Multi-Night Home Assessment of Total Sleep Time Misperception in Obstructive Sleep Apnea with and Without Insomnia Symptoms

Total sleep time (TST) misperception has been reported in obstructive sleep apnea (OSA). However, previous findings on predictors were inconsistent and predominantly relied on single-night polysomnography, which may alter patients' sleep perception. We leveraged advances in wearable sleep staging to investigate predictors of TST misperception in OSA over multiple nights in the home environment. The study included 141 patients with OSA, 75 without insomnia symptoms (OSA group), and 66 with insomnia symptoms (OSA-I group). Objective TST was measured using a previously validated wrist-worn photoplethysmography and accelerometry device. Self-reported TST was assessed using a digital sleep diary. TST misperception was quantified with the misperception index (MI), calculated as (objective - self-reported TST)/objective TST. MI values differed significantly between the OSA (median = -0.02, IQR = [-0.06, 0.02]) and the OSA-I group (0.05, [-0.02, 0.13], p < 0.001). Multilevel modeling revealed that the presence of insomnia symptoms (β = 0.070, p < 0.001) and lower daily reported sleep quality (β = -0.229, p < 0.001) were predictive of higher MI (TST underestimation), while a higher apnea-hypopnea index (AHI) was predictive of lower MI (TST overestimation; β = -0.001, p = 0.006). Thus, insomnia symptoms and AHI are associated with TST misperception in OSA patients, but in opposite directions. This association extends over multiple nights in the home environment.