Insomnia symptoms in primary care: A prospective study focusing on prevalence of undiagnosed co-morbid sleep disordered breathing

Published:January 24, 2019DOI:


      • High prevalence of OSA (25%) was detected in chronic insomnia patients
      • Chronic diseases are prevalent in patients suffering from sleep disorders
      • Patients with sleep disorders more frequently seek medical assistance
      • Patients with sleep disorders use more of prescription of medications
      • For improved identification and clinical management objective testing is warranted



      To determine prevalence of comorbid undiagnosed sleep disordered breathing (SDB) in chronic insomnia patients, using two complementary methods, one standard and one novel.


      Using prospective design, adult patients diagnosed with chronic insomnia, treated with prescription pharmacological agents for >3 months without prior objective sleep evaluation or diagnosis of SDB were invited to participate. All patients recorded their sleep for two consecutive nights using level 3 home-sleep-apnea-test (HSAT) device to derive Respiratory Event Index (REI) for OSA diagnosis. The electrocardiogram-signal (ECG) recorded by the same device was analyzed using FDA cleared medical software, Cardiopulmonary Coupling (CPC) to quantify sleep time and identify sleep-quality and pathology.


      Of 110 chronic insomnia patients who volunteered between May 2017 and June 2018, 88% were women. Prevalence of moderate-severe SDB (REI > 15) was 25% based on REI-scoring. Surrogate markers of moderate-severe SDB detected by the novel method identified prevalence of 33%, with negative predictive value 96%, reclassifying 10 individuals that HSAT diagnosed with mild SDB with more advanced disease state. Agreement between the methods is 88%.


      High prevalence and overlap in symptoms between insomnia and SDB warrants objective testing when evaluating sleep complaints before therapy is initiated. Diagnostic caution is even more importantly warranted for female patients presenting insomnia sleep complaints, as SDB may not be initially considered as a biological symptom driver. CPC-analysis can complement standard HSAT or serve as a standalone option to evaluate sleep complaints in individuals presenting insomnia symptoms before therapy is initiated.

      Clinical trial registry name and number

      Pilot study: Co-occurrence of Insomnia and Sleep Disordered Breathing (SDB) symptoms: Prospective study focusing on chronic insomnia patients treated with pharmacological agents. Approved by the Bioethics Committee on March 7th, 2017.
      VSNb: 17- 047- S1/ ST - GRA - 17029 – PDX – SH


      AASM (American Academy of Sleep Medicine), CAP (Cyclic Alternating Pattern), CPC (Cardiopulmonary Coupling), CVHR (Cyclic Variation of Heart Rate), EDR (Electrocardiogram Derived Respiration), ECG (Electrocardiogram), EEG (Electroencephalogram), eLFCBB (Elevated Low Frequency Broad-band), eLFCNB (Elevated Low Frequency Narrow-band), FDA (Federal and Drug Administration), HRV (Heart Rate Variability), HIPPA (Health Insurance Portability and Accountability Act), HFC (High Frequency Coupling), LFC (Low Frequency Coupling), HSAT (Home Sleep Apnea Test), NREM (Non-Rapid Eye Movement Sleep), non-CAP (Non-Cyclic Alternating Pattern), OSA (Obstructive Sleep Apnea), PSG (Polysomnography), ROC (Receiver Operating Characteristics), REI (Respiratory Event Index), SAI (Sleep Apnea Indicator), SDB (Sleep Disordered Breathing), SQI (Sleep Quality Index), TST (Total Sleep Time), vLFC (Very Low Frequency Coupling), SaMD (Software as Medical Device)


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