National Guide

Chapter 2 | Healthy living and health risks

Sleep







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      3. Sleep

Healthy living and health risks | Sleep

Dr Sarah Blunden, Dr Stephanie Yiallourou, A/Prof Fatima Yaqoot, A/Prof Subash Heraganahally 

Key messages

  • Good-quality sleep is fundamental to good health and wellbeing. Sleep affects all mental and physical health conditions, and improving sleep can improve mental and physical health.1–3
  • Sleep disorders are more common in Aboriginal and Torres Strait Islander populations compared with non-Indigenous Australians.4,5
  • Sleep disorders are more harmful in populations who experience disadvantage within social determinants of health and for people with chronic conditions.1,6,7 Health literacy in Aboriginal and Torres Strait Islander peoples cannot be assumed, especially in rural and remote populations.9
  • Conditions and behaviours that support healthy and good-quality sleep, such as a quiet, calm and a safe sleeping space, may not be accessible or modifiable for everyone and need to be considered in assessing and advising on sleep.10–12
  • To date, there have been no recommendations about screening for sleep disorders for Aboriginal and Torres Strait Islander people in a primary care setting, which obviously contributes to underdiagnosis of sleep disorders.13 Asking about sleep should be part of any general health assessment, especially where sleep issues are identified by the patient.
  • The use of validated screening tools for obstructive sleep apnoea (OSA)14 and insomnia15–18 is recommended, noting few have been specifically validated in Aboriginal and Torres Strait Islander populations.
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
People with a family history of sleep disorders such as OSA syndrome (OSAS), restless legs syndrome (RLS), non-rapid eye movement (NREM) parasomnias, insomnia Use early detection strategies and detailed history taking As clinically indicated when family history of sleep disorders is detected Good practice point International position statement1
Narrative review20		 OSA, RLS, NREM parasomnias, obesity and some forms of insomnia have genetic components
Children with snoring or noisy breathing during sleep (see Table 1) Assess for OSA (See Box 1)
Refer to paediatric ear, nose and throat (ENT), sleep or respiratory specialist if apnoea suspected		 As clinically indicated Strong Paediatric OSA update17
Single study21
Recent paediatric OSA and sleep quality studies22–24		 In children, snoring even without obstructed breathing is considered an indicator of sleep disordered breathing
Adults presenting with snoring, witnessed apnoea by bed partners and/or excessive daytime sleepiness (see Table 1) Assess for OSA, refer directly for sleep study if the patient qualifies (ie positive result on OSA50, STOP-BANG and Epworth Sleepiness Scale [ESS] score >8)
Consider referral to sleep specialist
Provide advice on healthy weight and exercise		 As clinically indicated Strong Narrative review25
Single study 26		 OSAS is a risk factor for stroke, diabetes, metabolic syndrome, appetite dysregulation

OSAS is not always related to overweight/obese patients
All people who present with sleep problems

Note sleep disturbance in children is usually reported by parents		 Assess sleep disorders through age-appropriate sleepiness and/or specific sleep-disorder questionnaires for adults, adolescents and children (see Box 1) As clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific studies27,28
Narrative reviews14,29
Scoping review30		 Anxiety and mood disorders are common causes of insomnia and daytime sleepiness

Sleep disturbance in children may be related to high stress, postnatal depression in parents and risk of overmedication and child maltreatment (eg head trauma due to shaking)
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Adults with insomnia Provide information about healthy sleep behaviours (see Box 2)

Assess the use of substances that could affect sleep, including alcohol, drinks containing caffeine/stimulants and recreational drug use

Consider referral for cognitive behavioural therapy (CBT) if appropriate and available (see Useful resources)		 Opportunistically, when unhealthy sleep behaviours are identified and with presentations of sleepiness Strong Single study32
Aboriginal and Torres Strait Islander-specific study33
Narrative reviews15,16
Randomised control trial34		 Health risk behaviours that negatively affect sleep onset and maintenance can be changed

International bodies recommend CBT for insomnia (CBT-i) as the first-line treatment for patients with insomnia disorder
Adults with situational factors that commonly affect sleep:
  • shift workers
  • pregnant women
 Promote good sleep health behaviours (see Box 2)
Refer to a psychologist specialising in behavioural and circadian sleep disorders		 Opportunistically and when presenting with fatigue Strong Systematic review35
International consensus statement36		 Evidence is strong for the detrimental effect of shift work and disrupted circadian rhythms, particularly rotating shift work, on both physical and mental health

Sleep in pregnancy is related to birth outcomes and maternal health in the postpartum period
Type of preventive activity - Medication
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
In adults, adolescents and neurodiverse children with poor sleep (see Box 3) Assess criteria for age-appropriate dosage and timing for prescribing melatonin

Note melatonin is accessible for adults aged >55 years over the counter		 As clinically indicated Conditional Narrative review38
TGA report39		 In adults, data suggest melatonin is safe and effective when prescribed by a medical practitioner

Data for short use and use up to two years duration suggest melatonin is safe and effective, but for those aged under two  years and for use greater than two years duration there are very little data

The safety of melatonin purchased online is unclear and it is not recommended
Children with reduced sleep duration or quality who are on track developmentally (typically developing) Recommend behavioural sleep strategies as first line of treatment

Melatonin is not recommended by the Therapeutic Goods Administration (TGA) for sleep problems in typically developing children		 As clinically indicated Strong Narrative review29
Scoping review30
TGA report 39
Single study40		 Recommendation not to use melatonin in typically developing children is strong because sleep can be improved with behavioural sleep strategies and there is little to no safety data for children
 

Box 1. Assessment: Initial generic screening tools and questionnaires for specific sleep disorders
Screening tools and questionnaires used to screen for and assess symptoms of sleep problems are listed below. Screening is undertaken through clinical interview and the use of questionnaires. Screening questionnaires are either: (i) culturally grounded (CG), that is codesigned with input from Aboriginal and/or Torres Strait Islander stakeholders; (ii) culturally adapted (CA), that is not codesigned but adapted for Aboriginal and/or Torres Strait populations; or (iii) not adapted at all (NA), that is no cultural adaptation for use with Aboriginal and/or Torres Strait populations.
 
In primary care during clinical history taking, the following tools can be used initially to alert the GP to generic symptoms of sleep problems or poor sleep health.
 
Initial generic sleep assessment tools
  • General sleep health and sleep behaviours
    • For children: BEARS screening instrument for children17 (NA)
    • For adults and adolescents: The Sleep Hygiene Index (NA)
    • Let’s Yarn About Sleep (CG) – this was co-developed with Aboriginal and Torres Strait Islander community members in Queensland
  • Sleepiness
 Assess sleeping environment, evaluate sleeping and housing arrangements
 
Screening questionnaires for specific sleep disorders

Subsequent to the initial assessment, the following screening questionnaires can be used to assess for specific sleep disorders:
  •  Let’s Yarn About Sleep: standard sleep diary developed for Aboriginal and Torres Strait Islander youth (CG)
  • Let’s Yarn About Sleep: sleep health assessment (CG)
  • The Sleep Disturbance Scale for Children and Adolescents (NA) and a version for preschoolers (NA)
  • For adult OSA and sleep breathing disorders: STOP-BANG OSA screening questionnaire (NA)
  • For adults: Insomnia Severity Index, recognised as a diagnostic tool for insomnia severity (NA), and the Screening Condition Indicator (NA)
 
Box 2. Advice for healthy sleep behaviours (also called ‘sleep hygiene’)
Note, many of these factors are inter-related.
Physiological risk factors
  • Avoid caffeine, tobacco and alcohol within four hours of going to bed
  • Manage/aim for healthy weight and diet1
  • Treat comorbid conditions (eg asthma, allergies)
  • Minimise light exposure to the eyes in the evening and maximise light exposure in the morning2
Psychological risk factors
  • Monitor sleepiness, discuss sleep-related concerns and seek help
  • Treat comorbid mental health issues
  • Practice stress reduction techniques (eg breathing, relaxation, mindfulness)
Behavioural/lifestyle solutions
  • Keep bedtimes and wake times consistent across weekdays and weekends; do not sleep in more than 1.5–2 hours on weekends (particularly adults and adolescents)
  •  Exercise daily; note, if exercising outside, morning light exposure supports good sleep maximises the best light1,2
  • Avoid screens, particularly tablets and mobile phones, for at least one hour before bed
  • Develop calming and consistent bedtime routines, especially in children2
Situational
  • Plan scheduled napping for shift work
  • Plan power naps if they are/you find them beneficial
  • Ensure safe, quiet and darkened rooms for children’s sleep2
Social determinants/psychosocial solutions
  • Check for safe sleeping in infants and toddlers2
  • Seek safe sleep spaces
  • Consider family and kinship needs

Box 3. Factors contributing to poor sleep health/sleep disorders and reduced sleep duration
Physiological factors
  • Family history (OSAS, RLS or insomnia)
  • Neurodevelopmental disorders (eg autism spectrum disorders, attention deficit hyperactivity disorder, some chromosomal syndromes)
  • Eczema, asthma, allergies
  • Chronic health conditions (eg depression, diabetes, obesity)
  • Enlarged tonsils and/or adenoids in children (OSA)
Psychological factors
  • Emotional and financial stress
  • Poor mental health, especially anxiety, depression and suicidality
  • Parenting style and individual temperaments
Behavioural/lifestyle factors
  • Irregular bed- and wake times
  • Reduced exercise
  • Reduced sunlight exposure, especially in the morning
  • Caffeine and alcohol close to bedtime
  • Excessive screen use and exposure to bright lights at night or before bedtime
  • Eating large meals close to bedtime
 Situational factors
  • Shift work
  • Pregnancy
Social determinants/psychosocial factors
  • Remoteness
  • Racism and dispossession
  • Overcrowded housing
  • Socioeconomic status
  • Lack of safe and clean sleeping spaces
  • Lack of culturally specific diagnostic and management pathways
Table 1. Common sleep disorders in the general population4,22,25,41
Sleep disorder Approximate prevalence in typically developing (ie developmentally on track) individuals (%)
  Children Adults Aboriginal and Torres Strait Islander childrenA Aboriginal and Torres Strait Islander adultsA
OSA 1–5 6–20 6–51 39–46
Insomnia 20–30 30–35 15–34 15–41
RLS 1–3 14–20 Unknown Unknown
Periodic limb movement disorder Rare 4–11 Unknown Unknown
Narcolepsy 0.002 0.5–3 Unknown Unknown
Parasomnias (sleepwalking, night terrors) 14–16 1.7 Unknown Unknown
Rhythmic movement disorders (eg rocking, head banging) 2–19 Rare Unknown Unknown
Circadian rhythm disorders 5–60 10–50 Unknown Unknown
ANote, based on limited data in Aboriginal and Torres Strait Islander populations.
OSA, obstructive sleep apnoea; RLS, restless legs syndrome.
 

Resources are marked as either CG (culturally grounded), CA (culturally adapted) or NA (not adapted).
Although there is generally a lack of CG resources for the screening and diagnosis of sleep issues in Aboriginal and Torres Strait Islander people, the Let’s Yarn About Sleep program has developed a suite of screening and educational resources publicly available through the program website and the Sleep Health Foundation.
 
Patient and family resources

Other resources

Background

Sleep is considered one of the main pillars of health, alongside good nutrition and physical activity.1 Good sleep is important for physical, mental and emotional wellbeing. In terms of physical health, sleep serves as a restorative process for muscle growth and tissue repair, and supports and strengthens the immune system.3,42 Adequate sleep is also vital for optimal cardiometabolic health, the metabolism of blood sugars and lipids, blood pressure control and the regulation of stress and appetite hormones.32,42 It is widely recognised that sleep is essential for good brain health and function, and that sleep plays an important role in cognitive processing, particularly learning and memory consolidation, and emotional regulation.43 In addition, metabolic waste products that build throughout the day that can be toxic to the brain (eg those involved in Alzheimer’s disease), are flushed out during sleep.33

In summary, there is substantial evidence that sleep is involved in almost every body system and understanding of how healthy sleep is fundamental to both health and wellbeing is growing.1 In this topic, the sleep health information presented is based on what is known about the two most common sleep disorders experienced by Australians, namely OSA and insomnia. Information is also provided on behavioural sleep disorders and, to a lesser extent, disorders of disrupted circadian rhythm (eg delayed or advanced sleep phase). Most of the evidence and discussion is general in nature because there is very little published data specifically on Aboriginal and Torres Strait Islander sleep health and a lack of culturally adapted tools to screen for sleep problems.

Common sleep problems and their impact on health and wellbeing

An estimated 1.9 million Australians were reported to have had a sleep disorder in 2019–20.2,44 This is of major concern, given the role sleep plays in mental health, cardiometabolic function, immune health and brain health.1 Insufficient or fragmented sleep can lead to both physiological and psychological health problems, as well as to impairments in daytime functioning. Excessive daytime sleepiness can increase the risk of road and workplace accidents.2 Poor sleep quantity and quality are also associated with cognitive impairment45 and depression.46 In adults, poor sleep is associated with an increased risk of obesity, diabetes, hypertension, cardiovascular disease, dementia and mortality, and is highly comorbid with mental health problems.1,2 In children, sleep dysfunction can be associated with increased cardiometabolic risk,24,47 altered mood, behavioural problems and poor school performance.23,48,49 Poor sleep in childhood is more likely to result in poor sleep in adolescence and adulthood. The importance of establishing good sleep in childhood is a priority.29

Although a range of sleep disorders are likely to present in primary care settings (see Table 1), the most prevalent sleep problems identified are OSA, which is a physiological sleep disorder, and insomnia, which is a behavioural sleep disorder. OSA is a condition causing repetitive episodes of partial or complete upper airway obstruction during sleep, leading to hypoxia and/or sleep disturbance, with significant daytime sequelae, and affects up to 20% of adults41 and 1–5% of children.25,41 Insomnia disorder is characterised by difficulties initiating or maintaining sleep in the absence of a physiological aetiology and despite adequate sleep opportunity, and is accompanied by daytime impairment.50 Insomnia symptoms consistent with the diagnosis of insomnia disorder occur in 15–20% of adults.44 Behavioural insomnia of childhood occurs in 20–30% of children,29,51 and includes trouble getting into bed and settling into sleep, waking up at night, getting up in the morning and/or not getting enough sleep.51

Sleep problems in Aboriginal and Torres Strait Islander populations

Aboriginal and Torres Strait Islander people experience higher rates of sleep problems than non-Indigenous Australians.10 The recent report published by the Australasian Sleep Association (ASA) on sleep health in Aboriginal and Torres Strait Islander populations4 provides a review on the current data available for the prevalence of sleep problems. There are limited published data available on the impact of poor sleep on health and wellbeing in Aboriginal and Torres Strait Islander peoples. Available data for Aboriginal and Torres Strait Islander adults show that short sleep duration (less than six hours per night) and disrupted sleep (a high number of awakenings throughout the night) were associated with higher blood pressure and blood sugar levels, respectively.6 Aboriginal and Torres Strait Islander people with OSA had a high prevalence of co-existing cardiac diseases (47%), with coronary artery disease being the most common (27%).52 Studies in Aboriginal and Torres Strait Islander children indicate that inadequate sleep (quality and duration) was associated with obesity53,54 and poorer academic performance,23,48,49 emotional regulation and behavioural outcomes.49

Aboriginal and Torres Strait Islander populations have a high prevalence of chronic disease and mental health problems.11,12,55 Insufficient sleep is likely to impact these conditions. Improving sleep may contribute to improving the overall health and wellbeing in Aboriginal and Torres Strait Islander people,6 but is often not prioritised in primary care in the face of other competing health issues.

Children

Obstructive sleep apnoea

The most common cause of OSA in children is enlarged adenoids and tonsils.8 In a systematic review of the limited literature on sleep and Aboriginal and Torres Strait Islander children, up to 14.2% report snoring, and one of every five children and adolescents had excessive daytime sleepiness (Sleep Disturbance Scale for Children, T score >60).22 Snoring is a strong indicator that sleep disordered breathing may be present and should be investigated. Although obesity is a risk factor for OSA in children, failure to gain weight is also an indication for suspected OSA.8 Other contributors in children include enlargement of lymphoid tissue in the pharynx and upper airway, allergic rhinitis or other nasal obstructions and other medical conditions (eg conditions associated with weakness, hypotonia, craniofacial abnormalities including retro/micrognathia, previous upper airway surgery and Down syndrome or achondroplasia).8

In children, a diagnosis of OSA is based on patient history, physical examination and the use of questionnaires. OSA can be confirmed with a sleep study (polysomnography [PSG]) via referral to a sleep centre or specialist sleep paediatrician. For children, depending on the cause, treatments include adenotonsillectomy, the use of nasal steroids and, less commonly, continuous positive airway pressure (CPAP) or bilevel positive airway pressure.8

Insomnia

Almost one-quarter (22%) of Aboriginal and Torres Strait Islander children experience insomnia-related symptoms and just over 10% of school-aged Aboriginal and Torres Strait Islander children do not obtain a sufficient amount of sleep.22 For young children, factors that predispose to insomnia include a child’s temperament, pre-existing conditions (eg neurodevelopmental disorders), anxiety and/or mood disorders, circadian rhythms disturbance (eg a delay in bed- and wake times), sharing a room with others and exposure to adverse experiences (eg family violence).29 Factors that may affect parental or caregiver bed-time limit setting (eg mental illness, emotional and financial stress, parenting styles, overcrowding) may also contribute to behavioural sleep problems in children.29 Excessive media/screen use, especially portable technologies and particularly in older children and adolescents, are known to predispose to problems initiating sleep, being associated with delayed bedtimes and shorter total sleep time.31

In children, insomnia is defined as symptoms of difficulty initiating and maintaining sleep at least three times a week for one month or longer, and is generally diagnosed by screening tools available for children (see Useful resources and Box 1).

Insomnia in children can be effectively treated by referral to psychologists trained in this area. The management of behavioural sleep problems includes setting consistent bedtime routines, good sleep habits and limiting screen time exposure.31 Medication for sleep should only be considered if behavioural strategies and attempts at good sleep hygiene have failed (see Box 2).

Adults

Obstructive sleep apnoea

Studies in Aboriginal and Torres Strait Islander populations indicate that one in five adults experience excessive daytime sleepiness, up to 35% sleep less than seven hours per night and over 50% self-report snoring.10 In those who are referred for suspected OSA, symptom severity is worse among Aboriginal and Torres Strait Islander than non-Indigenous Australians, with a higher proportion (46%) of Aboriginal and Torres Strait Islander people diagnosed with severe OSA (apnoea–hypopnoea index >30/h) than non-Indigenous Australians (31%).5 In adults, obesity is the primary risk factor for OSA and factors such as age, sex, craniofacial morphology and upper airway structure and neuromuscular control also play a role.41,52

OSA is confirmed by PSG after suspicion of OSA based on history, examination and OSA screening questionnaires. Screening tools for adult OSA include validated questionnaires, such as STOP-BANG and OSA50. Some common symptoms are loud snoring, stopping breathing noticed bed partners, choking, nocturia and waking up frequently during sleep. During the daytime, symptoms include, fatigue, excessive daytime sleepiness, depression and impaired concentration, memory and other executive functions.52 The risk for the presence of OSA can be assessed on physical examination (body mass index >30 kg/m2, neck circumference >42 cm).14 Confirmation of suspected OSA often requires an overnight sleep study (PSG; see Assessment of adults, Obstructive sleep apnoea below) Treatment for OSA can include weight loss, CPAP, mandibular advancement splint, positional therapy and surgery.14 Two relevant resources are the ASA guidelines for primary care and a dedicated edition on sleep disorders in the Medical Journal of Australia (see Useful resources).

Insomnia

Like children, a diagnosis of insomnia in adults is made by using screening questionnaires (seeTable 1) and based on reported difficulties initiating or maintaining sleep and/or early morning awakening with an inability to return to sleep for at least three nights a week for three months or more despite adequate opportunity for sleep.16 Predisposing risk factors include increased anxiety and mood disorders, stress or worry, inappropriate expectations about sleep and genetically determined factors.15 There are also known precipitating factors that initiate insomnia (eg stressful life events, shift work, environmental issues [such as noise disturbance] and lifestyle factors [such as caffeine or alcohol consumption]).44 Insomnia can be a short-term or chronic condition. Identified biological factors that increase the risk of sleep problems include age, sex, body mass index and chronic illness.15 There are also social determinants that influence sleep among Aboriginal and Torres Strait Islander peoples, such as level of remoteness, access to services, racism, socioeconomic status and housing.4 Joint RACGP and ASA guidelines for primary care of adult insomnia have been recently published (see Useful resources).

For adults with insomnia, first-line treatment includes non-pharmacological therapy such as brief behavioural therapy and CBT-i, either face to face, in groups or online by clinicians or psychologists trained in behavioural sleep medicine.16,34,56 The management of sleep hygiene and bedtime behaviours includes setting consistent sleep and wake times, reducing caffeine and alcohol intake and limiting stress and screen time exposure.16 Medication for sleep should only be considered if behavioural strategies and attempts at good sleep hygiene have failed. Pharmacological intervention is necessary in some circumstances, but should be limited to the lowest necessary dose and shortest necessary duration.38 Gold-standard treatment is usually CBT-i alone initially if possible (behavioural and psychological sleep interventions), and in combination with sleep medications in specific circumstances. Once the behavioural sleep interventions have been integrated into a patient’s lifestyle, medications can safely be ceased.34 It is also important to note is that a significant proportion of patients may present with both OSA and insomnia, known as COMISA (comorbid insomnia and sleep apnoea). COMISA symptoms are associated with high rates of medical and psychiatric comorbidity and reduced general health. Screening of each disorder in the presence of the other is highly recommended.57,58

Preventive strategies for sleep problems within the primary care setting start by understanding the causes of and contributors to sleep problems in general (see Box 3), as well as those experienced by Aboriginal and Torres Strait Islander patients particularly, and then by risk factor management (see Box 4).

The prevention of sleep disorders starts with recognising that sleep is foundational to health and wellbeing, that it is related to all physical and mental health and that it should be taken seriously because of these facts. Normalising discussions about sleep health and the importance of good sleep is important for all GPs within healthcare settings by initiating and including these discussions in initial and ongoing assessment, as well as in conversations with families and individuals. Aboriginal and Torres Strait Islander people may not always view or understand sleep in the same way as non-Indigenous Australians, so these initial discussions with a GP are especially important. This means culturally appropriate screening tools for sleep problems in Aboriginal and Torres Strait Islander peoples are needed. This is a significant gap in sleep healthcare, although there are some emerging materials being developed (eg TESS; see Useful resources.28 If possible, screening tools should be delivered with the assistance of Aboriginal health practitioners/health workers to aid in translation and the culturally appropriate delivery of questionnaires. Furthermore, means to improve OSA risk and sleep health habits should take into consideration cultural safety and the appropriateness of recommendations, and be inclusive of Aboriginal and Torres Strait Islander people knowledge (eg using online resources to promote relaxation prior to bedtime that have been developed by Aboriginal and Torres Strait Islander people; see Useful resources). Several sleep resources have been developed for Australian healthcare professionals, including GPs, but none of these include culturally appropriate resources (see Useful resources). The lack of culturally specific sleep resources, diagnostic tools and management pathways are a major barrier for primary care in assessing and managing sleep health, and there is great need for further research in this area. The identification of enablers and barriers to sleep health care, informed by community members, as well as programs codesigned from the outset for health service delivery, is likely to improve sleep health in Aboriginal and Torres Strait islander populations.

Assessment in children

Obstructive sleep apnoea

Parents/carers may not mention snoring and sleep problems in children unless specifically asked. If indicated, simple questions asking about noisy breathing during sleep and screening for enlarged tonsils or adenoids is recommended.8,19 Other features that may alert to the presence of OSA include unrefreshing sleep despite a seemingly adequate quantity of sleep (wakes tired and grumpy), waking with a dry mouth, secondary enuresis and poor weight gain.19 Symptoms of OSA should be considered in any child who presents even with mild snoring, with enlarged tonsils and/or disturbed or unrefreshing sleep.8,19 Screening questionnaires that identify symptoms of OSA in children are available, although they have not been culturally validated (see Box 1). Assessment of the presence or severity of OSA in children is confirmed with a sleep study (PSG), which involves non-invasively monitoring multiple physiological channels to record sleep and cardiorespiratory parameters. Sleep studies can be arranged through referral to a paediatric sleep centre or specialist sleep paediatrician, and parents can stay with the child overnight. Although PSG is the gold standard for sleep assessment, alternative sleep tests, including abbreviated studies with limited channels performed at home, show promise, with overnight oximetry having a strong predictive value for OSA.19

Insomnia

For children with reported or suspected behavioural insomnia of childhood, taking at least a 24-hour sleep history is a useful approach (refer to Useful resources).51,59 Screening questionnaires used to identify symptoms of insomnia in primary care can include the Sleep Disturbance Scale for Children,18 and the BEARS (Bedtime issues, Excessive daytime sleepiness, night Awakenings, Regularity and duration of sleep, Snoring)17 (see Box 1). These questionnaires can differentiate physiological sleep problems (such as snoring) from behavioural sleep problems indicative of insomnia. However, none of these questionnaires has been validated in Aboriginal or Torres Strait Islander populations. Newly available Let’s Yarn About Sleep sleep health assessments and sleep diaries for Aboriginal and Torres Strait Islander adolescents have been developed in consultation with Aboriginal or Torres Strait Islander communities (see Useful resources). For children who are presenting with insomnia symptoms, providing advice about healthy sleep behaviours is recommended (Box 2; see Useful resources).

Assessment in adults

Obstructive sleep apnoea

If a patient presents with excessive daytime sleepiness, snoring or overnight gasping for breath, an assessment for OSA should be undertaken. To assess daytime sleepiness, the ESS has recently been adapted for Aboriginal and Torres Strait Islander adults, the Top End Sleepiness Scale (TESS).28 The TESS uses a pictorial version, and although validated in communities in Northern Territory, may also be adapted to other communities, where appropriate,28 and may be most helpful with patients from remote locations. For suspected OSA, validated screening tools that align with Medicare OSA screening questionnaires include the OSA50, ESS and STOP-BANG with a detailed medical history (for detailed screening recommendations, see Useful resources for RACGP-endorsed primary care resources for OSA) with modifications available for adolescents. To confirm the presence of OSA, a diagnostic sleep study should be facilitated through the sleep specialist/physician/clinic.

Assessment of risk factors for OSA is also recommended. These are presented in Box 4 and included here.14 For example, alcohol use worsens the severity of OSA, with more respiratory events accompanied by greater falls in blood oxygen levels throughout the night, and increases sleepiness.60 In untreated OSA, it is recommended to avoid alcohol. Being overweight/obese increases the risk of OSA in adults, although less so in children. Weight loss decreases the severity of OSA, with studies showing that a 10% weight loss predicted an approximate 26% decrease in OSA severity.61

A non-supine sleeping position may be beneficial in patients with OSA, especially if the patient reports experiencing significant symptoms or this is determined using PSG information. Compared with the supine position, a non-supine sleeping position decreases the number of respiratory events.62

To confirm the presence of OSA, referral to a sleep specialist/physician/clinic for a diagnostic PSG sleep study should be facilitated. A PSG is conducted either in a sleep laboratory or increasingly via a home-based study. In-laboratory PSG is performed with a sleep scientist in attendance throughout the night. However, in-laboratory PSG can be costly, with long wait lists, and is not always accessible to or suitable for those living in regional and remote areas. Accordingly, portable home sleep study testing (set up by a sleep scientist or by a patient if possible), which shows reasonable diagnostic accuracy, is receiving more attention and may be beneficial for patients to reduce wait times and increase patient comfort, and may be more suitable for patients residing in rural/remote communities. There are four types of sleep studies:

  • Type 1: Full PSG in a sleep laboratory, attended by a sleep scientist, comprising seven or more channels (gold standard)
  • Type 2: Full PSG at home, unattended by a sleep scientist, comprising seven or more channels (most robust home sleep study)
  • Type 3: Portable testing at home, attended or unattended by a sleep scientist, comprising three to six channels
  • Type 4: Portable testing at home, unattended by sleep scientist, comprising one to two channels.

Detailed guidelines are available at the ASA website to inform decisions regarding the type of sleep studies best suited for patients.

For patients diagnosed as having symptomatic or significant OSA, avenues to facilitate CPAP therapy should be explored, including ongoing monitoring, compliance assessment and adherence to therapy.

Insomnia

For adults with suspected insomnia, questionnaires such as the Screening Condition Indicator or the Insomnia Severity Index (see Box 1) are recommended with modifications for adolescents (see RACGP-endorsed primary care resources for insomnia in Useful resources for a full list of screening recommendations). Seeking information about patients’ (un)healthy sleep behaviours is important but is not effective as a standalone avenue for treatment. Referral to practitioners of CBT-i would formalise whether the insomnia is a sleep initiation (getting to sleep) or a sleep maintenance (staying asleep) problem. GPs can assess any potential benefits of short-term medication for adults presenting with symptoms of acute insomnia (in concert with education about healthy sleep behaviours; see Box 2).15,16 However, the use of short-term medication must be closely monitored. Checking for comorbidity of OSA may also be appropriate.58

 

Box 4. Primary care recommendations for the ongoing prevention and management of the risk factors for obstructive sleep apnoea (OSA) and insomnia in adults8
For detailed recommendations, refer to Obstructive Sleep Apnoea - Management of Risk Factors
  • Limit the use of alcohol (less than two standard drinks, consumed at least four hours before bedtime) and certain sedatives and anti-anxiety/antidepressant medications (eg benzodiazepines)
  • A 5–15% weight reduction for overweight or (morbidly) obese patients by behavioural modification, diet, exercise and bariatric surgery
  • Change in sleep position (ie sleeping in a non-supine position for patients with positional OSA)
  • For patients with comorbid insomnia, cognitive behavioural therapy for insomnia should be used to improve insomnia symptoms

Recommendations for managing sleep issues in Aboriginal or Torres Strait Islander people are in three areas: awareness and knowledge; actions; and tools and resources.

Awareness and knowledge

GP/clinician understanding

Based on findings from the national Sleep health in Indigenous Australians report,4 sleep problems are highly prevalent in Aboriginal and Torres Strait Islander people and have the potential to affect overall health and wellbeing. The treatment of sleep disorders, such as OSA and insomnia, can significantly reduce blood pressure in people with hypertension,26,63,64 improve excessive daytime sleepiness, reduce anxiety and depression, reduce days of absenteeism and improve quality of life.56,58 There is also robust evidence that treating insomnia simultaneously improves compliance with CPAP for OSA patients,58 antidepressant response in patients with depression,56 mood and quality of life.34,38 So, it is imperative that GPs ensure they have adequate knowledge about sleep health and sleep disorders and that sleep health information is discussed as part of any clinical history taking, particularly with those who are at risk of poor mental health and at risk of or with chronic conditions such as diabetes, hypertension and cardiovascular disease.54 Ongoing professional development in sleep can be undertaken with many free and subscribed resources (see Useful resources).

Patient and community knowledge

Health literacy around sleep is not high in the general community.2 Discussions with patients and their families about sleep and its relationship to all other physical and mental health issues is an important part of healthcare delivery for all patients, and especially for Aboriginal and Torres Strait Islander patients. Opportunities to expand knowledge about the importance of good sleep health and how to achieve it within families and communities should be exploited.

Cultural differences and similarities

Aboriginal and Torres Strait Islander peoples have similar sleep problems to non-Indigenous Australians. However, the contributing factors and risk factors are greater in Aboriginal and Torres Strait Islander peoples when there is social disadvantage and a higher prevalence of chronic disease. A major priority for Aboriginal and Torres Strait Islander patients is effective communication and cultural respect when healthcare is discussed. Understanding that Aboriginal and Torres Strait Islander people may not view or discuss sleep in the same manner as non-Indigenous Australians is also important.7,9 Importantly, due to the kinship and family structure in Aboriginal and Torres Strait Islander culture, the role of a patient’s family and Aboriginal and Torres Strait Islander staff in encouraging sleep health discussion is vital. In this context, there are broader social determinants that affect an Aboriginal and Torres Strait Islander patient’s ability to practise sleep health recommendations.7 However, it is worth sharing the information on the impact of sleep loss on physical and mental health to encourage family-/community-level conversations on sleep health and encourage the adoption of sleep health messages when possible, being aware that whole families may need to be involved in this information sharing.
 

Actions

Initial evaluation and subsequent screening

To date, including sleep health in clinical conversations and using brief screening tools have not generally been included in primary care unless the patient presents with symptoms indicative of OSA and/or insomnia. There have been no recommendations about screening for sleep disorders in a primary care setting, which obviously contributes to the underdiagnosis of sleep disorders.13 However, although not specific for Aboriginal and Torres Strait Islander peoples, currently the National Centre for Sleep Health Services promotes knowledge and the engagement of primary care professionals in the management of OSA and insomnia. GPs should initiate discussions about sleep with all patients, as well as responding to complaints or symptoms of poor sleep, including asking about signs of poor sleep, sleepiness, daytime fatigue and family history of sleep disorders opportunistically, when clinically indicated and/or as part of an annual health check. There is significant potential for simplified, community-based models of care (eg using screening tools and limited channel sleep study testing) within primary care. Training Aboriginal and Torres Strait Islander health workers and/or nurses to diagnose and treating sleep disorders within Aboriginal and Torres Strait Islander communities, including in rural/remote regions, is a priority. Generic sleep evaluation tools are available (see Box 1) for both adults and children as an initial evaluation of the nature of the sleep problem. For example, investigating reported sleepiness with the TESS, ESS or the Paediatric Sleepiness Scale (Box 1) may inform the GP enough to investigate further by screening for a specific sleep disorder (eg OSA). In children and adults presenting with symptoms of snoring or noisy mouth breathing, assessment for OSA is imperative. For patients presenting with difficulties getting to sleep or staying asleep in the absence of snoring, assessment for insomnia with self-report (for adults and adolescents) or via parental/carer report (for children) is warranted .

Ongoing assessment of individuals and families

The state of sleep health should be monitored over time as a regular inclusion in patient healthcare, especially for those with comorbidities and chronic health conditions. Patients presenting with symptoms of sleep disorders, such as OSA, should be informed of the long-term complications of untreated OSA, the relative merits of the various diagnostic and treatment options available and the management of risk factors (eg obesity). If medications are advised for chronic insomnia, ongoing monitoring is necessary, especially if the patient has undertaken CBT-i with a sleep psychologist.

Referral

New guidelines endorsed by the RACGP that provide GPs with appropriate clinical management, treatment and referral options for OSA and insomnia have been released (see Sleep health primary care resources in Useful resources).14 Referral pathways include adult sleep specialist/services, paediatric sleep services and ear, nose and throat services. For acute or chronic insomnia in adults, and behavioural insomnia of childhood, if indicated, referral to a sleep trained psychologist is warranted and referral pathways can be found through the Australasian Sleep Association and the Australian Psychological Society (see Useful resources).

Tools, referrals and resources, including patient information and education

Familiarity with screening tools, including culturally appropriate tools where available

GPs should be aware of the range of generic and specific tools and screening questionnaires available and whether they are culturally validated. It is important to use culturally appropriate materials where possible, especially because inappropriate questionnaires can lead to misdiagnosis or missed diagnosis. However, there are specific Medicare criteria for direct access to sleep studies, which require the use of specific questionnaires. A wide range of other materials, and resources on various websites, are also available (seeUseful resources; Box 1). GPs should also be aware of referral pathways for OSA and insomnia in both adults and children.

Availability of hardcopy appropriate patient education materials and resources

It is important to provide information and education on contributing factors to poor sleep (Box 3) and advice for healthy sleep behaviours (Box 2) as hardcopies and/or online for both children and adults with presentations of sleepiness and symptoms of insomnia, including difficulties in initiating or maintaining sleep. When possible, the clinical approach and tools for the diagnosis and management of sleep issues should be guided by resources that are developed with Aboriginal and Torres Strait Islander community members and are responsive to the cultural needs of the patients. Although such resources are scarce, emerging research and programs (eg Let’s Yarn About Sleep; see Useful resources are offering meaning and culturally responsive tools to facilitate sleep health discussion in the primary care setting.

  1. Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: An American Academy of Sleep Medicine position statement. J Clin Sleep Med 2021;17(10):2115–19. doi: 10.5664/jcsm.9476.
  2. Deloitte Access Economics. Rise and try to shine: The social and economic cost of sleep disorders in Australia. Sleep Health Foundation, 2021 [Accessed 27 May 2024].
  3. Irwin MR. Sleep and inflammation: Partners in sickness and in health. Nat Rev Immunol 2019;19(11):702–15. doi: 10.1038/s41577-019-0190-z.
  4. Blunden S, Fatima Y, Yiallourou SR. Sleep health in Indigenous Australians. Australasian Sleep Association, 2022 [Accessed 27 May 2024].
  5. Heraganahally SS, Kruavit A, Oguoma VM, et al. Sleep apnoea among Australian Aboriginal and non-Aboriginal patients in the Northern Territory of Australia – a comparative study. Sleep 2020;43(3):zsz248. doi: 10.1093/sleep/zsz248.
  6. Blunden SL, Camfferman D. Can sleep contribute to ‘closing the gap’ for Indigenous children? Med J Aust 2013;199(1):19–20. doi: 10.5694/mja13.10302.
  7. Dudgeon P, Milroy H, Walker R. Working together: Aboriginal and Torres Strait Islander mental health and wellbeing principles and practice. Telethon Kids Institute, Kulunga Aboriginal Research Development Unit, 2014 [Accessed 27 May 2024].
  8. Nixon GM, Davey M. Sleep apnoea in the child. Aust Fam Physician 2015;44(6):352–55.
  9. Westerman T. Engagement of Indigenous clients in mental health services: What role do cultural differences play. Aust EJ Adv Ment Health 2004; 3(3). doi: 10.5172/jamh.3.3.88. [Editorial]
  10. Blunden S, Yiallourou S, Fatima Y; Australasian Sleep Association Indigenous Sleep Health Working Party. Sleep health and its implications in First Nation Australians: A systematic review. Lancet Reg Health West Pac 2022;21:100386. doi: 10.1016/j.lanwpc.2022.100386.
  11. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander adolescent and youth health and wellbeing 2018. AIHW, 2018 [Accessed 27 May 2024].
  12. Australia Government. Closing the gap report 2020. Australian Government, 2020 [Accessed 27 May 2024].
  13. Appleton SL, Vakulin A, McEvoy RD, et al. Undiagnosed obstructive sleep apnea is independently associated with reductions in quality of life in middle-aged, but not elderly men of a population cohort. Sleep Breath 2015;19(4):1309–16. doi: 10.1007/s11325-015-1171-5.
  14. National Centre for Sleep Health Services Research CRE. Sleep health primary care resources. Australian Sleep Association, 2022 [Accessed 28 May 2024].
  15. Grima NA, Bei B, Mansfield D. Insomnia theory and assessment. Aust J Gen Pract 2019;48(4):193–97. doi: 10.31128/AJGP-12-18-4780.
  16. Cunnington D, Junge M. Chronic insomnia: Diagnosis and non-pharmacological management. BMJ 2016;355:i5819. doi: 10.1136/bmj.i5819.
  17. Owens JA, Dalzell V. Use of the ‘BEARS’ sleep screening tool in a pediatric residents’ continuity clinic: A pilot study. Sleep Med 2005;6(1):63–69. doi: 10.1016/j.sleep.2004.07.015.
  18. Bruni O, Ottaviano S, Guidetti V, et al. The Sleep Disturbance Scale for Children (SDSC). Construction and validation of an instrument to evaluate sleep disturbances in childhood and adolescence. J Sleep Res 1996;5(4):251–61. doi: 10.1111/j.1365-2869.1996.00251.x.
  19. Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012;130(3):e714–55. doi: 10.1542/peds.2012-1672.
  20. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA 2004;291(16):2013–16. doi: 10.1001/jama.291.16.2013.
  21. Blechner M, Williamson AA. Consequences of obstructive sleep apnea in children. Curr Probl Pediatr Adolesc Health Care 2016;46(1):19–26. doi: 10.1016/j.cppeds.2015.10.007.
  22. Blunden S, Fatima Y, Yiallourou S. Sleep health in Indigenous Australian children: A systematic review. Sleep Med 2021;80:305–14. doi: 10.1016/j.sleep.2021.01.065.
  23. Blunden S, Magee C, Attard K, Clarkson L, Caputi P, Skinner T. Sleep schedules and school performance in Indigenous Australian children. Sleep Health 2018;4(2):135–40. doi: 10.1016/j.sleh.2017.12.006.
  24. Fatima Y, Doi SA, Mamun AA. Sleep quality and obesity in young subjects: A meta-analysis. Obes Rev 2016;17(11):1154–66. doi: 10.1111/obr.12444.
  25. Kaditis AG, Alonso Alvarez ML, Boudewyns A, et al. Obstructive sleep disordered breathing in 2- to 18-year-old children: Diagnosis and management. Eur Respir J 2016;47(1):69–94. doi: 10.1183/13993003.00385-2015.
  26. McEvoy RD, Antic NA, Heeley E, et al. CPAP for Prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med 2016;375(10):919–31. doi: 10.1056/NEJMoa1606599.
  27. Benn E, Wirth H, Short T, Howarth T, Heraganahally SS. The Top End Sleepiness Scale (TESS): A new tool to assess subjective daytime sleepiness among Indigenous Australian adults. Nat Sci Sleep 2021;13:315–28. doi: 10.2147/NSS.S298409.
  28. Heraganahally SS, Howarth TP, Wirth H, Short T, Benn E. Validity of the new ‘Top End Sleepiness Scale’ against the STOP-Bang tool in predicting obstructive sleep apnoea among Indigenous Australian adults. Intern Med J 2023;53(3):339–47. doi: 10.1111/imj.15633.
  29. Owens JA. Behavioral sleep problems in children. UpToDate, 2020 [Accessed 27 May 2024].
  30. Meltzer LJ, Wainer A, Engstrom E, Pepa L, Mindell JA. Seeing the whole elephant: A scoping review of behavioral treatments for pediatric insomnia. Sleep Med Rev 2021;56:101410. doi: 10.1016/j.smrv.2020.101410.
  31. Hisler GC, Hasler BP, Franzen PL, Clark DB, Twenge JM. Screen media use and sleep disturbance symptom severity in children. Sleep Health 2020;6(6):731–42. doi: 10.1016/j.sleh.2020.07.002.
  32. Gangwisch JE, Heymsfield SB, Boden-Albala B, et al. Short sleep duration as a risk factor for hypertension: Analyses of the first National Health and Nutrition Examination Survey. Hypertension 2006;47(5):833–39. doi: 10.1161/01.HYP.0000217362.34748.e0.
  33. Yiallourou SR, Maguire GP, Carrington MJ. Sleep quantity and quality and cardiometabolic risk factors in Indigenous Australians. J Sleep Res 2021;30(2):e13067. doi: 10.1111/jsr.13067.
  34. Espie CA, Emsley R, Kyle SD, et al. Effect of digital cognitive behavioral therapy for insomnia on health, psychological well-being, and sleep-related quality of life: A randomized clinical trial. JAMA Psychiatry 2019;76(1):21–30. doi: 10.1001/jamapsychiatry.2018.2745.
  35. Maghami M, Shariatpanahi SP, Habibi D, et al. Sleep disorders during pregnancy and postpartum depression: A systematic review and meta-analysis. Int J Dev Neurosci 2021;81(6):469–78. doi: 10.1002/jdn.10118.
  36. Jehan S, Zizi F, Pandi-Perumal SR, et al. Shift work and sleep: Medical implications and management. Sleep Med Disord 2017;1(2):00008.
  37. Ekambaram V, Owens J. Medications used for pediatric insomnia. Child Adolesc Psychiatr Clin N Am 2021;30(1):85–99. doi: 10.1016/j.chc.2020.09.001.
  38. Freeman D, Sheaves B, Waite F, Harvey AG, Harrison PJ. Sleep disturbance and psychiatric disorders. Lancet Psychiatry 2020;7(7):628–37. doi: 10.1016/S2215-0366(20)30136-X.
  39. Therapeutic Goods Administration. Australian public assessment report for melatonin. Proprietary product name: Slenyto. Sponsor: RAD Data Australia Pty Ltd. Australian Government, 2020 [Accessed 27 May 2024].
  40. Glass A, Attrill C, Magee C, Blunden S. Factors associated with melatonin use in child sleep disturbance: A survey of Australian parents. Sleep Med 2023;107:330–37. doi: 10.1016/j.sleep.2023.04.026.
  41. Heinzer R, Vat S, Marques-Vidal P, et al. Prevalence of sleep-disordered breathing in the general population: The HypnoLaus study. Lancet Respir Med 2015;3(4):310–18. doi: 10.1016/S2213-2600(15)00043-0.
  42. Van Cauter E, Holmback U, Knutson K, et al. Impact of sleep and sleep loss on neuroendocrine and metabolic function. Horm Res 2007;67(Suppl 1):2–9.
  43. Walker MP, Stickgold R. Sleep, memory, and plasticity. Annu Rev Psychol 2006;57(1):139–66. doi: 10.1146/annurev.psych.56.091103.070307.
  44. Reynolds AC, Appleton SL, Gill TK, Adams RJ. Chronic insomnia disorder in Australia: A report to the Sleep Health Foundation. Sleep Health Foundation of Australia, 2019 [Accessed 27 May 2024].
  45. Olaithe M, Bucks RS, Hillman DR, Eastwood PR. Cognitive deficits in obstructive sleep apnea: Insights from a meta-review and comparison with deficits observed in COPD, insomnia, and sleep deprivation. Sleep Med Rev 2018;38:39–49. doi: 10.1016/j.smrv.2017.03.005.
  46. Wheaton AG, Perry GS, Chapman DP, Croft JB. Sleep disordered breathing and depression among U.S. adults: National Health and Nutrition Examination Survey, 2005–2008. Sleep 2012;35(4):461–67. doi: 10.5665/sleep.1724.
  47. Horne RS, Yang JS, Walter LM, et al. Elevated blood pressure during sleep and wake in children with sleep-disordered breathing. Pediatrics 2011;128(1):e85–92. doi: 10.1542/peds.2010-3431.
  48. Bourke R, Anderson V, Yang JS, et al. Cognitive and academic functions are impaired in children with all severities of sleep-disordered breathing. Sleep Med 2011;12(5):489–96. doi: 10.1016/j.sleep.2010.11.010.
  49. Blunden S, Chervin RD. Sleep, performance and behaviour in Australian Indigenous and non-Indigenous children: An exploratory comparison. J Paediatr Child Health 2010;46(1-2):10–16. doi: 10.1111/j.1440-1754.2009.01610.x.
  50. Sateia MJ. International classification of sleep disorders – third edition: Highlights and modifications. Chest 2014;146(5):1387–94. doi: 10.1378/chest.14-0970.
  51. Sleep Health Foundation. Behavioural sleep problems in school aged children. Sleep Health Foundation, 2024 [Accessed 27 May 2024].
  52. Heraganahally SS, Rajaratnam B, Silva SAAS, et al. Obstructive sleep apnoea and cardiac disease among Aboriginal patients in the Northern Territory of Australia. Heart Lung Circ 2021;30(8):1184–92. doi: 10.1016/j.hlc.2021.01.007.
  53. Deacon-Crouch M, Skinner I, Tucci J, Skinner T. Association between short sleep duration and body mass index in Australian Indigenous children. J Paediatr Child Health 2018;54(1):49–54. doi: 10.1111/jpc.13658.
  54. Fatima Y, Al Mamun A, Bucks RS, Skinner TC. Late bedtime and body mass index gain in Indigenous Australian children in the longitudinal study of Indigenous children. Acta Paediatr 2020;109(10):2084–90. doi: 10.1111/apa.15219.
  55. Australian Institute of Health and Welfare (AIHW). Indigenous health and wellbeing. AIHW, 2022 [Accessed 27 May 2024].
  56. Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep 2008;31(4):489–95. doi: 10.1093/sleep/31.4.489.
  57. Sweetman A, Melaku YA, Lack L, et al. Prevalence and associations of co-morbid insomnia and sleep apnoea in an Australian population-based sample. Sleep Med 2021;82:9–17. doi: 10.1016/j.sleep.2021.03.023.
  58. Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: A randomized clinical trial. Sleep 2019;42(12):zsz178. doi: 10.1093/sleep/zsz178.
  59. Hannan K, Hiscock H. Sleep problems in children. Aust Fam Physician 2015;44(12):880–83.
  60. Issa FG, Sullivan CE. Alcohol, snoring and sleep apnea. J Neurol Neurosurg Psychiatry 1982;45(4):353–59. doi: 10.1136/jnnp.45.4.353.
  61. Peppard PE, Young T, Palta M, Dempsey J, Skatrud J. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA 2000;284(23):3015–21. doi: 10.1001/jama.284.23.3015.
  62. Benoist L, de Ruiter M, de Lange J, de Vries N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Med 2017;34:109–17. doi: 10.1016/j.sleep.2017.01.024.
  63. Dong Y, Dai Y, Wei G, Cha L, Li X. Effect of continuous positive airway pressure on blood pressure in hypertensive patients with coronary artery bypass grafting and obstructive sleep apnea. Int J Clin Exp Med 2014;7(11):4308–15.
  64. Montesi SB, Edwards BA, Malhotra A, Bakker JP. The effect of continuous positive airway pressure treatment on blood pressure: A systematic review and meta-analysis of randomized controlled trials. J Clin Sleep Med 2012;8(5):587–96. doi: 10.5664/jcsm.2170.




 

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