![]() Questionnaire and ProceduresĪll participants were invited to the outpatient clinic at Landspitali-The National University Hospital of Iceland in Reykjavik. Two y after treatment initiation, participants were invited for a followup visit where treatment adherence was examined and baseline assessments were repeated. ![]() 3 OSA had been recently diagnosed in all enrolled participants (minimum apnea-hypopnea index of 15 events/h) and these patients were about to begin PAP treatment. They are part of the Icelandic Sleep Apnea Cohort (ISAC). Patients in whom OSA had been diagnosed in Iceland and who were referred for PAP treatment to Landspitali-The National University Hospital of Iceland in Reykjavik (the only site in Iceland providing PAP treatment) from September 2005 through December 2009 were invited to participate in the study. However, we expected that symptoms of initial and late insomnia would be more resistant to change despite successful treatment of OSA and that patients with these symptoms would more likely not be using PAP at follow-up. It was hypothesized that symptoms of middle insomnia would have the strongest association with untreated OSA and would therefore improve significantly among patients on PAP treatment. The purpose of the current study was to compare the prevalence of symptoms of initial, middle, and late insomnia in patients with OSA prior to and following the start of PAP treatment, as well as to explore the changes in insomnia symptoms by subtype in individuals who were or were not using PAP at follow-up. Initial insomnia may be expected to diminish adherence to PAP because patients are awake longer and thus more likely to experience the adverse aspects of this treatment (e.g., mask or airflow discomfort) for longer periods of time. Therefore, patients who wake up frequently because of apneic episodes may experience more refreshing sleep when using PAP and as a result adjust favorably to the treatment. However, it seems likely that repeated breathing disturbances could result in sleep fragmentation and hence middle or late insomnia. 16 Theoretically, it is surprising that patients with OSA might find it difficult to fall asleep at night because excessive daytime sleepiness (EDS) is a common symptom of untreated OSA. Another study found symptoms of middle insomnia to be the most common subtype among patients with OSA. In our previous study, 2 we found that most patients with untreated OSA had symptoms of middle insomnia but the prevalence of initial insomnia was the same as in the general population. 15 found a negative effect of psychological factors related to insomnia symptoms on PAP adherence. 14 showed that symptoms of middle insomnia were related to poor PAP adherence in addition, a recent study by Pieh et al. 13 showed that even though insomnia symptoms were highly prevalent among patients with OSA, they had no effect on PAP adherence. Of the studies that exist, the findings are mixed. 11, 12 Currently, few studies have (1) assessed the relative prevalence of insomnia subtypes in patients with OSA, (2) explored how PAP affects insomnia that is comorbid with OSA (both overall and by subtype), and (3) evaluated how insomnia affects PAP adherence. Treatment with positive airway pressure (PAP) is the first-line treatment for OSA, but it can be diffcult for patients to tolerate PAP and studies have shown that as few as 50% of patients adhere to the treatment over time. It also may be the case that one or more of the insomnia subtypes respond differently to OSA treatment and/or are associated with different levels of OSA treatment adherence. ![]() 1 OSA may serve as a predisposing and/or a precipitating factor for each of the subtypes of insomnia. The subtypes of insomnia are typically characterized as difficulties initiating sleep (initial insomnia), difficulties maintaining sleep (middle insomnia), and early morning awakenings (late insomnia). There are a variety of types and subtypes. Insomnia is not, however, a homogenous disorder. Recent reviews have called for more research on the comorbidity between insomnia and OSA. 3 Further, the co-occurrence of OSA and insomnia symptoms may complicate OSA treatment and reduce PAP adherence. 1– 6 When these disorders coexist, not only is there an increase in cumulative morbidity, but it is likely that these two diseases interact to promote overall greater illness severity and influence each other in negative ways. Several studies have documented extensive comorbidity with these disorders, with the prevalence of insomnia symptoms in patients with OSA (40–60%) far exceeding that in the general population. ![]() Adherence, CPAP, insomnia, obstructive sleep apnea IntroductionĬhronic insomnia and obstructive sleep apnea (OSA) are two of the most common sleep disorders.
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