1. Behavioral Challenges in the lab: secondary insomnia and CPAP adherence Texas Society of Sleep Professionals Mary Rose, PsyD, CBSM Assistant Professor Lester & Sue Smith Breast Center Department of Medicine Baylor College Medicine

2. General Insomnia Criteria Adequate sleep opportunity Persistent sleep difficulty Daytime dysfunction (ICSD 2) >3/7 days for >1 month <6 hours sleep per day

3. Who is Referred for NPSG Punjabi et al, Sleep Disorders in Regional Centers: A National Cooperative Study, SLEEP, 23, 4, 2000

4. 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 *

6. So what we do watch

7. What is Diagnosed So…7.7 % are behavioral (2.7+1.7+1.5+1+0.8) + some portion of (2.6+6.1)

8. Insomnia SD Causes (in lab) OSA 39%-58% OSA have insomnia 29% -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)

9. Other causes of Insomnia in the lab Pain Sleep lab environment Other: uneasiness, change in the environment

10. 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 *

11. Sabotaging one’s study

12. Critical features of getting that study Collaboration with patient Review doctor notes Empathy Clear Goals Boundaries Soliciting feedback

13. Sleep Hygiene

14. 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

15. Preparing for Defensiveness

16. Managing Defensiveness Humor Let go of less important issues Sitting close to patient Affirmation of the difficulty with sleeping in the lab

17. CPAP Adherence

18. 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

19. 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

20. Patient- Report Barriers Mask discomfort Skin irritation Nasal dryness (40% have stuffiness, dry nose, sore throat) Congestion Leaks Difficulty with adapting

21. 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)

22. Social Factors Those who live alone CPAP use < When sleeping with partner CPAP used > CPAP use predicts marital conflict but not supportiveness.

23. 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

24. Facilitating Adherence First Few months-close monitoring Direct clinician follow up Technician care Tele-medicine Patient support groups Home visits

25. 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

26. 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)

27. 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)

28. 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

29. Major Issues to Address Personalization Degree to which reduction in pressure is possible What spouse feels about treatment

30. 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

31. 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

32. 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.

33. 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

34. 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

35. 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

36. Thank you