behavioral modification cpap and insomnia

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  • The Role of Behavioral Interventions in CPAP AdherenceAnstella Robinson, MD, FCCP, FAASMStanford University Sleep Disorders Center

  • Continuous Positive Airway Pressure (CPAP) therapy is the treatment of choice for OSAHS. It has been shown to improve ventilatory function.It has been shown to improve objective and subjective measures of daytime sleepiness.In patients with moderate to severe OSAHS.

  • CPAP Compliance DataAlthough evidence is limited compliance with CPAP is similar irrespective of mode of delivery.Fixed CPAPBiLevel PAPAuto-titrating Device

    Behavioral interventions may be effective in increasing hours of use.

  • Compliance DataInternationally some 5-50% of OSAHS patients recommended CPAP either reject this treatment option or discontinue use within the first week.

    12 to 25% of the remaining patients may be expected to have discontinued its use at 3 years

  • Compliance DataBiomedical investigations of patients CPAP use reveal frequent adverse effects, weak prospective relationships between symptomatic or physiological disease severity and CPAP use, and moderate correlation between use and benefit.

    Englemen HM, Wild MR (2003). Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Medicine Reviews, 7, 81-99

  • CPAP Compliance DataThe most exhaustive analysis of this subject to date is the Cochrane Review wherein interventions were reviewed. Randomized controlled, parallel or crossover single blind studiesWith participants of either gender with OSAHS by oximetry or sleep studies that showed a desaturation index DI of 5 events/hr and an AHI of 5 events/hr. Haniffa M, Lasserson TJ, Smith I (2004) Interventions to improve compliance with continuous positive airway pressure for obstructive sleep apnoea (Review). The Cochrane Database of Systematic Reviews, Issue 4 Art No: CD003531-pub2. DOI:10.1002/14651858.CD003531.pub2.

  • Cochrane ReviewTypes of interventions to improve compliance (adherence) reviewed included:Auto-CPAP (including forced oscillation technique) versus fixed CPAP (fixed pressure setting.Humidification plus CPAP versus fixed CPAP.Bi-level PAP versus conventional fixed CPAP.Self-titration versus fixed pressure fixed CPAP.Intensive education and/ or support plus CPAP (CPAP could be either fixed or auto but had to be the same in both limbs of the study).

  • Cochrane ReviewConclusionsThe studies showed a high level of compliance in the control limb.Future studies should be directed at those patients who have demonstrated difficulty accepting PAP therapy.Humidification may improve adherence.Current evidence does not justify the use of auto-titrating CPAP in unselected patients.This may be useful in patients with CPAP levels >10.May be useful in positional or REM dependent ApneaBi-level should be considered in patients with difficulty starting treatment.The evidence for educational interventions is too preliminary to allow firm recommendations at this time.Cost/Benefit ratio of this intervention needs to be evaluated.Inclusion of bed partners in the educational process should also be evaluated.

  • Cochrane ReviewImplications for ResearchBetter reporting of methodology and outcomeAssessment of the effects of treatment in those already using PAP who have been deemed poorly compliant.Assessment of treatment of people with lower AHIs than in existing studies.Head to head trials of auto-titrating and fixed CPAP to determine if there is similar response to different devices.Assessment and follow-up to be carried out for longer to determine if treatment effects last.Further studies of tailored educational interventions to determine improvement in initial acceptance and subsequent hour of use.Studies to evaluate if Bi-level therapy indeed represents a viable alternative for those who do not tolerate CPAP.

  • Psychosocial Consequences of SDBQuality of life and psychosocial functioningPsychiatric comorbidityAnxietyMoodPsychosis Alcohol Dependence

  • Positive Airway Pressure TherapyMainstay of treatment in all of its permutationsCPAPBiLevel PAPAuto-titrating PAP

  • Factors in adherence to therapyCPAP side effectsApnea severitySocial VariablesClinical Behavioral VariablesEducation and SupportPsychological VariablesPsychological interventions

  • Apnea SeverityInconsistent relationships have been found between apnea severity and adherence,

    As well as baseline levels of subjective and objective sleepiness.

    Possibly owing to the definition of adherence and whether patients were nave or experienced users.

    Self reported adherence is higher than objective measures (compliance meters).

  • Apnea SeverityMixed result in the studies also reflect comorbid illnessAdherence is worse among smokers and individuals with emphysema.

    McArdle, N Devereux G, etal (1999) Long term use of CPAP therapy for sleep apnea/hypopnea syndrome. American Journal of Respiratory and CriticalCare Medicine, 159, 1108-1114.

  • Apnea SeverityThere many also be cultural factors

    Age and gender influences

    Inconsistent findings may be due to individual differences in the perception of sleepiness.

  • Social VariablesIndividuals who live alone are less adherent to CPAPIndividuals whose partners initiate treatment referrals are less adherent than those who initiate treatment themselves.Approximately half of OSAHA patients report they would discontinue CPAP if it negatively affected the sleep of their bed partner.Thus, inclusion of the bed partner in any treatment program might increase adherence.

    Hoy CJ, Venelle M, et al (1999). Can intensive support improve CPAP use in patients with SAHS? American Journal of Respiratory and Critical Care Medicine, 159, 1096-1100.

    Weaver TE, Maislin G, Dinges DF et al (2003). Self-efficacy in sleep apnea: Instrument Development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use CPAP. Sleep, 26, 727-732.

  • Clinical behavioral trialsFew studies have developed interventions to improve CPAP adherence.Most interventions have been aimed at improvement of equipment.As the first week of CPAP use has been identified as a critical period for long term adherence, some investigator are studying close follow-up support at this time.

  • Education and supportHoy showed intensive support including weekly home visits and extra nights of in lab CPAP titration improved adherence at 6 months.Another study showed that 1, 2 hour group session improved CPAP adherence by 1 hour a night.Some studies have shown equivocal results however, Hui showed education did not improve adherence in but did lead to a greater improvement in quality of life during the reinforced period.

    Hui DSC, Chan JkW, Choy DKL et al (2000). Effects of augmented CPAP education and support on compliance and outcome on a Chinese population. Chest, 117, 1410-1416.

  • Psychological VariablesMoodAnxietyCoping Theory-based psychological variables.

  • Psychological VariablesMoodFew studies attempt to characterize psychological factors associated with CPAP adherenceEdinger found that adherent veterans had lower depression scale scores on the MMPI as compared to nonadherent veteransConversely a study by Lewis suggested that self reported measures of depression did not predict adherence in a prospective trial.Case reports cite bipolar disorder manic episodes as worsening adherence with consequent worsening of mood.

    Edinger JD et al (1994). Psychological status, syndromatic measures, and compliance with nasal CPAP therapy for sleep apnea. Perceptual and Motor Skills, 78, 1116-1118.Lewis KE et al (2004). Early predictors of CPAP use for the treatment of sleep apnea. Sleep, 27, 134-138.

  • Psychological Variables AnxietyAnxiety may be a stronger predictor of adherence than moodClaustrophobia is a common reaction reported in 11 to 28% of patients.These data that CPAP desensitization may play an important role in preventing nonadherenceBaseline rates of self-reported generalized anxiety do not appear to predict adherence although reported stress inducing life event may.

    Lewis KE et al (2004). Early predictors of CPAP use for the treatment of sleep apnea. Sleep, 27, 134-138.

  • Psychological Variables CopingA study by Stepnowsky examined the association between coping and CPAP adherence.Active coping strategies were a related to greater adherence at one week.Confrontive coping and planful problem solving were the strongest predictors of CPAP use.

    Stepanowsky CJ, Bardwell WA et al (2002). Psychologic correlates of compliance with continuous positive airway pressure. Sleep, 25,758-762.

  • Theory Based Psychological VariablesTwo theories associated with health behavioral change have been applied to predict and influence CPAP adherence.The transtheoretical model (TM).Social cognitive theory (SCT)

    These have previously been used successful in other medical illnesses.

  • Transtheoretical Model (TM)States of ChangeDifferent stages that help identify where a person is regarding the change of behavior.May relate to any number of activities in terms of behavioral modificationConsist of several different processes, divided into six main stages that describe an individuals attitude toward change.

  • States of ChangePrecontemplationContemplationPreparationActionMaintenanceTermination

  • Social Cognitive Theory (SCT)Two major factors influencing the likelihood that one will take preventive action: First, a person must believe that the benefits of performing the behavior outweigh the costs (i.e. a person should have more positive than negative outcome expectancies) Second, and perhaps most importan