Review Outlines Guidance for Military Personnel, Veterans With Sleep Disorders

In 2019, the US Department of Defense (DoD) and Department of Veterans Affairs (VA) approved clinical practice guidelines regarding management and treatment of chronic insomnia disorder and obstructive sleep apnea (OSA) in VA and DoD patients. The VA/DoD Evidence-Based Practice Work Group formulated the framework to enable more effective screening, treatment, and managements of these diseases, according to a review published in Annals of Internal Medicine.

Key recommendations involve diagnosing and assessing OSA and chronic insomnia, along with treatment and management of the diseases. Forty-one recommendations were formulated.

Sleep disorders are more prevalent in military and veteran populations than in the US general population. A recent study looked into the incidence of insomnia and OSA in US Army soldiers between 1997 and 2011. The study authors found “unprecedented increases in the incidence of both conditions (652% and 600%, respectively).” Military personnel with sleep disorders often have comorbidities like posttraumatic stress disorder (PTSD) and traumatic brain injuries.

One study found the number of veterans with diagnosed sleep disorders increased 6-fold between 2000 and 2010. However, the researchers note, “The actual prevalence of insomnia disorder among veterans is likely to be considerably higher because it is often not documented in the medical record.” They continued, “Comorbid PTSD was associated with a 7.6-fold greater risk for OSA and a 6.3-fold greater risk for insomnia.”

To create the guidelines, the VA/DoD Evidence-Based Practice Work Group created a panel of various stakeholders, including physicians of various backgrounds.

For patients with sleep apnea, specific recommendations include:

• Using continuous positive airway pressure (CPAP) therapy during a patient's entire sleep period
• Continued use of CPAP even by patients who do not use it for at least 4 hours per night
• Addressing barriers to CPAP adherence
• Conducting interventions to improve CPAP adherence in patients with sleep apnea and co-occurring PTSD, anxiety, and/or insomnia, as this cohort has higher rates of nonadherence

For patients with chronic insomnia, specific recommendations include:

• Implementing cognitive behavioral therapy or brief behavioral therapy
• Creating habits that improve nighttime sleep quality, such as limiting length of daytime naps and avoiding stimulants close to bedtime
• Avoiding antipsychotic drugs and over-the-counter agents, such as antihistamine and melatonin, as these medications are not helpful for treating chronic insomnia

A lead author of the review, Vincent Mysliwiec, MD, said the guidelines represent “a major step for these two organizations in recognizing the importance of appropriately diagnosing and treating sleep disorders in these unique populations.” He continued, “We expect the guidelines to be far-reaching and lead to necessary changes in clinical practice while helping to determine what clinical and research questions will need to be addressed in military personnel and veterans.”

Reference

Mysliwiec V, Martin JL, Ulmer CS, et al. The management of chronic insomnia disorder and obstructive sleep apnea: Synopsis of the 2019 U.S. department of veterans affairs and U.S. department of defense clinical practice guidelines [published online February 18, 2020]. Ann Intern Med. doi: 10.7326/M19-3575.