Effective Treatment for Sleep Apnea and Comorbid Insomnia (COMISA)

Sleep apnea and insomnia are the two most commonly diagnosed sleep disorders. When they occur together in the same person, it’s a special kind of torment called COMISA (Comorbid Insomnia and Sleep Apnea). Fortunately, treatment for sleep apnea and insomnia can be successful when proven therapeutic steps are followed.

COMISA impacts at least a third of people with insomnia or sleep apnea. Acknowledging and naming this condition is an important step in validating a patient’s experience and recognizing the toll it takes, physically, mentally, and emotionally. Successful treatment for sleep apnea and insomnia requires this acknowledgement as the starting point.

Left untreated, the effects of COMISA can be debilitating and additive, with multiple symptoms of poor-quality sleep and impaired daytime functioning. Daytime fatigue is a common symptom, which manifests as reduced productivity, low endurance for daily activities, and mood swings or irritability. Relationships may become strained under the weight of sleep deprivation. Personal well-being falters. Those affected can feel like they never really sleep well – and are never fully awake, either.

As a sleep medicine physician and professional sleep coach, it is my responsibility to help people:

• get healthy and restorative sleep night after night
• reliably experience alertness and vitality in the waking hours
• regain trust in their ability to sleep and feel awake
• get high-touch support for the treatment of sleep disorders
• be prepared with tools and support when sleep challenges come up

Throughout my years of practice in treatment for sleep apnea and insomnia, patients grappling with COMISA have presented a unique challenge. Untangling the sources of sleep disruption and implementing treatments is a tricky endeavor that usually takes more expertise, more diligence, and more time to resolve. For those reading, I hope that this information will help you to advocate for yourself as you partner with a physician or coach to finally get the deep sleep you deserve.

Diagnosis of Sleep Apnea and Comorbid Insomnia (COMISA)

The coexistence of sleep apnea and insomnia makes diagnosing and measuring the severity of either condition more complex. Insomnia and obstructive sleep apnea share risk factors (primarily obesity and age) and multiple overlapping day/night symptoms, so the possibility that both conditions are operating within the same person is worth considering.

On a backdrop of stress, irregular sleep schedules, excessive caffeine intake, environmental sleep challenges, and underlying health conditions (including depression and anxiety), there is a lot to unpack. Patients with COMISA often present with prominent symptoms of sleep disruption, daytime dysfunction, and a generalized complaint of “I don’t sleep well,” effectively lumping all effects of their sleep disorder together.

Insomnia is an example of how the mind-body connection can go awry, and there are layers of precipitating and perpetuating factors that result in a range of unwanted effects. Approximately 6-10% of the general population suffers from chronic insomnia. This condition is characterized by a state of hyperarousal causing problems getting to sleep and staying asleep.

Hyperarousal can manifest as thinking ruminations, anxiety, increased heart rate, and shallow breathing. A low threshold for arousal can cause a person to spend more time in transitional (light) sleep, and this commonly results in the perception that there has been no sleep at all.

Insomnia is a clinical diagnosis and severity is measured with the Insomnia Severity Index (ISI) questionnaire, which surveys both nighttime and daytime symptoms and yields a number score meant to capture severity. For example, a score equal to or above 15 indicates clinically significant insomnia. Consequences of untreated insomnia include reduced quality of life and long-term health risks related to sleep deprivation.

Sleep apnea, specifically obstructive sleep apnea (OSA), is best characterized as a breathing problem where repeated airway obstructions (due to collapse of the upper airway during sleep) cause drops in blood oxygen levels and sleep disruption. It’s estimated that 80% of people with OSA have not yet been diagnosed. Risk factors include obesity, age, airway and facial anatomy, and some medical conditions.

Airway obstructions can occur hundreds of times at night for those with moderate or severe obstructive sleep apnea but may not be perceived by the one with the condition. OSA is associated with increased inflammation, surges in the sympathetic (fight or flight) nervous system, hormonal dysregulation, and metabolic dysfunction. Without treatment for sleep apnea, patients can experience reduced life quality and long-term effects including cardiovascular, metabolic, and neurologic disease.

Obstructive sleep apnea severity is measured with the apnea-hypopnea index (AHI), with increasing AHI numbers corresponding to severity. The presence of untreated obstructive sleep apnea and its associated symptoms typically elevates the ISI score because a person with OSA can experience similar daytime symptoms as a person with insomnia.

Conversely, the presence of untreated insomnia can affect the AHI measurement (especially if home sleep apnea testing is used), and both insomnia and OSA are associated with sleep disruption. There is some evidence that partial sleep deprivation can exacerbate OSA. This could suggest an underlying mechanism by which symptoms of each disorder predispose patients to the other.

OSA may contribute to the development or worsening of insomnia. OSA is associated with brief awakenings and surges in heart rate after airway obstruction. This makes sense, because if a person awakens fully, it is often difficult to return to sleep and the perception may be that of insomnia. I frequently point out that untreated OSA is a threat to breathing, sleep, and oxygenation, so it naturally increases hypervigilance. Repeated instances of sleep interruption can quickly turn into frustration which only serves to perpetuate poor sleep and the experience of insomnia.

And then there is Upper Airway Resistance syndrome (UARS). This is a condition in between benign snoring and the lower limit of OSA, and it is not yet fully understood. With UARS, increased resistance of the upper airway (or flow limitation) is present and demonstrated with an in-lab sleep study to cause sleep disruption. A significant number of people with UARS report a lower quality of life despite not having a sleep-related breathing disorder recognized by insurance criteria.

In cases of UARS, the co-existence of insomnia may be associated with a reduced respiratory arousal threshold, which may predispose patients to awaken with smaller degrees of airway narrowing. I have had success in my practice in treating UARS patients with CBT-I (Cognitive Behavioral Therapy for Insomnia) and (self-paid) modes of OSA treatment, including PAP and oral appliance therapy.

Insomnia may exacerbate the severity of sleep sleep-disordered breathing. Conversely, the presence of sleep apnea can contribute to the development and worsening of insomnia. COMISA affects the diagnosis and determination of severity for both conditions. More importantly, the intricate dance between insomnia and sleep apnea necessitates a personalized, holistic, and responsive approach to treatment.

Treatment for Sleep Apnea and Comorbid Insomnia (COMISA)

Many sleep medicine specialists elect to start with treatment for sleep apnea first and then determine if insomnia symptoms are left over. In my experience, this can result in a dramatic worsening of the patient’s condition. People with COMISA rightly perceive that their sleep is fragile and adding OSA therapy to untreated insomnia results in further decline of sleep quality and significantly greater impairment of daytime functioning. This typically leaves a person feeling incredibly discouraged about their ability to have healthy sleep. So discouraged, in fact, that they may abandon care altogether.

In the course of a sleep apnea evaluation, there is an opportunity to address insomnia first. Insomnia treatment can start while a patient is waiting for their sleep test or waiting for their OSA treatment. The first-line treatment for insomnia is CBT-I (Cognitive Behavioral Therapy for Insomnia). This may be delivered by appropriately trained clinicians or sleep coaches. Regular interactions in as little as 4-6 weeks can be incredibly effective.

First-line treatment for sleep apnea (moderate to severe) is with Positive Airway Pressure (PAP, such as CPAP, AutoPAP, and other PAP modalities), which requires acclimation to the mask and pressure with nightly use for resolution of OSA. It is important to note that initial CPAP acceptance and use predicts future CPAP use, especially within the first month of CPAP.

In other words, a positive initial experience with CPAP therapy encourages and maintains greater long-term adherence. However, for people who didn’t have a good experience with CPAP but are still motivated to treat their sleep apnea, I’ve found that effective use of CPAP can absolutely be achieved in the treatment for sleep apnea through coaching, support, and education.

Those with COMISA are often less accepting of PAP therapy (even compared to people with OSA alone), which can understandably trigger hypervigilance — a barrier to acclimation to the mask and air pressure. Short-term use of prescription sleep aids, lifestyle modifications (including active stress reduction), and behaviors to engage the parasympathetic (rest and digest) nervous system can be personalized to promote acclimation to CPAP while still supporting sleep quality and quantity.

This requires trust, good communication, and frequent follow-up between the person with COMISA and their clinician or coach. Given the lack of access to sleep medicine providers, this work may fall to a sleep coach for a high-touch and personalized plan.

Non-CPAP therapies can and should be considered in the COMISA population. Non-surgical treatments (especially oral appliance therapy, or OAT) and surgical procedures for OSA are options. Selection of a CPAP treatment alternative is dependent on patient preference, the severity of OSA, co-existing medical conditions, and cost or insurance coverage. It is my practice to caution COMISA patients about hypoglossal nerve stimulation surgery because the implant for OSA can exacerbate insomnia.

For more guidance, watch my video interview about sleep apnea treatment alternatives without CPAP:

There is precedent for hope in the treatment for sleep apnea and insomnia. Research shows that those receiving both effective CBT-I and CPAP therapy report significantly greater improvement of global insomnia symptoms and meaningful sleep apnea treatment by 6 months follow-up.

In summary, people with COMISA require a higher level of expertise, more frequent care, and targeted diagnostic and therapy considerations. Insomnia therapy should occur at least simultaneously (or preferably before!) a sleep apnea evaluation. Insomnia should not be assumed to be a ‘secondary’ manifestation of OSA.

Left unaddressed, underlying insomnia can significantly impair a person’s ability to function as they begin treatment for sleep apnea, and a savvy clinician will pivot accordingly. Flexibility in choices for OSA therapy should be the norm, and frequent and personalized follow-up visits would be ideal for support and troubleshooting.