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

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So what we do watch

What is Diagnosed

So…7.7 % are behavioral (2.7+1.7+1.5+1+0.8) + some portion of (2.6+6.1)

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

*

Sabotaging one’s study

Critical features of getting that study

• Collaboration with patient

• Review doctor notes

• Empathy

• Clear Goals

• Boundaries

• Soliciting feedback

Sleep Hygiene

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

Preparing for Defensiveness

Managing Defensiveness

• Humor

• Let go of less important issues

• Sitting close to patient

• Affirmation of the difficulty with sleeping in the lab

CPAP Adherence

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

Thank youThank you