VA/DoD Provides Screening Algorithm, Management Pathway for Insomnia and OSA

The following article is a part of conference coverage from the 2021 American Association of Nurse Practitioners National Conference (AANP 2021), held virtually from June 15 to June 20, 2021. The team at the Clinical Advisor will be reporting on the latest news and research conducted by leading NPs. Check back for more from AANP 2021.

 

Key objectives from the Department of Veterans Affairs/Department of Defense (VA/DoD) clinical practice guideline for the management of chronic insomnia disorder (CID) and obstructive sleep apnea (OSA) were outlined in a poster presented at the 2021 American Association of Nurse Practitioners National Conference (AANP 2021).¹

Understanding chronic sleep disorders is particularly crucial for the patient population of veterans; 47% of veterans are diagnosed with sleep apnea and 27% have insomnia, according to the National Veteran’s Sleep Disorder study (2000-2010).² The authors noted that post-traumatic stress disorder (PTSD) is linked to a high prevalence (16%) of sleep disorders.²

“The best evidence-based clinical practice guidelines are essential for veterans. They deserve no less,” commented AANP 2021 attendee Mary Koslap-Petroco, DNP, PPCNP-BC, CPNP, FAANP, clinical assistant professor at Stony Brook University School of Nursing in Stony Brook, New York. “This well-researched clinical practice guideline offers a paradigm shift for treating veterans who suffer from these debilitating disorders. Thirty percent to 40% of the US population suffers from insomnia.³ The guidelines could also be useful for the many civilians who also suffer from these life-altering conditions,” Dr. Koslap-Petroco said.

In 2019, the VA/DoD assembled a clinical practice guideline to provide clinicians with evidence-based methods for improving the health and well-being of patients with CID and OSA. This publication included guidance for all aspects of treatment from diagnosis to follow-up.

The clinical practice guideline was intended to inform VA and DoD health care providers such as nurse practitioners (NPs), physician associates (PAs), primary care physicians, mental health providers, social workers, nurses, and pharmacists. However, clinical practice guidelines are not the standard of care, and implementing any recommendations from the clinical practice guideline must be decided upon within the context of each provider’s clinical judgment and the patient’s values and preferences, noted the authors of the poster.

Screening Algorithm for Sleep Disorders

The clinical practice guideline includes a 9-component screening algorithm for sleep disorders. First, the provider asks the patient if they, their partner, or their health care provider have any concerns about the patient’s sleep. If any concerns are raised, the next step is to provide a clinical assessment using validated screening tools, such as the Insomnia Severity Index or STOP-BANG tool (Snoring? Tired? Observed? Pressure? BMI? Age? Neck Size? Gender?).

Management Pathways for Insomnia and Obstructive Sleep Apnea

If the patient is provisionally diagnosed with CID or OSA following the screening, the clinical practice guideline offers management pathways for both disorders. For adults with a provisional diagnosis of CID, the clinical practice guideline recommends encouraging behavior-based treatment methods, such as cognitive behavioral therapy (CBT) or brief behavioral therapy for insomnia (BBT-I) after confirming the diagnosis. If the patient is willing to start behavioral therapy, the clinical practice guideline recommends referral to a trained CBT or BBT-I specialist.

If treatment with the behavioral specialist is effective, the primary provider should follow up as needed, and discuss relapse prevention strategies with the patient. If the behavioral therapy was not effective, the patient should be referred to a sleep specialist for further treatment, according to the guideline.

For patients who do not complete behavioral therapy to treat CID, short-term pharmacotherapy and/or complementary and integrative health (CIH) strategies should be implemented. If these strategies successfully remit the patient’s CID, the primary provider should follow-up as needed with a focus on relapse prevention. If pharmacotherapy and/or CIH do not sufficiently manage the patient’s CID symptoms, follow-up with a sleep specialist is necessary.

Patients who are provisionally diagnosed with OSA following screening should undergo a risk assessment. Patients at low risk for OSA should be referred to an in-lab sleep study, according to the guidelines.

For patients at high risk, the provider should determine if the patient has comorbidities or military occupational requirements for an in-lab determination of OSA. If yes, the patient should be referred to an in-lab sleep study; if this assessment confirms the OSA diagnosis, the primary provider should initiate treatment and support the adherence. If this treatment does not resolve the patient’s symptoms, referral to a sleep specialist is recommended.

If the patient does not have any comorbidities or military occupational requirements for an in-lab test an at-home test may be performed. If a high-risk patient has an apnea-hypopnea index (AHI) of less than 5 events per hour, they should be referred to an in-lab study. If the patient’s AHI is between 5 and 15 events per hour, the patient meets the criteria for OSA treatment, according to the guideline.

The full VA/DoD guide is available here. A pocket card for clinicians, as well as a patient- and family-friendly version, are also available.

Visit Clinical Advisor’s meetings section for complete coverage of AANP 2021. All conference sessions are available to registered attendees through August 31, 2021.

References

1. Stuffel EP, Devlin CKB, Pearson KET. VA/DoD clinical practice guideline management of chronic insomnia disorder and obstructive sleep apnea. Poster presented at: 2021 American Academy of Nurse Practitioners National Conference; June 15-June 20, 2021. Poster 10.
2. Alexander M, Ray MA, Hébert JR, et al. The national veteran sleep disorder study: Descriptive epidemiology and secular trends, 2000-2010. Sleep. 2016;39(7):1399-1410. doi:10.5665/sleep.5972
3. Dophelde, JA. Insomnia overview: epidemiology, pathophysiology, diagnosis and monitoring, and nonpharmacologic therapy. Am J Mange Care. 2020;26(4):S76-S84.  doi:org/10.37765/ajmc.2020.42769