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Introduction: Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA., Areas Covered: This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities., Expert Opinion: There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

Background: Single-night disease misclassification of OSA due to night-to-night variability may contribute to inconsistent findings in OSA trials., Research Question: Does multinight quantification of OSA severity provide more precise estimates of associations with incident hypertension?, Study Design and Methods: A total of 3,831 participants without hypertension at baseline were included in simulation analyses. Included participants had ≥ 28 days of nightly apnea-hypopnea index (AHI) recordings via an under-mattress sensor and ≥ three separate BP measurements over a 3-month baseline period followed by ≥ three separate BP measurements 6 to 9 months postbaseline. Incident hypertension was defined as a mean systolic BP ≥ 140 mm Hg or a mean diastolic BP ≥ 90 mm Hg. Simulated trials (1,000) were performed, using bootstrap methods to investigate the effect of variable numbers of nights (x = 1-56 per participant) to quantify AHI and the ability to detect associations between OSA and incident hypertension via logistic regression adjusted for age, sex, and BMI., Results: Participants were middle-aged (mean ± SD, 52 ± 12 y), mostly male (91%), and overweight (BMI, 28 ± 5 kg/m 2 ). Single-night quantification of OSA failed to detect an association with hypertension risk in 42% of simulated trials (α = .05). Conversely, 100% of trials detected an association when AHI was quantified over ≥ 28 nights. Point estimates of hypertension risk were also 50% higher and uncertainty was five times lower during multinight vs single-night simulation trials., Interpretation: Multinight monitoring of OSA allows for better estimates of hypertension risk and potentially other adverse health outcomes associated with OSA. These findings have important implications for clinical care and OSA trial design., (Copyright © 2023 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Objective: Investigate associations of objective and subjective indicators of sleep impairment and disorders with low muscle strength (LMS) in different age groups and genders using data from a population-based cohort study., Methods: Polysomnographic and subjective sleep data from participants (aged 40-80 years) of the HypnoLaus study (Lausanne, Switzerland) were cross-sectionally analyzed. Indicators of sleep impairment and disorders were based on pre-defined cutoffs. LMS was defined according to the diagnosis of sarcopenia (grip strength <27 kg for men and <16 kg for women). Results obtained by multivariate logistic regression were controlled for confounders., Results: 1902 participants (mean [SD] age, 57.4 [10.5] years; 968 [50.9 %] female) were enrolled. Objective short (<6.2 h) and long sleep durations (>8.5 h) were associated with LMS (OR = 1.74, 95 % CI = 1.07-2.82; OR = 6.66, 95 % CI = 3.45-12.87, respectively). Increased nighttime wakefulness >90 min and severe obstructive apnea (OSA) (AHI > 30) were associated with LMS (OR = 1.60, 95 % CI = 1.01-2.56; OR = 2.36, 95 % CI = 1.29-4.31, respectively). In adults aged over 60 years, these associations persisted, and reduced sleep efficiency was associated with LMS (aOR = 1.81, 95 % CI 1.05-3.13). Objective long sleep duration was associated with LMS in both genders and severe OSA predicted LMS among women (aOR = 2.64, 95 % CI 1.11-6.24)., Conclusions: Markers of early sarcopenia are affected by long sleep duration from middle age onwards in both genders. Older adults are more susceptible to the effects of other indicators of inappropriate sleep duration and quality. The findings support a potential role of sarcopenia in age-related OSA. The intricate relationships between sleep and muscle health are potential targets of public health interventions and clinical research on preventive and therapeutic strategies against the increasing morbimortality observed with ageing., Competing Interests: The authors declare that they have no competing interest., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Insomnia and obstructive sleep apnea commonly co-occur (co-morbid insomnia and sleep apnea), and their co-occurrence has been associated with worse cardiometabolic and mental health. However, it remains unknown if people with co-morbid insomnia and sleep apnea are at a heightened risk of incident cardiovascular events. This study used longitudinal data from the Sleep Heart Health Study (N = 5803) to investigate potential associations between co-morbid insomnia and sleep apnea and cardiovascular disease prevalence at baseline and cardiovascular event incidence over ~11 years follow-up. Insomnia was defined as self-reported difficulties initiating and/or maintaining sleep AND daytime impairment. Obstructive sleep apnea was defined as an apnea-hypopnea index ≥ 15 events per hr sleep. Co-morbid insomnia and sleep apnea was defined if both conditions were present. Data from 4160 participants were used for this analysis. The prevalence of no insomnia/obstructive sleep apnea, insomnia only, obstructive sleep apnea only and co-morbid insomnia and sleep apnea was 53.2%, 3.1%, 39.9% and 1.9%, respectively. Co-morbid insomnia and sleep apnea was associated with a 75% (odd ratios [95% confidence interval]; 1.75 [1.14, 2.67]) increase in likelihood of having cardiovascular disease at baseline after adjusting for pre-specified confounders. In the unadjusted model, co-morbid insomnia and sleep apnea was associated with a twofold increase (hazard ratio, 95% confidence interval: 2.00 [1.33, 2.99]) in risk of cardiovascular event incidence. However, after adjusting for pre-specified covariates, co-morbid insomnia and sleep apnea was not significantly associated with incident cardiovascular events (hazard ratio 1.38 [0.92, 2.07]). Comparable findings were obtained when an alternative definition of insomnia (difficulties initiating and/or maintaining sleep without daytime impairment) was used., (© 2022 European Sleep Research Society.)

Background: Increased mortality has been reported in people with insomnia and in those with obstructive sleep apnoea (OSA). However, these conditions commonly co-occur and the combined effect of comorbid insomnia and sleep apnoea (COMISA) on mortality risk is unknown. This study used Sleep Heart Health Study (SHHS) data to assess associations between COMISA and all-cause mortality risk., Methods: Insomnia was defined as difficulties falling asleep, maintaining sleep and/or early morning awakenings from sleep ≥16 times per month, and daytime impairments. OSA was defined as an apnoea-hypopnoea index ≥15 events·h -1 . COMISA was defined if both conditions were present. Multivariable adjusted Cox proportional hazards models were used to determine the association between COMISA and all-cause mortality (n=1210) over 15 years of follow-up., Results: 5236 participants were included. 2708 (52%) did not have insomnia/OSA (reference group), 170 (3%) had insomnia-alone, 2221 (42%) had OSA-alone and 137 (3%) had COMISA. COMISA participants had a higher prevalence of hypertension (OR 2.00, 95% CI 1.39-2.90) and cardiovascular disease (CVD) (OR 1.70, 95% CI 1.11-2.61) compared with the reference group. Insomnia-alone and OSA-alone were associated with higher risk of hypertension but not CVD compared with the reference group. Compared with the reference group, COMISA was associated with a 47% (hazard ratio 1.47, 95% CI 1.06-2.07) increased risk of mortality. The association between COMISA and mortality was consistent across multiple definitions of OSA and insomnia., Conclusions: COMISA was associated with higher rates of hypertension and CVD at baseline, and an increased risk of all-cause mortality compared with no insomnia/OSA., Competing Interests: Conflict of interest: B. Lechat has nothing to disclose. Conflict of interest: S. Appleton has nothing to disclose. Conflict of interest: Y.A. Melaku has nothing to disclose. Conflict of interest: K. Hansen reports grants from the Australian Research Council, during the conduct of the study. Conflict of interest: R.D. McEvoy reports grants from the National Health and Medical Research Council, during the conduct of the study. Conflict of interest: R. Adams reports grants from The Hospital Research Foundation, National Health and Medical Research Council, ResMed Foundation, Phillips Foundation and Sleep Health Foundation, during the conduct of the study. Conflict of interest: P. Catcheside reports grants from the National Health and Medical Research Council, Defence Science and Technology, and the Flinders Foundation, outside the submitted work. Conflict of interest: L. Lack reports grants, personal fees and nonfinancial support from Re-time Pty Ltd, outside the submitted work. Conflict of interest: D.J. Eckert reports grants from the National Health and Medical Research Council of Australia, during the conduct of the study; grants and personal fees from Apnimed, and Bayer, grants from the Collaborative Research Centre (CRC-P), outside the submitted work; and has a patent “Methods for estimating key phenotypic traits for obstructive sleep apnoea and simplified clinical tools to direct targeted therapy”, PCT patent application pending. Conflict of interest: A. Sweetman has nothing to disclose., (Copyright ©The authors 2022. For reproduction rights and permissions contact permissions@ersnet.org.)

Study Objectives: Most studies on diet and sleep apnea focus on calorie restriction. Here we investigate potential associations between dietary quality (Healthy Eating Index [HEI], Dietary Inflammatory Index [DII]) and overall healthy lifestyle with sleep apnea risk., Methods: National Health and Nutrition Examination Survey data (waves 2005-2008 and 2015-2018; n = 14,210) were used to determine HEI, DII, and their quintiles, with the fifth quintile indicating highest adherence to each dietary construct. A healthy lifestyle score was determined using diet, smoking, alcohol intake, and physical activity level. The STOP-BANG questionnaire was used to define sleep apnea risk. Generalized linear regression models with binomial family and logit link were used to investigate potential associations. The models were adjusted for socioeconomic status, lifestyle factors, and chronic conditions., Results: The prevalence of high sleep apnea risk was 25.1%. Higher DII was positively associated with sleep apnea (odds ratio Quintile 5 vs Quintile 1 = 1.55; 95% confidence interval, 1.24-1.94; P for trend < .001), whereas higher HEI was associated with reduced sleep apnea risk (odds ratio Quintile 5 vs Quintile 1 = 0.72; 95% confidence interval, 0.59-0.88; P for trend = .007). Higher healthy lifestyle score was also associated with decreased odds of sleep apnea ( P for trend < .001). There was a significant interaction between healthy lifestyle and sex with sleep apnea risk ( P for interaction = .049) whereby females with higher healthy lifestyle scores had a lower risk of sleep apnea compared to males., Conclusions: Higher-quality and anti-inflammatory diets and a healthier overall lifestyle are associated with lower sleep apnea risk. These findings underline the importance of strategies to improve overall diet quality and promote healthy behavior, not just calorie restriction, to reduce sleep apnea risk., Citation: Melaku YA, Reynolds AC, Appleton S, et al. High-quality and anti-inflammatory diets and a healthy lifestyle are associated with lower sleep apnea risk. J Clin Sleep Med . 2022;18(6):1667-1679., (© 2022 American Academy of Sleep Medicine.)

Rationale: Primary care clinicians may be well placed to play a greater role in obstructive sleep apnea (OSA) management. Objectives: To evaluate the outcomes and cost-effectiveness of sleep apnea management in primary versus specialist care, using an individual-participant data meta-analysis to determine whether age, sex, severity of OSA, and daytime sleepiness impacted outcomes. Methods: Data sources were the Cumulative Index to Nursing and Allied Health Literature (CINAHL) database, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE Ovid SP, Scopus, ProQuest, U.S. National Institutes of Health Ongoing Trials Register, and ISRCTN registry (inception until 09-25-2019). Hand searching was undertaken. Two authors independently assessed articles and included trials that randomized adults with a suspected diagnosis of sleep apnea to primary versus specialist management within the same study and reported daytime sleepiness using the Epworth Sleepiness Scale (range 0-24; >10 indicates pathological sleepiness; minimum clinically important difference 2 units) at baseline and follow-up. Results: The primary analysis combined data from 970 (100%) participants (four trials). Risk of bias was assessed (Cochrane Tool). One-stage intention-to-treat analysis showed a slightly smaller decrease in daytime sleepiness (0.8; 0.2 to 1.4), but greater reduction in diastolic blood pressure in primary care (-1.9; -3.2 to -0.6 mm Hg), with similar findings in the per-protocol analysis. Primary care-based within-trial healthcare system costs per participant were lower (-$448.51 U.S.), and quality-adjusted life years and daytime sleepiness improvements were less expensive. Similar primary outcome results were obtained for subgroups in both management settings. Conclusions: Similar outcomes in primary care at a lower cost provide strong support for implementation of primary care-based management of sleep apnea.

Rationale: Conventional markers of sleep disturbance, based on manual electroencephalography scoring, may not adequately capture important features of more fundamental electroencephalography-related sleep disturbance. Objectives: This study aimed to determine if more comprehensive power-spectral measures of delta wave activity during sleep are stronger independent predictors of mortality than conventional sleep quality and disturbance metrics. Methods: Power spectral analysis of the delta frequency band and spectral entropy-based markers to quantify disruption of electroencephalography delta power during sleep were performed to examine potential associations with mortality risk in the Sleep Heart Health Study cohort ( N  = 5,804). Adjusted Cox proportional hazard models were used to determine the association between disrupted delta wave activity at baseline and all-cause mortality over an approximately 11-year follow-up period. Results: Disrupted delta electroencephalography power during sleep was associated with a 32% increased risk of all-cause mortality compared with no fragmentation (hazard ratio, 1.32 [95% confidence interval, 1.14-1.50]), after adjusting for total sleep time and other clinical and lifestyle-related covariates, including sleep apnea. The association was of similar magnitude to a reduction in total sleep time from 6.5 hours to 4.25 hours. Conventional measures of sleep quality, including wake after sleep onset and arousal index, were not predictive of all-cause mortality. Conclusions: Delta wave activity disruption during sleep is strongly associated with all-cause mortality risk, independent of traditional potential confounders. Future investigation into the potential role of delta sleep disruption on other specific adverse health consequences such as cardiometabolic, mental health, and safety outcomes has considerable potential to provide unique neurophysiological insight.

Rationale: Recent studies suggest that obstructive sleep apnea (OSA) severity can vary markedly from night to night, which may have important implications for diagnosis and management. Objectives: This study aimed to assess OSA prevalence from multinight in-home recordings and the impact of night-to-night variability in OSA severity on diagnostic classification in a large, global, nonrandomly selected community sample from a consumer database of people that purchased a novel, validated, under-mattress sleep analyzer. Methods: A total of 67,278 individuals aged between 18 and 90 years underwent in-home nightly monitoring over an average of approximately 170 nights per participant between July 2020 and March 2021. OSA was defined as a nightly mean apnea-hypopnea index (AHI) of more than 15 events/h. Outcomes were multinight global prevalence and likelihood of OSA misclassification from a single night's AHI value. Measurements and Main Results: More than 11.6 million nights of data were collected and analyzed. OSA global prevalence was 22.6% (95% confidence interval, 20.9-24.3%). The likelihood of misdiagnosis in people with OSA based on a single night ranged between approximately 20% and 50%. Misdiagnosis error rates decreased with increased monitoring nights (e.g., 1-night F1-score = 0.77 vs. 0.94 for 14 nights) and remained stable after 14 nights of monitoring. Conclusions: Multinight in-home monitoring using novel, noninvasive under-mattress sensor technology indicates a global prevalence of moderate to severe OSA of approximately 20%, and that approximately 20% of people diagnosed with a single-night study may be misclassified. These findings highlight the need to consider night-to-night variation in OSA diagnosis and management.

Introduction: Insomnia and obstructive sleep apnoea (OSA) are the two most prevalent sleep disorders, and frequently co-occur (COMISA) in sleep clinic samples. However, few studies have investigated the prevalence or associations of COMISA in the general population., Methods: We used population-based online survey data from 2044 Australian adults. The prevalence and associations of insomnia, OSA and COMISA were investigated according to symptom-level, and disorder-level definitions. Insomnia was defined according to chronic difficulties initiating and/or maintaining sleep (DIMS; symptom-level), and ICSD-3 chronic insomnia disorder (disorder-level). OSA was defined according to self-reported frequent obstructive events, snoring or doctor-diagnosed OSA (symptom-level), and doctor-diagnosed OSA (disorder-level). COMISA was defined if both conditions were met (for symptom-level, and disorder-level threshold). Associations with other conditions, and general health were investigated with Poisson regression analyses., Results: Chronic insomnia occurred more frequently among participants with doctor-diagnosed OSA (22.3%), compared to those without (14.3%, p = 0.010). Doctor-diagnosed OSA was more common among participants with chronic insomnia (10.2%) compared to those without (6.2%; p = 0.010). DIMS also occurred more frequently among participants with OSA symptoms (66.6%), compared to those without (47.2%; p < 0.001). Participants with symptom-level COMISA reported increased co-morbid conditions, and worse general health compared to participants with symptoms of insomnia-alone, OSA-alone, or neither insomnia/OSA., Conclusions: COMISA at symptom and disorder level were common and associated with increased medical and psychiatric co-morbidity, as well as poor general health. More investigation is required to understand bi-directional associations underpinning the high co-morbidity, and improve diagnostic and treatment approaches for COMISA to reduce associated morbidity., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Objective: To assess whether monosodium glutamate (MSG) intake is associated with sleep-disordered breathing (SDB)., Methods: Data from 1227 Chinese subjects who participated in the Jiangsu Nutrition Study were analyzed. All the participants were examined at two time points (baseline in 2002 and follow-up in 2007). The MSG intake was assessed quantitatively in 2002 and a sleep questionnaire was used to assess snoring and to construct an SDB probability score in 2007. Those within the fifth quintile of the score (highest) were defined as having a high probability of SDB., Results: The MSG intake was positively associated with snoring and a high probability of SDB in participants who had a normal body weight but in those who were overweight. A comparison of the extreme quartiles of MSG intake in subjects with a body mass index lower than 23 kg/m² showed an odds ratio of 2.02 (95% confidence interval 1.02-4.00) for snoring and an odds ratio of 3.11 (95% confidence interval 1.10-8.84) for a high probability of SDB. There was a joint effect between MSG and overweight in relation to SDB., Conclusion: The intake of MSG may increase the risk of SDB in Chinese adults with a normal body weight., (Copyright © 2013 Elsevier Inc. All rights reserved.)