Practice Guidelines

Obstructive Sleep Apnea and Chronic Insomnia Disorder: Updated Guidelines from the VA/DoD

 

Am Fam Physician. 2021 Apr 1;103(7):442-443.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• The shorter STOP tool for evaluating OSA is easier to administer than the STOP-BANG criteria but equally sensitive.

• PAP is the most effective OSA treatment, although mandibular advancement devices are easier for patients to use.

• The Insomnia Severity Index and Athens Insomnia Scale are useful to grade insomnia before and after treatment.

• CBT is the most effective treatment for chronic insomnia, whereas sleep hygiene education alone is potentially harmful.

From the AFP Editors

Sleep disturbances are common and likely underdiagnosed. Obstructive sleep apnea (OSA) affects up to 38% of U.S. adults, especially men, postmenopausal women, and people with a higher body mass index. Insomnia symptoms affect up to 30% of U.S. adults, with up to 10% meeting criteria for chronic insomnia disorder. The U.S. Department of Veterans Affairs and Department of Defense (VA/DoD) approved a clinical practice guideline for the management of OSA and chronic insomnia disorder.

Diagnosis of OSA

Testing for sleep apnea should be considered based on clinical risk. The STOP and STOP-BANG criteria had the highest sensitivities for OSA screening, but using the shorter STOP tool (Table 1) is recommended because it is easier to administer. People with cardiovascular or cerebrovascular events, congestive heart failure, or long-term opioid use are considered high risk regardless of STOP score, although the evidence behind this recommendation is weak.

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TABLE 1.

STOP Criteria for OSA Risk

Snoring

Tiredness – fatigue or daytime sleepiness

Observed apnea episodes

Pressure – history of hypertension


Note: 0 to 1 criteria = low risk of OSA; 2 or more criteria = high risk of OSA.

OSA = obstructive sleep apnea.

TABLE 1.

STOP Criteria for OSA Risk

Snoring

Tiredness – fatigue or daytime sleepiness

Observed apnea episodes

Pressure – history of hypertension


Note: 0 to 1 criteria = low risk of OSA; 2 or more criteria = high risk of OSA.

OSA = obstructive sleep apnea.

In-laboratory polysomnography is the standard for diagnosing OSA. The diagnosis can also be made using home sleep apnea testing, with an unattended portable monitor. The home sleep apnea test can report the respiratory disturbance index, respiratory event index, or apnea-hypopnea index; 15 or more events per hour on any one index indicates OSA. Patients with a high risk of OSA and negative home sleep apnea test results should receive repeat testing, with home sleep apnea testing or

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Michael J. Arnold, MD, contributing editor.

A collection of Practice Guidelines published in AFP is available at https://www.aafp.org/afp/practguide.

 

 

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