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When Insomnia and Sleep Apnea Overlap: Understanding COMISA

Updated: Feb 4

A Personal Introduction by Steve Archer RRT, CCSH


Close-up of pinecones and green needles in focus, with blurred brown paper-wrapped gifts in the background, creating a festive mood.

Well, hello! I wanted to introduce myself since this is my first time writing a blog, and I'm very happy that Lorraine asked me to contribute. Lorraine and I have known each other for many years - her working in her own cognitive behavioural world of insomnia and other sleep disorders - and mine in the sleep apnea treatment world.


My name is Steve Archer. I am a Respiratory Therapist and have my certificate in clinical sleep health. I've been in the sleep apnea treatment world for around 15 years and have really enjoyed my time helping people sleep better. I used to own a fairly large clinic, which we sold a few years ago, but I am no longer with that group and am branching out on my own with my small company called Archer Sleep Care.



Understanding Sleep Disorders


Today, I want to talk a little bit about sleep disorders and touch on something called COMISA. This is just a fancy acronym for people who have both chronic insomnia and sleep apnea - oi, what a combo! But let's talk a little bit about sleep disorders first.


Did you know there are a total of 84 sleep disorders? Now, that is getting really picky and very detailed, but some common ones are:


  • Sleep Apnea

  • Insomnia

  • Restless Leg Syndrome

  • Night Terrors

  • Sleepwalking

  • Periodic Limb Movement Disorder


This post focuses on obstructive sleep apnea, which is the primary area I work with clinically.


Sleep Satisfaction and Symptoms

We're going to first talk about symptoms and sleep satisfaction. Sleep satisfaction is how you would rate your sleep - think of it as a scale from 0-10.


Consider these questions:


  • How quickly do you fall asleep?

  • What is your sleep depth and restfulness?

  • How many night awakenings do you have?

  • Do you have morning headaches or congestion?

  • How is your daytime energy, mood, and cognitive function?


Sleep dissatisfaction and daytime complaints are red flags.

The Five Pillars of Sleep Apnea Treatment


Now we're going to talk about the five reasons to treat sleep apnea, centred on five pillars:


1. Risk

Untreated sleep apnea increases the risk for high blood pressure, heart attack, stroke, diabetes, and overall mortality. It can also be disruptive to sleep. The Apnea-Hypopnea Index (AHI) quantifies how many times you stop breathing or have shallow breaths, but it does have limitations.


2. Snoring

This has social and relational impact. Even without daytime sleepiness, loud snoring may signal significant sleep apnea.


3. Sleep

Quality of sleep is vital for well-being, cognition, and mood. Sleep apnea disrupts sleep and restorative stages of sleep.


4. Wake

Daytime impairment, fatigue, accidents, neurocognitive changes, and mood disorders may result from poor sleep.


5. Comorbidities

Sleep apnea can worsen existing medical conditions-for example, hypertension, atrial fibrillation, and mental health disorders.



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Getting Tested and Treatment Options


Now, I guess the important thing here is: if you have some of the signs of sleep apnea, it's probably good to go to your doctor and get tested, whether it's a home sleep apnea test or an in-lab overnight polysomnography (which is more detailed but requires a night spent at a sleep lab).


If you do have a diagnosis of any type of sleep apnea - mild, moderate, or severe - and you have poor sleep satisfaction or daytime fatigue, it's really important to consider some form of treatment.


Now, I think we've all heard of a CPAP machine, but there are other treatments depending on how severe you are and your preferences. I think at times, since most of the sleep apnea testing is done by CPAP companies, there can be pressure to start on CPAP without a proper explanation or being given other options. This, combined with poor follow-up and troubleshooting, can lead to something called non-compliance, which - with a good clinic that follows their clients well - should decrease how many CPAP machines are sitting in a closet and not being used (my biggest pet peeve).


Now, for moderate to severe sleep apnea, CPAP is still the gold standard of treatment, but some examples of other therapies are:


  • Oral appliances: A dental device that keeps your jaw forward

  • Positional therapy: To stay off your back if this is where you have all your apneas

  • Weight loss: If weight is an issue (and if you're normal body weight and have symptoms, be aware that you still could have sleep apnea)


Just as an aside, I have a normal body mass index (BMI), but I have mild to moderate sleep apnea and do have some fatigue, and I am trying to figure out my best treatment option.


Understanding COMISA


So this is where we're going to talk a little bit more about COMISA. The relationship between sleep apnea and insomnia is a tricky two-way street that can create a self-perpetuating loop.


If someone has untreated sleep apnea, it can fragment their sleep and shatter your sleep quality, leading to symptoms of insomnia: inability to fall asleep early in the evening because you've had to sleep during the day because you're so tired, waking up in the middle of the night, and impacting your sleep.


But, we have had clients on CPAP who can't tolerate CPAP because their brain is active or the CPAP mask is not fitting right, which can lead to CPAP-related insomnia. So a lot of the times, just fixing one thing is not always best practice.


A Collaborative Approach


This is why Lorraine and I are going to be working more closely in the future to cross-refer patients to each other and perhaps work on these clients at the same time. For example, I would make sure that the CPAP experience is optimized - mask fit, pressure settings - and Lorraine would at the same time help with trying to shut off that active brain, along with other strategies for better sleep, including CBT-I - and come up with a game plan when it's hard to fall asleep with the CPAP device.


Final Thoughts


So to wrap it up: if you're tired, ask "why?" If you have symptoms of sleep apnea, get tested and be open to being treated if you're really serious about your sleep. If you have insomnia and sleep apnea, you may have to work on both of them together.


I'll end it with one of my funny respiratory sayings: breathing is really important - you should do it all the time.


Cheers,


Steve Archer RRT, CCSH




If You Need Support


If you’re dealing with CPAP challenges, suspect sleep apnea alongside insomnia (COMISA), or just want a clear next step, book a free 15-minute Initial CPAP/Sleep Conversation with Steve Archer (RRT, CCSH) at Archer Sleep Care.



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