67.1 Chronic Insomnia & Obstructive Sleep Apnea

ABFM Family Medicine Certification Study Guide Exam

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23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

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25 Chapter 25: Hematologic, Urologic & Dental Emergencies

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26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

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28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

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29 Chapter 29: Acute Upper Respiratory Tract Infections

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35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

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36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

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37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

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38 Chapter 38: Acute Infectious Dermatoses

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39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

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41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

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42 Chapter 42: Acute Ambulatory Fractures & Dislocations

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43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

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44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

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45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

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46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

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47 Chapter 47: Acute Women's Health & Early Pregnancy Care

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48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

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51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

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52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

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53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

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54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

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55 Chapter 55: Chronic Endocrine Disorders

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56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea

Key Takeaways Explain This Topic AI

Chronic insomnia disorder requires difficulty initiating or maintaining sleep at least 3 nights per week for at least 3 months with daytime impairment despite adequate sleep opportunity, and it is a clinical diagnosis that does not require polysomnography.

Cognitive behavioral therapy for insomnia is first-line treatment for all adults with chronic insomnia; sleep hygiene education alone is an inadequate monotherapy, and trazodone, diphenhydramine, and melatonin are specifically recommended against.

The apnea-hypopnea index grades obstructive sleep apnea as mild at 5 to under 15 events per hour, moderate at 15 to under 30, and severe at 30 or more; diagnosis requires an index of at least 5 with symptoms or comorbidity, or at least 15 regardless.

The USPSTF issued an I statement in 2022 on screening asymptomatic adults for obstructive sleep apnea, explicitly stating that this is neither a recommendation for nor against screening.

Home sleep apnea testing underestimates the apnea-hypopnea index, so a negative study in a patient with high clinical suspicion, cardiopulmonary disease, neuromuscular disease, stroke, or chronic opioid use requires in-laboratory polysomnography.

Last updated: September 2026

Two Disorders That Share a Complaint

Roughly one adult in three reports insomnia symptoms and roughly one in seven middle-aged adults meets criteria for at least moderate obstructive sleep apnea, yet the two conditions demand opposite first moves: chronic insomnia disorder is treated behaviorally before it is treated pharmacologically, while obstructive sleep apnea (OSA) requires objective testing before it is treated at all. They coexist often enough ( comorbid insomnia and sleep apnea, "COMISA" ) that the safest primary care habit is to screen for both whenever a patient complains of poor sleep or daytime sleepiness.

The distinction the examination rewards is "I cannot sleep" versus "I sleep but I am not rested." Difficulty initiating or maintaining sleep points toward insomnia; loud snoring, witnessed apneas, morning headache, and unrefreshing sleep with excessive daytime somnolence point toward sleep-disordered breathing.

Chronic Insomnia Disorder: Definition and Diagnosis

Chronic insomnia disorder is a clinical diagnosis requiring all of the following:

• Difficulty initiating sleep, maintaining sleep, or waking earlier than desired ;
• Occurring at least 3 nights per week ;
• Persisting for at least 3 months ;

Producing daytime impairment (fatigue, mood disturbance, cognitive complaint, impaired occupational or social function);

Despite adequate opportunity and circumstance for sleep.

That fifth criterion separates insomnia from insufficient sleep syndrome , in which the patient simply does not allow enough time in bed. No sleep study is needed to diagnose insomnia; polysomnography is not indicated for uncomplicated insomnia and is reserved for suspected comorbid sleep apnea, periodic limb movement disorder, or treatment-refractory presentations.

Structured evaluation

Sleep diary for 1 to 2 weeks — the single most useful instrument, capturing bedtime, sleep latency, awakenings, rise time, naps, caffeine, alcohol, and screen use.

Insomnia Severity Index (ISI) — a validated 7-item measure used for baseline severity and treatment response.

Secondary causes to exclude : depression and anxiety, chronic pain, nocturia, gastroesophageal reflux, restless legs syndrome, menopause-associated vasomotor symptoms, and medications (stimulants, bupropion, corticosteroids, beta-agonists, decongestants, evening diuretics, and — paradoxically — alcohol, which shortens latency but fragments the second half of the night).

Treating Chronic Insomnia: Behavior First

Cognitive behavioral therapy for insomnia (CBT-I) is first-line therapy for all adults with chronic insomnia disorder and should be initiated before pharmacotherapy is considered. This is a strong recommendation from the American College of Physicians (2016) and is echoed by the American Academy of Sleep Medicine and the 2025 VA/DoD guideline. Effect sizes match or exceed hypnotics in the short term and, unlike hypnotics, are durable after treatment ends.

CBT-I component What the patient does Mechanism

Stimulus control Bed for sleep and sex only; leave bed after ~20 minutes awake; return only when sleepy; fixed rise time Re-pairs the bed with sleep rather than with wakeful frustration

Sleep restriction Restrict time in bed to actual sleep time (never below ~5.5 hours), then titrate upward as efficiency exceeds 85–90% Builds homeostatic sleep drive and consolidates sleep

Cognitive restructuring Challenge catastrophic beliefs ("I will be useless tomorrow") Reduces performance anxiety about sleeping

Relaxation training Progressive muscle relaxation, diaphragmatic breathing Lowers pre-sleep arousal

Sleep hygiene Caffeine/alcohol timing, light, temperature, screens Adjunct only — sleep hygiene alone is not effective monotherapy

Important

A frequent distractor is offering sleep hygiene education alone as definitive treatment. Sleep hygiene is one component of CBT-I and performs poorly as a stand-alone intervention. Digital and app-delivered CBT-I are acceptable delivery routes when in-person therapy is unavailable, and access limitations are not a reason to skip straight to a hypnotic.

When pharmacotherapy is added

Medication is adjunctive, short-term, and shared-decision territory. AASM gives only weak recommendations for the agents it endorses, and explicitly recommends against several commonly used ones.

Suggested (weak) options : eszopiclone, zolpidem, zaleplon, temazepam, triazolam, low-dose doxepin (sleep maintenance), ramelteon (sleep onset), and dual orexin receptor antagonists ( suvorexant , lemborexant, daridorexant).

Recommended against : trazodone , diphenhydramine and other sedating antihistamines, melatonin, valerian, tiagabine, and L-tryptophan for chronic insomnia — evidence of benefit is insufficient relative to harms.

Older adults : the AGS Beers Criteria designate benzodiazepines and the non-benzodiazepine "Z-drugs" (zolpidem, eszopiclone, zaleplon) as potentially inappropriate , because they increase falls, fractures, delirium, and motor vehicle crashes without meaningful improvement in sleep latency. Anticholinergic antihistamines are likewise Beers-listed. Prescribing zolpidem to a 78-year-old with insomnia is a reliably wrong answer.

Obstructive Sleep Apnea: Pathophysiology and Definitions

OSA is repetitive collapse of the pharyngeal airway during sleep despite continued respiratory effort, producing intermittent hypoxemia, sympathetic surges, and arousals.

Apnea : cessation of airflow for at least 10 seconds .

Hypopnea : at least a 30% reduction in airflow lasting at least 10 seconds accompanied by a ≥3% oxygen desaturation or an arousal.

Apnea–hypopnea index (AHI) : events per hour of sleep.

• AHI (events/hour) Severity
• 5 to < 15 Mild
• 15 to < 30 Moderate
• ≥ 30 Severe

Diagnosis requires an AHI of ≥ 5 with symptoms or relevant comorbidity (sleepiness, unrefreshing sleep, insomnia, gasping, witnessed apnea, hypertension, mood disorder, cognitive dysfunction, coronary disease, atrial fibrillation, heart failure, stroke, or type 2 diabetes) or an AHI of ≥ 15 regardless of symptoms .

Screening: what the USPSTF actually says

The USPSTF concluded in 2022 that the evidence is insufficient (I statement) to assess the balance of benefits and harms of screening asymptomatic adults for OSA — including adults with unrecognized symptoms. The Task Force explicitly noted that an I statement is neither a recommendation for nor against screening, and that clinicians should use judgment for individual patients. This does not apply to symptomatic patients, who should be evaluated on clinical grounds.

STOP-BANG remains the most widely used case-finding instrument in symptomatic or high-risk patients:

• Letter Item
• S S noring loudly
• T T iredness / daytime sleepiness
• O O bserved apneas
• P High blood P ressure
• B B MI > 35 kg/m²
• A A ge > 50 years
• N N eck circumference > 40 cm
• G G ender male

A score of 0–2 is low risk, 3–4 intermediate, and ≥ 5 high risk . The Epworth Sleepiness Scale quantifies subjective sleepiness (score > 10 is abnormal) but does not diagnose OSA.

Testing: Home Study Versus In-Laboratory Polysomnography

Home sleep apnea testing (HSAT) is appropriate for uncomplicated adults with a high pretest probability of moderate-to-severe OSA. In-laboratory polysomnography (PSG) is preferred — and an HSAT should not be substituted — when any of the following are present:

Significant cardiopulmonary disease (advanced heart failure, moderate-to-severe COPD, suspected hypoventilation or hypoxemic disease);

• Neuromuscular disease or advanced primary neurologic disease;
• Chronic opioid or sedative-hypnotic use;
• History of stroke ;
• Significant chronic insomnia or other sleep disruption that undermines the recording;
• Suspected central sleep apnea , narcolepsy, or parasomnia;

Low pretest probability , or a negative/technically inadequate HSAT in a patient with persistent clinical suspicion — this last scenario is the classic stem, and the correct answer is in-laboratory PSG, not repeat HSAT or empiric CPAP.

Because HSAT records time recorded rather than true sleep time, it reports a respiratory event index (REI) that systematically underestimates the AHI. A negative home study therefore never excludes OSA.

Treatment of OSA

Positive airway pressure (PAP) is first-line for moderate-to-severe OSA and for symptomatic mild OSA. Auto-titrating CPAP is acceptable for uncomplicated OSA; in-laboratory titration is used for complex patients. Adherence is the outcome that matters — troubleshoot mask fit, nasal congestion, aerophagia, and claustrophobia rather than abandoning therapy.

Weight management is disease-modifying, not merely supportive; clinically meaningful weight loss lowers AHI, and bariatric surgery or incretin-based pharmacotherapy is reasonable in eligible patients with obesity.

Mandibular advancement devices are a reasonable alternative for mild-to-moderate OSA or for PAP-intolerant patients.

Positional therapy helps supine-predominant disease.

Hypoglossal nerve stimulation is an option for selected PAP-intolerant adults with moderate-to-severe OSA within device-specific AHI and BMI limits.

Avoid evening alcohol, benzodiazepines, and opioids, all of which worsen upper-airway collapsibility and blunt arousal.

Consequences the examination expects you to connect

OSA is the most common identifiable cause of secondary and resistant hypertension — a patient on three antihypertensives with a non-dipping nocturnal profile should be evaluated for OSA before further drug escalation.

Associations include atrial fibrillation recurrence after cardioversion or ablation , heart failure, pulmonary hypertension, stroke, insulin resistance, and perioperative respiratory complications.

Occupational safety : untreated moderate-to-severe OSA with excessive sleepiness carries clear drowsy-driving risk. Commercial drivers and other safety-sensitive workers require documented evaluation and treatment adherence, and clinicians should counsel all sleepy patients about driving.

Board Exam Traps

Chronic insomnia in a 70-year-old → CBT-I, not zolpidem (Beers-listed) and not trazodone (recommended against).

"Sleep hygiene handout" offered as the definitive treatment → insufficient as monotherapy.

Resistant hypertension plus loud snoring → test for OSA before adding a fourth antihypertensive.

Negative home sleep apnea test with high clinical suspicion → in-laboratory polysomnography, because HSAT underestimates AHI.

Asymptomatic adult, no complaints, request to "screen for sleep apnea" → USPSTF I statement; there is no graded screening recommendation.

Patient on chronic opioids or with advanced heart failure needing OSA testing → in-laboratory PSG, not HSAT.