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How to treat co-existing insomnia and sleep apnoea
While the comorbid condition can be managed in general practice, the pace of emerging research has made it challenging for GPs to stay up to speed.
Insomnia and obstructive sleep apnoea are the two most prevalent sleep disorders, and many people have both.
It is part of our daily routine, but sleep – or more precisely, a lack of it – is emerging as the cause of many health issues.
And in general practice, sleep disturbances, specifically insomnia and obstructive sleep apnoea (OSA), are among the most common presentations, according to sleep health expert Dr Alexander Sweetman.
The two also frequently co-exist, as the ‘prevalent and debilitating condition’, comorbid insomnia and sleep apnoea (COMISA).
‘While around 30–40% of people with insomnia also have OSA, and 30–50% of people with OSA have clinically significant insomnia symptoms, they are often seen as completely independent conditions with separate diagnostic, treatment and referral pathways,’ Dr Sweetman told newsGP.
‘People with COMISA generally experience worse sleep, mental and physical health outcomes, daytime functioning, and quality of life compared to people with either condition alone.’
Dr Sweetman, a researcher at Flinders University’s Adelaide Institute for Sleep Health and program manager at the Australasian Sleep Association, recently co-authored an article in the September issue of the Australian Journal of General Practice (AJGP), ‘General practitioner management of comorbid insomnia and sleep apnoea’.
The paper aims to raise awareness of the co-existence of insomnia and OSA in primary care patients, by providing an overview of the prevalence, consequences, assessment, and evidence-based management and referral options.
‘Research into the most effective treatment combination and sequence is still emerging,’ Dr Sweetman said.
‘The most recent evidence indicates that treatments for both disorders should be made available to patients with COMISA.
‘There are very effective treatments available for both conditions, and we are trying to make these treatments more accessible to GPs and other primary care clinicians.’
GPs should first assess for symptoms of both disorders in patients presenting with either insomnia or sleep apnoea, according to the paper, with targeted treatments for both disorders appropriate for people with COMISA.
To assess for insomnia and high-risk of sleep apnoea, standardised self-report questionnaires can be used, and GPs can refer eligible patients for a sleep study, which is eligible for Medicare rebates.
If insomnia symptoms are not addressed, people with COMISA may experience difficulties using continuous positive airway pressure (CPAP) therapy, the most effective treatment for sleep apnoea.
As well as being associated with poor mental and physical health outcomes, COMISA presents complex diagnostic, treatment and referral decisions.
Cognitive behavioural therapy for insomnia (CBTi) is considered the most effective treatment for insomnia, and improves insomnia symptoms in people with COMISA. CBTi may also increase subsequent acceptance of and improve patterns of nightly use of CPAP therapy, according to Dr Sweetman, thereby improving management of both conditions.
Despite evidence of its efficacy, GPs have reported limited access to CBTi treatment and referral pathways, with only around 1% of Australian adults with insomnia currently accessing the treatment.
Over the next five years, Dr Sweetman will continue to be involved in the development of such treatments, hoping to make them more effective and tailored, and increasingly available to GPs.
‘There has been a recent increase in recognition of COMISA in the sleep medicine community, that has resulted in more research into targeted treatment pathways for this condition,’ he said.
The AJGP paper’s authors anticipate their findings will help to raise more awareness of COMISA and up-to-date management pathways and address the ‘unique challenges’ the condition can present for GPs.
The national sleep health guidelines for primary care providers also include detailed information about risk factors, consequences, assessment and management of both insomnia and OSA.
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