Adherence to CPAP Treatment: History
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Contributor:
Athanasia Pataka
,
Seraphim Chrysovalantis Kotoulas
,
Panagiotis Raphael Gavrilis
,
Alice Karkala
,
Asterios Tzinas
,
Aimiliza Stefanidou

Obstructive sleep apnea (OSA) is considered a chronic disease that requires long-term multidisciplinary management for effective treatment. Continuous Positive Airway Pressure (CPAP) is still considered the gold standard of therapy. However, CPAP effectiveness is limited due to poor patients’ adherence, as almost 50% of patients discontinue treatment after a year. Several interventions have been used in order to increase CPAP adherence. Mindfulness-based therapies have been applied in other sleep disorders such as insomnia but little evidence exists for their application on OSA patients. 

  • obstructive sleep apnea
  • cognitive therapy
  • mindfulness

1. Introduction

Obstructive sleep apnea (OSA) is the most prevalent sleep breathing disorder (SDB) caused by complete or partial upper airway occlusion during sleep. The incidence of OSA is higher than previously believed, with almost 20% of adult males and 10% of women suffering from the moderate-to-severe disease. Obesity is considered to be one of the most important risk factors for OSA [1]. Apart from obesity, increased neck circumference, male sex, older age, upper airway, and craniofacial abnormalities are also considered significant clinical risk factors of the disease [2]. Several cluster analysis studies have found that the classical phenotype of OSA, i.e., the obese sleepy male, represents only a part of the patients, and have identified other clinical phenotypes, with atypical symptoms, such as insomnia, gender-specific, with different co-morbidities and polysomnographic findings [3].
OSA interrupts the physiological sleep structure leading in sleep fragmentation causing excessive daytime sleepiness (EDS), and impaired vigilance, resulting in an increased risk of work and motor vehicle accidents [4]. Undiagnosed and untreated OSA has been associated with increased mortality and has serious health consequences such as hypertension, arrythmias, cardiovascular and cerebrovascular disease, diabetes, impairment of heart failure, and pulmonary hypertension [5]. All the aforementioned consequences have a significant economic burden [6]. However, with early identification and treatment, the negative implications of OSA can be significantly decreased.
OSA is considered a chronic disease that requires long-term multidisciplinary management for effective treatment. Continuous Positive Airway Pressure (CPAP) is still considered the gold standard of therapy, even though there are several treatment options such as mandibular advancement devices, weight loss, lifestyle interventions, positional therapy, hypoglossal nerve stimulation, and surgical operations. CPAP is recommended as the first choice for patients with moderate to severe disease and those with mild and clinical symptoms, such as EDS, or co-morbidities [7]. CPAP provides a stream of pressurized air constantly during inspiration and expiration in order to maintain the upper airways open. The application of CPAP resolves obstructive respiratory events, improves oxygen desaturations, resulting in improved daytime sleepiness, cognitive function, and mood [8]. Additionally, treatment with CPAP has beneficial cardiovascular effects as it reduces arterial blood pressure, especially in patients with severe disease; it improves pulmonary hypertension and left ventricular ejection fraction in patients with heart failure [9][10]. CPAP also reduces mortality and improves the quality of life [11][12][13][14]. A dose-response relationship has been found between the improvement in health and CPAP adherence [9][11][12][13][14]. However, CPAP effectiveness is limited due to poor patients adherence. It has been shown that almost 50% of patients discontinue CPAP after a year of treatment [15][16][17], within a range of 29% to 83%, while 8 to 15% of patients reject treatment as early as the first night of application [18][19]. In the comprehensive systematic literature review of Rotenberg et al. [18] that evaluated data from 82 trials regarding CPAP adherence over a twenty-year timeframe, it was found that CPAP adherence remained persistently low, around 34% (30–40%). It was also found that approximately 11% of the participants of the trials were unable to remain on CPAP treatment over the duration of the trial. Discontinuance of CPAP is a global problem despite the different cultural characteristics of the patients.

2. Interventions to Improve Non-Adherence to Continuous Positive Airway Pressure Therapy

During the last decades, several non-pharmacological treatments have been developed in order to help patients with sleep disorders. Sleep medicine combines the work of many health professionals, such as pulmonologists, neurologists, psychiatrists, otolaryngologists, maxillofacial surgeons and psychologists. Due to the multidisciplinary nature of sleep medicine different specialties are required to work together for the effective diagnosis and treatment. Psychology and Sleep medicine are closely related. Non pharmacologic treatment options include cognitive, behavioral, psychosocial, and educational interventions that may help in improving patients’ quality of life. In order to improve adherence to CPAP many different interventions have been used (Table 1) [20][21][22]. Behavioral sleep specialists use evidenced-based therapies combining cognitive techniques with behavioral approaches [22]. Cognitive-behavioral treatment is one of the most important behavior change interventions. A recent meta-analysis revealed that motivational interventions were more successful than educational programs and usual care in improving CPAP adherence, even though the results were not always sustained across all the studies [23].
Table 1. Strategies to Enhance self-efficacy for better CPAP adherence [24].
Education Educational material (leaflets, videos) by one-on-one clinic
visits, group meetings, telephone calls, telemedicine interactions, official internet sites
Behavioral Interventions Cognitive behavioral therapy (CBT)
Motivational enhancement therapy (MET),
Telemonitoring Data on treatment effectiveness and level of adherence.
Possible mask leaks, residual respiratory events, CPAP use duration
CPAP: Continuous Positive Airway Pressure.
The clinical observation that even though the therapeutic value of CPAP is undeniable, the percentage of patients that are compliant with treatment is rather low, created the need for educational and behavioral support. Despite the significant technological improvement of masks and devices and telemedicine applications, adherence to CPAP continues to be a major problem [25]. Some patients underestimate the severity of their disease due to its chronicity or some other perceives it as a disability and for that refuse treatment. The continuity of use affects compliance. When used as indicated, CPAP normalizes sleep architecture, reduces daytime sleepiness, cardiovascular risk, and improves health outcomes [26].
One of the most difficult problems to solve is the psychological acceptance of the device. Behavioral change is an important aspect in the acceptance of every treatment and is a complex procedure including not only psychological and motivational, but also socio-environmental aspects [27]. It includes the evaluation of the patient’s adherence to a treatment considering the level of awareness of the disease and its health consequences (reasons for change), the eagerness of the patient to change, the readiness of the patient to change, the perceived significance of this change and the spirit in the ability to change [28]. Several behavior change interventions have been used in order to improve adherence to treatment in several chronic conditions including respiratory disease [29] and more specifically for CPAP treatment [24][30]. The most successful intervention over the years for optimizing adherence has been behavioral therapy [31]. The comprehensive explanation to the patient and partner regarding the sleep disorder, its therapy with the function of equipment (mask, humidifier), the early resolution of problems—side effects, psychological consultations, and a careful follow-up are the main elements that may increase the compliance [32] (Table 2).
Table 2. Issues that should be discussed during the first visits for CPAP treatment.
Explain about OSA and its impact on patients’ health if left untreated
Suggest lifestyle changes such as weight loss, sleep hygiene
Explaining the importance of treatment with CPAP
CPAP device demonstration: different types of masks, humidifier, ramp
Discuss a follow-up plan (short-term and long-term: face-to-face, telephone, telemedicine)
Solve practical issues with CPAP
Behavioral interventions, such as the use of cognitive-behavioral therapy (CBT) and of motivational enhancement therapy (MET) in order to increase the self-efficacy of the patient, in addition to education, seem to be a promising approach [33]. The goal of CBT is, through the conversational exchange, to correct the patients’ beliefs that are incorrect in order to change their behaviors toward treatment [34]. MET applies motivational interviewing through directed interview questions in order to reinforce patients’ motivations [35]. A comprehensive program should ideally be multifactorial including the intervention of different specialists such as sleep physicians, technologists, sleep psychologists, and nurses but also partners or caregivers.
OSA and insomnia often coexist. OSA patients present a higher prevalence of insomnia symptoms (40–60%) compared to that of the general population and this has led to the identification of a new disorder named co-morbid insomnia and OSA (COMISA), that has been highly underestimated [36]. The treatment of COMISA should combine positive-airway pressure (PAP) for OSA, together with CBT for insomnia. The combined treatment has been found to have a better patient outcome in comparison to that of every single treatment alone [36].

3. Mindfulness Interventions to Increase Continuous Positive Airway Pressure Adherence

Mindfulness, as a quite heterogeneous term in contemporary psychology, is viewed as an umbrella term that can refer to various facets of mindfulness, from a mental state to a personality trait and from a meditation practice to a type of clinical intervention. Mindfulness has been used as a form of meditation emphasizing a nonjudgmental state of complete or heightened awareness of one’s thoughts, experiences, or emotions [37][38]. Conceptualizing mindfulness as an art or as a science makes it unique in some way and different backgrounds, disciplines, ideologies, and practices try to achieve ‘ownership’ of that complicated concept. Depending on the viewing angle, mindfulness can be viewed as a ‘state’ or ‘trait’ mindfulness, but it is characterized as both since the practice of mindfulness is linked with the state and trait changes. People may change drastically during their lifetime when experiencing the benefits of mindfulness. It is worth noting that ‘state’ mindfulness can occur during meditation practices and ‘trait’ mindfulness is an individual trait that has been associated with being more conscious and aware in everyday life. ‘Trait’ mindfulness (or sometimes called ‘dispositional’ mindfulness) can be accessed through several psychometric questionnaires, such as the Mindful Awareness Scale (MAAS) and the Five Facet Mindfulness Questionnaire (FFMQ) and the Cognitive and Affective Mindfulness Scale-Revised (CAMS-R). Mindfulness skills (integration of knowledge and practice) are powerful mind/body life skills that can be applied to a variety of settings and conditions, alleviating the burden of symptoms and increasing psychological well-being [39][40][41].
A growing body of literature suggests that adding acceptance-based therapies in mindfulness approaches can optimize patient engagement and response to treatment. The idea is for the patient to accept thoughts and feelings (positive or negative) which eventually leads to self-care, a major determinant of outcomes. Mindfulness helps people to accept their experiences and become more compassionate with themselves (self-compassion) and with others as evidenced by enhanced prefrontal activation in imaging studies as fMRI and electrophysiologically in EEG [40][41]. The most widespread protocol used both in the clinical and non-clinical context is the Mindfulness-Based Stress Reduction (MBSR), a rigorous 8-week program that involves formal and informal meditation practices and was originally designed for stress reduction [37][38][41][42][43][44][45][46]. The aim of MBSR programs is to enhance well-being and coping with stress in diverse populations. MBSR has been proven to address chronic pain, depression, anxiety, and other conditions and overall increase the patient’s quality of life yielding significant benefits both in clinical and non-clinical samples [40][43][44][45][46].
Mindfulness therapies have been applied to patients suffering from sleep disorders [40][41][42]. Mindfulness interventions are suggested as a therapeutic option by the American Academy of Sleep Medicine in patients with insomnia, more frequently in a group format [42]. In this group of patients, mindfulness techniques may be also combined with other therapies, such as CBT (sleep restriction therapy, stimulus control, and sleep hygiene) [40][42]. Claustrophobia is highly prevalent among CPAP-treated patients influencing short and longer-term CPAP non-adherence [47]. In an attempt to examine if mindfulness interventions may be effective in improving CPAP adherence of OSA patients, Gawrysiak et al. [44] have structured a detailed protocol targeting claustrophobia (Mindfulness-based Exposure for PAP-associated Claustrophobia, MBE-PC) once per week for eight consecutive weeks in group meetings. The results of this study have not been published yet.
Studies demonstrate that depression, anxiety, and cognitive functions are considered complications of OSA and may be improved after using CPAP [48][49][50][51]. For that someone may consider that possibly other treatment interventions targeting psychological distress may be effective in OSA patients [52][53]. Li et al. [54] have evaluated whether mindfulness was associated with CPAP adherence using the MAAS. The authors have concluded that only MAAS and OSA severity were associated with CPAP adherence irrespective of the presence of psychological distress assessed by the Hospital Anxiety and Depression Scale (HADS); even though HADS evaluating depression was found higher in the nonadherent group.
Furthermore, chronic stress can reduce the prefrontal cortex and increase the size of the amygdala making the brain more receptive to stress. Chronic stress can also weaken emotion regulation [55]. Emotion regulation or emotional self-regulation refers to a person’s ability to affect one’s emotional state. A recent study [56] indicated that fragmented sleep and the reduction of REM sleep, which both characterize the sleep architecture of OSA, were associated with the difficulty of patients to recall details from the past and overall, with poor memory consolidation. In this regard, an embodied emotion regulation framework could be employed to understand how mindfulness, through top-down or bottom-up pathways affects emotion regulation from a cognitive or clinical perspective [53].
In addition, emerging evidence suggests that mobile Health interventions may improve treatment adherence and outcomes. Technological advancements in the digital realm can indeed improve patient compliance. Some mindfulness-related apps have been evaluated for clinical efficacy (e.g., Calm app is one app that specializes in audio and video programs intended to help someone relax before bedtime) and could be a viable option to help patients with OSA reduce self-reported anxiety and get a high-quality sleep [57][58].

This entry is adapted from the peer-reviewed paper 10.3390/life13020296

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