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The Role of Behavioral The Role of Behavioral Interventions in CPAP Interventions in CPAP

AdherenceAdherence

Anstella Robinson, MD, FCCP, FAASMAnstella Robinson, MD, FCCP, FAASM

Stanford University Sleep Disorders Stanford University Sleep Disorders CenterCenter

Continuous Positive Airway Continuous Positive Airway Pressure (CPAP) therapy Pressure (CPAP) therapy isis the the

treatment of choice for OSAHS. treatment of choice for OSAHS. It has been shown to improve It has been shown to improve

ventilatory function.ventilatory function. It has been shown to improve It has been shown to improve

objective and subjective measures of objective and subjective measures of daytime sleepiness.daytime sleepiness.

In patients with moderate to severe In patients with moderate to severe OSAHS.OSAHS.

CPAP Compliance DataCPAP Compliance Data

Although evidence is limited Although evidence is limited compliance with CPAP is similar compliance with CPAP is similar irrespective of mode of delivery.irrespective of mode of delivery. Fixed CPAPFixed CPAP BiLevel PAPBiLevel PAP Auto-titrating DeviceAuto-titrating Device

Behavioral interventions may be Behavioral interventions may be effective in increasing hours of use. effective in increasing hours of use.

Compliance DataCompliance Data

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

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

Compliance DataCompliance Data

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

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

CPAP Compliance DataCPAP Compliance Data

The most exhaustive analysis of this subject The most exhaustive analysis of this subject to date is the Cochrane Review wherein to date is the Cochrane Review wherein interventions were reviewed. interventions were reviewed.

Randomized controlled, parallel or crossover Randomized controlled, parallel or crossover single blind studiessingle blind studies

With participants of either gender with With participants of either gender with OSAHS by oximetry or sleep studies that OSAHS by oximetry or sleep studies that showed a desaturation index DI of 5 showed a desaturation index DI of 5 events/hr and an AHI of 5 events/hr.events/hr and an AHI of 5 events/hr.

Haniffa M, Lasserson TJ, Smith I (2004) Interventions to improve compliance with continuous Haniffa M, Lasserson TJ, Smith I (2004) Interventions to improve compliance with continuous

positive airway pressure for obstructive sleep apnoea (Review). positive airway pressure for obstructive sleep apnoea (Review). The Cochrane Database The Cochrane Database of Systematic Reviewsof Systematic Reviews, Issue 4 Art No: CD003531-pub2. , Issue 4 Art No: CD003531-pub2. DOI:10.1002/14651858.CD003531.pub2. DOI:10.1002/14651858.CD003531.pub2.

Cochrane ReviewCochrane Review

Types of interventions to improve Types of interventions to improve compliance (adherence) reviewed included:compliance (adherence) reviewed included: Auto-CPAP (including forced oscillation technique) Auto-CPAP (including forced oscillation technique)

versus fixed CPAP (fixed pressure setting.versus fixed CPAP (fixed pressure setting. Humidification plus CPAP versus fixed CPAP.Humidification plus CPAP versus fixed CPAP. Bi-level PAP versus conventional fixed CPAP.Bi-level PAP versus conventional fixed CPAP. Self-titration versus fixed pressure fixed CPAP.Self-titration versus fixed pressure fixed CPAP. Intensive education and/ or support plus CPAP Intensive education and/ or support plus CPAP

(CPAP could be either fixed or auto but had to be (CPAP could be either fixed or auto but had to be the same in both limbs of the study).the same in both limbs of the study).


ConclusionsConclusions The studies showed a high level of compliance in the control The studies showed a high level of compliance in the control

limb.limb. Future studies should be directed at those patients who have Future studies should be directed at those patients who have

demonstrated difficulty accepting PAP therapy.demonstrated difficulty accepting PAP therapy. Humidification may improve adherence.Humidification may improve adherence. Current evidence does not justify the use of auto-titrating Current evidence does not justify the use of auto-titrating

CPAP in unselected patients.CPAP in unselected patients. This may be useful in patients with CPAP levels >10.This may be useful in patients with CPAP levels >10. May be useful in positional or REM dependent ApneaMay be useful in positional or REM dependent Apnea

Bi-level should be considered in patients with difficulty Bi-level should be considered in patients with difficulty starting treatment.starting treatment.

The evidence for educational interventions is too preliminary The evidence for educational interventions is too preliminary to allow firm recommendations at this time.to allow firm recommendations at this time.

Cost/Benefit ratio of this intervention needs to be evaluated.Cost/Benefit ratio of this intervention needs to be evaluated. Inclusion of bed partners in the educational process should also Inclusion of bed partners in the educational process should also

be evaluated.be evaluated.


Implications for ResearchImplications for Research Better reporting of methodology and outcomeBetter reporting of methodology and outcome Assessment of the effects of treatment in those already Assessment of the effects of treatment in those already

using PAP who have been deemed poorly compliant.using PAP who have been deemed poorly compliant. Assessment of treatment of people with lower AHIs than in Assessment of treatment of people with lower AHIs than in

existing studies.existing studies. Head to head trials of auto-titrating and fixed CPAP to Head to head trials of auto-titrating and fixed CPAP to

determine if there is similar response to different devices.determine if there is similar response to different devices. Assessment and follow-up to be carried out for longer to Assessment and follow-up to be carried out for longer to

determine if treatment effects last.determine if treatment effects last. Further studies of tailored educational interventions to Further studies of tailored educational interventions to

determine improvement in initial acceptance and determine improvement in initial acceptance and subsequent hour of use.subsequent hour of use.

Studies to evaluate if Bi-level therapy indeed represents a Studies to evaluate if Bi-level therapy indeed represents a viable alternative for those who do not tolerate CPAP.viable alternative for those who do not tolerate CPAP.

Psychosocial Consequences of Psychosocial Consequences of SDBSDB

Quality of life and psychosocial Quality of life and psychosocial functioningfunctioning

Psychiatric comorbidityPsychiatric comorbidity AnxietyAnxiety MoodMood Psychosis Psychosis Alcohol DependenceAlcohol Dependence

Positive Airway Pressure Positive Airway Pressure TherapyTherapy

Mainstay of treatment in all of it’s Mainstay of treatment in all of it’s permutationspermutations CPAPCPAP BiLevel PAPBiLevel PAP Auto-titrating PAPAuto-titrating PAP

Factors in adherence to Factors in adherence to therapytherapy

CPAP side effectsCPAP side effects Apnea severityApnea severity Social VariablesSocial Variables Clinical Behavioral VariablesClinical Behavioral Variables Education and SupportEducation and Support Psychological VariablesPsychological Variables Psychological interventionsPsychological interventions

Apnea SeverityApnea Severity

Inconsistent relationships have been found Inconsistent relationships have been found between apnea severity and adherence, between apnea severity and adherence,

As well as baseline levels of subjective and As well as baseline levels of subjective and objective sleepiness.objective sleepiness.

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

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


Mixed result in the studies also reflect Mixed result in the studies also reflect comorbid illnesscomorbid illness

Adherence is worse among smokers and Adherence is worse among smokers and individuals with emphysema.individuals with emphysema.

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


There many also be cultural factorsThere many also be cultural factors

Age and gender influencesAge and gender influences

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

Social VariablesSocial Variables

Individuals who live alone are less adherent to Individuals who live alone are less adherent to CPAPCPAP

Individuals whose partners initiate treatment Individuals whose partners initiate treatment referrals are less adherent than those who initiate referrals are less adherent than those who initiate treatment themselves.treatment themselves.

Approximately half of OSAHA patients report they Approximately half of OSAHA patients report they would discontinue CPAP if it negatively affected would discontinue CPAP if it negatively affected the sleep of their bed partner.the sleep of their bed partner.

Thus, inclusion of the bed partner in any Thus, inclusion of the bed partner in any treatment program might increase adherence.treatment program might increase adherence.

Hoy CJ, Venelle M, et al (1999). Can intensive support improve CPAP use in patients with SAHS? American 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. 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 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, patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use CPAP. Sleep, 26, 727-732.26, 727-732.

Clinical behavioral trialsClinical behavioral trials

Few studies have developed Few studies have developed interventions to improve CPAP interventions to improve CPAP adherence.adherence.

Most interventions have been aimed at Most interventions have been aimed at improvement of equipment.improvement of equipment.

As the first week of CPAP use has been As the first week of CPAP use has been identified as a critical period for long identified as a critical period for long term adherence, some investigator are term adherence, some investigator are studying close follow-up support at this studying close follow-up support at this time.time.

Education and supportEducation and support

Hoy showed intensive support including weekly Hoy showed intensive support including weekly home visits and extra nights of in lab CPAP titration home visits and extra nights of in lab CPAP titration improved adherence at 6 months.improved adherence at 6 months.

Another study showed that 1, 2 hour group session Another study showed that 1, 2 hour group session improved CPAP adherence by 1 hour a night.improved CPAP adherence by 1 hour a night.

Some studies have shown equivocal results Some studies have shown equivocal results however, Hui showed education did not improve however, Hui showed education did not improve adherence in but did lead to a greater improvement adherence in but did lead to a greater improvement in quality of life during the reinforced period.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 Hui DSC, Chan JkW, Choy DKL et al (2000). Effects of augmented CPAP education and support on compliance and outcome on a Chinese population. and outcome on a Chinese population. ChestChest, 117, 1410-1416., 117, 1410-1416.

Psychological VariablesPsychological Variables

MoodMood AnxietyAnxiety Coping Coping Theory-based psychological Theory-based psychological

variables.variables.

Psychological VariablesPsychological Variables

MoodMood Few studies attempt to characterize psychological factors Few studies attempt to characterize psychological factors

associated with CPAP adherenceassociated with CPAP adherence Edinger found that adherent veterans had lower Edinger found that adherent veterans had lower

depression scale scores on the MMPI as compared to depression scale scores on the MMPI as compared to nonadherent veteransnonadherent veterans

Conversely a study by Lewis suggested that self reported Conversely a study by Lewis suggested that self reported measures of depression did not predict adherence in a measures of depression did not predict adherence in a prospective trial.prospective trial.

Case reports cite bipolar disorder manic episodes as Case reports cite bipolar disorder manic episodes as worsening adherence with consequent worsening of worsening adherence with consequent worsening of mood.mood.

Edinger JD et al (1994). Psychological status, syndromatic measures, and compliance Edinger JD et al (1994). Psychological status, syndromatic measures, and compliance with nasal CPAP therapy for sleep apnea. with nasal CPAP therapy for sleep apnea. Perceptual and Motor Skills, Perceptual and Motor Skills, 78, 1116-78, 1116-1118.1118.

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

Psychological Variables Psychological Variables

AnxietyAnxiety Anxiety may be a stronger predictor of adherence than Anxiety may be a stronger predictor of adherence than

moodmood Claustrophobia is a common reaction reported in 11 to Claustrophobia is a common reaction reported in 11 to

28% of patients.28% of patients. These data that CPAP desensitization may play an These data that CPAP desensitization may play an

important role in preventing nonadherenceimportant role in preventing nonadherence Baseline rates of self-reported generalized anxiety do Baseline rates of self-reported generalized anxiety do

not appear to predict adherence although reported not appear to predict adherence although reported stress inducing life event may.stress inducing life event may.

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

Psychological Variables Psychological Variables CopingCoping

A study by Stepnowsky examined the A study by Stepnowsky examined the association between coping and CPAP association between coping and CPAP adherence.adherence.

Active coping strategies were a related to Active coping strategies were a related to greater adherence at one week.greater adherence at one week.

Confrontive coping and planful problem solving Confrontive coping and planful problem solving were the strongest predictors of CPAP use.were the strongest predictors of CPAP use.

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

Theory Based Psychological Theory Based Psychological VariablesVariables

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

These have previously been used These have previously been used successful in other medical illnesses.successful in other medical illnesses.

Transtheoretical Model Transtheoretical Model (TM)(TM)

““States of Change”States of Change” Different stages that help identify where a Different stages that help identify where a

person is regarding the change of behavior.person is regarding the change of behavior. May relate to any number of activities in May relate to any number of activities in

terms of behavioral modificationterms of behavioral modification Consist of several different processes, Consist of several different processes,

divided into six main stages that describe divided into six main stages that describe an individual’s attitude toward change. an individual’s attitude toward change.

““States of Change”States of Change”

PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance TerminationTermination

Social Cognitive Theory Social Cognitive Theory (SCT)(SCT)

Two major factors influencing the likelihood that one Two major factors influencing the likelihood that one will take preventive action: will take preventive action:

FirstFirst, a person must believe that the benefits of , a person must believe that the benefits of performing the behavior outweigh the costs (i.e. a performing the behavior outweigh the costs (i.e. a person should have more positive than negative person should have more positive than negative outcome expectancies)outcome expectancies)

SecondSecond, and perhaps most important, the person , and perhaps most important, the person must have a sense of personal agency, or self-must have a sense of personal agency, or self-efficacy with respect to performing the preventive efficacy with respect to performing the preventive behavior must believe that he or she has the skills behavior must believe that he or she has the skills and abilities necessary for performing the behavior and abilities necessary for performing the behavior under a variety of circumstances." under a variety of circumstances."

SCTSCT

Social Cognitive Theory defines human Social Cognitive Theory defines human behavior as a triadic, dynamic, and behavior as a triadic, dynamic, and reciprocal interaction of personal factors, reciprocal interaction of personal factors, behavior, and the environment. behavior, and the environment.

Unlike other cognitive development Unlike other cognitive development theories, the social-cognitive theory theories, the social-cognitive theory incorporates a complex, three-way incorporates a complex, three-way relationship between learners, their relationship between learners, their environment, and their self-regulating environment, and their self-regulating process of efficacy. process of efficacy.


Stepnowsky, Marler et al found that Stepnowsky, Marler et al found that no SCT or TM measured on the day of no SCT or TM measured on the day of fitting significantly predicted CPAP fitting significantly predicted CPAP use at one month use at one month

However a number of variables However a number of variables measured one week after fitting did measured one week after fitting did significantly predict CPAP adherence significantly predict CPAP adherence at one monthat one month


TM variable the decision balance index TM variable the decision balance index significantly predicted adherence at one significantly predicted adherence at one month.month. This index measures the ratio of benefits to This index measures the ratio of benefits to

barriers in CPAP use.barriers in CPAP use. The SCT variables (self-efficacy, outcome The SCT variables (self-efficacy, outcome

expectations, social support and knowledge) expectations, social support and knowledge) together significantly predicted adherence.together significantly predicted adherence. Self efficacy and knowledge together explained Self efficacy and knowledge together explained

the majority of the variance in CPAP use.the majority of the variance in CPAP use.

Theory-based Psychological Theory-based Psychological VariablesVariables

The implications of these resultsThe implications of these results Findings suggest that adherence may be Findings suggest that adherence may be

enhanced by education (self efficacy)enhanced by education (self efficacy) And by identifying the benefits of CPAP thereby And by identifying the benefits of CPAP thereby

decreasing the barriers to use.decreasing the barriers to use. Also these findings provide further Also these findings provide further

impetus for the investigation of mediating impetus for the investigation of mediating variables rather than pre-existing variables rather than pre-existing moderating variables, in CPAP adherence.moderating variables, in CPAP adherence.

Differences in adherence are most likely to Differences in adherence are most likely to emerge after the patient has had emerge after the patient has had experience with CPAP.experience with CPAP.

Self-Efficacy Measure for Sleep Self-Efficacy Measure for Sleep Apnea (SEMSA)Apnea (SEMSA)

Stepnowsky and colleagues developed an Stepnowsky and colleagues developed an instrument to identify individuals at high instrument to identify individuals at high risk for CPAP nonadherence.risk for CPAP nonadherence.

This is currently under evaluation.This is currently under evaluation. Early results suggest that nonadherence to Early results suggest that nonadherence to

CPAP may be related to the inability of the CPAP may be related to the inability of the patients to realize the full spectrum of patients to realize the full spectrum of negative outcomes of untreated OSAHA.negative outcomes of untreated OSAHA.

Stepnowsky CJ, Marler M, Ancoli-Israel S (2002). Determinants of CPAP compliance. Stepnowsky CJ, Marler M, Ancoli-Israel S (2002). Determinants of CPAP compliance. Sleep MedicineSleep Medicine, , 3, 239247.3, 239247.

Haynes PL (2005). The role of behavioral sleep medicine in the assessment and treatment of sleep Haynes PL (2005). The role of behavioral sleep medicine in the assessment and treatment of sleep disordered breathing. 25,673-7005.disordered breathing. 25,673-7005.

Psychological InterventionsPsychological Interventions

CPAP desensitization has been CPAP desensitization has been effectively implemented in a veteran effectively implemented in a veteran population in a group session format population in a group session format (Haynes).(Haynes).

A clinical trial is underway applying A clinical trial is underway applying motivational enhancement strategies motivational enhancement strategies to CPAP.to CPAP. This involves motivational interviewing This involves motivational interviewing

using decisional balance techniques.using decisional balance techniques.

Aloia M, (2004). Motivating Adherence to CPAP in in Obstructive Sleep Apnea. National Aloia M, (2004). Motivating Adherence to CPAP in in Obstructive Sleep Apnea. National institutes of Health CRISP Database.institutes of Health CRISP Database.

The Stanford ExperienceThe Stanford Experience

A New CPAP tolerance programA New CPAP tolerance program 7 session group format7 session group format

Desensitization and optimization of Desensitization and optimization of equipmentequipment

Cognitive behavioral interventions for Cognitive behavioral interventions for equipment toleranceequipment tolerance

Education about consequences of untreated Education about consequences of untreated OSAHSOSAHS

Group experience sharing in class setting.Group experience sharing in class setting.

The Stanford ExperienceThe Stanford Experience

Two courses are finished and initial Two courses are finished and initial findings suggest:findings suggest: Patients benefit greatly from the interactional Patients benefit greatly from the interactional

aspects of programaspects of program The role of circadian dysregulation and The role of circadian dysregulation and

untreated insomnia is becoming apparent.untreated insomnia is becoming apparent. It appears patients who are not CPAP naïve It appears patients who are not CPAP naïve

may benefit from the program.may benefit from the program.

Personal communication with Tracy Kuo, PhD..Personal communication with Tracy Kuo, PhD..

ConclusionsConclusions CPAP adherence or nonadherence is determined as CPAP adherence or nonadherence is determined as

much from mediating variables as from pre-existing much from mediating variables as from pre-existing moderating variables.moderating variables.

Technological approaches to improving adherence Technological approaches to improving adherence are not proved to be efficaciousare not proved to be efficacious

Behavioral sleep medicine techniques offer an Behavioral sleep medicine techniques offer an untapped resource, a novel approach to remediation untapped resource, a novel approach to remediation of nonadherent CPAP users.of nonadherent CPAP users.

When considering cost, balance the cost of When considering cost, balance the cost of development of behavioral techniques versus the development of behavioral techniques versus the benefits against the social burden ofuntreated benefits against the social burden ofuntreated OSASH. OSASH.

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