Abstract

Background

A recent study found that 29.2% of OSA patients also had significant insomnia and around 80% of people with chronic insomnia also have sleep apnea. Linked to these conditions were a lower quality of life, lower sleep quality, and a higher percentage of depression.

Case presentation

A healthy and active 55-year-old male with a BMI of 23 and a history of OSA was previously diagnosed with severe obstructive sleep apnea (AHI: 31). The patient also experiences heart palpitations and has been prescribed a mandibular advancement device to control his breathing.

 

The patient’s Wesper tests concluded that their oral appliance appropriately corrected their severe obstructive sleep apnea to a normal level. However, the patient showed signs of poor sleep quality due to frequent awakenings despite his excellent sleep hygiene.

 

In consultation with the Wesper sleep expert, the patient was happy to see that his sleep apnea was well controlled and was more comfortable to proceed with prescription medication to address his insomnia.

Conclusion 

This case study demonstrates the importance of testing for common comorbid sleep disorders and treating both sleep disorders in tandem to ensure better health outcomes.

Background

Chronic insomnia and obstructive sleep apnea (OSA) are two common sleep disorders; both are considered independent risk factors for extreme conditions such as heart disease.

 

A recent study found that 29.2% of OSA patients also had significant insomnia and around 80% of people with chronic insomnia also have sleep apnea. Linked to these conditions were a lower quality of life, lower sleep quality, and a higher percentage of depression.

 

Comorbid insomnia with OSA may constitute a cumulative risk factor for cardiovascular disease and other sleep-related diseases. This case study warrants further attention to the treatment of the patient as a whole, considering all contributing factors and devising more efficient treatments.

Case presentation

A healthy and active 55-year-old male with a BMI of 23 and a history of OSA was previously diagnosed with severe obstructive sleep apnea (AHI: 31). The patient also experiences heart palpitations and has been prescribed a mandibular advancement device to control his breathing. The patient is proactive with their sleep health and follows a strict sleep hygiene regimen.

 

The patient purchased Wesper to monitor their breathing while using their oral appliance and investigate their poor sleep quality, which includes chronic restless sleep and frequent nighttime awakenings, despite good sleep hygiene practices. The patient described themselves as a restless, light sleeper that is easily disturbed during sleep. The patient wanted to understand whether their breathing was contributing to their excessive arousal from sleep.

 

Despite the patient’s previous diagnosis of severe Obstructive Sleep Apnea, all 21 tests showed normal breathing while wearing his oral appliance.

 

The patient’s diagnostic test, which was scored and reviewed by a board-certified sleep physician, showed the following:

 

• The patient’s diagnostic tests reported an AHI of 0 (normal)
• The patient’s diagnostic test reported an REI of 0 (normal)
• The patient’s diagnostic test reported an ODI of 1.5 (normal)
• The patient’s mean SPO2 was 96%, and the minimum SP02 was 89%. He only had one desaturation under 90%, which occurred when he was upright and awake.

 

The patient’s 20 completed wellness reports demonstrated the following metrics while wearing his oral appliance:

 

• The patient’s average breathing event per hour score across 20 tests was 4 (min/max 1, 6; normal).
• The patient’s average % snoring time across 20 years was 0%, with no tests reporting snoring (normal)
• The patient’s average total sleep time was across 7.57 hours (normal)
• The patient’s average sleep quality score across 20 tests was 69.65 (low)
• The patient’s average nighttime awakenings across 20 tests were 10.6

 

The patient’s Wesper tests concluded that their oral appliance appropriately corrected their severe obstructive sleep apnea to a normal level. However, the patient showed signs of poor sleep quality due to frequent awakenings despite his excellent sleep hygiene.

 

Hyperarousal is a key feature of insomnia. The patient had previously discussed using a low-dose prescription hypnotic, eszopiclone, to reduce his restlessness and frequent awakenings with his physician.

 

In consultation with the Wesper sleep expert, the patient was happy to see that his sleep apnea was well controlled and was more comfortable to proceed with prescription medication to address his insomnia.

 

The patient was advised to follow his doctor’s instructions and continue seeing his doctor for monitoring while taking the medications. The Wesper sleep expert advised the patient to continue testing with Wesper once they adjusted to their medication to determine if it improved their sleep quality.

 

After one month of taking the eszopiclone, the patient resumed testing with Wesper and completed 6 additional tests while taking their medication and using their oral appliance. Their new tests indicated that their breathing was still corrected, with an AHI of 0 and an average number of breathing events per hour of 2.5.

 

Average sleep quality had also improved from 66.6% to 79.5%, indicating that both sleep time and sleep efficiency improved. Finally, the patient’s average nighttime awakenings decreased from 10.6 awakenings per night to 7.25 awakenings per night, which indicates an improvement in their hyperarousal.

 

During the patient’s second meeting with the Wesper sleep expert, he reported that he felt like he was achieving deeper sleep and his awakenings were less noticeable. His daytime sleepiness and cognition had also improved. The patient also reported remembering his dreams for the first time in years.

Conclusions

Consistent testing with the Wesper device confirmed that the patient’s sleep apnea was well-corrected and unlikely to be responsible for his poor sleep quality.

 

The patient’s sleep history and data indicated sleep maintenance insomnia with hyperarousal. Estimates have demonstrated that approximately 80% of people with chronic insomnia also have sleep apnea; however, sleep apnea treatment is often placed at a higher importance. Thus, individuals who are comorbid for both disorders may never properly address their insomnia.

 

This case study demonstrates the importance of testing for common comorbid sleep disorders and treating both sleep disorders in tandem to ensure better health outcomes.

Explanation of metrics

1. Apnea/Hypopnea Index (AHI) – the combined average number of apneas and hypopneas that occur per hour of sleep
2. Respiratory Event Index (REI) – the total number of apneas and hypopneas divided by the total device (Wesper) monitoring time in hours.
3. Oxygen Desaturation Index (ODI) – the number of times per hour of sleep that the blood oxygen level drops by ≥ 4% from baseline
4. Mean SPO2: The average blood oxygen saturation score
5. Minimum SPO2: The lowest blood oxygen saturation score
6. Breathing events—Moments of increased respiratory effort, which include reduced airflow and prolonged breathing stoppages.
7. Snoring %- Percentage of snoring detected for the duration of the test
8. Total sleep time – Total accumulation of sleep in minutes.
9. Sleep quality score – Takes into consideration both sleep duration and sleep efficiency.
10. Awakenings – The total number of awakenings during the testing period.

 

References 

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3763954/#:~:text=Among%20individuals%20with%20a%20presenting,between%206%25%20and%2084%25.
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837842/
3. https://erj.ersjournals.com/content/60/1/2101958
4. https://www.frontiersin.org/articles/10.3389/fneur.2018.00804/full