Patient Support Key to Sleep Apnea Therapy Adherence

For patients with obstructive sleep apnea (OSA), letting them know what to expect from continuous positive airway pressure (CPAP) treatment, and helping them get the support they need while they adjust to the routine, increases adherence.

These are the findings of studies presented on Monday at SLEEP 2009, the 23rd Annual Meeting of the Associated Professional Sleep Societies in Seattle.

Obstructive sleep apnea is when patients have episodes in which their airways become blocked during sleep. During deep sleep, breathing can stop completely for a short period of time, often more than 10 seconds. Treatment for this condition is called continuous positive airway pressure (CPAP) in which slightly pressurized air is delivered during sleep to make breathing easier. It is administered through a mask that is placed and secured over the person's nose or nose and mouth before sleep.

"Individuals who need CPAP who are unable to use it are without a doubt the most difficult patients I treat," Dr. Robert Glidewell told Reuters Health in an interview. "We know now that sleep apnea is connected to heart disease, diabetes, and hypertension, so if we can't treat it, there can be real life-altering consequences."

He noted that about half of the patients seem to have no problem adjusting to CPAP, whereas others may struggle for months before they get used to it. He explained that the mask or headgear may be uncomfortable and some patients experience insomnia when they first start CPAP. "We also find that some parents are embarrassed to wear it, and that it can interfere with marital relations or intimacy."

However, he added, "We haven't found anything yet to tell us before we send patients home with the machine if they will struggle or not."

For that reason, Glidewell and Dr. W. C. Orr at the Lynn Institute of the Rockies in Colorado Springs conducted a study in which 39 patients completed standardized questionnaires evaluating personality, problem solving, and coping styles, before they started CPAP treatment. The investigators correlated these factors with CPAP adherence after 1 week and again after 1 month.

"The first thing we found is that the construct called strategic planning — which is breaking the problem down into smaller piece, and taking a systematic approach to deal with each aspect of it — that was actually negatively correlated with CPAP use, which was not what I expected at all," Glidewell said.

On the other hand, they consistently observed that "personal control — a person's ability to manage their own emotions and reactions when faced with a problem — was positively correlated with CPAP adherence. Therefore, individuals most able to control their behaviors when they were frustrated were better able to persist with CPAP."

In short, "they could tolerate it long enough to allow their body to adjust."

Glidewell recommends that clinicians "let people know that adjusting to CPAP is a process and a challenge that can take 30 to 90 days, and to not give up."

"The other piece is to make sure patients have the support they need to handle any distress or problems. I think there's a large role for medical equipment providers to have someone available who could just help patients talk through the distress they experience while adjusting."

In similar research presented during the same session, Dr. Kelly Glazer Baron at Northwestern University in Chicago looked at domestic factors. "We were interested in learning how patient adherence to CPAP is affected by spouse involvement," the researcher told Reuters Health.

Their study included 23 married or cohabiting men with OSA who completed questionnaires regarding their partner's involvement with their adjustment to CPAP.

"We found that partners are involved in many different ways, including encouragement, working together, and trying to provoke fear of the consequence of not using CPAP, both at 1 week of treatment and also at 3 months of treatment," Baron said. "Patients who reported working together with their partner had higher adherence."

"What was surprising to us," the researcher added, "was that encouragement from the partner alone without working together was not related to adherence."

Baron's advice to clinicians is therefore to "involve the partner in a supportive and helpful manner to improve adherence."