Circadian factors in comorbid insomnia and sleep apnea (COMISA)

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

Sleep Medicine ◽

10.1016/j.sleep.2021.05.043 ◽

2021 ◽

Author(s):

Miguel Meira e Cruz ◽

Meir Kryger ◽

Charles Morin ◽

Luciana Palombini ◽

Cristina Salles ◽

...

Keyword(s):

Sleep Apnea ◽

Sleep Disorder ◽

Comorbid Insomnia

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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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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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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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Traditional and Nontraditional Cardiovascular Risk Factors in Comorbid Insomnia and Sleep Apnea

SLEEP ◽

10.5665/sleep.3506 ◽

2014 ◽

Vol 37 (3) ◽

pp. 593-600 ◽

Cited By ~ 16

Author(s):

Faith S. Luyster ◽

Kevin E. Kip ◽

Daniel J. Buysse ◽

Aryan N. Aiyer ◽

Steven E. Reis ◽

...

Keyword(s):

Risk Factors ◽

Cardiovascular Risk ◽

Sleep Apnea ◽

Cardiovascular Risk Factors ◽

Comorbid Insomnia

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The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

SLEEP ◽

10.1093/sleep/zsaa002 ◽

2020 ◽

Vol 43 (7) ◽

Cited By ~ 4

Author(s):

Alexander Sweetman ◽

R Doug McEvoy ◽

Simon Smith ◽

Peter G Catcheside ◽

Nick A Antic ◽

...

Keyword(s):

Sleep Apnea ◽

Daytime Sleepiness ◽

Behavioral Therapy ◽

Controlled Trial ◽

Sleep Apnoea ◽

Comorbid Insomnia ◽

Randomized Controlled ◽

Obstructive Sleep ◽

Sleep Parameters ◽

Cognitive And Behavioral Therapy

Abstract Study Objectives While cognitive and behavioral therapy for insomnia (CBTi) is an effective treatment in patients with comorbid moderate and severe obstructive sleep apnea (OSA), there is concern that the bedtime restriction component of CBTi might dangerously exacerbate daytime sleepiness in such patients. We examined randomized controlled trial data to investigate the effect of OSA severity, and pretreatment daytime sleepiness on week-to-week changes in daytime sleepiness and sleep parameters during CBTi and no-treatment control. Methods One hundred and forty-five patients with untreated physician-diagnosed OSA (apnea–hypopnea index ≥15) and psychologist-diagnosed insomnia (ICSD-3) were randomized to a 4-week CBTi program (n = 72) or no-treatment control (n = 73). The Epworth sleepiness scale (ESS) and sleep diaries were completed during pretreatment, weekly CBTi sessions, and posttreatment. Effects of OSA severity, pretreatment daytime sleepiness, and intervention group on weekly changes in daytime sleepiness and sleep parameters were investigated. Results The CBTi group reported a 15% increase in ESS scores following the first week of bedtime restriction (M change = 1.3 points, 95% CI = 0.1–2.5, p = 0.031, Cohen’s d = 0.27) which immediately returned to pretreatment levels for all subsequent weeks, while sleep parameters gradually improved throughout CBTi. There were no differences in changes in daytime sleepiness during treatment between CBTi and control groups or OSA-severity groups. Higher pretreatment ESS scores were associated with a greater ESS reduction during CBTi. Conclusions CBTi appears to be a safe and effective treatment in the presence of comorbid moderate and severe OSA. Nevertheless, patients living with comorbid insomnia and sleep apnea and treated with CBTi should be monitored closely for increased daytime sleepiness during the initial weeks of bedtime restriction therapy. Clinical Trial Registration Treating comorbid insomnia with obstructive sleep apnoea (COMISA) study: A new treatment strategy for patients with combined insomnia and sleep apnoea, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id = 365184 Australian New Zealand Clinical Trials Registry: ACTRN12613001178730. Universal Trial Number: U1111-1149-4230.

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