Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older Veterans

Sleep disturbance is common in older adults and is associated with increased healthcare
utilization, more depressive symptoms, and other adverse effects on health-related quality of
life. Obstructive sleep apnea (OSA) is a disorder characterized by repetitive episodes of
complete or partial upper airway obstruction occurring during sleep. OSA increases in
prevalence with age, and is associated with increased risk of cardiovascular disease,
decreased quality of life, and increased mortality. Insomnia also increases in prevalence
with age, and is associated with numerous adverse outcomes, including cognitive decline,
decreased quality of life, increased healthcare costs and increased mortality. The diagnostic
criteria for insomnia include a decreased ability to fall asleep or stay asleep, frequent
nighttime awakening or poor quality sleep that is associated with daytime impairment such as
fatigue, impaired attention, or daytime sleepiness. Increasing evidence suggests that
insomnia often coexists with OSA, particularly in older adults, and predicts worse outcomes
of OSA. Both OSA and insomnia have a higher prevalence among Veterans, compared to the
general population.

Little is known of the best approaches to manage the large number of patients with coexisting
OSA and comorbid insomnia. Guidelines for best practice typically address these conditions
separately, where positive airway pressure (PAP) is the standard for the treatment of OSA,
and cognitive behavioral therapy for insomnia (CBT-I) is considered first-line treatment for
chronic insomnia. CBT-I is particularly recommended for insomnia in older adults, where
adverse effects of sleeping medications are most problematic. Early adherence to PAP therapy
(i.e., within the first week of PAP therapy) is one of the strongest predictors of long-term
PAP adherence. However, adherence rates to PAP therapy in patients with OSA are low. In
addition, CBT-I has not been widely implemented for treatment of insomnia (in part due to
limited access to mental health specialists able to provide CBT-I), untreated OSA limits
response to treatment of insomnia, and untreated insomnia negatively impacts PAP adherence.

Based on this evidence and findings from the investigators' prior work, the investigators
believe that an integrated, behavioral treatment approach which addresses both OSA and
insomnia early in the course of PAP therapy is needed to maximize patient adherence and
treatment success when these conditions coexist. The investigators propose a randomized
controlled trial to test a novel, behavioral approach integrating best practices for
management of both conditions among older Veterans with OSA who are prescribed PAP therapy
and have comorbid insomnia. The purpose of this project is to determine whether this
intervention improves nighttime sleep, PAP adherence, mood and health-related quality of
life.

Inclusion Criteria:

- Meets diagnostic criteria for insomnia

- Diagnosis of obstructive sleep apnea (AHI > or = 15) and prescription of PAP therapy

- Age > or =50

- Community-dwelling

- Live within a 30-mile radius of VA GLAHS

- Have transportation to VA GLAHS to attend the intervention/control programs

Exclusion Criteria:

- Significant cognitive impairment (MMSE < 24)

- History of mania, major psychopathology or a psychiatric hospitalization in prior two
years