All-Cause Mortality in People with Co-Occurring Insomnia Symptoms and Sleep Apnea: Analysis of the Wisconsin Sleep Cohort

Abstract

Purpose Insomnia symptoms and sleep apnea frequently co-occur and are associated with worse sleep, daytime function, mental health and quality of life, compared to either insomnia or obstructive sleep apnea (OSA) alone. This study aimed to investigate the association of symptoms of co-morbid insomnia and sleep apnea (COMISA) with all-cause mortality. Patients and Methods Wisconsin Sleep Cohort data were analysed to assess potential associations between COMISA symptoms and all-cause mortality. Nocturnal insomnia symptoms were defined as difficulties initiating sleep, maintaining sleep, and/or early morning awakenings “often” or “almost always”, and/or regular sedative-hypnotic medicine use. OSA was defined as an apnea-hypopnea index ≥5/hr sleep. Participants were classified as having neither insomnia symptoms nor OSA, insomnia symptoms alone, OSA alone, or COMISA symptoms. Associations between the four groups and all-cause mortality over 20 years of follow-up were examined via multivariable adjusted Cox regression models. Results Among 1115 adult participants (mean ± SD age 55 ± 8 years, 53% males), 19.1% had COMISA symptoms. After controlling for sociodemographic and behavioral factors, COMISA symptoms were associated with an increased risk of all-cause mortality compared to no insomnia symptoms or OSA (HR [95% CI]; 1.71 [1.00–2.93]). OSA alone (0.91 [0.53, 1.57]) and insomnia symptoms alone (1.04 [0.55, 1.97]) were not associated with increased mortality risk. Conclusion Co-morbid insomnia symptoms and sleep apnea is associated with increased all-cause mortality risk. Future research should investigate mechanisms underpinning COMISA and the effectiveness of different treatment approaches to reduce mortality risk for this common condition.

Contemporary Concise Review 2022: Sleep

“…However, analysing 5236 participant data from the same cohort they demonstrated an increased risk of all‐cause mortality in those with COMISA compared with no insomnia/OSA 42 . The same team demonstrated similar findings from the Wisconsin Sleep Cohort when reviewing symptoms of COMISA 43 . Although COMISA only had a prevalence rate of 2%–3% in the SHHS, the negative cardiovascular effects and mortality risk strengthen the need for effective treatments for both when they co‐exist.…”

“…42 The same team demonstrated similar findings from the Wisconsin Sleep Cohort when reviewing symptoms of COMISA. 43 Although COMISA only had a prevalence rate of 2%-3% in the SHHS, the negative cardiovascular effects and mortality risk strengthen the need for effective treatments for both when they co-exist. At least one study where patients were randomized to receive either CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only, has demonstrated that concomitant PAP treatment for OSA and CBT-I may accelerate treatment outcomes.…”

The role of neuromuscular function in sleep apnea pathogenesis and management: A consensus of experts

“…Regarding phenotypes, the data suggest various clusters in which some OSA patients are asymptomatic, some have comorbid insomnia and some have daytime sleepiness (Ye et al, 2014). Of note, OSA patients with hypersomnia as well as comorbid insomnia (Lechat et al, 2022) are thought to be at cardiovascular risk, suggesting that only a subset of OSA patients may experience improvements in cardiovascular risk when treated for OSA. Therefore, recognition of OSA endophenotypes is challenging the "one-size-fits-all" approach of giving nasal CPAP to all OSA patients regardless of mechanism or symptoms (Bosi et al, 2017;.…”

Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions

“…COMISA generally experience worse objective sleep quality/fragmentation, daytime function [12,18], and higher rates of cardiovascular disease [27,29], compared to people with insomnia-alone [7 && ,8]. Three recent studies in population-based cohorts have investigated the association between COMISA and all-cause mortality over 10-20 years of follow-up [27,30,31]. In all three studies, those with COMISA experienced a 47-71% increased risk of mortality in adjusted models compared to people with neither insomnia nor sleep apnea (Table 1).…”

“…Three recent studies in population-based cohorts have investigated the association between COMISA and all-cause mortality over 10–20 years of follow-up [27,30,31]. In all three studies, those with COMISA experienced a 47–71% increased risk of mortality in adjusted models compared to people with neither insomnia nor sleep apnea (Table 1).…”