CPAP Discipline - How to Keep From Slipping Out of Your Treatment Routine

By Admin

One of the most important aspects of positive airway pressure (PAP) therapy is regular treatment adherence. Defined as a minimum of four hours per night at least two thirds of the time, or five out of seven nights, adherence is required for the treatment to be effective, and most medical professionals recommend using a CPAP device as much as possible. Treatment non-adherence, sometimes called non-compliance when more intentional, is one of the most common reasons for inadequate results, caused by a range of issues often related to early complications or lack of sufficient knowledge about devices and proper fittings. But treatment non-adherence is not always an all-or-nothing decision. In many cases, non-adherence occurs periodically or cumulatively, caused by interruptions to daily routines. Over time, this can lead to bad habits of disregarding treatment in favor of more convenient sleep settings. While patients may view these lapses as occasional setbacks, a lapse can very easily lead to more sustained periods of untreated sleep apnea, a situation that is both unhealthy and dangerous, especially during a global pandemic that increases patient susceptibility to disease. For those who struggle with these types of treatment disruptions, the best course of action is double up on discipline. Remaining diligent about one’s treatment is a necessity during a public health crisis, and is a critical component of a healthy lifestyle. Using CPAP, as we know, improves both sleep and health in ways that can stave off comorbidities, increase longevity, and improve quality of life. But to recognize the full extent of those benefits, a treatment routine must remain consistent, and any help or support needed to maintain that routine and keep a patient on a path to a happier, healthier life should be indispensable.

Why Adherence is so Important

According to professional estimates, over 20 million Americans suffer from sleep apnea while 80 percent remain untreated or undiagnosed. Among those who are diagnosed with the disorder, at least a third do not continue with treatment. This rate of non-adherence has remained stagnant over a 20-year period despite improvements in treatment technologies and intervention strategies. While this rate is not excessively low, it is a concern from a public-health perspective because, combined with the rate of undiagnosed cases, as well as the rate of under-treated cases caused by low adherence and reluctance, it is a significant obstacle in the treatment and maintenance of the disorder. Furthermore, research on the effectiveness of CPAP has concluded that higher rates of use lead to more significant health benefits for the patient. Investigators identified that at least five hours per night of CPAP treatment was necessary to restore sleepiness to normal levels in some patients. Thus, when adherence is defined as greater than the four-hour minimum of nightly use, up to 80 percent of patients have been reported to be non-adherent to treatment. This means that adherence, as normally defined, may be a low threshold from a medical standpoint. For optimal treatment results, patients often require high rates of adherence involving nightly use of CPAP throughout the sleeping hours.

An Unhealthy Ambivalence

As many CPAP users know, it is very easy to slip out of a treatment routine. All it takes is a tired night, falling asleep on the couch, an unplanned naptime, or some other change in the daily schedule that can throw you off in a direction of non-adherence. And right now, during a global pandemic, there are many things that can throw you off. These minor slips may not seem like a major concern on their own, but they can add up very quickly to the point of becoming a habit. The more you allow yourself to sleep without therapy, the greater the chances will be for symptoms to arise, which can affect your health in a number of ways. Undertreated sleep apnea, in some cases, can be just as damaging to health and wellbeing as untreated conditions. And yet, ambivalence persists among sleep apnea patient populations. According to one study, a high number of sleep apnea patients express ambivalent attitudes about PAP-therapy treatment, whether or not they remain adherent. In other words, patients who continue with treatment often show ambivalent adherence and consider stopping, while those who do stop express ambivalent non-adherence and consider continuing with treatment. While the term non-adherence is often used to imply a somewhat unintentional decision, resulting from difficulties, accident, or circumstances, an ambivalent attitude can be extremely detrimental to treatment goals. Whether intended or not, a reluctance to seek help or make the necessary changes for continued, effective therapy leads to the same result: a lack of proper treatment.

Strategies for Staying Disciplined

A disruption in the sleep routine can be unsettling whether or not it is related to CPAP. Our sleep routines are part of our inner chronobiological system, or biological clock, which determines when we feel tired and when we have the most energy. This system is highly dependent upon patterns of behavior at certain hours in the day. Keeping a routine tells the body and mind what is going to happen next, and this helps give body and mind cues for certain chemical changes that occur in the night. Without those regular cues, the sleep and sleep onset processes can become less balanced, and therefore less restful.

A number of studies have outlined the most effective means of support for continued adherence, and many of these tactics focus on the early experience of the setup process, equipment choices, proper titration, and the like, but additional focus on the long term is needed to support those who may struggle beyond the first few weeks. One study, for example, lists the following considerations as important focus areas for CPAP treatment adherence:

Treatment Monitoring - from a provider’s point of view, this is one of the most important considerations, as it continues throughout the life of the patient. If you, as a patient, do not feel that your treatment and its effectiveness are being consistently monitored, you should bring this to the attention of your provider. Taking initiative on issues of personal health is an important first step for a lot of people and it’s a good way to counteract any feelings of ambivalence.

Education - While education is very important for treatment, it often focuses on the introductory phase. Even so, it is crucial for the proper treatment of conditions and there is always more you can know about your own health and treatments.

Symptoms and Relief - This is an extremely important consideration, both for the short term of the introductory phase and the long term. The more effective the treatment is at reducing symptoms, the more likely it will be that a patient recognizes the benefits over time. This is especially important for severe cases that are particularly harmful to patient’s health and wellbeing.

Side Effects - Again, this should be a primary focus during the introductory phase because any complaints or side effects should be dealt with immediately. Many side effects can be corrected with another choice of mask (for example, full-face, nasal, or nasal-pillow), another device such as a BiPAP (bilateral positive airway pressure) that uses two pressure levels, or comfort features such as a reduction of inhalation pressure, a heated humidifier, or slow-pressure startup settings.

Psychological Factors - Sometimes personality types can affect treatment adherence, for example, a low tolerance for problems or side effects, or difficulties with routines in general can lead to lapses in treatment at any stage. Prior experience, another consideration mentioned in the study, relates to psychological factors in a similar way, as a patient’s previous experiences with the healthcare system are likely to influence future decisions. In either case, coping mechanisms such as the use of cognitive behavioral therapy may help a patient adapt to a treatment lifestyle.

Improved Tech - This consideration is mentioned already as a possible solution to side effects and complaints, but it should also be noted that new, advanced equipment can make a big difference to patients struggling with lapses in treatment. Travel-size machines, for example, can make things easier for those who work on the road or perfer the outdoors. Modern devices also make monitoring much easier with online capabilities and cloud applications. These machines already perform much of the day-to-day troubleshooting once required of patients and doctors.

The Role of Self-Efficacy

In addition to intervention strategies, patient self-efficacy is possibly the most important consideration when addressing long-term adherence. While many of the focus areas listed above are the responsibility of the health provider, self-efficacy is the patient’s obligation. It is the belief in one’s own ability to organize and execute a required course of action. And in the case of treatment adherence, this also includes teamwork. Research published in the Journal of Clinical Medicine found that both self-efficacy and the incorporation of a health care team, made up of the patient, provider, and partner or spouse, enhanced treatment adherence over the long term. A complete and comprehensive adherence management plan would consist of each of these factors working together toward a shared goal of effective treatment. In such a case, momentary lapses in treatment can be addressed immediately and effectively before becoming a repeat problem.