Usefulness of Reinforcing Interventions on CPAP Compliance
Obstructive sleep apnea (OSA) is a common sleep disorder characterized by intermittent partial or complete upper airway obstruction during sleep, associated to recurrent arousals, nocturnal intermittent hypoxemia, sleep fragmentation and poor sleep quality. The prevalence of OSA associated with accompanying excessive daytime sleepiness (EDS) is approximately 3 to 7% in adult men and 2 to 5% in adult women in the general population. Factors that increase vulnerability to the disorder include age, male sex, obesity, craniofacial abnormalities, family history, menopause, and behaviours such as cigarette smoking and alcohol use.
Sleep-disordered breathing adversely affects daytime alertness and cognition: patients suspected of suffering from sleep apnea show several typical symptoms including habitual snoring (often disruptive to bed partners), feeling unrefreshed at wake-up, EDS or fatigue, lack of concentration, memory impairment, and at times neurobehavioural disturbances. OSA is an independent risk factor for cardiovascular diseases, including hypertension, atrial fibrillation, coronary artery disease, stroke, and for metabolic diseases like type 2 diabetes. OSA is associated with automobile accidents, reduced participation in work activities, increased absenteeism, and a loss of productivity, with a consequent increase in the use of resources. Severe OSA is associated with increased mortality, especially in young subjects. Although mortality risk associated with OSA tends to disappear from the age of 50, it has been suggested that OSA treatment by continuous positive airway pressure (CPAP) improves survival even in older subjects.
CPAP is the gold standard treatment for OSA. Adherence to CPAP treatment is important, since when CPAP is adequately used it eliminates apneas, improves sleep quality and health related quality of life (HRQoL), and reduces EDS. Furthermore, it can reduce morbidity and mortality from cardiovascular diseases as well as consumption of health care resources. However it is not always well tolerated. It requires follow-up, and the adherence rates are often low. Adherence to CPAP therapy is the key for effective management of OSA patients. Epidemiological data show that on average 25% of OSA patients do not accept CPAP treatment and, of those who undertake the therapy, only 30–60% can be considered adherent. An acceptable adherence to therapy is usually considered a minimum of 4 hours/night for at least 70% of the nights of therapy. Some of the key determinants of CPAP rejection and non-adherence may include apprehension regarding how CPAP will make patients look and feel, interference with normal life and sexual functioning, and other behavioural or psychological factors. In order to enhance adherence to CPAP, treatment should be presented as desirable for the patient, must not appear too complex, must be proposed several times, and must be effective.
Several recent studies show that adherence to CPAP therapy can be improved with some strategies: patient educational training and information at the start of therapy, timely approach to the resolution of possible causes of non-adherence to therapy, structured follow-up and motivational support. However, the effects in the long-term of a short early motivational support on adherence to treatment are poorly known.
The aim of the study was to assess the adherence to CPAP therapy with and without early reinforcing interventions, consisting of motivational reinforcement and technical support in the first month of therapy, and to evaluate if the possible benefit of the support could extend to one year.
Background
Obstructive sleep apnea (OSA) is a common sleep disorder characterized by intermittent partial or complete upper airway obstruction during sleep, associated to recurrent arousals, nocturnal intermittent hypoxemia, sleep fragmentation and poor sleep quality. The prevalence of OSA associated with accompanying excessive daytime sleepiness (EDS) is approximately 3 to 7% in adult men and 2 to 5% in adult women in the general population. Factors that increase vulnerability to the disorder include age, male sex, obesity, craniofacial abnormalities, family history, menopause, and behaviours such as cigarette smoking and alcohol use.
Sleep-disordered breathing adversely affects daytime alertness and cognition: patients suspected of suffering from sleep apnea show several typical symptoms including habitual snoring (often disruptive to bed partners), feeling unrefreshed at wake-up, EDS or fatigue, lack of concentration, memory impairment, and at times neurobehavioural disturbances. OSA is an independent risk factor for cardiovascular diseases, including hypertension, atrial fibrillation, coronary artery disease, stroke, and for metabolic diseases like type 2 diabetes. OSA is associated with automobile accidents, reduced participation in work activities, increased absenteeism, and a loss of productivity, with a consequent increase in the use of resources. Severe OSA is associated with increased mortality, especially in young subjects. Although mortality risk associated with OSA tends to disappear from the age of 50, it has been suggested that OSA treatment by continuous positive airway pressure (CPAP) improves survival even in older subjects.
CPAP is the gold standard treatment for OSA. Adherence to CPAP treatment is important, since when CPAP is adequately used it eliminates apneas, improves sleep quality and health related quality of life (HRQoL), and reduces EDS. Furthermore, it can reduce morbidity and mortality from cardiovascular diseases as well as consumption of health care resources. However it is not always well tolerated. It requires follow-up, and the adherence rates are often low. Adherence to CPAP therapy is the key for effective management of OSA patients. Epidemiological data show that on average 25% of OSA patients do not accept CPAP treatment and, of those who undertake the therapy, only 30–60% can be considered adherent. An acceptable adherence to therapy is usually considered a minimum of 4 hours/night for at least 70% of the nights of therapy. Some of the key determinants of CPAP rejection and non-adherence may include apprehension regarding how CPAP will make patients look and feel, interference with normal life and sexual functioning, and other behavioural or psychological factors. In order to enhance adherence to CPAP, treatment should be presented as desirable for the patient, must not appear too complex, must be proposed several times, and must be effective.
Several recent studies show that adherence to CPAP therapy can be improved with some strategies: patient educational training and information at the start of therapy, timely approach to the resolution of possible causes of non-adherence to therapy, structured follow-up and motivational support. However, the effects in the long-term of a short early motivational support on adherence to treatment are poorly known.
The aim of the study was to assess the adherence to CPAP therapy with and without early reinforcing interventions, consisting of motivational reinforcement and technical support in the first month of therapy, and to evaluate if the possible benefit of the support could extend to one year.
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