Predicting Treatment Adherence in Obstructive Sleep Apnea Using Principles of Behavior Change

TLDR

OSA affects 2–4 % of adults, causes daytime sleepiness, depression, irritability, and is linked to major morbidity and mortality; despite CPAP’s proven efficacy, most patients discontinue or underuse it, underscoring the need for new adherence perspectives beyond demographic and disease factors. The study redirects focus to psychological constructs, applying two primary theories to predict CPAP adherence, since traditional interface changes and autotitration have not reliably improved adherence or symptoms.

Abstract

O bstructive sleep apnea (OSA) affects 2% to 4% of middle- aged women and men, respectively, 1 with higher rates in the elderly 2 and in certain racial groups. 3It has significant daytime consequences, including excessive daytime sleepiness, depression, irritability, and attention problems, and is now known to be strongly associated with chief causes of morbidity and mortality in adults. 4,5Despite the demonstrated efficacy of continuous positive airway pressure (CPAP) for treating OSA, 6-8 the majority of patients who are prescribed CPAP either discontinue it completely or fail to use it as recommended (ie, all night every night). 9,10This may lead providers to accept less-than-optimal adherence despite the recent evidence suggesting that continuous nightly CPAP use is required to normalize hallmark symptoms of the disorder. 11An alternative viewpoint is that new perspectives on the CPAP-adherence issue are needed.Studies of CPAP nonadherence have traditionally focused on demographic and disease-related factors.Among these, perceived improvement in daytime sleepiness is the most consistent indicator of continued CPAP use. 12Other factors related to better adherence, including more education, greater severity of OSA, daytime somnolence, and the absence of comorbid medical conditions have been identified less reliably. 9,10Side effects of CPAP therapy, although often cited as a primary reason for discontinuing treatment, 13,14 produce only minimal adherence improvements when treated. 15Thus, changing interface type, 15 using autotitration instead of standard overnight titration methods, 16 and changing patients from CPAP to bilevel positive airway pressure 17 do not reliably produce improvements in adherence or in OSA-related symptoms.Recently, investigators have begun to emphasize the importance of psychological constructs in predicting CPAP adherence.The advantage of this shift is that it can point to potential targets for treatment.Two primary theories have been applied to CPAP