Insomnia—characterized by difficulties initiating or remaining asleep throughout the night—and sleep apnea—characterized by complete or partial reduction in breathing during sleep—are the two most common sleep disorders, and each is associated with great impairment to daytime functioning and quality of life. Did you know these two debilitating conditions also frequently co-occur within the same patient?
Sleep Apnea and Insomia
COMISA is now gaining recognition as a highly prevalent condition, with a recent study finding that 30% to 70% of insomnia patients also suffer from sleep apnea and 40% to 60% of sleep apnea patients report significant insomnia symptoms. The same study found that the impairments to daytime functioning, quality of life, and overall sleep quality experienced by patients suffering from COMISA are greater than those experienced by patients with either insomnia or sleep apnea alone.2 Therefore, developing an understanding of the unique mechanisms operating within COMISA, and finding effective approaches to its treatment, are essential hurdles that the field of sleep medicine must jump. The issue has stimulated the collaboration and ongoing discussion between researchers and clinicians specializing in the diagnosis and treatment of both insomnia and sleep apnea disorders.
The ESRS symposium began with Christian Guilleminault, MD, PhD, (a professor at Stanford University in California and commonly considered the forefather of research in the COMISA field) who presented “The early recognition of co-morbid insomnia and obstructive sleep apnea.” Guilleminault spoke of his research history into central/mixed sleep apnea, narcolepsy, and insomnia, and the discovery of co-occurring insomnia and central sleep apnea, which led to the seminal paper published in Science in 1973.3 Guilleminault continues to play an instrumental role in the COMISA field, with several publications examining characteristics and treatment approaches in the COMISA population, including studies investigating cognitive and behavioral therapy for insomnia (CBT-I), and surgical procedures targeting the sleep apnea in COMISA patients.
Following Guilleminault’s early discovery of co-occurring insomnia and sleep apnea, the field remained relatively dormant for several decades. However, in 2001, research interest in the COMISA population was reignited by Barry Krakow, MD, and his group, who published an important and highly cited article examining the prevalence of co-occurring insomnia in 231 patients with diagnoses of sleep-disordered breathing.1 It was found that 50% of these patients had clinically meaningful insomnia complaints, which were associated with increased sleep-onset latency and decreased total sleep time. Krakow (of Maimonides Sleep Arts and Sciences, and Sleep & Human Health Institute, Albuquerque, NM), the second symposium speaker, has actively continued treating patients with comorbid insomnia and sleep apnea and published a range of insightful and well-timed research papers documenting the prevalence, characteristics, and treatment approaches in various subgroups of the COMISA population. Krakow’s presentation (“Positive airway pressure to treat co-morbid insomnia and sleep-disordered breathing: A rationale for advanced auto-adjusting dual pressure technology”) provided an overview of evidence suggesting that the insomnia experienced by many COMISA patients is frequently related to respiratory events throughout the night, and it can be effectively treated and improved with auto-adjusting dual-level positive airway pressure (PAP) devices.
1. Krakow B, Melendrez D, Ferreira E, et al. Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest. 2001;120(6):1923-9.
2. Sweetman A, Lack LC, Catcheside PG, et al. Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev. 2016 May 6; doi: 10.1016/j.smrv.2016.04.004. [E pub ahead of print]
3. Guilleminault C, Eldridge FL, Dement WC. Insomnia with sleep apnea: a new syndrome. Science. 1973;181(4102):856-8.
4. Krakow B, Romero E, Ulibarri V. Prospective assessment of nocturnal awakenings in a case series of treatment-seeking chronic insomnia patients: a pilot study of subjective and objective causes. Sleep. 2012;35(12):1685-92.
5. Björnsdóttir E, Janson C, Sigurdsson JF, et al. Symptoms of insomnia among OSA patients before and after 2 years of PAP treatment. Sleep. 2013;36(12):1901-9.
6. Lack LC, Hunter M, Gradisar M, Harris JK. Is the treatment of insomnia impaired when OSA is also present? Sleep (Abstract suppl). 2011;34:A174.