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Factors that influence CPAP adherence: an overview

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Abstract

Background

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea syndrome (OSAS). Consistent adherence to CPAP improves the patient’s longevity and quality of life as well as public safety. However, nonadherence is a significant contributor to the growing burden of untreated OSAS, and is associated with negative consequences for the patient, public safety, and the healthcare system.

Objective

The use of CPAP is a classic example of an effective treatment for which adherence is extremely variable. This paper examines a multiplicity of factors that influence CPAP adherence.

Factors

These factors are traditionally thought of in terms of patient and equipment variables, but in addition physician, family, healthcare facility, and governmental issues all contribute to CPAP adherence.

Discussion

These factors are reviewed and pragmatic recommendations are made for improving clinical practice.

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References

  1. McNicholas WT, Bonsigore MR (2007) Sleep apnoea as an independent risk factor for cardiovascular disease: current evidence, basic mechanisms and research priorities. Eur Respir J 29:156–178

    Article  CAS  PubMed  Google Scholar 

  2. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235

    Article  CAS  PubMed  Google Scholar 

  3. Tishler PV, Larkin EK, Schluchter MD, Redline S (2003) Incidence of sleep-disordered breathing in an urban adult population: the relative importance of risk factors in the development of sleep-disordered breathing. JAMA 289:2230–2237

    Article  PubMed  Google Scholar 

  4. Tarasiuk A, Greenberg-Dotan S, Simon-Tuval T, Oksenberg A, Reuveni H (2008) The effect of obstructive sleep apnea on morbidity and health care utilization of middle-aged and older adults. J Am Geriatr Soc 56:247–254

    Article  PubMed  Google Scholar 

  5. Sigurdson K, Ayas NT (2007) The public health and safety consequences of sleep disorders. Can J Physiol Pharmacol 85:179–183

    Article  CAS  PubMed  Google Scholar 

  6. Mulgrew AT, Ryan CF, Fleetham JA, Cheema R, Fox N, Koehoorn M, Fitzgerald JM, Marra C, Ayas NT (2007) The impact of obstructive sleep apnea and daytime sleepiness on work limitation. Sleep Med 9:42–53

    Article  CAS  PubMed  Google Scholar 

  7. Philip P, Taillard J, Niedhammer I, Guilleminault C, Bioulac B (2001) Is there a link between subjective daytime somnolence and sickness absenteeism? A study in a working population. J Sleep Res 10:111–115

    Article  CAS  PubMed  Google Scholar 

  8. Schwartz DJ, Kohler WC, Karatinos G (2005) Symptoms of depression in individuals with obstructive sleep apnea may be amenable to treatment with continuous positive airway pressure. Chest 128:1304–1309

    Article  PubMed  Google Scholar 

  9. Finn L, Young T, Palta M, Fryback DG (1998) Sleep-disordered breathing and self-reported general health status in the Wisconsin Sleep Cohort Study. Sleep 21:701–706

    CAS  PubMed  Google Scholar 

  10. Harris M, Glozier N, Ratnavadivel R, Grunstein RR (2009) Obstructive sleep apnea and depression. Sleep Med Rev 13(6):437–444

    Article  PubMed  Google Scholar 

  11. Marshall NS, Barnes M, Travier N, Campbell AJ, Pierce RJ, McEvoy RD, Neill AM, Gander PH (2006) Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis. Thorax 61:430–434

    Article  CAS  PubMed  Google Scholar 

  12. Phillips B (2005) Sleep-disordered breathing and cardiovascular disease. Sleep Med Rev 9:131–140

    Article  PubMed  Google Scholar 

  13. Wild MR, Engleman HM, Douglas NJ, Espie CA (2004) Can psychological factors help us to determine adherence to CPAP? A prospective study. Eur Respir J 24:461–465

    Article  CAS  PubMed  Google Scholar 

  14. Horne JA, Reyner LA (1995) Sleep related vehicle accidents. BMJ 310:565–567

    CAS  PubMed  Google Scholar 

  15. Sassani A, Findley LJ, Kryger M, Goldlust E, George C, Davidson TM (2004) Reducing motor-vehicle collisions, costs, and fatalities by treating obstructive sleep apnea syndrome. Sleep 27:453–458

    PubMed  Google Scholar 

  16. Marti S, Sampol G, Munoz X, Torres F, Roca A, Lloberes P, Sagales T, Quesada P, Morell F (2002) Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 20:1511–1518

    Article  CAS  PubMed  Google Scholar 

  17. Basner RC (2007) Continuous positive airway pressure for obstructive sleep apnea. N Engl J Med 356:1751–1758

    Article  CAS  PubMed  Google Scholar 

  18. Weaver TE, Maislin G, Dinges DF, Younger J, Cantor C, McCloskey S, Pack A (2003) Self-efficacy in sleep apnea: instrument development and patient perceptions of obstructive sleep apnea risk, treatment benefit, and volition to use continuous positive airway pressure. Sleep 26:727–732

    PubMed  Google Scholar 

  19. Ip MS, Tse HF, Lam B, Tsang KW, Lam WK (2004) Endothelial function in obstructive sleep apnea and response to treatment. Am J Respir Crit Care Med 169:348–353

    Article  PubMed  Google Scholar 

  20. Dhillon S, Chung SA, Fargher T, Huterer N, Shapiro CM (2005) Sleep apnea, hypertension, and the effects of continuous positive airway pressure. Am J Hypertens 18:594–600

    Article  PubMed  Google Scholar 

  21. Flemons WW (2002) Clinical practice. Obstructive sleep apnea. N Engl J Med 347:498–504

    Article  PubMed  Google Scholar 

  22. Parish JM, Lyng PJ (2003) Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure. Chest 124:942–947

    Article  PubMed  Google Scholar 

  23. Baron KG, Smith TW, Czajkowski LA, Gunn HE, Jones CR (2009) Relationship quality and CPAP adherence in patients with obstructive sleep apnea. Behav Sleep Med 7:22–36

    Article  PubMed  Google Scholar 

  24. Vital FM, Saconato H, Ladeira MT, Sen A, Hawkes CA, Soares B, Burns KE, Atallah AN (2008) Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema. Cochrane Database Syst Rev CD005351

  25. Albarrak M, Banno K, Sabbagh AA, Delaive K, Walld R, Manfreda J, Kryger MH (2005) Utilization of healthcare resources in obstructive sleep apnea syndrome: a 5-year follow-up study in men using CPAP. Sleep 28:1306–1311

    PubMed  Google Scholar 

  26. George CF, Boudreau AC, Smiley A (1997) Effects of nasal CPAP on simulated driving performance in patients with obstructive sleep apnoea. Thorax 52:648–653

    Article  CAS  PubMed  Google Scholar 

  27. Taylor SE (2006) Health Psychology. McGraw Hill, Toronto

    Google Scholar 

  28. Lutfey KE, Wishner WJ (1999) Beyond ‘compliance’ is ‘adherence’: improving the prospect of diabetes care. Diab Care 22(4):635–639

    Article  CAS  Google Scholar 

  29. Pruitt B (2009) Top 10 Practices to Increase CPAP Compliance. 2009. RT for Decision Makers in Respiratory Care. Available at: http://www.rtmagazine.com/issues/articles/2009-02_03.asp. Accessed 5 May 2010

  30. Weaver TE, Grunstein RR (2008) Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 5:173–178

    Article  PubMed  Google Scholar 

  31. Sin DD, Mayers I, Man GC, Pawluk L (2002) Long-term compliance rates to continuous positive airway pressure in obstructive sleep apnea: a population-based study. Chest 121:430–435

    Article  PubMed  Google Scholar 

  32. Nowak C, Bourgin P, Portier F, Genty E, Escourrou P, Bobin S (2003) Nasal obstruction and compliance to nasal positive airway pressure. Ann Otolaryngol Chir Cervicofac 120:161–166

    CAS  PubMed  Google Scholar 

  33. Centre for the advancement of Health (2003) Talking the talk: improving patient-provider communication. Facts of Life 8(1)

  34. Smith SS, Lang CP, Sullivan KA, Warren J (2004) A preliminary investigation of the effectiveness of a sleep apnea education program. J Psychosom Res 56:245–249

    Article  CAS  PubMed  Google Scholar 

  35. Brostrom A, Stromberg A, Ulander M, Fridlund B, Martensson J, Svanborg E (2009) Perceived informational needs, side-effects and their consequences on adherence—a comparison between CPAP treated patients with OSAS and healthcare personnel. Patient Educ Couns 74:228–235

    Article  PubMed  Google Scholar 

  36. Hoy CJ, Vennelle M, Kingshott RN, Engleman HM, Douglas NJ (1999) Can intensive support improve continuous positive airway pressure use in patients with the sleep apnea/hypopnea syndrome? Am J Respir Crit Care Med 159:1096–1100

    CAS  PubMed  Google Scholar 

  37. Hoffstein V, Viner S, Mateika S, Conway J (1992) Treatment of obstructive sleep apnea with nasal continuous positive airway pressure. Patient compliance, perception of benefits, and side effects. Am Rev Respir Dis 145:841–845

    CAS  PubMed  Google Scholar 

  38. Aloia MS, Stanchina M, Arnedt JT, Malhotra A, Millman RP (2005) Treatment adherence and outcomes in flexible vs standard continuous positive airway pressure therapy. Chest 127:2085–2093

    Article  PubMed  Google Scholar 

  39. Edinger JD, Radtke RA (1993) Use of in vivo desensitization to treat a patient's claustrophobic response to nasal CPAP. Sleep 16:678–680

    CAS  PubMed  Google Scholar 

  40. Engleman HM, Martin SE, Douglas NJ (1994) Compliance with CPAP therapy in patients with the sleep apnoea/hypopnoea syndrome. Thorax 49:263–266

    Article  CAS  PubMed  Google Scholar 

  41. Haniffa M, Lasserson TJ, Smith I (2004) Interventions to improve compliance with continuous positive airway pressure for obstructive sleep apnoea. Cochrane Database Syst Rev CD003531

  42. Damjanovic D, Fluck A, Bremer H, Muller-Quernheim J, Idzko M, Sorichter S (2009) Compliance in sleep apnoea therapy: influence of home care support and pressure mode. Eur Respir J 33:804–811

    Article  CAS  PubMed  Google Scholar 

  43. Pressman MR, Peterson DD, Meyer TJ, Harkins JP, Gurijala L (1995) Ramp abuse. A novel form of patient noncompliance to administration of nasal continuous positive airway pressure for treatment of obstructive sleep apnea. Am J Respir Crit Care Med 151:1632–1634

    CAS  PubMed  Google Scholar 

  44. Rose MW (2006) Positive airway pressure adherence: problems and interventions. Sleep Med Clin 1(4):533–539

    Article  Google Scholar 

  45. Vermeire E, Hearnshaw H, Van Royen P, Denekens J (2001) Patient adherence to treatment: three decades of research. A comprehensive review. J Clin Pharm Ther 26:331–342

    Article  CAS  PubMed  Google Scholar 

  46. Krieger J, Kurtz D, Petiau C, Sforza E, Trautmann D (1996) Long-term compliance with CPAP therapy in obstructive sleep apnea patients and in snorers. Sleep 19:S136–S143

    CAS  PubMed  Google Scholar 

  47. Villar I, Izuel M, Carrizo S, Vicente E, Marin JM (2009) Medication adherence and persistence in severe obstructive sleep apnea. Sleep 32:623–628

    PubMed  Google Scholar 

  48. Budhiraja R, Parthasarathy S, Drake CL (2007) Early CPAP use identifies subsequent adherence to CPAP therapy. Sleep 30:320–324

    PubMed  Google Scholar 

  49. Rasheid S, Banasiak M, Gallagher SF, Lipska A, Kaba S, Ventimiglia D, Anderson WM, Murr MM (2003) Gastric bypass is an effective treatment for obstructive sleep apnea in patients with clinically significant obesity. Obes Surg 13(1):58–61

    Article  PubMed  Google Scholar 

  50. Haines KL, Nelson LG, Gonzalez R, Torrella T, Martin T, Kandil A, Dragotti R, Anderson WM, Gallagher SF, Murr MM (2007) Objective evidence that bariatric surgery improves obesity-related obstructive sleep apnea. Surgery 141:354–358

    Article  PubMed  Google Scholar 

  51. Lettieri CJ, Eliasson AH, Greenburg DL (2008) Persistence of obstructive sleep apnea after surgical weight loss. J Clin Sleep Med 4:333–338

    PubMed  Google Scholar 

  52. Gay P, Weaver T, Loube D, Iber C, Positive Airway Pressure Task Force, Standards of Practice Committee, American Academy of Sleep Medicine (2006) Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults. Sleep 29:381–401

    PubMed  Google Scholar 

  53. Joo MJ, Herdegen JJ (2007) Sleep apnea in an urban public hospital: assessment of severity and treatment adherence. J Clin Sleep Med 3:285–288

    PubMed  Google Scholar 

  54. Yetkin O, Kunter E, Gunen H (2008) CPAP compliance in patients with obstructive sleep apnea syndrome. Sleep Breath 12:365–367

    Article  PubMed  Google Scholar 

  55. Brin YS, Reuveni H, Greenberg S, Tal A, Tarasiuk A (2005) Determinants affecting initiation of continuous positive airway pressure treatment. Isr Med Assoc J 7:13–18

    PubMed  Google Scholar 

  56. Simon-Tuval T, Reuveni H, Greenberg-Dotan S, Oksenberg A, Tal A, Tarasiuk A (2009) Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment. Sleep 32:545–552

    PubMed  Google Scholar 

  57. Platt AB, Field SH, Asch DA, Chen Z, Patel NP, Gupta R, Roche DF, Gurubhagavatula I, Christie JD, Kuna ST (2009) Neighborhood of residence is associated with daily adherence to CPAP therapy. Sleep 32:799–806

    PubMed  Google Scholar 

  58. DiMatteo MR, Giordani PJ, Lepper HS, Croghan TW (2002) Patient adherence and medical treatment outcomes: a meta-analysis. Med Care 40:794–811

    Article  PubMed  Google Scholar 

  59. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL (1992) Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med 15:447–468

    Article  CAS  PubMed  Google Scholar 

  60. Aloia MS, Arnedt JT, Stepnowsky C, Hecht J, Borrelli B (2005) Predicting treatment adherence in obstructive sleep apnea using principles of behavior change. J Clin Sleep Med 1:346–353

    PubMed  Google Scholar 

  61. Thompson SC, Nanni C, Schwankovsky L (1990) Patient-oriented interventions to improve communication in a medical office visit. Health Psychol 9(4):390–404

    Article  CAS  PubMed  Google Scholar 

  62. van Dulmen S, Sluijs E, van Dijk L, de Ridder D, Heerdink R, Bensing J, International Expert Forum on Patient Adherence (2008) Furthering patient adherence: a position paper of the international expert forum on patient adherence based on an internet forum discussion. BMC Health Serv Res 8(47):47

    Article  PubMed  Google Scholar 

  63. Shen J, Barbera J, Shapiro CM (2006) Distinguishing sleepiness and fatigue: focus on definition and measurement. Sleep Med Rev 10:63–76

    Article  PubMed  Google Scholar 

  64. Lau RR, Hartman KA, Ware JE Jr (1986) Health as a value: methodological and theoretical considerations. Health Psychol 5:25–43

    Article  CAS  PubMed  Google Scholar 

  65. Edinger JD, Carwile S, Miller P, Hope V, Mayti C (1994) Psychological status, syndromatic measures, and compliance with nasal CPAP therapy for sleep apnea. Percept Mot Skills 78:1116–1118

    CAS  PubMed  Google Scholar 

  66. Wallston KA (1992) Hocus-pocus, the focus isn't strictly on locus: Rotter's social learning theory modified for health. Cogn Ther Res 16:183–199

    Article  Google Scholar 

  67. de Zeeuw J, Baberg HT, Duchna HW, Kempkens DJ, Walther JW, Schultze-Werninghaus G, Rasche K, Orth M (2007) Locus of control belief is a predictor of CPAP-compliance in patients with obstructive sleep apnea syndrome. Pneumologie 61:283–290

    Article  PubMed  Google Scholar 

  68. Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR (2007) Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. Sleep 30:635–640

    PubMed  Google Scholar 

  69. Cartwright R (2008) Sleeping together: a pilot study of the effects of shared sleeping on adherence to CPAP treatment in obstructive sleep apnea. J Clin Sleep Med 4:123–127

    PubMed  Google Scholar 

  70. Kulik JA, Carlino P (1987) The effect of verbal commitment and treatment choice on medication compliance in a pediatric setting. J Behav Med 10:367–376

    Article  CAS  PubMed  Google Scholar 

  71. Kaplan RM, Simon HJ (1990) Compliance in medical care: reconsideration of self-predictions. Ann Intern Med 12:66–71

    Google Scholar 

  72. Haug MR (1994) Elderly patients, caregivers, and physicians: theory and research on health care triads. J Health Soc Behav 35:1–12

    Article  CAS  PubMed  Google Scholar 

  73. Lynch DJ, Birk TJ, Weaver MT, Gohara AF, Leighton RF, Repka FJ, Walsh ME (1992) Adherence to exercise interventions in the treatment of hypercholesterolemia. J Behav Med 15:365–377

    Article  CAS  PubMed  Google Scholar 

  74. Olsen S, Smith S, Oei TP (2008) Adherence to continuous positive airway pressure therapy in obstructive sleep apnoea sufferers: a theoretical approach to treatment adherence and intervention. Clin Psychol Rev 28:1355–1371

    Article  PubMed  Google Scholar 

  75. Poulet C, Veale D, Arnol N, Levy P, Pepin JL, Tyrrell J (2009) Psychological variables as predictors of adherence to treatment by continuous positive airway pressure. Sleep Med 10(9):993–999

    Article  CAS  PubMed  Google Scholar 

  76. Smith CE, Dauz ER, Clements F, Puno FN, Cook D, Doolittle G, Leeds W (2006) Telehealth services to improve nonadherence: a placebo-controlled study. Telemed J E Health 12:289–296

    Article  PubMed  Google Scholar 

  77. Waldhorn RE, Wood K (1993) Attended home titration of nasal continuous positive airway pressure therapy for obstructive sleep apnea. Chest 104:1707–1710

    Article  CAS  PubMed  Google Scholar 

  78. Mullen PD, Green LW (1985) Meta-analysis points way toward more effective medication teaching. Promot Health 6:6–8

    CAS  PubMed  Google Scholar 

  79. Friman PC, Christophersen ER (1986) Biobehavioral prevention in primary care. In: Krasnegor NA, Arasteh J, Cataldo MF (eds) Child health behavior: a behavioral pediatrics perspective. Wiley, New York

    Google Scholar 

  80. Peck CL, King NJ (1982) Increasing patient compliance with prescriptions. JAMA 248:2874–2878

    Article  CAS  PubMed  Google Scholar 

  81. Haynes RB (1979) Strategies to improve compliance with referrals, appointments, and prescribed medical regiments. In: Haynes RB, Taylor DW, Sackett DL (eds) Compliance in health care. Johns Hopkins University Press, Baltimore

    Google Scholar 

  82. Pieters T, Collard P, Aubert G, Dury M, Delguste P, Rodenstein DO (1996) Acceptance and long-term compliance with nCPAP in patients with obstructive sleep apnoea syndrome. Eur Respir J 9:939–944

    Article  CAS  PubMed  Google Scholar 

  83. Kaplan JL, Chung SA, Fargher T, Shapiro CM (2007) The effect of one versus two nights of in-laboratory continuous positive airway pressure titration on continuous positive airway pressure compliance. Behav Sleep Med 5:117–129

    PubMed  Google Scholar 

  84. Canadian Medical Association (2000) Determining Medical Fitness to Drive. A Guide for Physicians. 6th Edition. Ref Type: Report

  85. Ontario Highway Traffic Act. (2009) Chapt. 198, Section (203). Ref Type: Report

  86. George CF, Findley LJ, Hack MA, Douglas McEvoy R (2002) Across-country viewpoints on sleepiness during driving. Am J Respir Crit Care Med 165:746–749

    PubMed  Google Scholar 

  87. Miller CM, Khanna A, Strohl KP (2007) Assessment and policy for commercial driver license referrals. J Clin Sleep Med 3:417–423

    PubMed  Google Scholar 

  88. Shen J, Moller HJ, Wang X, Chung SA, Shapiro GK, Li X, Shapiro CM (2009) Mirtazapine, a sedating antidepressant, and improved driving safety in patients with major depressive disorder: a prospective, randomized trial of 28 patients. J Clin Psychiatry 70:370–377

    Article  CAS  PubMed  Google Scholar 

  89. Ontario Ministry of Health and Long-Term care (2008) ADP: Continuous/Autotitrating Positive Pressure Systems. 8-20-2008. Ref Type: Report

  90. Engleman HM, Wild MR (2003) Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 7:81–99

    Article  PubMed  Google Scholar 

  91. Stepanowsky CJ Jr, Bardwell WA, Moore PJ, Ancoli-Israel S, Dimsdale JE (2002) Psychologic correlates of compliance with continuous positive airway pressure. Sleep 25(7):36–40

    Google Scholar 

  92. Sopkova Z, Dorkova Z, Tkacova R (2009) Predictors of compliance with continuous posivie airway pressure treatment in patients with obstructive sleep apnea and metabolic syndrome. Wien Klin Wochenschr 121(11–12):298–404

    Google Scholar 

  93. Chung SA, Jairam S, Hussain MR, Shapiro CM (2001) Knowledge of sleep apnea in a sample grouping of primary care physicians. Sleep Breath 5(3):115–21

    Article  CAS  PubMed  Google Scholar 

  94. Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard RD, Magalang UJ (2006) Medical therapy for obstructive sleep apnea: a review by the medical therapy for obstructive sleep apnea task force of the standards of practice committee of the American academy of sleep medicine. Sleep 29(8):1036–1044

    PubMed  Google Scholar 

  95. Hoffstein V (2007) Review of oral appliances for treatment of sleep-disordered breathing. Sleep Breath 11(1):1–22

    Article  PubMed  Google Scholar 

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Shapiro, G.K., Shapiro, C.M. Factors that influence CPAP adherence: an overview. Sleep Breath 14, 323–335 (2010). https://doi.org/10.1007/s11325-010-0391-y

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