Polysomnographic Variables Describing Comorbid Insomnia and Mild

Obstructive Sleep Apnea in Military Personnel as Revealed by Cluster Analysis CPT David Anderson MD; LTC Vincent Mysliwiec, MD; Panagiotis Matsangas, M.Sc; Marquisha Lee, Ph.D; LTC Nici Bothwell, MD; Tristin Baxter, AAS; Bernard Roth, MD Madigan Healthcare System, Tacoma WA

Comorbid Insomnia and OSA Well recognized yet under appreciated clinical entity Estimated prevalence is as high as 55% (1) PSG variables: sleep onset latency (SOL), sleep efficiency (SE) and wakefulness after sleep onset (WASO) when abnormal are consistent with insomnia(2)

Military Significance Military personnel frequently report “sleep disturbances”

Prevalence as high as 80% Etiologies include: sleep disorders (OSA , insomnia),

PTSD, mTBI, anxiety, depression and pain

Hypothesis/Objectives There is a high prevalence of comorbid insomnia and mild OSA in military personnel. 1. Determine prevalence of comorbid insomnia and mild OSA 2. Identify PSG phenotypes of patients with comorbid insomnia

and mild OSA vs. mild OSA alone by cluster analysis

Methods Retrospective cross-sectional cohort study 206 PSGs and linked clinic notes were reviewed to obtain:

Biometric parameters of age, height, weight and BMI along with gender and deployment history

Self-reported sleep and Epworth Sleepiness Scale score Diagnoses of PTSD, mTBI , anxiety and depression Medical co-morbidities

Diagnosis of Insomnia Medical records assessed to determine if they met ICSD-2

criteria for insomnia

Statistical Analysis Cluster analysis, multivariate technique used in exploratory data analysis, implemented using K means method

Utilized all PSG variables Resulted in 3 groups, 2 of which were clinically significant Comparison based on Wilcoxon Rank Sum Test and effect size assessed by Cohen’s d

Results Comorbid Insomnia

195 patients with adequate data to assess for insomnia 11 with inadequate data

167 (81%) were positive PSG variables of interest Cohort Comorbid

SOL ≥ 31 minutes: 18 (8.7%) 17 (10.2%) WASO ≥ 31 minutes: 102 (49.5%) 92 (55.1%) SE < 85%: 35 (17.0%) 32 (19.2%)

Medical comorbidities All patients with anxiety diagnosed with insomnia (37/37) Patients with comorbid insomnia/OSA, 2.49 (1.17-5.28)

more likely to have anxiety Patients with insomnia and Mild OSA are more likely to be in

Cluster 1 (1-sided Fischers exact test p = .009; Odds ratio = 5.27 [1.20-23.1])

Conclusion and Discussion Comorbid insomnia and mild OSA are highly prevalent in the

Active Duty population Higher prevalence than civilian studies Likely due to deployments/comorbid illnesses

Findings from a PSG can indicate the diagnosis of Insomnia even in setting of mild OSA, these include:

Increased WASO (≥ 31 minutes) Decreased sleep efficiency (<85%)

PSG has a role in assessing insomnia Treatment of both OSA and Insomnia is indicated in military

personnel with comorbid disease Continuous positive airway pressure and cognitive

behavioral therapy are recommended

References 1. Okun ML, Kravitz HM, Sowers MF, Moul DE, Buysse DJ, Hall M.. J Clin Sleep Med. 2009 Feb 15;5(1):41-51. 2. Al-Jawder SE, Bahammam AS. Sleep Breath. 2012 Jun;16(2):295-304. 3. Krakow B, Melendrez D, Ferreira E, Clark J, Warner TD, Sisley B, et al. Chest. 2001 Dec;120(6):1923-9. 4. Chung KF.. Respiration. 2005 Sep-Oct;72(5):460-5. 5. Krell SB, Kapur VK. Sleep Breath. 2005 Sep;9(3):104-10.

[n1]These numbers seem reversed: SOL mean should be 14.6minutes with a SD of 11.2 minutes. Does this change any of the analysis?

Abbreviations: OSA – Obstructive Sleep Apnea AHI – Apnea Hypopnea Index CIO – Comorbid Insomnia and OSA PSG – Polysomnography PTSD – Post Traumatic Stress Disorder mTBI – Mild Traumatic Brain Injury

Characteristics of Military Personnel Diagnosed with Mild OSA Characteristics of Military Personnel Diagnosed with Mild OSA Characteristics of Military Personnel Diagnosed with Mild OSA

Demographic Characteristics

Mild OSA Clusters

Disclaimer The opinions and assertions in this manuscript are those of the authors and do not necessarily represent those of the Department of the Army, Department of Defense, US Government, or the Center for

Neuroscience and Regenerative Medicine.

Age 36.2(8.14)

Male,% (No.) 96.6(199)

BMI in Kg/m2 30.3(3.66)

Deployment Status% 85.4(176)

Epworth Sleepiness Scale 12.5(5.06)

Self Reported Home Sleep 5.36(1.7)

Sleep<5 hours, % (No.) 47(95)

Medical Co-morbidity

Anxiety,% (No.) 18(37)

Depression,% (No.) 21.95(45)

PTSD,%(No.) 9.71(20)

mTBI,%(no.) 14.6(30)75

80

85

90

95

100

Cluster 1 Cluster 3

.

.

82%

Diagnosis of Insomnia and Mild OSA

ADSM – Active Duty Service Member ICSD – International Classification of Sleep Disorders BMIT – Body Mass Index SOL – Sleep Onset Latency REM – Rapid Eye Movement TST – Total Sleep Time WASO – Wakefulness After Sleep Onset

PSG variable Cluster 1 (n=52) Cluster 3 (n=150) Wilcoxon Rank Sum Test Cohen’s d

M (SD) M (SD)

SOL n(%) 16.1 (14.5) 8.61 (10.8) X2(1)=15.6, p<0.001* 0.586

REML (min) 140 (87.5) 96.2 (41.9) X2(1)=4.97, p=0.026* 0.639

TST (hrs) 6.28 (0.698) 7.53 (0.526) X2(1)=89.6, p<0.001* 2.02

SE n(%) 82.6 (5.82) 94.7 (2.82) X2(1)=112, p<0.001* 2.65

% I 12.9 (6.14) 8.23 (3.77) X2(1)=25.4, p<0.001* 0.917

% II 40.2 (8.19) 49.6 (9.72) X2(1)=35.1, p<0.001* 1.05

%SWS 15.7 (7.54) 18.1 (8.16) X2(1)=3.02, p=0.082** 0.306

% REM 14.3 (5.44) 18.8 (5.05) X2(1)=27.8, p<0.001* 0.857

WASO n(%) 77.3 (27.7) 24.9 (13.5) X2(1)=103, p<0.001* 2.41

AR 24.9 (8.92) 18.6 (7.34) X2(1)=20.5, p<0.001* 0.771

AHI 8.67 (3.78) 8.30 (2.76) X2(1)=0.673, p>0.400 0.112

% desat 86.4 (3.87) 85.7 (4.39) X2(1)=1.22, p=0.269 0.169 

96%