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Behavioral Challenges in the lab: secondary insomnia and CPAP
adherence
Texas Society of Sleep ProfessionalsMary Rose, PsyD, CBSM
Assistant ProfessorLester & Sue Smith Breast Center
Department of MedicineBaylor College Medicine
General Insomnia Criteria
• Adequate sleep opportunity
• Persistent sleep difficulty
• Daytime dysfunction
(ICSD 2)
• >3/7 days for >1 month
• <6 hours sleep per day
Who is Referred for NPSG
Punjabi et al, Sleep Disorders in Regional Centers: A National Cooperative Study, SLEEP, 23, 4, 2000
Why not just refer insomnia out
• Insomnia often associated with other sleep disorders
• May be a substantial % of patients seen• Reinforces you as a comprehensive lab• Perceived well by accreditation programs• May expand your referral base• Is a major sleep complaint needing
treatment
*
Insomnia SD Causes (in lab)
• OSA
39%-58% OSA have insomnia29% -67% of insomnia pts have AHI > 5 (Comorbid Insomnia and Obstructive Sleep Apnea: Challenges for Clinical Practice and Research. Luyster, Buysse, Strollo. J Clin Sleep Med. 2010 April 15; 6(2): 196–204.)
• PLMD 12% (Coleman ‘82)
• RLS 12% (Coleman)
Other causes of Insomnia in the lab
• Pain
• Sleep lab environment
• Other: uneasiness, change in the environment
Insomnia Challenge in the Lab
• Patient does not sleep all night
• Patient does not bring medication
• The patient is sensitive to noise (those in the other room)
• The patient can not sleep alone
• Unreasonable use of poor sleep to deflect
*
Critical features of getting that study
• Collaboration with patient
• Review doctor notes
• Empathy
• Clear Goals
• Boundaries
• Soliciting feedback
Working with insomnia & PSG
• Feedback on the interface between insomnia & other SD
• Making sure meds are brought to study
• Accommodating schedule
• Allowing a spouse to stay
• Giving personal examples
Managing Defensiveness
• Humor
• Let go of less important issues
• Sitting close to patient
• Affirmation of the difficulty with sleeping in the lab
Predictors of CPAP Adherence
• 296 patients over 6 month time
• Best predictors: female gender, increasing age, and reduction in ESS score
• Use for first week predicts use for the 2st year (Rosenthal, 2000)
• More severe OSA
Predictors of Poor Adherence
• Poor history of prior adherence
• Anxiety
• Health Value, Health Locus of Control (incorporating internality, chance, powerful others) and Self-Efficacy (Wild, 2004)
• Insomnia, especially when this is being ignored by the providers
Patient- Report Barriers
• Mask discomfort
• Skin irritation
• Nasal dryness (40% have stuffiness, dry nose, sore throat)
• Congestion
• Leaks
• Difficulty with adapting
Patient PAP Barriers
• Claustrophobia (abnomal fear of enclosed spaces) Fear and Avoidance Scale suggested 2x poorer adherence in high FA patients (Chasens, 2005)
• Problems with CPAP noise
• Mouth breathers (less adherent)
Social Factors
• Those who live alone CPAP use <
• When sleeping with partner CPAP used >
• CPAP use predicts
marital conflict but not
supportiveness.
Comparisons 63 users vs 40 non users (Janson 2000)
• Oxygen desaturation index was an independent negative predictor of non-compliance
• Problems in the nose or pharynx & lack of subjective effect by the treatment
• High age was an independent risk factor for non-compliance b/c problems in the nose or pharynx
• Having undergone UPPP was a risk factor for non-compliance because of lack of effect
Facilitating Adherence
• First Few months-close monitoring
• Direct clinician follow up
• Technician care
• Tele-medicine
• Patient support groups
• Home visits
Health Belief’s Model
• Health Belief Model: negative health can be avoided
• Expectation that one’s actions can affect health
• Belief that the person themselves can successfully take recommended action
SES Effects on CPAP use
• Private patients look for a diagnosis earlier in the course of the disease than public patients, adhere more to follow-up, and abandon continuous positive airway pressure treatment less than public patients do (Brazilian sample, Zonato, 2004)
Strategies for Implementing Adherence
• Video education (viewers at 1st vist >2x adherence at 1 month FU) (Jean, 2005)
• CPAP support groups < use by 2 hours (Likar 1997)
• In lab CPAP desensitization
• Home desensitization (stepwise)
Major issues to address
• Humidity (heated associated with <restedness in am) Massie, 1999
• Mask fit
• Movement of patient in bed compatible with mask
• Noise interference
• Time of night used
Major Issues to Address
• Personalization
• Degree to which reduction in pressure is possible
• What spouse feels about treatment
PAP Compliance
Intervention:
• R/O mask fit px, pressure problems
• Easy: mask discomfort, pressure miss-set
• Harder: sense of suffocation, panic
• Hardest: challenge to identity as healthy, sexual
severe mental illness
PAP Compliance Easy & Hard Treatment
Multi-step week by week 2 hour intervals:
a) Wear mask no pressure for 2 hours awake @ house
b) Wear mask pressure for 2 hours awake
c) Nap 2 hours with mask pressure
d) Sleep @ least 4 hours mask pressure
PAP Compliance Easy & Hard to Treat
• Trouble shoot at every stage- where does something going wrong
• Change mask, gradual exposure to habituate to pressure
• Weekly FU improved complinace, phone calls, a contact person, etc.
PAP Compliance Hardest
• Cognitive therapy to
a) challenge how identity is defined by the patient
b) Identify other ways in which identity is still stable despite OSA
c) education re: effects of untreated OSA on sexuality, intimacy, overall health
Summary Insomnia in the Lab
• Common
• Be prepared by reading notes
• Your lab manager may want to prep docs and other staff to take an added step with the comorbid insomnia pt
• Empathy, normalize
• Emphasize to patient to review with doc
Summary CPAP
• Provide a questionnaire to list severity of content with adherence issues
• 1 Month follow up post study
• Make sure they understand what the DME does vs what you do
• Normalize/empathy