Abstract
Background
In the clinical practice of sleep medicine, the coexistence of common sleep disorders is not uncommon. Patients with sleep disordered breathing (SDB) may present with insomnia, and studies have shown that SDB is common among insomnia patients. Little is known about the pathophysiological mechanisms underlying this coexistence, and limited information is available regarding the impact of each disorder on the other. It is essential to consider the effect of each disorder on the other and to understand the clinical consequences anticipated when treating each disorder in isolation. The management plan should be directed toward both disorders in a systematic and evidence-based approach. Unfortunately, a consensus standard approach for the management of comorbid insomnia and SDB is not yet available.
Methods
Therefore, we have reviewed published studies that investigated insomnia in patients with different types of SBD; obstructive sleep apnea, central sleep apnea, and hypoventilation syndromes, as well as studies that assessed SBD in patients with insomnia. In addition, we reviewed the effects of SBD treatment modalities on insomnia and the effects of insomnia treatments on SBD.
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References
Bahammam AS, Aljafen B (2007) Sleep medicine service in Saudi Arabia. A quantitative assessment. Saudi Med J 28(6):917–921
Punjabi NM, Welch D, Strohl K (2000) Sleep disorders in regional sleep centers: a national cooperative study. Coleman II Study Investigators. Sleep 23(4):471–480
Bonnet MH, Arand DL (2010) Hyperarousal and insomnia: state of the science. Sleep Med Rev 14(1):9–15
Riemann D, Spiegelhalder K, Feige B, Voderholzer U, Berger M, Perlis M, Nissen C (2010) The hyperarousal model of insomnia: a review of the concept and its evidence. Sleep Med Rev 14(1):19–31
American Academy of Sleep Medicine (2005) International classification of sleep disorders: diagnostic and coding manual, 2nd edn. American Academy of Sleep Medicine, Westchester
Young T, Peppard P (2000) Sleep-disordered breathing and cardiovascular disease: epidemiologic evidence for a relationship. Sleep 23(Suppl 4):S122–S126
Guilleminault C, Eldridge FL, Dement WC (1973) Insomnia with sleep apnea: a new syndrome. Science 181(102):856–858
Krakow B, Melendrez D, Ferreira E, Clark J, Warner TD, Sisley B, Sklar D (2001) Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest 120(6):1923–1929
Alotair H, Bahammam A (2008) Gender differences in Saudi patients with obstructive sleep apnea. Sleep Breath 12(4):323–329
Chung KF (2005) Insomnia subtypes and their relationships to daytime sleepiness in patients with obstructive sleep apnea. Respiration 72(5):460–465
Krell SB, Kapur VK (2005) Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath 9(3):104–110
Smith S, Sullivan K, Hopkins W, Douglas J (2004) Frequency of insomnia report in patients with obstructive sleep apnoea hypopnea syndrome (OSAHS). Sleep Med 5(5):449–456
Wickwire EM, Smith MT, Birnbaum S, Collop NA (2010) Sleep maintenance insomnia complaints predict poor CPAP adherence: a clinical case series. Sleep Med 11(8):772–776
Lavie P (2007) Insomnia and sleep-disordered breathing. Sleep Med 8(Suppl 4):S21–S25
Chung KF (2003) Relationships between insomnia and sleep-disordered breathing. Chest 123(1):310–311, author reply 311–313
Ambrogetti A, Olson LG, Saunders NA (1991) Differences in the symptoms of men and women with obstructive sleep apnoea. Aust N Z J Med 21(6):863–866
Pillar G, Lavie P (1998) Psychiatric symptoms in sleep apnea syndrome: effects of gender and respiratory disturbance index. Chest 114(3):697–703
Shepertycky MR, Banno K, Kryger MH (2005) Differences between men and women in the clinical presentation of patients diagnosed with obstructive sleep apnea syndrome. Sleep 28(3):309–314
Gold AR, Gold MS, Harris KW, Espeleta VJ, Amin MM, Broderick JE (2008) Hypersomnolence, insomnia and the pathophysiology of upper airway resistance syndrome. Sleep Med 9(6):675–683
Lichstein KL, Riedel BW, Lester KW, Aguillard RN (1999) Occult sleep apnea in a recruited sample of older adults with insomnia. J Consult Clin Psychol 67(3):405–410
Stone JMC, Hart RP, Remsberg S, Mercer J (1994) Neuropsychological functioning in older insomniacs with or without obstructive sleep apnea. Psychol Aging 9(2):231–236
BaHammam A (2004) Polysomnographic characteristics of patients with chronic insomnia. Sleep Hypn 6(4):163–168
Guilleminault C, Palombini L, Poyares D, Chowdhuri S (2002) Chronic insomnia, postmenopausal women, and sleep disordered breathing: part 1. Frequency of sleep disordered breathing in a cohort. J Psychosom Res 53(1):611–615
Krakow B, Ulibarri VA, Romero EA (2010) Patients with treatment-resistant insomnia taking nightly prescription medications for sleep: a retrospective assessment of diagnostic and treatment variables. Prim Care Companion J Clin Psychiatry 12 (4). doi:10.4088/PCC.09m00873bro
Krakow B, Ulibarri VA, Romero E (2010) Persistent insomnia in chronic hypnotic users presenting to a sleep medical center: a retrospective chart review of 137 consecutive patients. J Nerv Ment Dis 198(10):734–741
Umlauf MG, Chasens ER, Greevy RA, Arnold J, Burgio KL, Pillion DJ (2004) Obstructive sleep apnea, nocturia and polyuria in older adults. Sleep 27(1):139–144
Leiter JC, Knuth SL, Bartlett D Jr (1985) The effect of sleep deprivation on activity of the genioglossus muscle. Am Rev Respir Dis 132(6):1242–1245
Desai AVMG, Grunstein R (2003) Does sleep deprivation worsen mild obstructive sleep apnea? Sleep 26:1038–1041
Series F, Roy N, Marc I (1994) Effects of sleep deprivation and sleep fragmentation on upper airway collapsibility in normal subjects. Am J Respir Crit Care Med 150(2):481–485
Bonnet MH, Arand DL (1995) 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep 18(7):581–588
Stepanski E, Zorick F, Roehrs T, Young D, Roth T (1988) Daytime alertness in patients with chronic insomnia compared with asymptomatic control subjects. Sleep 11(1):54–60
Guilleminault CEF, Phillips JR, Dement WC (1976) Two occult causes of insomnia and their therapeutic problems. Arch Gen Psychiatry 33(10):1241–1245
Javaheri S (2006) Sleep disorders in systolic heart failure: a prospective study of 100 male patients. The final report. Int J Cardiol 106(1):21–28
Oldenburg OLB, Faber L, Teschler H, Horstkotte D, Topfer V (2007) Sleep-disorder breathing in patients with symptomatic heart failure. A contemporary study of prevalence in and characteristics of 700 patients. Eur J Heart Fail 9:251–257
Brostrom A, Stromberg A, Dahlstrom U, Fridlund B (2004) Sleep difficulties, daytime sleepiness, and health-related quality of life in patients with chronic heart failure. J Cardiovasc Nurs 19(4):234–242
Labanowski M, Schmidt-Nowara W, Guilleminault C (1996) Sleep and neuromuscular disease: frequency of sleep-disordered breathing in a neuromuscular disease clinic population. Neurology 47(5):1173–1180
Bourke SC, Gibson GJ (2002) Sleep and breathing in neuromuscular disease. Eur Respir J 19(6):1194–1201
Klink MQS (1987) Prevalence of reported sleep disturbances in a general adult population and their relationship to obstructive airways diseases. Chest 91(4):540–546
Cormick W, Olson LG, Hensley MJ, Saunders NA (1986) Nocturnal hypoxaemia and quality of sleep in patients with chronic obstructive lung disease. Thorax 41(11):846–854
van Manen JG, Bindels PJ, IJzermans CJ, van der Zee JS, Bottema BJ, Schade E (2001) Prevalence of comorbidity in patients with a chronic airway obstruction and controls over the age of 40. J Clin Epidemiol 54(3):287–293
Phillips BA, Cooper KR, Burke TV (1987) The effect of sleep loss on breathing in chronic obstructive pulmonary disease. Chest 91(1):29–32
Bellia VCF, Scichilone N, Incalzi RA, Spatafora M, Vergani C, Rengo F (2003) Sleep disorders in the elderly with and without chronic airflow obstruction: the SARA study. Sleep 26(3):318–323
Kales A, Kales JD (1983) Sleep laboratory studies of hypnotic drugs: efficacy and withdrawal effects. J Clin Psychopharmacol 3(2):140–150
Leiter JCKS, Krol RC, Bartlett D Jr (1985) The effect of diazepam on genioglossus muscle activity in normal human subjects. Am Rev Respir Dis 132(2):216–219
Maillard D, Thiercelin JF, Fuseau E, Rosenzweig P, Attali P (1992) Effects of zolpidem versus diazepam and placebo on breathing control parameters in healthy human subjects. Int J Clin Pharmacol Res 12(1):27–35
Hedemark LL, Kronenberg RS (1983) Flurazepam attenuates the arousal response to CO2 during sleep in normal subjects. Am Rev Respir Dis 128(6):980–983
Berry RB, McCasland CR, Light RW (1992) The effect of triazolam on the arousal response to airway occlusion during sleep in normal subjects. Am Rev Respir Dis 146(5 Pt 1):1256–1260
Bezel R, Russi E, Kronauer H, Mothersill I (1987) Life-threatening apnea after midazolam administration in a patient with obstructive sleep apnea syndrome. Schweiz Med Wochenschr 117(15):579–583
Dolly FR, Block AJ (1982) Effect of flurazepam on sleep-disordered breathing and nocturnal oxygen desaturation in asymptomatic subjects. Am J Med 73(2):239–243
Hoijer UHJ, Ejnell H et al (1994) Nitrazepam in patients with sleep apnoea: a double-blind placebo-controlled study. Eur Respir J 7:2011–2015
Camacho ME, Morin CM (1995) The effect of temazepam on respiration in elderly insomniacs with mild sleep apnea. Sleep 18(8):644–645
Nickol AHLJ, Richards P, Seal P, Harris GA, Cleland J, Dubowitz G, Collier DJ, Milledge J, Stradling JR, Morrell MJ (2006) Temazepam at high altitude reduces periodic breathing without impairing next-day performance: a randomized cross-over double-blind study. J Sleep Res 15(4):445–454
Guilleminault C, Crowe C, Quera-Salva MA, Miles L, Partinen M (1988) Periodic leg movement, sleep fragmentation and central sleep apnoea in two cases: reduction with clonazepam. Eur Respir J 1(8):762–765
Block AJ, Dolly FR, Slayton PC (1984) Does flurazepam ingestion affect breathing and oxygenation during sleep in patients with chronic obstructive lung disease? Am Rev Respir Dis 129(2):230–233
Cummiskey J, Guilleminault C, Del Rio G, Silvestri R (1983) The effects of flurazepam on sleep studies in patients with chronic obstructive pulmonary disease. Chest 84(2):143–147
Murciano D, Armengaud MH, Cramer PH, Neveux E, L'Heritier C, Pariente R, Aubier M (1993) Acute effects of zolpidem, triazolam and flunitrazepam on arterial blood gases and control of breathing in severe COPD. Eur Respir J 6(5):625–629
Sanger DJ (2004) The pharmacology and mechanisms of action of new generation, non-benzodiazepine hypnotic agents. CNS Drugs 18(Suppl 1):9–15, discussion 41, 43–15
Rosenberg R, Roach JM, Scharf M, Amato DA (2007) A pilot study evaluating acute use of eszopiclone in patients with mild to moderate obstructive sleep apnea syndrome. Sleep Med 8(5):464–470
Lettieri CJ, Quast TN, Eliasson AH, Andrada T (2008) Eszopiclone improves overnight polysomnography and continuous positive airway pressure titration: a prospective, randomized, placebo-controlled trial. Sleep 31(9):1310–1316
Collen J, Lettieri C, Kelly W, Roop S (2009) Clinical and polysomnographic predictors of short-term continuous positive airway pressure compliance. Chest 135(3):704–709
Lettieri CJEA, Andrada T, Khramtsov A, Kristo DA (2005) Does zolpidem enhance the yield of polysomnography? J Clin Sleep Med 1(2):129–131
Berry RB, Patel PB (2006) Effect of zolpidem on the efficacy of continuous positive airway pressure as treatment for obstructive sleep apnea. Sleep 29(8):1052–1056
Beaumont M, Batejat D, Coste O, Van Beers P, Colas A, Clere JM, Pierard C (2004) Effects of zolpidem and zaleplon on sleep, respiratory patterns and performance at a simulated altitude of 4,000 m. Neuropsychobiology 49(3):154–162
Beaumont M, Batejat D, Pierard C, Van Beers P, Philippe M, Leger D, Savourey G, Jouanin JC (2007) Zaleplon and zolpidem objectively alleviate sleep disturbances in mountaineers at a 3,613 meter altitude. Sleep 30(11):1527–1533
Quadri S, Drake C, Hudgel DW (2009) Improvement of idiopathic central sleep apnea with zolpidem. J Clin Sleep Med 5(2):122–129
Girault C, Muir JF, Mihaltan F, Borderies P, De La Giclais B, Verdure A, Samson-Dollfus D (1996) Effects of repeated administration of zolpidem on sleep, diurnal and nocturnal respiratory function, vigilance, and physical performance in patients with COPD. Chest 110(5):1203–1211
Steens RD, Pouliot Z, Millar TW, Kryger MH, George CF (1993) Effects of zolpidem and triazolam on sleep and respiration in mild to moderate chronic obstructive pulmonary disease. Sleep 16(4):318–326
Bayliss DA, Viana F, Talley EM, Berger AJ (1997) Neuromodulation of hypoglossal motoneurons: cellular and developmental mechanisms. Respir Physiol 110(2–3):139–150
Veasey SC, Panckeri KA, Hoffman EA, Pack AI, Hendricks JC (1996) The effects of serotonin antagonists in an animal model of sleep-disordered breathing. Am J Respir Crit Care Med 153(2):776–786
Veasey SC, Fenik P, Panckeri K, Pack AI, Hendricks JC (1999) The effects of trazodone with l-tryptophan on sleep-disordered breathing in the English bulldog. Am J Respir Crit Care Med 160(5 Pt 1):1659–1667
Heinzer RC, White DP, Jordan AS, Lo YL, Dover L, Stevenson K, Malhotra A (2008) Trazodone increases arousal threshold in obstructive sleep apnoea. Eur Respir J 31(6):1308–1312
Carley DW, Olopade C, Ruigt GS, Radulovacki M (2007) Efficacy of mirtazapine in obstructive sleep apnea syndrome. Sleep 30(1):35–41
Castillo JL, Menendez P, Segovia L, Guilleminault C (2004) Effectiveness of mirtazapine in the treatment of sleep apnea/hypopnea syndrome (SAHS). Sleep Med 5(5):507–508
Marshall NS, Yee BJ, Desai AV, Buchanan PR, Wong KK, Crompton R, Melehan KL, Zack N, Rao SG, Gendreau RM, Kranzler J, Grunstein RR (2008) Two randomized placebo-controlled trials to evaluate the efficacy and tolerability of mirtazapine for the treatment of obstructive sleep apnea. Sleep 31(6):824–831
Erman M, Seiden D, Zammit G, Sainati S, Zhang J (2006) An efficacy, safety, and dose-response study of Ramelteon in patients with chronic primary insomnia. Sleep Med 7(1):17–24
Zammit G, Erman M, Wang-Weigand S, Sainati S, Zhang J, Roth T (2007) Evaluation of the efficacy and safety of ramelteon in subjects with chronic insomnia. J Clin Sleep Med 3(5):495–504
Roth T, Seiden D, Sainati S, Wang-Weigand S, Zhang J, Zee P (2006) Effects of ramelteon on patient-reported sleep latency in older adults with chronic insomnia. Sleep Med 7(4):312–318
Kryger M, Wang-Weigand S, Roth T (2007) Safety of ramelteon in individuals with mild to moderate obstructive sleep apnea. Sleep Breath 11(3):159–164
Kryger MW-WS, Zhang J, Roth T (2008) Effect of ramelteon, a selective MT(1)/MT (2)-receptor agonist, on respiration during sleep in mild to moderate COPD. Sleep Breath 12(3):243–250
Kryger M, Roth T, Wang-Weigand S, Zhang J (2009) The effects of ramelteon on respiration during sleep in subjects with moderate to severe chronic obstructive pulmonary disease. Sleep Breath 13(1):79–84
Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M (2008) Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med 4(5):487–504
Spielman AJ, Saskin P, Thorpy MJ (1987) Treatment of chronic insomnia by restriction of time in bed. Sleep 10(1):45–56
Morin CM, Azrin NH (1987) Stimulus control and imagery training in treating sleep-maintenance insomnia. J Consult Clin Psychol 55(2):260–262
Means MK, Lichstein KL, Epperson MT, Johnson CT (2000) Relaxation therapy for insomnia: nighttime and day time effects. Behav Res Ther 38(7):665–678
Harvey AG, Sharpley AL, Ree MJ, Stinson K, Clark DM (2007) An open trial of cognitive therapy for chronic insomnia. Behav Res Ther 45(10):2491–2501
NIH State-of-the-Science Conference Statement on manifestations and management of chronic insomnia in adults (2005) NIH Consens State Sci Statements 22(2):1–30
Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, Coleman J, Kapur V, Lee-Chiong T, Owens J, Pancer J, Swick T (2006) Practice parameters for the psychological and behavioral treatment of insomnia: an update. An American Academy of Sleep Medicine report. Sleep 29(11):1415–1419
Krakow B, Melendrez D, Lee SA, Warner TD, Clark JO, Sklar D (2004) Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath 8(1):15–29
Guilleminault C, Davis K, Huynh NT (2008) Prospective randomized study of patients with insomnia and mild sleep disordered breathing. Sleep 31(11):1527–1533
Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ (2006) Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 3:CD001106
Wright J, White J (2000) Continuous positive airways pressure for obstructive sleep apnoea. Cochrane Database Syst Rev (2):CD001106.
White J, Cates C, Wright J (2002) Continuous positive airways pressure for obstructive sleep apnoea. Cochrane Database Syst Rev (2):CD001106.
Marin J, Carrizo S, Vincente E, Agusti AG (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea–hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365:1046–1053
Richard W, Venker J, den Herder C, Kox D, van den Berg B, Laman M, van Tinteren H, de Vries N (2007) Acceptance and long-term compliance of nCPAP in obstructive sleep apnea. Eur Arch Otorhinolaryngol 264(9):1081–1086
McArdle NDG, Heidarnejad H, Engleman HM, Mackay TW, Douglas NJ (1999) Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 159:1108–1114
Krieger J (1992) Long-term compliance with nasal continuous positive airway pressure (CPAP) in obstructive sleep apnea patients and nonapneic snorers. Sleep 15(6 Suppl):S42–S46
Lettieri CJ, Shah AA, Holley AB, Kelly WF, Chang AS, Roop SA (2009) Effects of a short course of eszopiclone on continuous positive airway pressure adherence: a randomized trial. Ann Intern Med 151(10):696–702
Budhiraja RPS, Drake CL, Roth T, Sharief I, Budhiraja P, Saunders V, Hudgel DW (2007) Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep 30(3):320–324
Chasens ER, Pack AI, Maislin G, Dinges DF, Weaver TE (2005) Claustrophobia and adherence to CPAP treatment. West J Nurs Res 27(3):307–321
Nguyên XLCJ, Rakotonanahary D, Fleury B (2010) Insomnia symptoms and CPAP compliance in OSAS patients: a descriptive study using data mining methods. Sleep Med 11(8):777–784
Smith I, Nadig V, Lasserson TJ (2009) Educational, supportive and behavioural interventions to improve usage of continuous positive airway pressure machines for adults with obstructive sleep apnoea. Cochrane Database Syst Rev (2):CD007736.
Haynes PL (2005) The role of behavioral sleep medicine in the assessment and treatment of sleep disordered breathing. Clin Psychol Rev 25(5):673–705
Krakow B, Ulibarri V, Melendrez D, Kikta S, Togami L, Haynes P (2008) A daytime, abbreviated cardio-respiratory sleep study (CPT 95807–52) to acclimate insomnia patients with sleep disordered breathing to positive airway pressure (PAP-NAP). J Clin Sleep Med 4(3):212–222
AlDabal L, BaHammam AS (2010) Cheyne-Stokes respiration in patients with heart failure. Lung 188(1):5–14
Pinto AC, Evangelista T, Carvalho M, Alves MA, Sales Luis ML (1995) Respiratory assistance with a non-invasive ventilator (Bipap) in MND/ALS patients: survival rates in a controlled trial. J Neurol Sci 129(Suppl):19–26
Kleopa KA, Sherman M, Neal B, Romano GJ, Heiman-Patterson T (1999) Bipap improves survival and rate of pulmonary function decline in patients with ALS. J Neurol Sci 164(1):82–88
Lyall RA, Donaldson N, Fleming T, Wood C, Newsom-Davis I, Polkey MI, Leigh PN, Moxham J (2001) A prospective study of quality of life in ALS patients treated with noninvasive ventilation. Neurology 57(1):153–156
Barbe F, Quera-Salva MA, de Lattre J, Gajdos P, Agusti AG (1996) Long-term effects of nasal intermittent positive-pressure ventilation on pulmonary function and sleep architecture in patients with neuromuscular diseases. Chest 110(5):1179–1183
Piper AJ, Wang D, Yee BJ, Barnes DJ, Grunstein RR (2008) Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation. Thorax 63(5):395–401
Martin RJ, Bartelson BL, Smith P, Hudgel DW, Lewis D, Pohl G, Koker P, Souhrada JF (1999) Effect of ipratropium bromide treatment on oxygen saturation and sleep quality in COPD. Chest 115(5):1338–1345
Krakow B, Melendrez D, Pedersen B, Johnston L, Hollifield M, Germain A, Koss M, Warner TD, Schrader R (2001) Complex insomnia: insomnia and sleep-disordered breathing in a consecutive series of crime victims with nightmares and PTSD. Biol Psychiatry 49(11):948–953
Gooneratne NS, Gehrman PR, Nkwuo JE, Bellamy SL, Schutte-Rodin S, Dinges DF, Pack AI (2006) Consequences of comorbid insomnia symptoms and sleep-related breathing disorder in elderly subjects. Arch Intern Med 166(16):1732–1738
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Al-Jawder, S.E., BaHammam, A.S. Comorbid insomnia in sleep-related breathing disorders: an under-recognized association. Sleep Breath 16, 295–304 (2012). https://doi.org/10.1007/s11325-011-0513-1
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DOI: https://doi.org/10.1007/s11325-011-0513-1