Summary
Things you should know:
- Insomnia and obstructive sleep apnoea are the two most common sleep disorders.
- Insomnia and sleep apnoea frequently co-exist (COMISA).
- People with COMISA can experience worse sleep and health outcomes compared to people with either insomnia alone or sleep apnoea alone.
- People with COMISA may require treatments for both disorders.
- There are effective treatments for both insomnia and sleep apnoea.
- Cognitive Behavioural Therapy for Insomnia (CBTi) is the best treatment for insomnia.
- CBTi is effective in people with COMISA.
- Continuous Positive Airway Pressure (CPAP) therapy is the most effective treatment for moderate and severe sleep apnoea.
What is COMISA?
Co-Morbid Insomnia and Sleep Apnoea (COMISA) refers to the co-existence of insomnia and obstructive sleep apnoea at the same time. About 30-40% of people with insomnia also have sleep apnoea, and about 30-50% of people with sleep apnoea also report insomnia symptoms. In the general population, up to 10% of Australian adults are thought to have COMISA.
Insomnia is characterised by difficulties falling or staying asleep during the night, and sleep apnoea is characterised by narrowing or closure of the upper airway during sleep. Sleep apnoea causes snoring, choking/gasping awakenings, reduced oxygen levels, and non-feelings of a restorative sleep. For more information on each disorder, see the Sleep Health Foundation fact sheets on insomnia and obstructive sleep apnoea.
What are the symptoms of COMISA?
People with insomnia symptoms should be aware of symptoms and risk factors for sleep apnoea;
- Loud snoring, breathing interruptions, or choking/gasping awakenings from sleep
- Feelings of non-refreshing sleep
- Overweight or obesity
- Daytime sleepiness (Could unintentionally fall asleep in different situations during the day)
- Some people can have sleep apnoea without experiencing these obvious symptoms
People with sleep apnoea should be aware of symptoms of insomnia:
- Insomnia includes sleep difficulties on at least 3 nights/week:
- Difficulties falling asleep, and/or
- Frequent or long awakenings from sleep, and/or
- Awakenings early in the morning and difficulties returning to sleep.
- Insomnia can also cause reduced daytime feelings and functioning.
How does COMISA impact people?
Both insomnia and sleep apnoea cause sleep difficulties, reduced sleep quality, and difficulties maintaining sleep. Insomnia and sleep apnoea can also both cause feelings of daytime fatigue, lethargy, poor mood, sleepiness, and concentration difficulties. Therefore, COMISA is also associated with these sleep and daytime symptoms. Because of the impacts of two sleep disorders, people with COMISA may have reduced mood, quality of life, and cardiovascular health compared to people with insomnia alone or sleep apnoea alone. Sleep disorders can also increase risk of motor-vehicle accidents due to daytime sleepiness and delayed reaction time.
How is it treated?
Most people with COMISA need treatments for both disorders. Very effective treatments exist for both insomnia and sleep apnoea:
- Maintain good sleep habits, such as reducing evening alcohol consumption, limiting caffeine after midday, getting exposure to natural light early in the day, and maintaining a regular bedtime routine and relaxing ‘wind down’ routine before bed.
- People with overweight or obesity may benefit from weight loss and lifestyle interventions.
- Continuous Positive Airway Pressure (CPAP) therapy is the recommended treatment for moderate and severe obstructive sleep apnoea.
- Some people with COMISA find that CPAP therapy improves symptoms of both insomnia and sleep apnoea. In this case, it may not be necessary to treat insomnia symptoms if they improve with CPAP.
- Other people with COMISA can find it difficult to fall asleep while using CPAP therapy, or report that CPAP therapy causes more nighttime awakenings. In this case, it can be helpful to treat the insomnia symptoms before re-starting CPAP therapy.
- Other treatments for sleep apnoea include oral appliance devices, positional devices for people that experience worse sleep apnoea when sleeping on their back, and upper airway surgery. These treatments for sleep apnoea are generally recommended if CPAP therapy is not tolerated.
- Cognitive Behavioural Therapy for Insomnia (CBTi) is the best treatment for insomnia, and is effective in people with COMISA.
- Some CBTi recommendations can increase how sleepy you feel during the day and in the evening. These feelings of sleepiness aim to help people fall asleep quicker and return to sleep quicker throughout the night. However, this also means that CBTi can sometimes lead to reduced daytime alertness during the first 2-3 weeks of treatment. You should be aware of feelings of daytime sleepiness, and avoid driving or operating heavy machinery if feeling sleepy.
- In people with COMISA, treating insomnia with CBTi can make it easier start using CPAP therapy. Treating insomnia can help people fall asleep quicker and spend less time awake while using CPAP. This increase in time spent asleep using CPAP can lead to better treatment outcomes for both the insomnia and sleep apnoea.
- Sleeping pills (sedative medications) are not recommended in people with obstructive sleep apnoea, as they can relax muscles and make sleep apnoea worse in some patients. For insomnia, sleeping pills are not recommended for more than 4 weeks.
Where to access care for COMISA
An overnight sleep study is the best way to test for sleep apnoea. Your GP can refer you to a sleep physician or refer you for an overnight sleep study to test for sleep apnoea.
See the Sleep Health Foundation CPAP fact sheet for information about access to CPAP therapy.
GPs and other health professionals can assess for symptoms of insomnia.
Cognitive Behavioural Therapy for Insomnia (CBTi) can be delivered by trained clinicians. GPs can refer people to a psychologist for CBT-I with a Medicare ‘Mental Health Treatment Plan’ to subsidise treatment costs. Digital CBTi programs have been developed and are effective in people with insomnia alone, but few studies have assessed the effectiveness or safety of digital CBTi in people with COMISA.
Where can I find out more?
See Sleep Health Foundation fact sheets on;