We know that both insomnia and sleep apnea are two important sleep disorders affecting millions in this country. There are several types as well, including hypersomnia, narcolepsy, Restless leg Syndrome. All these put together affect nearly one-quarter of adult American population.
“I don’t get enough sleep” is a common complaint we hear or make. But do we really know what we mean by that in the sense that how many hours of sleep would be sufficient for an adult? While sleep needs keep on changing for an individual and it depends on which stage he or she is in her life cycle, National Sleep Foundation confirms that adults need 7 to 9 hours of sleep during the day.
Having said so, let us understand how the association between insomnia and sleep apnea begins. But before that, what exactly are these sleep disorders?
We all suffer from sleeplessness some time of the other. Doctors would not like to label such sleep loss as insomnia, which can only be confirmed after tests, medical history, physical examination etc. But doctors would call the condition insomnia when the patient cannot get sleep or remain asleep and the problem shows up continuously for 3 to 4 weeks. Though insomnia can be a stand-alone ailment, it could also be the outcome of an underlying condition.
In this article, we would be talking more about those underlying but predominant disease conditions which result in not only sleep loss and inability to fall back to sleep but also robbing the patient of restorative sleep throughout the night. While such concealed disease conditions can range from various types of physiological illnesses to mental conditions, insomnia typically affects daytime alertness and could usher in several health conditions that impair his or her daytime lifestyle.
One of the common sleep disorders which often lead to insomnia is sleep apnea.
The paradoxical relationship between the two ailments is interesting in the sense that two sleep disorders with otherwise separate origins and different disease profiles can be closely interlinked to the extent that treating one can cure the other illness simultaneously. Sleep apnea, especially obstructive sleep apnea is a breathing related sleep disorder that results in recurrent cessation of breathing during sleep. More physiological in origin than psychological, sleep apnea happens when the upper airways narrow, collapse or block the flow of air during breathing.
Insomnia and sleep apnea: how they co-exist in men
Why men suffer from insomnia can be different from women. Older men, most of whose low levels of testosterone (male sex hormone) makes them more vulnerable to develop sleep apnea which leads to insomnia. The restrictive breathing and recurrent breathing pauses cause major impediment to sleep in the night. These episodes keep most of these men awake and insomnia sets in.
It has been observed that testosterone replacement therapy often relieves apnea symptoms in men. When the testosterone levels are brought back to optimal levels, deep and restorative sleep can be expected. Hormone supplementation therapy along with balanced nutrition and moderate physical exercise can suitably address several hormonal deficiency and lifestyle-related causes behind the onset of sleep apnea.
How the final outcome of the disease conditions create diagnostic confusion
Excessive daytime sleepiness is one of the common complaints of patients suffering from any type of sleep disorder. At times, a sleep apnea patient may consult the doctor with this complaint only. If the doctor does not route the diagnostic procedure using tools like polysomnography, Multiple Sleep Latency Test, etc, he could well start treating daytime alertness without even bothering to check the patient for sleep apnea.
This could be one of the reasons why so many millions of people affected with sleep apnea go misdiagnosed or not diagnosed at all.
How is insomnia diagnosed?
Polysomnography or PSG is the gold standard in the diagnosis of several sleep disorders. The diagnostic examination involves testing and recording several physiological activities that happen during sleep, which may be indicative of onset of the disease. However, according to PSG practice guidelines issued by American Academy of Sleep Medicine, polysomnography is not recommended for routine diagnosis of insomnia.
However, the testing can be appropriate if after clinically evaluating the complaints, it is found necessary to assess the patient for any sleep related breathing disorder including abrupt arousals from sleep, etc. Many doctors prefer PSG when the insomnia patient does not respond to primary therapy to rule out any other sleep problems but never for the diagnosis of transient or chronic insomnia, or when the condition is linked to any mental illness.
For evaluating insomnia doctors prefer to do a physical examination followed by studying the medical and sleep history of the patient. Factors like recent weight gain, snoring, restlessness in sleep, etc could indicate sleep apnea when the doctor recommends PSG as a confirmatory test.
- Epworth Sleepiness Scale: This is essentially a questionnaire scores of which help in the measurement of daytime sleepiness.
- Actigraphy: This test essentially records the sleeping and waking patterns over a certain period of time.
Doctors also examine your mental health with the help of relevant questions that relate to depression, anxiety, stress, recent life-changing events, etc. All these examinations are part of the initial examination to diagnose insomnia.
Sleep apnea vs Insomnia: The present and the future
As we have noticed in the earlier paragraphs, the relationship between the two is interwoven in the sense that while increased daytime lethargy is one of the important apnea symptoms, insomnia is also a major complication of sleep apnea. Using medical parlance, a patient who is affected by both the conditions is called a ‘sleep apnea plus’ individual. Research has revealed that such sleep apnea plus patients frequently suffer from typical insomnia symptoms including depression, anxiety and mood fluctuations.
The relevant issues here are: a) the combination of these two disorders is more severe than the illnesses, taken in isolation; and b) treatment of these co-existing conditions is tougher than treating the conditions as separate illnesses.
A few simple solutions are provided by sufferers who suffer from both these conditions:
– The room temperature should be optimally comfortable.
– Drinking plenty of water (a glass every hour)
– Learn to truly relax for about an hour before going to bed.
While the illnesses frequently co-exist, the associated health risks of the combo can be far-reaching. These include decreased quality of life; deteriorating mental condition; falling standards in work performance including unannounced and sudden departures from work; diminished productivity; increased chances of road accidents and more. Health-wise, the combination increases risks for heart failure, congestive heart failure, stroke and hypertension.
What is route of onset of insomnia for an apnea patient?
Sleep apnea causes the following during sleep: repeated arousal resulting in increased metabolism of brain and body; increased heart rate and disturbance in the sympathetic nervous system. This is the route how insomnia sets in since it raises the level of alertness both during the day and night. On the other hand, increased daytime alertness is a prominent symptom of sleep apnea, though all apnea patients need not necessarily show this sign.
Can the conditions be treated simultaneously?
The correct strategy for treating the two co-existing conditions is still not clear. Researchers feel that further research needs to be done on the impact of insomnia on CPAP therapy (Continuous Positive Airway Pressure) users and because of the overlapping nature of the symptoms of the two conditions, it might need multidisciplinary approach from different specialties of doctors. However, some studies have been done on the effect of sequential therapy for treating apnea along with Cognitive Behavioral Therapy (CBT) for managing insomnia.
Non-compliance with CPAP therapy for an insomnia patient is understandable because of the increased levels of awareness of mask discomfort, etc during the frequent arousals during sleep. However, doctors feel that if the insomnia patient is counseled properly before initiation of CPAP therapy, including involvement in the CBT programs, etc, then patient compliance could improve.
In another study, patients with co-existing conditions improved significantly when the therapy consisted of CPAP/dental appliances/turbinectomy along with CBT.
A number of studies have already been done to study the effect of several types of drugs for treating the conditions simultaneously. However, the results have not yet been very promising for example the effect of benzodiazepines on sleep apnea is rather modest; while nonbenzodiazepine agents are shown to improve insomnia to a moderate extent.
What are the future challenges in this area?
Agreeably, it is difficult to assess and evaluate the co-existence of insomnia and sleep apnea in a patient, considering the overlapping nature of the symptoms and also the similarity in the diagnostic methods. However the more recent guidelines for diagnosing insomnia mentions three major criteria: a) when insomnia is linked to other sleep disorders; b) insomnia linked to medical or mental problems, substance abuse, etc and c) primary insomnia including idiopathic (no cause), etc.
These guidelines will hopefully help the clinicians diagnose the ailment more easily. Additionally, for sleep apnea patients assessing whether there are other co-existing medical and mental disorders that may disturb sleep should be investigated. This too can help the doctors identify the existence of insomnia. Certain behavioral changes are important for patients suffering from these conditions. Thus doctors should provide adequate counseling on areas like: sleeping more to catch up with lost sleep; dietary control, physical exercise, impact of alcohol and tobacco on these co-existing conditions, etc not only to diagnose the cause of onset for insomnia but also to provide the correct therapy to the patient.