Standard practice should be to screen clinically for both SRBD symptoms and insomnia complaints. At a minimum, snoring and witnessed apneas should be inquired about, as well as difficulty initiating and maintaining sleep. Clinicians should keep in mind that patients with comorbid insomnia disorder and SRBD may present atypically, without common symptoms such as loud snoring or low oxygen desaturations.
It is especially important to assess patients’ subjective sleep quality and to screen for daytime symptoms of nonrestorative sleep, such as sleepiness or fatigue, lethargy, anhedonia, decreases in motivation, mood disturbance, or anxiety. Although these symptoms can be primary complaints associated with either insomnia disorder or OSA, they are more common in patients with combined insomnia disorder and OSA and can also be subtle indications of either undetected insomnia disorder or occult OSA.
When evaluating patients referred for suspected SRBD, keep in mind that one-third to over one-half present with comorbid insomnia complaints and may benefit from adjunctive insomnia evaluation and treatment. Comprehensive assessment is essential. In our interdisciplinary practices, this involves screening patients referred for evaluation of SRBD for insomnia complaints, and referral to behavioral sleep medicine for CBT-I.
Similarly, patients presenting with complaints of difficulty initiating or maintaining sleep are unlikely to be aware of breathing disturbances during sleep. Because both insomnia disorder and OSA increase with age and remain largely undiagnosed among these populations, older adults in general, and postmenopausal women in particular, may be at particular risk for occult OSA.
Be mindful of treatment context and the lack of patient awareness regarding sleep disorders, as well as the potential impact of social desirability on patient responses. Clinical experience suggests that many patients hold negative stereotypes about sleep-related breathing disorders and may incorrectly ascribe their symptoms to insomnia, when in reality, breathing or other factors may underlie or contribute to patient complaints. Conversely, patients may hold stereotypes about behavioral intervention for insomnia disorder or CPAP acceptance and adherence, which should be normalized as early in the evaluative process as possible.
The AASM guidelines do not recommend use of PSG for routine evaluation of insomnia disorder105 unless there is a suspected occult sleep disorder (other than insomnia) or unless the patient has failed previous behavioral or pharmacologic treatment of insomnia disorder. However, the practice parameters note that evidence is lacking regarding the diagnostic usefulness of PSG in insomnia disorder and were published prior to recent studies demonstrating high rates of co-occurring insomnia disorder and OSA. Providers bear ultimate responsibility for providing the best care to their patients. Patients presenting with primary complaints of insomnia may also have occult OSA, and providers should consider clinical presentation and risk factors thoroughly.
Although there are clear guidelines for the treatment of SRBD and of insomnia disorder, there is a lack of understanding about how to apply these evidence-based treatments in the context of the disorders occurring simultaneously. Clinical judgment should guide this process, attending to patient perception of disease and readiness for potentially demanding treatment such as CBT-I or CPAP. We recommend thoroughly educating patients regarding co-existing sleep disorders and treatment options, keeping in mind that (1) many patients prefer nonpharmacologic treatment options when available and (2) CBT-I and CBT for CPAP adherence can be integrated to enhance continuity of care and maximize patient benefit. Regardless of treatment approach, close monitoring of patient progress is essential.
Patients reporting extended SOL, wake after sleep onset, or early morning awakening (ie, ≥ 30 min) with daytime complaint should be referred to an expert in insomnia disorder and/or behavioral sleep medicine. In situations in which such referral is impractical or impossible, symptoms should be monitored carefully. At a minimum, patients can be referred to insomnia self-help treatments.106 However, providers unfamiliar with delivering CBT are cautioned that sleep hygiene, particularly when instructions are distributed as a handout or pamphlet, has no demonstrated efficacy as a monotherapy for chronic insomnia. Furthermore, clinical experience suggests that patients often become even more discouraged regarding their chances for improvement following unsuccessful efforts to improve sleep based on sleep hygiene handouts. If handouts alone changed behavior, anyone could be a concert pianist. In our practices, patients are commonly treated for insomnia via behavioral sleep medicine (ie, CBT-I) and OSA via medical therapies (ie, CPAP) simultaneously. Although the number of behavioral sleep medicine providers is rapidly expanding, growing demand currently far exceeds available supply,107 and this approach is not yet feasible in all sleep medicine centers. Nonetheless, this approach combines current “gold standard” treatments for insomnia disorder and OSA, and patients report greatly appreciating this full-service, comprehensive sleep care. For commercial sleep medicine centers, provision of comprehensive sleep health services is likely to become a distinct marketplace advantage, if not a necessity, as patients and referring providers become increasingly aware of the complex interaction of sleep disorders and symptoms and demand the most effective treatments available.
Although treating patients experiencing both insomnia and difficulty adhering to CPAP can be challenging, in our practices behavioral sleep medicine specialists routinely incorporate CBT for CPAP108 into highly effective CBT-I treatment protocols. This process is aided by identifying patient-specific psychologic factors likely to interfere with adjustment to CPAP, including insomnia complaints. As part of routine clinical practice, patients receiving a diagnosis of OSA are assessed in a number of domains related to CPAP adherence, such as attitudes and beliefs regarding OSA and CPAP, perceived costs and benefits of CPAP use, self-efficacy to use CPAP, daytime functioning, subjective distress, and so forth. (See, for example, Wickwire85 for a review of modifiable factors known to impact CPAP use.) The results of this brief behavioral sleep medicine evaluation are used to guide OSA treatment planning. When barriers likely to interfere with medical (ie, CPAP) treatment are identified, additional intervention might include CBT for CPAP, or other follow-up recommendations on a case-by-case basis. Because the likelihood of engaging in CPAP is established as early as titration and psychologic variables measured pretitration can classify with high accuracy patients likely to fail at CPAP,109 we conduct this evaluation as early as possible in the treatment process, so that additional support or CBT for CPAP can be provided as needed. Careful patient monitoring is essential.
Clinicians have long known that alcohol is also commonly used as a sleep aid. Although alcohol induces slow-wave sleep, rapid eye movement decreases sleep latency and rebound occurs as the alcohol wears off, and patients are likely to experience arousals and awakenings during the night.110 A respiratory depressant even below the “legal blood alcohol concentration,”111 alcohol suppresses the arousal response112 and is known to worsen breathing during sleep, inducing apnea in susceptible individuals and increasing disease severity in OSA patients.29,112,113 OSA patients should be cautioned against drinking alcohol close to bedtime. Although more study is needed,114 alcohol does not appear to affect CPAP’s efficacy.
Many drugs, especially drugs that depress the CNS, such as sedatives, narcotics, and hypnotics commonly prescribed for insomnia disorder, can negatively affect breathing during sleep. Use of these medications should be monitored, and they should be prescribed with caution. Benzodiazepines and opioids should be avoided in patients with diagnosed or suspected SRBD unless they are being used in conjunction with CPAP.