Diagnosis and Management of OSA Comorbid with Insomnia (COMISA)

Abstract

Research addressing comorbid insomnia with obstructive sleep apnea (OSA) (COMISA) has been conducted in two different ways—firstly, looking for the insomnia among subjects with OSA and secondly, assessment of OSA among subjects with chronic insomnia. This research has shown that prevalence of insomnia among subjects with OSA is higher than the prevalence of OSA among subjects with insomnia. While investigated through polysomnography, subjects with pure insomnia and COMISA show shorter total sleep time, greater percentage of wake after sleep onset and, poorer sleep efficiency compared to subjects having OSA and normal controls. Patients with COMISA suffer from two disorders and this combination is likely to produce greater disability and poorer quality of life among them compared to patients with either disorders alone. Pathophysiological models based on the scientific evidences favor that (i) OSA may lead to insomnia, (ii) insomnia may also lead to OSA and both can work in feed forward manner to develop COMISA. Insomnia is difficult to be diagnosed in the presence of other sleep disorders including OSA. It needs to be remembered that overlap of symptoms between OSA and insomnia may have a positive influence the diagnosis of either disorders before and, even after the treatment of both the disorders making the diagnosis difficult. A number of other challenges also make diagnosis of COMISA difficult that include physician’s knowledge of all versus selected sleep disorders and, methods of assessment of sleep disorders. In view of limited literature, no consensus exists on the management of cases having COMISA. However, available evidences suggest that concurrent therapy (CBTi with PAP) could be better than sequential therapies where management of one disorder is followed by other.