Comorbid Insomnia and Sleep Apnea: mechanisms and implications of an underrecognized and misinterpreted sleep disorder

Abstract Introduction Only few studies looked for a possible association of cardiovascular disorders (CVD), in comorbid insomnia with obstructive sleep apnea (COMISA) even though this is a relevant topic in order to prevent one of the major causes of morbimortality. The present study aimed to investigate the association of insomnia symptoms in patients at risk for obstructive sleep apnea in terms of prevalence and clinical interactions and to evaluate the risk of CVD in patients with a risk for COMISA. Methods This is a cross-sectional study. All medical records with data such as age, sex, height, weight and BMI, time to sleep, time to wake up, total sleep time, the Epworth Sleepiness Scale (ESS), STOP-BANG Questionnaires were studied. Insomnia and comorbidities were also investigated, and the patientsanswered yes or no to systemic arterial hypertension, diabetes, CVD. Results 685 patients were enrolled on the present study. We observed that the mild, moderate, and high risk for COMISA presented progressively increasing levels for the frequency of hypertension, diabetes, and CVD. A binary logistic regression was performed to assess whether risk for COMISA could be a predictor for CVD, and it was found that the model containing risk for COMISA was statistically significant: [x2(1)=5.273;p<0.021, R2 Negelkerke=0.014]. Risk for COMISA presented itself as a significant predictor for CVD (OR=1.672; 95% CI=1.079–2.592). Conclusion There was an increased frequency of associated comorbidities such as CVD, systemic arterial hypertension, and diabetes, according to the mild, moderate, or high risk. These findings highlight the need for a cardiometabolic evaluation in patients with this comorbid condition which may impact prognosis and therapeutic success. Support (if any):

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Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea

SLEEP ◽

10.1093/sleep/zsaa235 ◽

2020 ◽

Author(s):

Cathy A Alessi ◽

Constance H Fung ◽

Joseph M Dzierzewski ◽

Lavinia Fiorentino ◽

Carl Stepnowsky ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Sleep Onset ◽

Apnea Hypopnea Index ◽

Sleep Onset Latency ◽

Pressure Therapy ◽

Comorbid Insomnia ◽

Obstructive Sleep

Abstract Study Objectives Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. Methods 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a “sleep coach” (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. Results Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (−3.2 and −1.7), SOL-D (−16.2 and −15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). Conclusions An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. Trial Registration ClinicalTrials.gov Study name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older Veterans URL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist= Registration: NCT02027558

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363 The Apnea and Insomnia Research (AIR) Trial: An Interim Report

SLEEP ◽

10.1093/sleep/zsab072.362 ◽

2021 ◽

Vol 44 (Supplement_2) ◽

pp. A144-A145

Author(s):

Jack Edinger ◽

Rachel Manber

Keyword(s):

Sleep Apnea ◽

Treatment Phase ◽

Additional Treatment ◽

Cognitive Behavioral ◽

Comorbid Insomnia ◽

Blood Institute ◽

Online Treatment ◽

Insomnia Disorder ◽

National Heart Lung ◽

Pre Treatment

Abstract Introduction Many sleep apnea patients suffer from comorbid insomnia disorder. Although cognitive behavioral insomnia therapy (CBTI) is recommended as the first line insomnia treatment for such patients, access to trained providers of this treatment remains limited. The current study is testing he efficacy of an online CBTI among CPAP treated sleep apnea patient with comorbid insomnia. Methods Patients enrolled in this trial complete baseline measures and then are randomized to either an online version of Cognitive Behavioral Insomnia Therapy (CBTI) or no additional treatment beyond their CPAP therapy (CTRL). After 8 weeks of treatment all patients are reassessed. The current report considers changes in scores on the ISI and Epworth Sleepiness Scale (ESS) as well as average minutes of nightly CPAP use from pre-treatment to the end of the initial 8 weeks of online treatment relative to the no treatment CTRL. The sample for this report included the first 276 participants enrolled in this trial (mean age = 56.5±12.5 yrs; 58.7% females). Results Those receiving online CBTI showed greater reductions in their ISI scores from baseline to the end of the initial 8-week treatment phase than did those in the CTRL group (p = .0001). Average ISI score improvements among those receiving online CBTI moved patients from moderately severe insomnia to mild insomnia symptoms. In contrast, no differences were noted between the online CBTI and CTRL groups in regard to pre- to post-treatments changes on the ESS (p= .2541) scores or amount of CPAP use (p = .4383). Conclusion Whereas online CBTI does not seem to reduce daytime sleepiness or improve CPAP adherence among patients with comorbid sleep apnea and insomnia, it appears to be an effective intervention for reducing insomnia severity for this patient group. Support (if any) National Heart. Lung and Blood Institute Grant # 1R01HL130559-01A1

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The Association of Unreported Sleep Disturbances and Systemic Inflammation: Findings from the 2005-2008 NHANES

Sleep Disorders ◽

10.1155/2018/5987064 ◽

2018 ◽

Vol 2018 ◽

pp. 1-8

Author(s):

Jeff A. Dennis ◽

Ahmad Alazzeh ◽

Ann Marie Kumfer ◽

Rebecca McDonald-Thomas ◽

Alan N. Peiris

Keyword(s):

Sleep Apnea ◽

Sleep Disturbance ◽

Sleep Disorders ◽

Sleep Disorder ◽

Inflammatory Markers ◽

Sleep Disturbances ◽

Laboratory Data ◽

Poor Sleep ◽

Distribution Width ◽

Inflammatory Status

Background/Objective. Sleep apnea is associated with elevated inflammatory markers. A subgroup of patients never report sleep disturbances to their physician. The inflammatory status of this subgroup is not known. The present study aims to evaluate two inflammatory markers, C-reactive protein (CRP) and red cell distribution width (RDW), in those with unreported sleep disturbances and compares these findings to those with and without reported sleep disorders. We also investigate the utility of RDW as an inflammatory marker in sleep disorders. Methods. Sample includes 9,901 noninstitutionalized, civilian, nonpregnant adults from the 2005-2008 National Health and Nutrition Examination Survey, a nationally representative, cross-sectional U.S. study. Sleep questionnaire and laboratory data were used to compare inflammatory markers (CRP and RDW) in five subgroups of individuals: reporting physician-diagnosed sleep apnea, reporting another physician-diagnosed sleep disorder, reported sleep disturbance to physician with no resulting diagnosis, unreported sleep disturbance (poor sleep quality not reported to physician), and no diagnosed sleep disorder or sleep disturbance. Results. Individuals with unreported sleep disturbance had significantly higher odds of elevated RDW (>13.6%) when compared to those without a sleep disturbance in adjusted models (OR=1.33). Those with unreported sleep disturbance had significantly higher odds of elevated CRP levels (>1 mg/L) than those without sleep disturbances (OR 1.34), although the association was not significant when adjusted for obesity and other controls. Conclusion. Self-identified unreported sleep disturbances are associated with significantly higher odds of elevated RDW than those without sleep disturbances. RDW may serve as a valuable indicator in identifying individuals at higher risk for sleep apnea and other sleep disorders.

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O013 The pathogenesis of obstructive sleep apnea in individuals with comorbid insomnia and obstructive sleep apnoea (COMISA)

SLEEP Advances ◽

10.1093/sleepadvances/zpab014.012 ◽

2021 ◽

Vol 2 (Supplement_1) ◽

pp. A6-A7

Author(s):

E Brooker ◽

L Thomson ◽

S Landry ◽

B Edwards ◽

S Drummond

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Upper Airway ◽

Severity Index ◽

Loop Gain ◽

Comorbid Insomnia ◽

Arousal Threshold ◽

Obstructive Sleep ◽

High Loop ◽

Insomnia Severity

Abstract Obstructive sleep apnea (OSA) and Insomnia are prevalent sleep disorders which are highly comorbid. This frequent co-occurrence suggests a shared etiology may exist. OSA is caused by the interaction of four pathophysiological traits: a highly collapsible upper airway, elevated loop gain, a low arousal threshold, and poor muscle compensation. No study has ascertained whether these traits are influenced by insomnia. We aimed to quantify the four traits which contribute to OSA in individuals diagnosed with comorbid insomnia and OSA (COMISA). We non-invasively determined these traits in 52 COMISA patients (Age: 56±14 years) with mild-to-severe OSA (AHI=21.2±10.63 events/h) using polysomnography. Our results indicated that 83% of COMISA patients had a low arousal threshold and only 2% of patients exhibited a highly collapsible airway using previously defined thresholds. Multiple linear regression revealed the arousal threshold (b=0.24, 95%CI[0.11, 0.37], β=0.47, p<0.001) and loop gain (b=23.6, 95%CI[7.02, 40.18], β=0.33, p<0.01) were the strongest predictors of OSA severity in our sample. There was no significant relationship between the arousal threshold and insomnia severity measured by the insomnia severity index (ISI). Further work is being performed to compare these findings with a matched sample of OSA only participants. Our preliminary findings demonstrate OSA in COMISA is characterized by a mildly collapsible airway/low arousal threshold phenotype and is largely driven by non-anatomical factors including a low arousal threshold and high loop gain. OSA treatments which are effective in patients with mild anatomical compromise and raise the arousal threshold may provide therapeutic benefit in COMISA patients.

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Attention and Attention-Related Behavior Problems Among Filipino Children with Obstructive Sleep Apnea Syndrome Seen At the Comprehensive Sleep Disorder Center of the St. Luke's Medical Center, Philippines

CHEST Journal ◽

10.1378/chest.126.4_meetingabstracts.786s-b ◽

2004 ◽

Vol 126 (4) ◽

pp. 786S

Author(s):

Consuelo A. Lu

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Behavior Problems ◽

Sleep Disorder ◽

Obstructive Sleep Apnea Syndrome ◽

Medical Center ◽

Sleep Apnea Syndrome ◽

Obstructive Sleep ◽

Filipino Children ◽

Apnea Syndrome

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Risk Screening of Obstructive Sleep Apnea Syndrome by Body Profiles via Random Forests Model

10.21203/rs.3.rs-22545/v1 ◽

2020 ◽

Author(s):

Cheng-Yu Tsai ◽

Wen-Te Liu ◽

Yin-Tzu Lin ◽

Shang-Yang Lin ◽

Arnab Majumdar ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Waist Circumference ◽

Sleep Disorder ◽

Random Forests ◽

Sleep Apnea Syndrome ◽

Obstructive Sleep ◽

Gender And Age ◽

Apnea Syndrome ◽

And Gender

Abstract Background Obstructive Sleep Apnea Syndrome (OSAS) is a major global health concern and is typically diagnosed by in-lab polysomnography (PSG). This examination though has high medical manpower costs and alternative portable methods have further limitations. This paper develops a new model for screening the risk of OSAS in different age groups and gender by using body profiles. The effects of body profiles for different subgroups in sleep stage alteration and OSAS severity are also investigated. Methods The data is derived from 6614 Han-Taiwanese subjects who have previously undergone PSG in order to assess the severity of OSAS in the sleep center of Taipei Medical University Shuang-Ho Hospital between March 2015 and October 2019. Characteristics of subjects, including age, gender, body mass index (BMI), neck circumference, and waist circumference, were obtained from a questionnaire. Pearson regression was used to evaluate the correlations between body profiles and sleep stages as well as sleep disorder indexes. To develop an age and gender independent model, random forests (RF), which is an ensemble learning method with high explainability, were trained by the four groups by gender and age (older or younger than 50 years old) with ratios of 70% (training dataset) and 30% (testing dataset), respectively. Prediction performance was evaluated by sensitivity, specificity and accuracy. Variable importance was assessed by averaging the impurity decrease to account for the effect of different factors. Results Results indicate that high BMI, neck circumference and waist circumference decreased the duration of slow-wave sleep and increased the sleep disorder indices and the percentage of wake and N1. Additionally, screening models for different gender and age utilizing anthropometric features as predictors via RF were established and demonstrated to have high accuracy (75.63% for younger males, 74.72% for elder males, 78.81% for younger females, and 72.10% for elder females). Feature importance indicated that waist circumference was the highest contributing factor in females and elder males, whereas the BMI was the highest contribution in younger males. Conclusions The authors recommend the use of the prediction models for those with Han-Taiwanese craniofacial features.

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0803 Clinical and Polysomnographic Features of Trauma Associated Sleep Disorder (TASD)

SLEEP ◽

10.1093/sleep/zsaa056.799 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A305-A305

Author(s):

H O Sanchez ◽

V Mysliwiec ◽

R E Froese ◽

J L Creamer ◽

P Matsangas ◽

...

Keyword(s):

Sleep Disorder ◽

Rem Sleep ◽

Clinical History ◽

Active Duty ◽

High Rate ◽

Comorbid Insomnia ◽

Significant Difference ◽

Rem Sleep Without Atonia ◽

Behavioral Health Disorders ◽

Autonomic Disturbances

Abstract Introduction Trauma associated sleep disorder (TASD) is an emerging parasomnia that develops after trauma with clinical features of trauma related nightmares (TRN), disruptive nocturnal behaviors (DNB), and autonomic disturbances. The purpose of this study is to characterize the clinical and polysomnographic (PSG) features of TASD. Methods Clinical history and detailed video-PSG review, to include post-PSG nightmare reports, of a cohort of patients with TASD. Results Patients (n=40, 32 men, 8 women) were active duty service members with a median age of 38.9 yrs (range 24-57 yrs). Dream content typically related to combat (n=37, 92.5%), with 75% (n=30) reporting TRN and 60% (n=24) reporting dream enactment at least weekly. Self-reported DNB included vocalizations, violent limb movements, thrashing, defensive posturing, and jumping from bed. There was a high rate of comorbid insomnia (n=35, 87.5%), PTSD (n=23, 63.9%), anxiety (n=25, 62.5%), depression (n=20, 50%), OSA (n=19, 47.5%), chronic pain (n=12, 30%), and TBI (n=13, 32.5%). Most patients had REM sleep without atonia (RSWA) (n=33, 82.5%), though a minority had purposeful DNB (n=11, 27.5%). Vocalizations were present in seven (17.5%) patients. Patients with PTSD were more likely to have purposeful DNB (n=9, 100%) than those without PTSD (n=13, 50%; p=0.013), whereas patients with purposeful DNB had markedly less N3 sleep (1.0±11.4%) than those without purposeful DNB (13.8±16.2%; p=0.002). There was no significant difference in medications between DNB groups. Conclusion TASD is frequently comorbid with other sleep and behavioral health disorders. Characteristics of TASD are often captured on video-PSG during REM sleep, though DNB may be less pronounced than what patients report in their habitual sleeping environment. Clinical and video-PSG correlations are invaluable in assessing patients with TASD. This study, which is the largest cohort to date, provides a further basis for establishing TASD as a unique REM-related parasomnia. Support N/A

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A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

SLEEP ◽

10.1093/sleep/zsaa041 ◽

2020 ◽

Vol 43 (9) ◽

Cited By ~ 1

Author(s):

Jason C Ong ◽

Megan R Crawford ◽

Spencer C Dawson ◽

Louis F Fogg ◽

Arlener D Turner ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Outcome Measure ◽

Controlled Trial ◽

Secondary Outcome ◽

Concomitant Treatment ◽

Clinical Endpoint ◽

Comorbid Insomnia ◽

Obstructive Sleep ◽

Treatment Models

Abstract Study Objectives To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia. Methods 121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints. Results No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure. Conclusions The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

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