Welcome to the SBSM Practice and Consultation Webinar
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1 Welcome to the SBSM Practice and Consultation Webinar CPAP Adherence We will be joined by our Presenter: Melanie Leggett, PhD, CBSM VA Medical Center Durham, NC Our Discussant is Christi Ulmer, PhD, CBSM VA Medical Center Durham, NC
2 CPAP Adherence Melanie K. Leggett, PhD, CBSM Associate Professor Psychiatry and Behavioral Sciences Duke University Medical Center Staff Psychologist Durham VA Healthcare System 7/25/18 SBSM Practice Consultation Webinar
3 Disclosures This presentation does not represent the views of the Department of Veterans Affairs or the United States Government. I do not have any financial conflicts of interest.
4 Educational Objectives Understand challenges to PAP therapy within the biopsychosocial model Characterize the research on PAP adherence Describe behavioral approaches for improving PAP adherence
5 Obstructive Sleep Apnea Prevalence : 9%-38% Primary risk factors: advancing age male sex higher BMI Associated with cardiovascular, metabolic, and psychiatric disorders
6 Treatment Options for OSA Devices Surgical Alternative/Adjunctive Positive airway pressure devices Oral appliances Upper airway modification Upper airway neurostimulation Skeletal modifications Tracheostomy Bariatric surgery (for obesity) Weight loss Sleep position training Expiratory nasal resistors Hypoglossal nerve stimulation Myofunctional Therapy Oral pressure therapy Acupuncture Pharmacotherapy
7 Decision Tree for Treating OSA Sleep Apnea Diagnosis Mild Moderate to Severe PAP Oral Appliance Alternative/ Adjunctive PAP PAP Failure PAP Failure Oral Appliance Surgery Alternative/ Adjunctive Oral Appliance Surgery Alternative/ Adjunctive
8 CPAP Acceptance and Adherence Acceptance rate is 70-75% Over half of patients started on CPAP may not be using it after 1 year Of those using CPAP at 1 year, most use it less than prescribed Average use is around 5 hrs./night Durham VA (n = 833) 1 month 3 months % of nights 65.8% 61.2% Hrs per night 4.4 hrs. 4.5 hrs.
9 Biopsychosocial Model of PAP Adherence Biomedical Psychological Social
10 Biopsychosocial Model of PAP Adherence Biomedical Psychological Social Patient demographics Beliefs Partner involvement Apnea severity Attitudes Family attitudes PAP modality Motivation Patient-provider communication Pressure settings Coping style Travel Mask interface Stress Socioeconomic factors Humidification Medications Confidence Knowledge Claustrophobia Anxiety Depression Insomnia
11 Durham VA BSM Clinic Referrals
12 Interdisciplinary Team Approach to PAP Adherence Address problems early on Monitor adherence and provide feedback Provide support, education, and encouragement Instill importance of treatment
13 Assessment of PAP Adherence No standard protocol Clinical interview Questionnaires Attitudes to CPAP Treatment Inventory Perceived Self-Efficacy Measure for Sleep Apnea Adherence Barriers to CPAP Questionnaire Objective data
14
15 Interventions to Promote PAP Adherence Biomedical pressure humidification mask interface Psychological education motivational enhancement cognitive behavioral exposure Social telemedicine couples
16 Biomedical Interventions: PAP Technology Pressure modality Continuous positive airway pressure (CPAP) Auto-titrating positive airway pressure (APAP) Bi-level positive airway pressure (BiPAP) Adaptive servoventilation (ASV) Flexible pressure (C-flex, A-flex) Heated humidification
17 Biomedical Interventions: Mask Interface
18 Psychological/Behavioral Interventions: Patient Education Interventions: Video recordings Telephone calls/phone coaching Didactic sessions/lectures Printed information Reviewing PSG data Intensive support (education + nurse home visits) Meta-analysis (Wozniac et. al., 2014): 36 min increase in PAP use 13% increase in # of pts using CPAP > 4 hrs.
19 Psychological/Behavioral Interventions: Theoretical Models Social cognitive theory Transtheoretical model Health belief model Cognitive behavioral theory 2 factor theory of avoidance Chronic disease self management model
20 Common Applications to CPAP Adherence Motivational Enhancement Therapy (MET) Cognitive Behavioral Therapy (CBT) Exposure Therapy
21 Motivational Enhancement Therapy (MET) for CPAP Adherence Evaluate readiness, confidence, and motivation to use CPAP Explore ambivalence regarding CPAP Provide personalized feedback about effects of sleep apnea on health Discuss how CPAP could improve patient s health Identify discrepancies between values and behavior Foster motivation, build confidence, support self efficacy
22 Cognitive Behavioral Therapy (CBT) for CPAP Adherence Education specific to sleep apnea/cpap Identify/challenge dysfunctional beliefs Breathing or relaxation exercises to reduce anxiety May include elements from other theoretical approaches (modeling, pros/cons, readiness to change, motivation, confidence)
23 Exposure Based Interventions for CPAP Adherence Specific to side effect of claustrophobia Graded exposure therapy Desensitization therapy 1/3 of sleep apnea patients endorse CPAPrelated claustrophobia
24 Research on Psychological/Behavioral Interventions Most research has been done on ME and CBT strategies Exposure based interventions need RCTs Meta-analysis: (Wozniac et. al., 2014) CPAP by 86 min/night compared to UC % of patients using CPAP > 4 hrs. from 28% to 47%
25 Social Interventions: Telemedicine Definition: use of electronic/communications technologies to support health Advantages: Access to care Collaborative care with patient involvement Detecting issues early on Cost effectiveness
26 Social Interventions: Telemedicine Applications to CPAP Adherence: Data transmission from CPAP device to sleep practitioner Web-based education modules based on self-reported adherence Web-based feedback about daily PAP adherence Interactive voice response system Compares favorably with UC
27 Social Interventions: Dyadic Perspective Influence of spouse/partner on CPAP adherence Couples oriented intervention
28 Future Directions Acceptance RCTs/empirically-supported interventions Identification of specific subgroups for focused interventions Cost effectiveness
29 Questions & Discussion
30 Thank you for participating in the SBSM Practice and Consultation Webinar Join us for future scheduled events: Mark you Calendars! 9/26/2018, Nightmare Treatment/Imagery Rehearsal; Presenter: Kristi Pruiksma, PhD 2018 SBSM Fall Course - September 15-16, Birmingham, AL
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