Why "Do I have Sleep Apnea or Insomnia?" is the Wrong Question.
Insomnia and sleep apnea are two extraordinarily common problems. Patients, and many medical practitioners, often attempt to put these two issues into separate boxes, when in reality, they can be quite interconnected. Having an understanding of the interdependence between insomnia and sleep apnea and illuminating the causal relationship between the two will point you in the right direction to get the help that you need.
The CDC reports that nearly 10% of the U.S. population has chronic insomnia. According to the American Academy of Sleep Medicine (AASM), approximately a quarter of all American adults between ages 30 and 70 have sleep apnea. These are enormous numbers! For a frame of reference, 9.3% of the U.S. population has diabetes.
It's Clearly the Chicken not the Egg
Obstructive sleep apnea (OSA) is a common cause of chronic "sleep maintenance insomnia," i.e. waking up excessively during the night. OSA results from repetitive episodes of upper airway collapse. Each episode leads to a brain micro-awakening, called an "arousal." A cluster of breathing events in short succession, or just one prolonged one, can activate your sympathetic nervous system (the "fight or flight" response) resulting in a surge of adrenaline and awakening from sleep feeling wide awake. Typically, the sufferer is completely unaware of the link between abnormal breathing and the awakening.
What about Trouble Falling Asleep?
Difficulty falling asleep, called "sleep onset insomnia," may also be due to sleep apnea in certain circumstances. Central sleep apnea (CSA) is a form of sleep-disordered breathing in which the brain forgets to tell the body to breathe. Central breathing events are particularly common in wake-sleep transitions and may result in trouble falling asleep. Overall, CSA is rarer than OSA, but occurs frequently in people with certain heart, brain, spine, and kidney problems. It can also result regular use of some pain medications.
Patients with very severe obstructive sleep apnea can experience the obstructive breathing events during sleep-wake transitions as well. A helpful question for patients with chronic sleep onset insomnia is, "Do you feel like you're dozing on and off and can't get into deep sleep?" If the answer is yes, my suspicion for sleep apnea as a causal factor is high. If the patient says, "No, I feel wide awake the whole time," then it's less likely that sleep apnea alone is causing the problem.
What Are other Risk Factors for Sleep Apnea?
Some of the most common risk factors to suggest that you need a sleep apnea test include the following:
- overweight (body mass index [BMI] ≥25-29.9) or obese (BMI ≥30)
- snoring on the majority of nights of the week (loudness of snoring isn't as important as regularity of snoring)
- waking up gasping, coughing or choking
- your bedpartner voices concerns about abnormal breathing (such as stopping breathing) in your sleep
- neck circumference ≥17" in men or ≥16" in women
- excessive daytime sleepiness or fatigue
Note: for the purposes of diagnosing sleep apnea, a home sleep study is just as good (and arguably better in certain circumstances) as an in-lab study.
There are certain populations that are often overlooked for referral for a sleep study when they consult their doctors about chronic insomnia. This is because these folks don't "fit the profile" of the typical sleep apnea patient: middle-aged, male, loud snorer, and overweight. However, the following populations are indeed at increased risk for sleep apnea:
- overweight or obese women - it's common for these patients to have abnormal breathing events limited to REM sleep which, often manifests as waking up at about the same times every night
- elderly patients, even when normal weight - in this group. sleep apnea often presents as excessive trips to the bathroom to urinate during the night
- thin people with jaw and head structures predisposing them to OSA such as retrognathia (recessed lower jaw), micrognathia (small lower jaw), high arched palate, adenoidal facies (people with long, narrow faces who are prone to mouthbreathing), etc.
- people of Asian descent
"The Monopoly Rule"
When counseling insomniacs whom I've just diagnosed with sleep apnea, I invoke my version of "The Monopoly Rule:" do not pass go, do not collect $200, treat the sleep apnea first. Essentially, when insomnia and OSA co-occur, I don't focus on the insomnia complaints right off the bat. I ask the patient to table further discussion about the insomnia until our follow-up visit, after he or she has used CPAP for a month or so, and then we'll reevaluate the insomnia. Much of the time, the CPAP kills two birds with one stone.
The Bottom Line:
- Insomnia is a symptom unless proven otherwise. When chronic, there's often an underlying medical cause for the insomnia, and sleep apnea needs to be definitely ruled out with a sleep study.
- Be proactive. If you've been suffering for years with insomnia, talk to your doctor about getting a sleep study. Or order a home sleep apnea test
About Dr. Krainin
Joseph Krainin, M.D., FAASM is the founder of Singular Sleep, the world's first online sleep center. He is a Fellow of the American Academy of Sleep Medicine and board certified in both sleep medicine and neurology. Singular Sleep specializes in home sleep apnea testing and offers comprehensive sleep apnea solutions including online sleep doctor consultations, CPAP and BPAP machines, masks. The company is authorized SoClean dealer.
If you have any questions or would like to learn more please contact Dr. Krainin at: firstname.lastname@example.org or call (844) 757-9355.