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POSTGRADUATE EDUCATION CORNERCONTEMPORARY REVIEWS IN SLEEP MEDICINEInsomnia and Sleep-Related Breathing Disorders
Section snippets
Insomnia Disorder and Obstructive Sleep Apnea: Definition, Prevalence, Costs
Insomnia, characterized by difficulty initiating or maintaining sleep, early morning awakening, or nonrestorative sleep, is the most common sleep complaint among adults4 and perhaps the second most frequent health complaint after pain.5 Approximately 30% of adults in the United States experience occasional transient insomnia, and prevalence estimates for chronic insomnia range from 9% to 12%.6, 7 Insomnia disorder is positively correlated with age and negatively correlated with employment,
Cause
Although the cause of chronic insomnia is unknown, the disorder is most often conceptualized within a biopsychosocial framework. Physiologic abnormalities, including increased activity in the CNS and hyperarousal of the hypothalamic-pituitary axis (HPA)22 and proinflammatory cytokines, as well as personality traits such as anxious temperament, predispose individuals to react negatively to stress, the most common precipitating cause of insomnia disorder.5 Following a period of acute sleep
Co-occurrence of Insomnia Disorder and OSA
Several recent reviews have concluded that insomnia disorder and OSA are likely to coexist in sleep clinic patients.1, 2, 3 For example, a number of reports have documented high rates of insomnia complaints among patients referred for evaluation of SRBD (Table 1). All but one have relied on paper and pencil assessment of insomnia complaints. Smith et al33 required a daytime complaint and Insomnia Severity Index5 score ≥ 15, complaint duration of >6 months, and sleep-onset latency (SOL) or wake
Assessment
Whereas PSG is typically required to confirm the diagnosis of OSA, the foundation of insomnia disorder assessment is a thorough sleep history.54 At a minimum, providers should evaluate the type of insomnia complaints; the onset, frequency, and duration; sleep schedule and sleep-wake patterns on both weekdays and weekends; the sleep environment, including temperature, light, and noise; sleep behaviors such as diet, exercise, and bedroom activities; sleep-related beliefs and expectations
Treatment of OSA
For patients with mild SRBD, conservative treatment approaches include weight loss and mechanical interventions such as using a “tennis ball shirt” (ie, with a tennis ball sewn into the back) to avoid sleeping in the supine position. Careful monitoring of symptoms progression is essential. However, once SRBD has progressed beyond the mild stage, most OSA patients are currently treated using one of three approaches. Customized oral mandibular repositioning devices represent the next least
Treatment of Comorbid Insomnia and OSA
Despite the empirically supported treatments for insomnia disorder and OSA when they occur in isolation, less in known about how to treat the two disorders when they co-occur. In the most methodologically rigorous study treating combined insomnia disorder and OSA, Guilleminault et al87 randomized 30 patients matched for age, BMI, and gender to either group CBT-I followed by surgery, or surgery followed by CBT-I. At 3 months, participants were reassessed and then assigned to the alternative
Clinical Recommendations
Providing clinical recommendations regarding the co-occurrence of insomnia disorder and SRBD is challenging, controversial, and not supported by large clinical trials. Nonetheless, it is clear that a substantial number of patients experience insomnia disorder and OSA simultaneously, that patients treated for both conditions show the greatest improvement, and that sleep medicine patients will benefit from improved clinical care.
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Standard practice should be to screen clinically for both SRBD
Conclusions and Future Directions
Clinicians and researchers have become increasingly aware of the frequent co-occurrence and additive negative consequences of insomnia disorder and SRBD. Extant literature lacks consistent assessment protocols and diagnostic criteria, and there remains a paucity of systematic evaluation regarding the relationship between the two disorders. More thorough evaluation of the comorbidity and consequences of the two disorders in population and clinical samples is required. Nonetheless, it is clear
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Wickwire has served as a scientific consultant for Health Media. Dr Collop has reported no potential conflicts of interest with any companies/organizations whose products or services may be discussed in this article.
Other contributions: We thank the reviewers for their helpful observations.
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