Prospective Assessment of Nocturnal Awakenings in a Case Series of Treatment-Seeking Chronic Insomnia Patients: A Pilot Study..., 2012, Krakow et al.

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Prospective Assessment of Nocturnal Awakenings in a Case Series of Treatment-Seeking Chronic Insomnia Patients: A Pilot Study of Subjective and Objective Causes
Barry Krakow, Edward Romero, Victor A Ulibarri, Shara Kikta
https://pmc.ncbi.nlm.nih.gov/articles/PMC3490361/ (PDF available)

Background: The cause of nocturnal awakenings in patients with chronic insomnia is rarely researched. This study prospectively assessed the etiology of nocturnal awakenings (subjectively and objectively) among patients with insomnia at a private, community-based sleep medical center.

Methods: Twenty adult patients with chronic insomnia enrolled between April 2008 and February 2010 met diagnostic criteria for an insomnia disorder, never previously visited a sleep specialist or underwent sleep testing, and reported no classic sleep disordered breathing symptoms. Patients completed validated scales for insomnia, sleepiness, impairment, anxiety, depression, and quality of life, a qualitative interview to assess subjective reasons for awakenings, and a diagnostic sleep study to objectively assess awakenings and their precipitants.

Results: Subjective and objective data showed clinically meaningful insomnia, primarily sleep maintenance insomnia. The most common self-reported reasons for awakenings were: uncertain cause (50%), nightmares (45%), nocturia (35%), bedroom distractions (20%), or pain (15%). No patient identified breathing symptoms as a cause. Objectively, 531 awakenings were observed in the total sample, and 478 (90%) were preceded by sleep breathing events (apnea, hypopnea, or respiratory effort-related event). Fifty-three awakenings were caused by other factors (independent leg jerks [7], spontaneous [14], and sleep that was laboratory-induced [32]). Thirty awakenings ≥ 5 min-a duration sufficient to predispose toward an insomnia episode-were each preceded by a breathing event.

Conclusions: Among patients with insomnia with no classic sleep breathing symptoms and therefore low probability of a sleep breathing disorder, most of their awakenings were precipitated by a medical condition (sleep disordered breathing), which contrasted sharply with their perceptions about their awakenings

 

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Other S4ME threads related to obstructive sleep-disordered breathing (OSA/UARS) and chronic insomnia:

Prospective RCT on the Efficacy of CPAP and Adaptive Servo-Ventilation in the Treatment of Chronic Complex Insomnia, 2019, Krakow et al.

Chronic insomnia remitting after maxillomandibular advancement for mild obstructive sleep apnea: a case series, 2019, Proothi et al.

 

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Participants
MSAS = Maimonides Sleep Arts and Sciences sleep center SDB = sleep-disordered breathing

We prospectively recruited patients with insomnia without breathing symptoms linked to SDB to ensure a sample of “classic” patients with insomnia who would suffer neither from a diagnosis of obstructive sleep apnea (OSA) nor from nocturnal awakenings due to the pathophysiology of this common sleep disorder. To refine our sample, we included only those patients who (1) sought initial sleep evaluation at MSAS and had not previously visited a sleep specialist or undergone PSG; (2) ranked insomnia as their primary sleep complaint; (3) scored ≥ 15 on the Insomnia Severity Index (ISI) (4) reported sleep-related impairment; (5) met research criteria for an insomnia disorder (6) completed an Internet-based intake survey; (7) spoke English; and (8) were 18 yr of age or older.

A total of 1,326 patients sought care at MSAS from April 2008 to February 2010, and 512 patients (38.6%) presented with a chief complaint of chronic insomnia. Of these 512 patients, 461 (90%) also reported co-occurring sleep breathing disorders, problems, or symptoms and were excluded from the study. Also, 11 scored < 15 on the ISI, and eight had previously been evaluated or tested at another sleep facility, leaving our sample at 32 of the original 1,326 patients (2.4%). Sedative or psychotropic medication use was not an exclusion criterion. Of the 32 patients who qualified during this 22-mo period, four chose not to participate, and eight did not complete the prediagnostic interview or postdiagnostic interview due to logistical problems such as travel and work commuting issues, leaving our final sample at 20 patients.

Of 20 patients, 17 reported both SOI [sleep-onset insomnia] and SMI [sleep maintenance insomnia], and three reported sleep maintenance problems only. Two women reported postmenopausal status, but neither was on hormone replacement therapy. 11/20 patients reported mild snoring, but dividing the sample by this variable yielded no systematic distinctions between groups on any subsequent analysis of sociodemographics, validated questionnaires, subjective and objective sleep measures, and subjective and objective causes of awakenings. Sleepiness scores were low, but tiredness scores were high.

Of the 20 patients, 11 met criteria OSA. Of the remaining 9 patients, 8 met criteria for upper airway resistance syndrome (UARS) based on a RDI (AHI + RERA index) ≥ 15.