Mary Rose, PsyD, CBSM Assistant Professor Lester & Sue Smith Breast Center Department of Medicine

1. Behavioral Challenges in the lab: secondary insomnia and CPAP adherenceTexas 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) • RLS12% (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 & HardTreatment Multi-step week by week 2 hour intervals: • Wear mask no pressure for 2 hours awake @ house • 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 & Hardto 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