Behavioral sleep medicine techniques for sleep apnea patients

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1 Behavioral sleep medicine techniques for sleep apnea patients Jack D. Edinger, Ph.D., C.B.S.M. National Jewish Health, Denver, CO Duke University Medical Center, Durham, NC Associated Professional Sleep Societies, LLC 1

2 Conflict of Interest Disclosures for Speakers x 1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Type of Potential Conflict Grant/Research Support Consultant Speakers Bureaus Financial support Other Details of Potential Conflict National Institutes of Health; Merck; Philips Respironics Oxford University Press; Springer Press (Book Royalties) 3. The material presented in this lecture has no relationship with any of these potential conflicts, OR x 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture: 1. Bjornsdottir E, Janson C, Sigurdsson JF, Gehrman P, Perlis M, Juliusson S, Arnardottir ES, Kuna ST, Pack AI, Gislason T, Benediktsdottir B. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013;36(12): doi: /sleep PubMed PMID: ; PubMed Central PMCID: PMC Guilleminault C, Davis K, Huynh NT. Prospective Randomized Study of Patients with Insomnia and Mild Sleep Disordered Breathing. Sleep. 2008;31(11): PubMed PMID: WOS: Associated Professional Sleep Societies, LLC 2

3 Presentation Objectives/Outline What the BSM specialist has to offer OSA patients Techniques for Promoting CPAP Adherence Graded Exposure Therapy for CPAP related claustrophobia Motivational Interviewing Risk Perception Enhancement through Personalized Videos Interventions for Insomnia Disorder occurring comorbid to OSA [Weight reduction interventions] not discussed Associated Professional Sleep Societies, LLC 3

4 PAP Adherence Background PAP is safe, effective non-invasive 1 st line therapy However PAP adherence remains a challenge Initial acceptance rate is 70-75%* > 50% patients started on CPAP not using it after 1 year* Most of those using PAP at 1 year, use it < prescribed* < entire night < nightly use *Stepnowsky CJ, Jr., Moore, PJ. Nasal CPAP treatment for obstructive sleep apnea: developing a new perspective on dosing strategies and compliance. J Psychosom Res Jun;54(6): Associated Professional Sleep Societies, LLC 4

5 PAP Usage Across 12 Month RCT 300 PAP Mean Hrs Used/Night N = 273 Minutes of Use MONTH 1 MONTH 2 MONTH 3 MONTH 4 MONTH 5 MONTH 6 MONTH 7 MONTH 8 MONTH 9 MONTH 10 MONTH 11 MONTH 12 Percent of sample Degrees of PAP Adherence Across 12 Months Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12 0 hours per night > 0 & < 2 Hrs 2 to 4 Hrs 4 to 6 Hrs >= 6 hours Associated Professional Sleep Societies, LLC 5

6 Factors determining PAP adherence Physical Comfort Mechanical Problems Social Factors Psychological Factors Associated Professional Sleep Societies, LLC 6

7 Psychological factors affecting PAP use Anxiety reactions Claustrophobia fear of suffocation sense of being trapped - panic Comorbid Psychiatric Conditions Beliefs/Attitudes about OSA Risks and PAP My OSA is not that serious PAP does little to improve my symptoms Associated Professional Sleep Societies, LLC 7

8 Conditioned Arousal UCS CS Meat powder + Bell UCS Confinement + Restricted breathing CS Drooling Drooling UCR CR Panic/Anxiety Panic/Anxiety UCR CR Associated Professional Sleep Societies, LLC 8

9 Reinforcement of Mask Removal Anxiety Anxiety Mask Removal (PAP Avoidance) = immediate anxiety decrease Associated Professional Sleep Societies, LLC 9

10 Case Example Associated Professional Sleep Societies, LLC 10

11 Graded Exposure Treatment of PAP Anxiety Reactions Sample PAP Exposure Hierarchy 1. Connect the mask and hose to the PAP unit. Hold the mask over your face and turn on the PAP. Practice breathing with the machine on while you are awake. 2. Strap the mask on your head, and turn on the CPAP. Practice breathing with the mask on, starting with 5 to 10 min and gradually increasing time for longer periods up to 20 to 30 min. 3. Take a short daytime nap with PAP. Start with 5-10 minute nap and gradually increase up to 30 minutes Reintroduce PAP into nighttime sleep. You can begin using it a portion of the night and gradually increase up to entire night. *Proceed from one step to the next only when you are completely comfortable. If you feel any anxiety or discomfort, return to previous step, then proceed again when comfortable. Associated Professional Sleep Societies, LLC 11

12 Graded PAP Exposure: Tracking Progress Associated Professional Sleep Societies, LLC 12

13 Objective Measures of Practice Adherence Associated Professional Sleep Societies, LLC 13

14 Efficacy of PAP Graded Exposure Protocol Means & Edinger, Behavioral Sleep Medicine, 2007 % Associated Professional Sleep Societies, LLC 14

15 Efficacy of PAP Graded Exposure Protocol Means & Edinger, Behavioral Sleep Medicine, 2007 Associated Professional Sleep Societies, LLC 15

16 Case Example 60 year old African American Female Marital status: Divorced Hx of OSA since 2003 AHI = 11 Hx of treatment with CPAP and BiPAP Referred due to PAP intolerance Associated Professional Sleep Societies, LLC 16

17 Medical History Problems Medication List Diabetes Ambien Albuterol HTN Amlodipine Obesity BMI = 35.2 ASA Osteoarthritis Wafarin Renal Disease Cozaar Asthma Allopurinol Zocar GERD Insulin Associated Professional Sleep Societies, LLC 17

18 Psychiatric History PTSD related to hx of domestic violence Engaged in active treatment (UCMC) Group and individual therapy Sertraline for PTSD & Depression Benefiting from treatment but has recurrent memories of domestic abuse Associated Professional Sleep Societies, LLC 18

19 OSA Treatment History Given Trials of CPAP & BiPAP Most recent titration shows 26/21 most effective Patient intolerant to therapy Reminds her of ex-husband trying to suffocate her Gets palpitations when she hears PAP machine on Anxious when in same room as PAP Longest usage per night = 3 hours Not using PAP at all at time of referral Associated Professional Sleep Societies, LLC 19

20 Treatment Approach Graded Exposure 6 visits between July 2013 and April 2014 First visit (1 hr.) = assessment + treatment introduction Subsequent visits (30 min) = follow-up & support Associated Professional Sleep Societies, LLC 20

21 PAP Exposure Hierarchy 1. Get comfortable with CPAP in same room 2. Connect the mask and hose to the PAP unit. Hold the mask over your face and turn on the PAP. Practice breathing with the machine on while you are awake. 3. Strap the mask on your head, and turn on the CPAP. Practice breathing with the mask on, starting with 5 to 10 min and gradually increasing time for longer periods up to 20 to 30 min. 4. Take a short daytime nap with PAP. Start with 5 10 minute nap and gradually increase up to 30 minutes Reintroduce PAP into nighttime sleep. You can begin using it a portion of the night and gradually increase up to entire night. *Proceed from one step to the next only when you are completely comfortable. If you feel any anxiety or discomfort, return to previous step, then proceed again when comfortable. Associated Professional Sleep Societies, LLC 21

22 Treatment Outcome Associated Professional Sleep Societies, LLC 22

23 In Lab Protocol to Enable PAP Titration Associated Professional Sleep Societies, LLC 23

24 Motivational Interviewing Intervention for PAP Adherence Aloia et al, Sleep, 2013 Associated Professional Sleep Societies, LLC 24

25 Use of Personalized Videos to Enhance Risk Perception Aloia et al., Sleep (suppl) 2013 Average CPAP Hourly Adherence By Group Hours per night hrs 4.2 hrs BPV NPV week1 month1 month2 month3 allmonths Date Associated Professional Sleep Societies, LLC 25

26 Management of the OSA Patient with Comorbid Insomnia Disorder Associated Professional Sleep Societies, LLC 26

27 Associated Professional Sleep Societies, LLC 27

Relative Disease Risk: OSA+I vs. OSA I Gupta & Knapp, PLoS ONE 9(3): e90021.

28 Relative Disease Risk: OSA+I vs. OSA I Gupta & Knapp, PLoS ONE 9(3): e doi: / journal.pone Associated Professional Sleep Societies, LLC 28

29 Impact of comorbid apnea on insomnia patients medical and mental health Data from Edinger et al. Archives of General Psychiatry, % Depression No Depression 43.1 Insomnia + Apnea 29.3 Insomnia Only N = 304 adults who met RDC for insomnia disorder Associated Professional Sleep Societies, LLC 29

30 ISI & Epworth Score Ranges Clinic Data 65 OSA + Insomnia vs. 64 Insomnia only ISI Score Ranges by Insomnia Grouping Daytime Sleepiness and Insomnia Diagnosis P = P = Insomnia+OSA Insomnia Other 0 Insomnia+OSA Insomnia Other ISI< 8 ISI 8-14 ISI ISI >=22 ESS <= 10 ESS > 10 Associated Professional Sleep Societies, LLC 30

31 Effects of Insomnia & PAP Adherence on daytime sleepiness and quality of life Wohlgemuth et al., Sleep, 2012 N = 442 Veterans at Miami VAMC P <.001 ANCOVA (controlling for age, medical and psychiatric conditions, service connection, AHI, PAP pressure, BMI, days of having PAP, medication, caffeine and nicotine use). Associated Professional Sleep Societies, LLC 31

32 CPAP ADHERENCE AS A MEDIATOR BETWEEN CO MORBID INSOMNIA,OSA AND SUBJECTIVE DAYTIME SLEEPINESS Wohlgemuth et al WASM Associated Professional Sleep Societies, LLC 32

33 What is known about treating patients with comorbid insomnia & OSA? Associated Professional Sleep Societies, LLC 33

34 Efficacy of CBT with Comorbid insomnia &OSA Lack et al, Sleep, 2011 N= 344 consecutive patients in an insomnia treatment program who met the criteria of chronic insomnia A full home diagnostic PSG was conducted pre-treatment. Sample characteristics 219 with primary insomnia 92 with co-morbid mild OSA (apnea/hypopnea index, 15<AHI<30) 33 patients with moderate to severe OSA (AHI>30). Outpatient treatment program for insomnia stimulus control therapy & bedtime restriction therapy cognitive therapy (sleep education, sleep perception re-training, relaxation) bright light therapies appropriate to needs of each patient. Measures = 7-day sleep diaries & daytime functioning questionnaires Baseline, after 5 weeks and at 3 month follow-up. Associated Professional Sleep Societies, LLC 34

35 Sleep and Waking Function Lack et al, Sleep, 2011 No OSA Mild OSA Mod/Sev ere OSA Mild OSA Mod/Sev ere OSA No OSA Associated Professional Sleep Societies, LLC 35

received either PAP (n=14); Oral appliance (n=2); or surgical (n=1)

36 Sequential Treatment CBT for Insomnia and OSA Therapy Krakow et al., Sleep and Breathing, 2004 ISI FOSQ Results from 17 patients who received either PAP (n=14); Oral appliance (n=2); or surgical (n=1) OSA therapy after CBT Associated Professional Sleep Societies, LLC 36

37 CBT + Surgical Treatment of Comorbid OSA & Insomnia Guilleminault et al., Sleep, 2008 Associated Professional Sleep Societies, LLC 37

38 Overall Conclusions Guilleminault, et al., Sleep 2008 OSA treatment alone eliminated insomnia complaints in only 5 of 15 patients CBT did not improve most sleep variables Combined therapy needed to normalize sleep and associated complaints in the majority of subjects Associated Professional Sleep Societies, LLC 38

39 Clinical Considerations & Case Vignettes Associated Professional Sleep Societies, LLC 39

Sizing up the case What are presenting symptoms? Are they specifically insomnia symptoms? Or. Could they result from under-treated OSA? What is usage pattern and tolerance for OSA therapy?

40 Sizing up the case What are presenting symptoms? Are they specifically insomnia symptoms? Or. Could they result from under-treated OSA? What is usage pattern and tolerance for OSA therapy? What benefits does patient derive from OSA therapy? Are there behavioral targets for CBT? Does OSA therapy contribute to sleep disruption? How should the treatment be sequenced? PAP then CBT CBT then PAP Simultaneous CBT + PAP Associated Professional Sleep Societies, LLC 40

41 Perpetuating Mechanisms + Treatment Approach Sleep restriction Unhelpful sleep beliefs Napping TIB Variable sleep schedules Performance anxiety Low sleep drive and/or Improper circadian timing and/or Stimulus control = Insomnia Cognitive therapies Conditioned arousal Attentional bias Active mind Excessive bedtime arousal Associated Professional Sleep Societies, LLC 41

42 The game of mix and match.. CBT + Associated Professional Sleep Societies, LLC 42

43 Insomnia Symptom Improvements in PAP Users and Nonusers (N = 705 w OSA + Insomnia pre PAP) Björnsdóttir et al. Sleep, 2013 Associated Professional Sleep Societies, LLC 43

44 Insomnia Before and After PAP Initiation Caetano Mota et al. Rev Port Pneumol. 2012;18(1): Insomnia Before and After PAP # of Patients Insomnia Pre PAP No Insomnia Pre PAP Total Group Pre PAP # with Insomnia After PAP Associated Professional Sleep Societies, LLC 44

45 Special Consideration: OSA Patients who remain sleepy Modify SRT so that initial TIB = TST + 30 min. Recommend short naps Reassess OSA and treatment adequacy Use counter-control instead of strict SC Less effective in beginning of night Equally effective in middle of night Associated Professional Sleep Societies, LLC 45

46 Case 1: 63-year-old single male BMI = 35 Referred due to sleep onset/maintenance complaints Medical Conditions: asthma, hypertension, aortic valve disease, benign prostatic hypertrophy, chronic migraine headaches, gastroesophageal reflux disease, chronic back pain. Prior dx (10 yrs. ago) of OSA PAP trial but discontinued after 1 month No Psychiatric history Associated Professional Sleep Societies, LLC 46

47 Case 1 continued: Current findings His bedtime varied between 9:30 p.m. and 10:30 p.m. his rising time varied between 5:15 a.m. and 7:15 a.m. No pattern of napping watches TV in bed 2 to 3 nights a week and reads in bed one night per week take Ambien CR, 12.5 m.g., and Melatonin, 10 m.g. to aid his sleep and he reports that this medication is helpful. Insomnia Severity Index = 11; Epworth = 2 Sleep study conducted the week before my consultation showed a baseline AHI = 36; 12 cm H 2 O reduced AHI to 1. Assessment & Plan Mild insomnia but severe OSA Allow patient to restart PAP therapy Keep sleep diary for 2 weeks once using PAP on regular basis and return to clinic to re-evaluate sleep symptoms Associated Professional Sleep Societies, LLC 47

48 Sleep Diary Post PAP Initiation Associated Professional Sleep Societies, LLC 48

49 Case 2 37 yr. old married male 2 year history of insomnia mostly sleep onset difficulty Insomnia began with suicide of co-worker/friend Recently moved to Denver for work with charitable organization directs youth center Work stressful long hours & dysfunctional staff Medical conditions = chronic bronchitis, GERD, and cough all effectively treated. Patient does not view as contributory to sleep problems No history of mental/emotional problems MSE mildly anxious mood but otherwise normal ISI = 20; Epworth Scale = 13 Diagnostic PSG showed AHI = 10 events/hour Associated Professional Sleep Societies, LLC 49

50 Case 2 continued Reported sleep schedule: bedtime = 9:30 PM; rise time = 5:00 AM Works hour days 6 days per week Sundays works as pastor ½ of day Usually watches TV in bed nightly Has active mind in bed thinks about work Uses over the counter sleep aides intermittently to manage sleep Associated Professional Sleep Societies, LLC 50

51 Case 2 continued Associated Professional Sleep Societies, LLC 51

52 Case 2 continued Treatment Plan: Standard SC and SRT Increase exercise for stress release One hour buffer time prior to bed Initiate CPAP concurrent to behavioral treatment Associated Professional Sleep Societies, LLC 52

53 Case 2 after 6 weeks of CBT + PAP therapy Associated Professional Sleep Societies, LLC 53

54 Managing comorbid insomnia & OSA Emerging area of sleep medicine focus CBT has proven effective alone and with OSA therapies Combined therapy presumed optimal but adherence to therapies a challenge Future studies should ascertain: Optimal therapies for sleep-wake and health outcomes Strategies for making therapies acceptable/tolerable Best treatment sequence Assure dissemination/translation of findings so patients have access to best treatment practices Associated Professional Sleep Societies, LLC 54

Welcome to the SBSM Practice and Consultation Webinar

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