Co-occurrence of Sleep Disorders With Other Health Conditions

C. Michael Gibson, MD: Ashgan, can you talk to us about special populations? I’m a cardiologist, so I’m concerned about cardiovascular disease. You’re a pulmonologist. Talk to us about that and people with respiratory conditions, neurological conditions, COVID-19, and some chronic inflammatory conditions.

Ashgan A. Elshinawy, DO: I see a lot of patients with chronic obstructive pulmonary disease and interstitial lung disease. A lot of them are on oxygen or noninvasive ventilators at night. I find a problem with their sleep, whether it’s pure insomnia or a comorbid insomnia. I often see sleep disordered breathing. In the cardiovascular group, we see a lot of Cheyne-Stokes respiration. We see a lot of central sleep apnea that complicates the treatment as well. But in my patients with respiratory disease, I see a lot of hyperventilation—people who have much worse oxygenation issues at night than my patients with pure OSA, or obstructive sleep apnea. If somebody has an underlying lung disease and sleep apnea, they’re a little tougher to treat because sometimes they’ll need nonventilation, oxygen therapy, and treatment for their underlying disease. This becomes an issue with insomnia too. Do they have insomnia because of their underlying respiratory issue, inflammatory condition, or fibromyalgia? Is the fibromyalgia making the sleep worse? Which direction is it going? Then the question is, which 1 do you treat? What is the underlying problem? Do you treat both? That’s the challenge we face, and I see plenty of it in my office.

C. Michael Gibson, MD: That’s what I was going to ask. As you just said, which direction is it going in? Could it be bidirectional? Is this a vicious circle?

Ashgan A. Elshinawy, DO: I see that often. To take 1 example of a comorbidity, let’s say someone has generalized anxiety disorder or major depressive disorder. Let’s say they often they sleep poorly, whether it’s quantity or quality of sleep. You try to ask, which came first? It almost doesn’t matter because what we find, and the data support this, is that it’s so important to treat both entities. Treat both disorders separately and equally as opposed to trying to kill 2 birds with 1 stone. You often won’t be successful if you try to do that when it comes to sleep disorders like insomnia and a comorbidity like anxiety, depression, chronic pain, or cancer. You should treat both separately, and both will respond a lot better if you do that.

Nathaniel F. Watson, MD: Those are great points. I totally agree. When we think about it, we spend a third of our life sleeping, so it’s not a stretch to imagine that it impacts, in some way, every aspect of our physiology. Therefore it has an impact on all the diseases that we could potentially suffer from. Pain is another area that’s bidirectional. We know that pain and chronic pain can be disruptive to sleep, and we also know that when you disturb the sleep of a healthy individual, their experience of pain changes. In other words, when you test them with something called dolor imagery, which is applying a painful stimulus to the skin of the individual, they have much less tolerance of that after being sleep deprived than being sleep satiated. We’re talking about bidirectionality. As Dr Elshinawy states, we need to be treating both entities to have maximal treatment success.

Transcript Edited for Clarity