Sleep Apnea and Insomnia: Are They Related?

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Raj Dasgupta, MD

If you struggle with insomnia despite trying various medications without success, it’s possible you might have sleep apnea or another breathing disorder disrupting your sleep. Some people endure years of failed treatments, feeling exhausted and hopeless. But there’s hope. Forward-thinking sleep experts have discovered that sleep apnea can be the root cause of certain insomnia cases.

This article examines the connection between these sleep disorders, discusses the risks of having both, and outlines treatment options for comorbid insomnia and sleep apnea (COMISA).

What is Insomnia?

Sleep Apnea and Insomnia

Insomnia, as defined by the International Classification of Sleep Disorders, Edition 3, is the repeated difficulty with sleep initiation, duration, consolidation, or quality despite having adequate opportunity and circumstances for sleep, leading to daytime impairment.

Signs of insomnia include trouble falling asleep at the start of the night (sleep onset insomnia) and waking in the middle of the night and being unable to return to sleep (sleep maintenance insomnia).

Diagnosis of insomnia relies on the patient’s subjective description of their sleep patterns—difficulty falling asleep or staying asleep—rather than on sleep tests.

Traditionally viewed as psychologically-based, treatment for insomnia includes pharmaceutical drugs, behavioral therapies, psychological therapies, or relaxation techniques. However, it’s worth considering if insomnia may have a physical cause instead of solely psychological.

What is Obstructive Sleep Apnea?

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder (SRBD) where the airway repeatedly closes partially or completely during sleep.

OSA is the most severe type of SRBD, but other types include hypopneas, respiratory-effort related arousal (RERA), and upper airway resistance (UAR). During OSA, the airway is fully obstructed, while in hypopneas, RERAs, and UARs, the obstruction is partial. All of these SRBDs can lead to various medical issues.

How Are Sleep Apnea and Insomnia Related?

There’s strong evidence linking insomnia and sleep apnea. According to a 2019 review, having one condition increases the likelihood of having the other by 30–50%. Another study from 2021 suggests that insomnia symptoms are 40–60% more common among those with sleep apnea compared to the general population.

The exact reasons for this association aren’t fully understood, but there are several potential connections:

  • Insomnia-induced sleep deprivation may weaken upper-airway muscles and reduce oxygen levels.
  • Chronic insomnia could predispose individuals to more frequent episodes of obstructive sleep apnea.
  • Light sleep caused by insomnia may lead to easier awakenings during apnea events.
  • Sleep apnea itself can disrupt sleep patterns and contribute to insomnia.

These factors may interact differently in each case of comorbid insomnia and sleep apnea (COMISA), and ongoing research aims to better understand this relationship.

Symptoms to Watch For

Sleep-related breathing disorders (SRBDs), such as obstructive sleep apnea (OSA), are linked to various health issues like heart disease, stroke, depression, metabolic problems, and even mortality. Lesser-known symptoms of OSA/SRBD include:

  1. Dry Mouth: OSA reduces oxygen intake due to airway blockage, prompting mouth breathing to compensate and leading to dry mouth in the morning. This dryness is a reliable indicator of OSA.

  2. Morning Headaches: SRBD causes a buildup of carbon dioxide in the brain, leading to vasodilation and pressure on cerebral arteries, resulting in morning headaches.

  3. Urinating at Night: Frequent urination at night is caused by increased pressure in the obstructed airway during apnea events. This pressure affects the venous blood system, leading to distension of the heart’s right atrium. The heart signals fluid overload, triggering the release of a natural diuretic peptide and increased urine production, causing frequent nighttime bathroom trips.

Risks of COMISA

Insomnia and sleep apnea share common symptoms, which can be more severe in individuals with comorbid insomnia and sleep apnea (COMISA). These symptoms include:

  • Feeling unrefreshed by sleep
  • Fatigue or daytime sleepiness
  • Difficulty falling asleep, staying asleep, or waking up
  • Issues with attention, concentration, and memory
  • Mood or social dysfunctions

These symptoms can reduce quality of life and raise the risk of accidents. Moreover, poor sleep quality is increasingly linked to serious health issues such as stress, high blood pressure, high cholesterol, heart attack, and cancer, as indicated by a 2017 review. Given these potential consequences, it’s crucial for individuals with COMISA to seek diagnosis and treatment.

COMISA Diagnosis and Treatment

Diagnosing COMISA involves identifying both sleep apnea and insomnia in the same individual. There’s no standardized diagnostic procedure; doctors typically diagnose each condition separately.

For insomnia diagnosis, doctors may use:

  • Questionnaires
  • Reviewing sleep diaries
  • Actigraphy, which monitors sleep habits using a wristwatch-like device

Polysomnography tests, primarily used for sleep apnea diagnosis, may also be employed if other sleep disorders are suspected.

Treatment for COMISA involves addressing both insomnia and sleep apnea. However, treating both simultaneously presents unique challenges. Continuous positive airway pressure (CPAP) therapy is standard for moderate to severe sleep apnea but may be challenging for those with insomnia due to discomfort.

Some experts suggest starting insomnia treatment, particularly cognitive behavioral therapy for insomnia (CBT-I), before CPAP therapy. Evidence supports the effectiveness of initiating CBT-I before or alongside CPAP therapy, but the optimal combination remains uncertain as research continues.

For mild cases of sleep apnea, you may consider using some anti-snoring devices or anti-snoring mouthpieces.

How to Improve Sleep with Sleep Apnea and Insomnia

Getting healthy sleep is vital, especially when dealing with serious sleep disorders like sleep apnea and insomnia. Here are four tips to enhance your sleep:

1. Establish a Consistent Bedtime Routine

Consistency matters! Going to bed and waking up at the same times each day helps regulate your body’s sleep-wake cycle. Dedicate the hour before bedtime to winding down with relaxing activities like reading or meditating. Avoid stimulating activities and electronic devices that emit blue light, which can interfere with sleep.

2. Watch Your Diet and Drinks

Avoid large meals, caffeine, and alcohol close to bedtime. Large meals can disrupt sleep by prioritizing digestion over rest, while caffeine’s stimulant effects can keep you awake. Alcohol may initially make you feel sleepy but can disrupt sleep patterns and worsen sleep apnea symptoms.

3. Get Tested for Both Disorders

If you have symptoms of one sleep disorder, consider getting tested for the other as well. Sleep apnea and insomnia often coexist and share similar symptoms. A sleep study can help diagnose any underlying sleep disorders accurately.

4. Follow Your Treatment Plan

Consistently follow the prescribed treatments for your sleep disorders. For insomnia, treatments may include sleep aids or cognitive behavioral therapy. Continuous positive airway pressure (CPAP) therapy is a common treatment for sleep apnea, but if it’s uncomfortable or ineffective, discuss alternatives with your doctor.

Remember, untreated sleep disorders can impact your overall health. If you’re unsure about your sleep quality or suspect a sleep disorder, seek evaluation and treatment from a sleep specialist. Prioritizing good sleep habits is essential for your well-being.

Need professional help to diagnose and address your sleep problems? Schedule an online consultation with sleep specialist Dr. Owen Napleton.

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