VA/DoD CLINICAL PRACTICE GUIDELINES The Management of Chronic Module A: Screening for Sleep Disorders Module B: Management of Chronic Insomnia Disorder Insomnia Disorder and 11 Adults with a provisional diagnosis of 15 Adult patient 14 Obstructive Sleep Apnea chronic insomnia disorder Refer to trained CBT-I or BBT-I Did the patient 2 provider, either in-person or using complete CBT-I or Sidebar 1: Clinical Features of OSA and Chronic Insomnia Disorder Does the patient, their bed 12 telehealth BBT-I? 3 OSA (see Appendix D in the full CPG for detailed ICSD -3 diagnostic criteria): partner, or their healthcare No Confirm diagnosis and then use SDM and encourage 20 Initiate short-term Yes • Sleepiness provider have complaints Exit algorithm behaviorally-based interventions for chronic insomnia No and/or concerns about the (i.e., CBT-I or BBT-I) (See Sidebar 3) pharmacotherapy • Loud, bothersome snoring patient’s sleep? treatment and/or CIH • Witnessed apneas 16 Yes 13 Was CBT-I or • Nightly gasping/choking 4 Is the patient ablea and willing Yes BBT-I 2 b • Obesity (BMI >30 kg/m ) Perform a clinical assessment, to complete CBT-I or BBT-I? 21 effective? Yes • Treatment resistant hypertension including use of validated screening No No Did insomnia remit after 17 Chronic Insomnia Disorder (see Appendix D in the full CPG for detailed tools (e.g., ISI and STOP 18 Is short-term pharmacotherapy Yes treatment with CIH or short- ICSD-3 diagnostic criteria): questionnaire) (See Sidebar 1) and/or CIH appropriate? (See Refer to sleep term pharmacotherapy with • Difficulty initiating sleep, difficulty maintaining sleep, or early -morning Sidebars 4 and 5) specialist for further no additional medication No assessment awakenings 6 No 5 19 required? • The sleep disturbance causes clinically significant distress or impairment in Are screening, history, Manage the important areas of functioning and/or physical exam No diagnosed sleep Reassess or reconsider behavioral treatments as needed. • The sleep difficulty occurs at least 3 nights per week suggestive of chronic disorder(s) or Use motivational interviewing to encourage behavioral Yes 22 insomnia disorder or OSA? consider referral to treatments. Follow-up as needed. • The sleep difficulty has been present for at least 3 months Follow-up as needed; encourage attention to (See Sidebar 2) sleep specialist • The sleep difficulty occurs despite adequate opportunity for sleep relapse prevention strategies among those a In cases where the patient requires immediate intervention, providers may exercise clinical judgment to • The insomnia is not better explained by and does not occur exclusively during Yes benefitting from behavioral treatments for 7 determine if pharmacotherapy may be safely initiated. the course of another sleep- w ake disorder b insomnia disorder 10 CBT -I and BBT -I are not equivalent, and there is more robust evidence for CBT -I . While this algorithm uses • The insomnia is not attributable to the physiological effects of a substance Conclude that screening, Continue to OSA CBT -I and BBT -I similarly, providers referring patients for these treatments should consider availability of the • Coexisting mental disorders and/or medical conditions do not adequately history, and/or physical exam Management treatment, the complexity and comorbidities of the patient, and the training of the provider. explain the predominant complaint of insomnia are consistent with OSA, Algorithm (See chronic insomnia disorder, or Module C) Sidebar 3: Components of Sleep Education, Overview of Behavioral Interventions, and Contraindications Sidebar 2: Other Sleep Disorders both Patient education and SDM: Behavioral treatment components (CBT -I and BBT -I): Conditions requiring tailored or delayed • Insufficient sleep syndrome • General information on • Sleep Restriction Therapy: Limits time in bed to actual sleep duration to increase CBT- I : • Restless legs syndrome 9 insomnia disorder sleep drive; time in bed extended across treatment • Medically unstable 8 • Narcolepsy/idiopathic CNS hypersomnia • Education about • Stimulus Control: Strengthens bed as a cue for sleep rather than wakefulness • Active alcohol or drug use disorder Continue to Continue to both OSA • Nightmare disorder behavioral treatment • Relaxation: Reduces physiological arousal and promotes optimal conditions for sleep • Excessive daytime sleepiness Insomnia and Insomnia options • Engaged in exposure -based PTSD • REM sleep behavior disorder • Sleep Hygiene Education : Counseling regarding behaviors that interfere with sleep Management Management • Discussion of treatment treatment • Circadian rhythm sleep disorders Algorithm (See Algorithms (See options (risks, benefits, • Cognitive Restructuring (CBT-I only): Addresses cognitive arousal (busy or racing • Uncontrolled seizure disorder • NREM parasomnias – sleepwalking/sleep eating Module B) Modules B and C) preferences, and mind) by challenging unhelpful thoughts and beliefs about sleep, a natural result of • Bipolar disorder • Central sleep apnea alternatives) the struggle with insomnia • Current acute mental health symptoms VA/DoD CLINICAL PRACTICE GUIDELINES Sidebar 4: Pharmacotherapy Considerations for Chronic Insomnia Disorder Sidebar 7: Comorbidities Module C: Management of Obstructive Sleep Apnea Before starting short -t erm pharmacotherapy, review sleep history, and evaluate • Significant cardiorespiratory disease 23 contraindications for pharmacotherapy: • Cardiovascular comorbidities including congestive heart Patients in whom screening, • Evaluate for other sleep disorders (e.g., apnea, NREM parasomnias), daytime sleepiness, failure history, and/or physical exam 30 suggests OSA respiratory impairment, cognitive impairment, substance abuse history, and medication • Pulmonary comorbidities that impact baseline oxygen Consider alternative interactions saturation (or requiring oxygen therapy) including chronic 24 diagnoses and/or referral to • Encourage non- pharmacologic approaches (e.g., CBT- I or BBT -I) obstructive pulmonary disease: GOLD Stage III or IV Assess risk for OSA (See Sidebar sleep specialist When short -t erm pharmacotherapy is appropriate, consider the following: • Stroke 6) • Low- d ose doxepin; or • Respiratory muscle weakness No 28 29 • Non- b enzodiazepine benzodiazepine receptor agonists (all patients offered treatment with a • Hypoventilation/suspected hypoventilation due to 25 Yes non- b enzodiazepine benzodiazepine receptor agonist should be specifically counseled neuromuscular or pulmonary disorder Does assessment show high No For low risk of OSA, refer Was the study regarding the risk of complex sleep- r elated behaviors) • Opioid use risk for OSA? to in-lab sleep study diagnostic of OSA? The use of antipsychotic agents is NOT suggested for treatment of chronic insomnia • Chronic insomnia Yes disorder. • PTSD 26 31 Consider sleep specialist referral in patients who do not respond to pharmacotherapy. Are comorbidities (See Sidebar 8: AHI 5 – 15 on HSAT Sidebar 7) or military or Refer for home sleep testing Sidebar 5: Other Approaches No 1. Treatment for OSA is recommended for symptomatic patients occupational requirements (if technically inadequate, CIH treatments suggested for chronic insomnia disorder: with an AHI or REI of 5 – 15 events per hour for an in-lab determination of repeat once) (See Sidebar 8) OSA present? • Auricular acupuncture with seed and pellet 2. For patients who will have limitations to their work and/or 33 Other treatments NOT suggested for chronic insomnia disorder: lifestyle, definitive testing with an in -l ab PSG is recommended 32 The event index is 5 – 15 • Alpha -s tim 3. For the general population without such restrictions, an AHI of Yes In patients at high risk events/hour and the patient • Cranial electrical stimulation 5 – 15 events per hour on HSAT should be treated as OSA for OSA, is the AHI meets criteria for treatment • Diphenhydramine Yes <5 events/hour? No (See Sidebar 8), or there is • Melatonin Sidebar 9: Treatment of OSA 27 event index >15 events/hour • Chamomile Refer to in-lab 1. For patients with severe OSA (i.e., AHI >30 events per hour), the • Valerian sleep study recommended initial therapy is PAP CIH treatments NOT recommended for chronic insomnia disorder: 34 2. For patients with mild to moderate OSA (i.e., AHI 5 – <30 events 36 • Kava No per hour), either PAP or MAD therapy can be considered for Was the study OSA is unlikely; consider diagnostic of OSA? alternate diagnoses Sidebar 6: Risk of OSA* initial therapy; choice of treatment should be based on clinical evaluation, comorbidities, and patient preference Consider using STOP questionnaire for risk stratification: 3. Educational, behavioral therapy, and supportive interventions Yes 1. for hypSnoring loudly should be offered to improve PAP adherence Abbreviations: AHI: apnea -h ypopnea index; BMI: body mass index; BBT -I : brief behavioral 2. Tired, fatigue, sleepy in daytime 4. Weight loss and a comprehensive lifestyle intervention program therapy for insomnia; CBT -I : cognitive behavioral therapy for insomnia; CIH: complementary and integrative health; CNS: central nervous system; GOLD: Global Initiative for Chronic Obstructive 3. Observed to stop breathing should be encouraged in all patients with OSA who are 35 4. Treated ertension overweight or obese; while weight loss alone is typically 37 Lung Disease; HSAT: home sleep apnea testing; ICSD -3 : International Classification of Sleep Disorders, 3rd edition; ISI: Insomnia Severity Index; kg/m2: kilograms per meter squared; MAD: High risk if >2 items are answered “yes” insufficient as therapy for OSA, weight loss may result in Initiate appropriate treatments and If the patient is not adherence support; see mandibular advancement device; NREM: non -r apid eye movement; OSA: obstructive sleep Low risk if <2 items are answered “yes” improvement of AHI improving or apnea; PAP: positive airway pressure; PSG: polysomnogram; PTSD: posttraumatic stress Recommendations 7 – 18 in the 5. In those OSA patients who are not adherent to PAP and/or MAD adhering to disorder; REI: respiratory event index; REM: rapid eye movement; SDM: shared decision STOP questionnaire should not replace clinical judgment; clinical assessment should full CPG for choice of treatment, therapy or have persistent symptoms despite adequate therapy, making; STOP: Snoring, Tiredness, Observed apnea, and high blood Pressure include: BMI >30 kg/m2, age >50, menopausal status, neck circumference, family history, improvement of adherence, or treatment, consider referral to a physician with expertise in sleep medicine is and crowded oropharynx alternative treatments (See referral to a sleep Access to the full guideline and additional resources are available at the recommended *i.e., high risk or high pretest probability of OSA Sidebar 9) specialist following link: https://www.healthquality.va.gov/guidelines/cd/insomnia/