significant differences between women and men with insomnia or OSA in sleep-related symptoms, impairment, or polysomnography-based apnea-hypopnea index. Military men with COMISA had a significantly greater apnea-hypopnea index as compared to military women with COMISA, but women had greater symptoms of nightmare disorder, posttraumatic stress disorder, and anxiety.

CONCLUSIONS

In contrast to civilian studies, minimal differences were observed in self-reported sleep symptoms, impairment, and polysomnography metrics between men and women diagnosed with the most frequent sleep disorders in military personnel (ie, insomnia, OSA, or COMISA) except in those with COMISA. Military service may result in distinct sleep disorder phenotypes that differ negligibly by sex.

CITATION

Mysliwiec V, Pruiksma KE, Matsangas P, et al. Sex differences in US military personnel with insomnia, obstructive sleep apnea, or comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2024;20(1):17-30.

Obstructive sleep apnoea-hypopnoea syndrome

Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a common disorder characterised by repetitive episodes of the complete or partial collapse of the pharyngeal airway during sleep. This results in cessation (apnoea) or reduction (hypopnoea) of airflow, leading to oxygen desaturation and sleep fragmentation. An individual's disposition to develop OSAHS depends on the collapsibility of a segment of the upper airway. The degree of collapsibility can be quantified by the balance between occluding or extraluminal pressures of the surrounding tissues. Patients can experience snoring, unrefreshing sleep, witnessed apnoeas, waking with a choking sensation and excessive daytime sleepiness. OSAHS has a broad range of consequences, including cardiovascular, metabolic, and neurocognitive sequelae. Treatment options include lifestyle measures, in particular weight loss, and strategies to maintain upper airway patency overnight, including continuous positive airway pressure, mandibular advancement devices and positional modifiers.

Experience with the use of a digital sleep diary in symptom management by individuals with insomnia -a pilot mixed method study

Background

Insomnia is the most common sleep disorder. The recommended treatment is cognitive behavioural therapy for insomnia (CBTi). A sleep diary is a core tool in CBTi. We have developed a digital sleep diary with a standardised feedback function.

Aim

To study feasibility of the digital sleep diary in participants of the Akershus Sleep Apnea (ASAP) cohorts with difficulties falling asleep or maintaining sleep. To describe sleep diary engagement and explore experiences with the digital sleep diary with potential influences in insomnia symptom management.

Material and methods

Twenty participants were recruited from the ASAP. All filled out a digital sleep diary up to 12 weeks. Treatment options provided were a self-help book (N = 11) or electroencephalography neurofeedback (N = 9) in addition to the sleep diary standardised feedback function. We collected quantitative data from the sleep diary reports and we sub-divided insomnia by sleep onset insomnia and non-sleep onset insomnia. Finally, we performed qualitative interviews.

Results

The median number of entries to the sleep diary was 81 (25th quartile: 26, 75th quartile 84). In the qualitative analysis, we identified two main themes; "structure and overview" and "usability and digital features".

Conclusion

The sleep diary was found to be feasible when distributed in combination with a self-help book or electroencephalography neurofeedback. The qualitative results emphasised the importance of a timely graphical overview and visualisations of self-recorded sleep.

Self-reported sleep status and influencing factors: a web-based national cross-sectional survey in China

OBJECTIVES

To investigate self-reported sleep duration, sleep timing, sleep status and influencing factors in the Chinese population.

METHODS

This web-based cross-sectional survey was conducted in 2022, covering 31 provinces (91%) in China. 11,000 questionnaires were collected, of which 8970 were valid for analysis. Self-reported sleep habits, problems and quality were investigated. Good or fair sleep ratings, enough duration, regular, with no sleep disturbances and <30 min sleep latency was defined as a composite variable: 'Good sleep'. Factors influencing sleep patterns and 'Good sleep' were analyzed by multivariate logistic regression.

RESULTS

Most participants sleep less than 7 h per night (55.13%), usually go to bed at 10-12 pm (47.99%), wake up at 6-8 am (49.86%), and take less than 30 min to fall asleep (66.30%) with regular sleep schedule (76.01%). Only 12.36% have 'Good sleep'. In the past 3 months, 46.80% of the participants reported symptoms of insomnia, and 21.54% had snoring problems. Among the adults, the young, males, college students, freelancers, and those who resided in urban areas and pandemic-free areas slept later, and the northerners woke up earlier. The adults with low-moderate and moderate income and the minors at elementary and middle school slept earlier and woke up earlier. Mid-aged adults who often napped at noon were more likely to have 'Good sleep' than any other age group, and urban dwellers with the same habit were more likely to have 'Good sleep' than people dwelled in other regions. While people who slept late, woke up too early or too late, slept too little or too much, resided at GMT 7-8 area or pandemic area, had high income, or took up some occupations (entrepreneurs/individuals, professionals, manual and non-manual workers, housewives) were less likely to get a 'Good sleep'.

CONCLUSIONS

The national survey provided a sleep profile of the Chinese population. Both socio-economic status and personal sleep hygiene habits had an impact on 'Good sleep'.

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.

Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea

STUDY OBJECTIVES

Upper airway stimulation (UAS) is a hybrid surgical-medical device used to treat moderate-to-severe obstructive sleep apnea (OSA). Comorbid insomnia and OSA (COMISA) is present in ∼50% of these patients. Our aim was to study UAS outcomes and adherence in patients with COMISA.

METHODS

A retrospective review of 379 patients with OSA who underwent UAS implantation at a single institution between 2014 and 2021. Demographics, OSA severity metrics, and insomnia data were collected. Patients were categorized into OSA alone (OSAa) or COMISA. Objective adherence data were collected from device downloads during follow-up. Data were analyzed with using R Studio (R Foundation for Statistical Computing, Vienna, Austria) and Prism (Boston, MA, USA).

RESULTS

Of the 274 patients included, 148 had COMISA (54.0%) and 126 OSAa (46.0%). Average follow-up time was 2.5 years and OSAa had more males than COMISA (P < .001). Patients with COMISA had higher insomnia severity index scores than OSAa preoperatively (16 vs 8.7; P = .003). All groups showed significant decreases in objective and self-reported OSA outcomes postoperatively, but there was no difference between COMISA and OSAa. Patient with COMISA had decreased device usage (4.9 vs 5.8 h/night; P = .015) and paused therapy more often than patients with OSAa (1.4 vs 0.4 pauses/night; P < .001). Multivariate linear regression, when controlling for sex as a covariate, showed insomnia to be an independent predictor of lower UAS hours/night and more pauses/night (P < .01).

CONCLUSIONS

Patients with COMISA use UAS therapy for shorter durations and require more breaks from therapy when compared with those with OSAa. Future research is needed to explore the underlying mechanism and improve UAS treatment adherence in patients with COMISA.

CITATION

Kaffenberger TM, Chandna M, Kaki P, et al. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):1997-2004.

Redefining Comorbid Insomnia and Sleep Apnea: The Association of Sleep Breathing Impairment and Insomnia with Incident Diabetes

Rationale: Obstructive sleep apnea (OSA) is a prevalent sleep disorder that is frequently comorbid with insomnia and often accompanied by metabolic diseases such as type 2 diabetes. Although the apnea-hypopnea index (AHI) is currently the diagnostic criterion for gauging the severity of OSA, the AHI has not consistently predicted incident diabetes. Objectives: To test whether a combined insomnia-OSA (COMISA) phenotype based on comorbid insomnia and sleep breathing impairment index (COMISA-SBII) predicts incident diabetes and to compare the association with an AHI definition of COMISA (COMISA-AHI) in the MrOS (Osteoporotic Fractures in Men) study. Methods: The study samples came from participants in the MrOS sleep study without diabetes at their baseline examination. The SBII was derived as the product of the duration of each respiratory event (apnea and hypopnea) and the accompanying desaturation area from baseline unattended polysomnography. A subgroup of individuals classified as having comorbid insomnia (difficulties falling asleep, waking up in the middle of the night and/or early morning awakenings >15 times per month, and daytime impairments) and sleep breathing impairment (greater than 50th percentile of SBII) were identified at baseline. The primary outcome was incident diabetes during the follow-up visits. Cox proportional models were built to assess the adjusted hazard ratios of COMISA-AHI and COMISA-SBII. Prediction model performances of incident diabetes were compared across different models. Results: A total of 2,365 men (mean age, 76 yr) without diabetes at baseline were included. During a median follow-up of 10.0 years, diabetes developed in 181. After adjusting for demographic characteristics, comorbidities, and behavioral risk factors, participants with COMISA-SBII had a higher risk of incident diabetes (hazard ratio, 1.82; 95% confidence interval, 1.15-2.89) than those without sleep disorders (those with an SBII ⩽13.17 and no insomnia). The result remained significant in the risk competing model. Compared with COMISA-AHI, the addition of COMISA-SBII to a crude model with established risk factors significantly improved the predictive value of incident diabetes. Conclusions: COMISA-SBII, but not COMISA-AHI, predicted incident diabetes after accounting for multiple covariates in a cohort of older men. A comorbid insomnia phenotype based on SBII plus insomnia symptoms may be an important clinical subtype.

Urinary metabolite signatures reflect the altered host metabolism in severe obstructive sleep apnea

Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder. The onset and progression of OSA are often linked with severe cardiovascular and metabolic comorbidities. At the same time, given the increasing prevalence of OSA, novel methods to screen OSA and its follow-up are needed. Untargeted metabolic profiling of OSA patients and healthy controls was planned to capture a snapshot of urinary metabolites and potential biomarkers using the gas chromatography-mass spectrometry (GC-MS) method.Polysomnography (PSG) confirmed severe OSA patients with AHI index ≥ 30 were considered for urine sample collection. The sample size was constituted of OSA (n = 36) and healthy controls (n = 36). Metabolite extraction and derivatization were performed and metabolomic analysis was performed by using GC-MS.The obtained data set was statistically analyzed using univariate and multivariate analysis. The Orthogonal partial least-squares discriminant analysis (OPLS-DA) was performed to screen differential metabolites between OSA patients and healthy controls.The metabolomic analysis revealed a total of 142 significantly altered metabolites of interest.Biomarker analysis allows for the creation of a list of putative urinary biomarkers including GABA, malic acid, glutamic acid, epichoric acid etc., with an accuracy of 99.8 % to 100 % for OSA screening. Subsequently, pathway analysis revealed that related biochemical pathways like the tricarboxylic acid cycle (TCA), glutamate/glutamine, amino acid and fatty acid metabolism, that are significantly interlinked with these metabolic biomarkers can play a crucial role in the pathogenesis of OSA. This study paves the way to undertake mass screening in a larger population to identify specific and reliable biomarkers.

Mechanisms of cognitive behavioural therapy for insomnia

Although much is known now about behavioural, cognitive and physiological consequences of insomnia, little is known about changes after cognitive behavioural therapy for insomnia on these particular factors. We here report baseline findings on each of these factors in insomnia, after which we address findings on their changes after cognitive behavioural therapy. Sleep restriction remains the strongest determinant of insomnia treatment success. Cognitive interventions addressing dysfunctional beliefs and attitudes about sleep, sleep-related selective attention, worry and rumination further drive effectiveness of cognitive behavioural therapy for insomnia. Future studies should focus on physiological changes after cognitive behavioural therapy for insomnia, such as changes in hyperarousal and brain activity, as literature on these changes is sparse. We introduce a detailed clinical research agenda on how to address this topic.

The importance and limitations of polysomnography in insomnia disorder-a critical appraisal

The importance polysomnography (PSG) in the diagnosis and treatment process of insomnia disorder (ID) remains highly disputed. This review summarises the state of the science regarding PSG indications and findings in ID, and the indications to conduct PSG in ID as stated by relevant guidelines. It then highlights the most relevant questions regarding the topic, including the relevance of ID subtyping, to allow an individualised pharmacological or psychotherapeutic treatment approach.

Delirium and sleep disturbances-A narrative review

BACKGROUND

Delirium is considered a severe complication. It increases morbidity and mortality and represents a major financial burden for healthcare systems. Thus, prevention becomes a focal point of research. Sleep disturbances have been linked to the occurrence of delirium. Consequently, several interventions that target a possible connection have been studied in recent years.

OBJECTIVE

This narrative literature review explores the published data for an association between delirium and different types of sleep disturbances, the pathophysiological interactions and prevention methods.

MATERIAL AND METHODS

A literature search was carried out utilizing PubMed, the Cochrane Library, Livivo and Google Scholar.

RESULTS

Although an association between several types of sleep disturbances and delirium has been shown, no causality has been proven so far. Nevertheless, several pharmacological and nonpharmacological interventions for delirium prevention have been attempted; however, the level of evidence is insufficient at this point.

CONCLUSION

Further research is required to prove causality between sleep disturbances and delirium. Nonpharmacological interventions should be used in construction and maintenance of intensive care units and hospitals. Pharmacological interventions could be effective for prevention but further research is needed. Screening patients at risk of delirium for sleep disturbances and antihistaminergic/anticholinergic medication seems beneficial.

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.

Association between Acute Respiratory Distress Syndrome Due to COVID-19 and Long-Term Sleep and Circadian Sleep-Wake Disorders

Current studies agree on the impact of sleep and circadian rest-activity rhythm alterations in acute respiratory distress syndrome (ARDS) survivors. However, research on the duration of this impact is scarce. In this study, we evaluate the impact of ARDS on the sleep and circadian rest-activity rhythm of COVID-19 survivors twelve months after hospital discharge. This is a prospective study including COVID-19 survivors with and without ARDS during hospitalization. Data was collected four and twelve months after hospital discharge. The interventions included one-week wrist actigraphy and a home sleep apnea test (HSAT), and evaluations were conducted according to the Pittsburgh sleep quality index (PSQI), Epworth sleepiness scale (ESS), and insomnia severity index (ISI). Fifty-two patients were evaluated (ARDS = 31 and non-ARDS = 21); they had a median age of 49.0 [39.0;57.2] years and 53.8% were male. After twelve months, 91.3% presented poor sleep quality, 58.7% presented insomnia, 50% presented daytime somnolence, and 37% presented comorbid insomnia and obstructive sleep apnea (COMISA). No significant improvement was observed in relation to sleep or the circadian rest-activity rhythm between four and twelve months. A tendency of poor sleep quality, insomnia, daytime somnolence, and COMISA was observed. Finally, there was no significant impact on the circadian rest-activity rhythm between four and twelve months or between the groups.

Insomnia and Early Incident Atrial Fibrillation: A 16-Year Cohort Study of Younger Men and Women Veterans

Background There is growing consideration of sleep disturbances and disorders in early cardiovascular risk, including atrial fibrillation (AF). Obstructive sleep apnea confers risk for AF but is highly comorbid with insomnia, another common sleep disorder. We sought to first determine the association of insomnia and early incident AF risk, and second, to determine if AF onset is earlier among those with insomnia. Methods and Results This retrospective analysis used electronic health records from a cohort study of US veterans who were discharged from military service since October 1, 2001 (ie, post-9/11) and received Veterans Health Administration care, 2001 to 2017. Time-varying, multivariate Cox proportional hazard models were used to examine the independent contribution of insomnia diagnosis to AF incidence while serially adjusting for demographics, lifestyle factors, clinical comorbidities including obstructive sleep apnea and psychiatric disorders, and health care utilization. Overall, 1 063 723 post-9/11 veterans (Mean age=28.2 years, 14% women) were followed for 10 years on average. There were 4168 cases of AF (0.42/1000 person-years). Insomnia was associated with a 32% greater adjusted risk of AF (95% CI, 1.21-1.43), and veterans with insomnia showed AF onset up to 2 years earlier. Insomnia-AF associations were similar after accounting for health care utilization (adjusted hazard ratio [aHR], 1.27 [95% CI, 1.17-1.39]), excluding veterans with obstructive sleep apnea (aHR, 1.38 [95% CI, 1.24-1.53]), and among those with a sleep study (aHR, 1.26 [95% CI, 1.07-1.50]). Conclusions In younger adults, insomnia was independently associated with incident AF. Additional studies should determine if this association differs by sex and if behavioral or pharmacological treatment for insomnia attenuates AF risk.

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.

The burden of untreated insomnia disorder in a sample of 1 million adults: a cohort study

BACKGROUND

Insomnia disorder is a highly prevalent, significant public health concern associated with substantial and growing health burden. There are limited real-world data assessing the burden of insomnia disorder on daytime functioning and its association with comorbidities. The objective of this study was to leverage large-scale, real-world data to assess the burden of untreated insomnia disorder in terms of daytime impairment and clinical outcomes.

METHODS

This United States medical claims database study compares patients diagnosed with insomnia disorder but not receiving treatment ('untreated insomnia' cohort) to patients without an insomnia disorder diagnosis and without treatment ('non-insomnia' cohort). International Classification of Disease, Tenth Revision codes were used as a proxy to represent the three symptom domains (Sleepiness, Alert/Cognition, Mood) of the Insomnia Daytime Symptoms and Impacts Questionnaire (IDSIQ), a newly developed and validated tool used in clinical studies to assess daytime functioning in insomnia disorder. Chronic Fatigue (R53.83) and Other Fatigue (R53.83), Somnolence (R40.0) and Disorientation (R41.0) were selected as categories representing one or more IDSIQ domains. Clinical outcomes included cardiovascular events, psychiatric disorders, cognitive impairment and metabolic disorders.

RESULTS

Approximately 1 million patients were included (untreated insomnia: n = 139,959; non-insomnia: n = 836,975). Compared with the 'non-insomnia' cohort, the 'untreated insomnia' cohort was more likely to experience daytime impairments, with mean differences in occurrences per 100 patient-years for: (a) fatigue, at 27.35 (95% confidence interval [CI] 26.81, 27.77, p < 0.01); (b) dizziness, at 4.66 (95% CI 4.40, 4.90, p < 0.01); (c) somnolence, at 4.18 (95% CI 3.94, 4.43, p < 0.01); and (d) disorientation, at 0.92 (95% CI 0.77, 1.06, p < 0.01). During the 1-year look-back period, patients in the 'untreated insomnia' cohort were also more likely to have been diagnosed with arterial hypertension (40.9% vs. 26.3%), psychiatric comorbidities (40.1% vs. 13.2%), anxiety (29.2% vs. 8.5%), depression (26.1% vs. 8.1%) or obesity (21.3% vs. 11.1%) compared with those in the 'non-insomnia' cohort.

CONCLUSIONS

This large-scale study confirms the substantial burden of insomnia disorder on patients in a real-world setting, with significant daytime impairment and numerous comorbidities. This reinforces the need for timely insomnia disorder diagnosis and treatments that improve both sleep, as well as daytime functioning.

Contribution of obstructive sleep apnea to disrupted sleep in a large clinical cohort of patients with suspected obstructive sleep apnea

STUDY OBJECTIVES

The response of sleep depth to CPAP in patients with OSA is unpredictable. The odds-ratio-product (ORP) is a continuous index of sleep depth and wake propensity that distinguishes different sleep depths within sleep stages, and different levels of vigilance during stage wake. When expressed as fractions of time spent in different ORP deciles, nine distinctive patterns are found. Only three of these are associated with OSA. We sought to determine whether sleep depth improves on CPAP exclusively in patients with these three ORP patterns.

METHODS

ORP was measured during the diagnostic and therapeutic components of 576 split-night polysomnographic (PSG) studies. ORP architecture in the diagnostic section was classified into one of the nine possible ORP patterns and the changes in sleep architecture were determined on CPAP for each of these patterns. ORP architecture was similarly determined in the first half of 760 full-night diagnostic PSG studies and the changes in the second half were measured to control for differences in sleep architecture between the early and late portions of sleep time in the absence of CPAP.

RESULTS

Frequency of the three ORP patterns increased progressively with the apnea-hypopnea index. Sleep depth improved significantly on CPAP only in the three ORP patterns associated with OSA. Changes in CPAP in the other six patterns, or in full diagnostic PSG studies, were insignificant or paradoxical.

CONCLUSIONS

ORP architecture types can identify patients in whom OSA adversely affects sleep and whose sleep is expected to improve on CPAP therapy.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

A study on the prevalence of RLS in OSA and the consequences of co-occurrence

Background

Restless leg syndrome (RLS) is common among patients with obstructive sleep apnoea (OSA) but the prognostic importance of this is not studied. We have called OSA and RLS coexistence as ComOSAR.

Materials and Methods

A prospective observational study was done on patients referred for polysomnography (PSG) with the aims to evaluate 1) the prevalence of RLS in OSA and comparing it with RLS in non-OSA, 2) the prevalence of insomnia, psychiatric, metabolic and cognitive disorders in ComOSAR versus OSA alone, 3) chronic obstructive airway disease (COAD) in ComOSAR versus OSA alone. OSA, RLS and insomnia were diagnosed as per respective guidelines. They were evaluated for psychiatric disorders, metabolic disorders, cognitive disorders and COAD.

Results

Of 326 patients enrolled, 249 were OSA and 77 were non-OSA. 61/249 OSA patients, i.e. 24.4% had comorbid RLS, i.e. ComOSAR. RLS in non-OSA patients was similar (22/77, i.e. 28.5%); P = 0.41. ComOSAR had a significantly higher prevalence of insomnia (26% versus 10.1%; P = 0.016), psychiatric disorders (73.7% versus 48.4%; P = 0.00026) and cognitive deficits (72.1% versus 54.7%, P = 0.016) compared to OSA alone. Metabolic disorders like metabolic syndrome, diabetes mellitus, hypertension and coronary artery disease were also observed in a significantly higher number of patients with ComOSAR versus OSA alone (57% versus 34%; P = 0.0015). COAD was also seen in a significantly higher number of patients with ComOSAR compared to OSA alone (49% versus 19% respectively; P = 0.00001).

Conclusion

It is essential to look for RLS in patients with OSA as it leads to a significantly higher prevalence of insomnia, and cognitive, metabolic and psychiatric disorders. COAD is also more common in ComOSAR compared to OSA alone.

10-Year Risk for Cardiovascular Disease Associated with COMISA (Co-Morbid Insomnia and Sleep Apnea) in Hypertensive Subjects

Due to the few studies available, this study aimed to investigate the 10-year risk for cardiovascular disease (CVD) associated with COMISA (co-morbid insomnia and sleep apnea) in hypertensive subjects. Clinical data of 1009 hypertensive subjects extracted from the Sleep Laboratory database were analyzed. Framingham Risk Score ≥ 10% was used as a cut-off to identify hypertensive subjects with high 10-year risk for CVD. The association between 10-year risk for CVD and COMISA was investigated using logistic regression analyses. 65.3% of hypertensive subjects from our sample presented a high 10-year risk for CVD. After controlling for major confounding factors, multivariate logistic regression analyses demonstrated that unlike its components present separately, COMISA was significantly associated with high 10-year risk for CVD in hypertensive subjects (OR 1.88, 95% CI 1.01-3.51). In this study, we have demonstrated that the negative synergy between obstructive sleep apnea syndrome and insomnia disorder seems to play a central role in the 10-year risk for CVD in hypertensive subjects, which seems to indicate that the establishment of a systematic research and an adapted treatment of COMISA could open new perspectives to promote a better cardiovascular outcome in this specific subgroup of patients.

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.