What do I treat first when a patient presents with both insomnia and sleep apnea?

What do I treat first when a patient presents with both insomnia and sleep apnea? 

Why not both? At our sleep center, we use concurrent treatment in almost 90% of these cases, which as you know are incredibly common. In other words, we go forward with polysomnography (PSG) to explore the pathophysiology, and we start in with basic cognitive behavioral therapy for insomnia (CBT-I) to explore the psychophysiology. Surprisingly or not, most patients show some appreciation for this approach instead of the sequential or traditional pathway of starting with one disorder and then moving to the next one depending upon the response to the first treatment. My concern with sequential therapy has always been that the patient may often benefit from one treatment for one disorder and then feel sufficiently satisfied with the outcome to no longer desire any other treatment. Yet, in many such cases the patient has developed a “ceiling effect,” because once he or she experiences a significant improvement, it is all too common to imagine that this “better” is all the better it gets.

Another salient perspective regarding this widespread comorbidity is growing awareness that we are dealing with two sides of the same coin. In a nutshell, if treating sleep apnea decreases sleep fragmentation and awakenings and increases sleep consolidation, all of which improves insomnia, then why wait to treat sleep apnea? If treating insomnia leads to less anxiety about the sleep period and facilitates an easier adaptation to the PAP therapy device, all of which improves sleep apnea, then why wait to treat insomnia?

The above model is exactly how we learned to embrace concurrent therapies, which still has numerous pathways to consider due to the personal interests of each patient. For example, virtually all complex insomnia (comorbid insomnia and sleep apnea) patients receive a complimentary copy of Insomnia Cures, our short primer on sleep hygiene and CBT-I, often before they set foot in our sleep center or no later than at the time of their initial diagnostic PSG. From there, the pathways vary at minimum in the following ten ways:

1. For very severe insomnia patients, usually with other mental health factors adversely influencing the sleeplessness, we strongly encourage the patient to obtain a copy of the Sound Sleep, Sound Mind book, which details our extensive mind-body Sleep Dynamic TherapyTM program for the insomniac. This program goes beyond CBT-I and includes very specific instructions on cognitive-imagery tools and sleep-related emotion focused therapy tools, which are often critical pathways for severe insomniacs.
2. Once the diagnosis of sleep apnea or UARS is confirmed by PSG, most insomnia patients will proceed next to a titration study, because he or she has been educated to appreciate that enhancing sleep consolidation will directly impact insomnia.
3. However, for more severe insomniacs, the PAP-NAP is the next step after the diagnostic study but before the titration study. Although the PAP-NAP is successful in 80 to 90% of cases in engaging the patient to promote the necessary motivation to move forward with the titration study, a smaller proportion of insomnia patients recognize that the PAP experience will overwhelm them, so they return to clinic as soon as possible to meet with me as well as with our sleep technologists for daytime appointments to clarify what specific insomnia treatments are needed next.
4. Daytime appointments are quite varied in time and scope. In some cases, again usually among the most severe insomniacs, the patient or our staff or usually both may determine such patients need to start in the clinic before any testing. This scenario is especially relevant for those patients suffering acute-on-chronic insomnia where some degree of desperation or exasperation has emerged. These special intake appointments are exclusively conducted by myself and range in time from approximately 1 to 3 hours, thus permitting extensive work on cognitive restructuring, CBT-I, imagery work and an introduction to emotional processing techniques.
5. Telephone follow-up calls are essential when working with these severe insomnia patients and are often conducted by both my staff and myself to make fine tuning adjustments in the first few weeks to help alleviate the patient’s desperation and reinforce treatment steps. As expected clinic follow-ups often prove essential as well.
6. Remarkably, starting PAP therapy even in a desperate and anxious insomnia patient remains a priority in our system, because sooner rather than later the patient begins to realize how much the pathophysiological effects of broken sleep are in fact playing a major role in the insomnia. This scenario is quite prevalent among patients who tried CBT-I somewhere else and failed and now are in need of engagement with the use of imagery or emotional work or both to create a new sense of optimism in the patient’s attitude. And, this work with imagery and emotional systems can further facilitate the patient’s efforts in finding a way to gain a degree of comfort toward PAP therapy. In so doing, the patient may be ripe for our REPAP protocol (repeat, rescue, retitrations) involving more frequent titration PSGs or PAP-NAPs to give these patients more hands-on experience with the device, administered under the watchful eye of the professional sleep technologist.
7. On the other side of the equation, we have been nothing short of flabbergasted at the higher proportion of insomnia cases who embrace the idea of PAP therapy much faster than we would have imagined possible just a few years ago. The logic is so solid on the sleep apnea-insomnia connection, these patients develop considerable enthusiasm for initiating PAP therapy. A huge proportion of these cases never follow-up for more specific insomnia coaching, because their insomnia all but disappears once they adjusted to the device. As an example, it is common to see patients presenting with an Insomnia Severity Index (ISI) score of 20 or higher (placing them in the moderately severe range or greater) who return for a PAP Management Appointment with the sleep tech a month or two later where we find the ISI score is now less than 5.
8. One might ask whether or not these patients really suffered from insomnia or whether it was a pronounced sleep fragmentation problem masquerading as insomnia. My hunch is that both possibilities can occur, but I remain somewhat concerned about patients who do not follow-up to discuss more preventative steps, which may assist them long-term if they suffer a relapse from the psychological component of insomnia. In these cases, there will always be an attempt at a long-term follow-up phone call at 6 or 12 months to clarify not only the progress with PAP therapy, but also whether or not the insomnia has flared up for any other reason.
9. In terms of our most specific strategies, we usually engage the majority of our insomnia patients with psycho-education on the perpetuating influences of time monitoring behavior and the necessity to eliminate this behavior as soon as feasible. The patients first learn about this problem in the Insomnia Cures book, and then they receive reinforcement coaching from the sleep tech on the night of the first PSG. We like this particular introductory step because so many insomniacs engage in self-defeating time monitoring behavior, and the vast majority report clear-cut and immediate improvements by learning to disengage from the clock. Overall, this approach seems most gratifying to the majority of insomnia patients, because they sense early on that we really are espousing a concurrent treatment model. Along the same lines, many such patients will be coached on nasal hygiene issues the morning after the diagnostic study, so that they can begin therapy for OSA or UARS by using conservative steps including nasal saline rinses, netipot washes, prescription nasal sprays, or a nightly regimen of nasal dilator strips.
10. Last and not least, technology solutions are incredibly important for these patients. As described in prior posts, it is our opinion that trying to engage an insomnia patient to use CPAP is like trying to shove a square peg into a round hole. We use ABPAP or ASV devices in nearly 99% of these cases, spend considerable time working with the patient to find the best mask combined with the use of mask liner systems (eg, REMZzzzs), and with great precision manually titrate their pressures in the sleep lab, where we often find the changes of a magnitude of 0.2 units of pressure show objective improvements and resultant subjective satisfaction. It cannot go without commenting on the critical role played by the DME company in implementing successful technological solutions, which is why we have been so enthusiastic about our collaboration with Classic SleepCare.

Now, there can be no question that others in the field who look at complex insomnia may choose the analogy of the Venn diagram, suggesting that some patients show more overlap than others in their distinctive patho-physiologies that link insomnia and sleep apnea. I would not argue against this model, but I would reiterate that we have been routinely surprised how much more the overlap exists beyond what we would have imagined in years past.

No doubt, some might ask what is the role of sleep aids (OTC or prescription) in this model, and I think it’s an important consideration. The bias in our system is that we are much more likely to meet an insomniac who is already on sleep aids and seeking care to reduce or entirely eliminate these medications. It is relatively rare these patients ask for a medication for an insomnia problem that interferes with their use of PAP therapy and even more rare for someone to specifically ask for a new medication just for the insomnia unrelated to the PAP therapy. We find it interesting that a substantial number of patients are really suffering from Restless Leg Syndrome (RLS)/Periodic Limb Movement Disorder (PLMD), but their prescribing physicians were not aware of leg movement issues upon prescribing a sleep aid. So, for these specific individuals, we might be working rapidly to start them on evidence-based medications for RLS/PLMD before resorting to a prescription sedative to facilitate their combined efforts to treat insomnia and sleep apnea concurrently.

In sum, multiple pathways arise in the concurrent treatment approach to complex insomnia, and the vast majority of patients prove receptive and capable of managing this therapeutic load.

Barry Krakow MD


Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.

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