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Simonelli C, Vitacca M, Salvi B, Saleri M, Paneroni M. Comparison among three different follow-up models for obstructive sleep apnea syndrome patients: focus on the physiotherapist's role. Monaldi Arch Chest Dis 2023. [PMID: 37817742 DOI: 10.4081/monaldi.2023.2673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/28/2023] [Indexed: 10/12/2023] Open
Abstract
In obstructive sleep apnea syndrome (OSAS) subjects different follow-up modalities have been proposed to improve adherence to the continuous positive airway pressure (CPAP) device. This retrospective study compares three different health professional approaches dedicated to caring OSAS patients in three consecutive follow-up periods of 15 months each. The three different follow-up models are: i) physician-oriented follow-up (P-F); ii) physiotherapist-oriented follow-up (PT-F); and iii) tele-titration plus PT-oriented follow-up (TT-PT-F). Health personal visits and actions delivered, patients' adherence, CPAP efficacy, and problems under CPAP use were considered for comparison. Data from 122 OSAS patients with a new prescription of CPAP were analyzed: 39 (32.0%) in the P-F, 38 (31.1%) in the PT-F, and 45 (36.9%) in the TT-PT-F period. We found a reduction over time (from 40.9% in P-F to 8.2% in TT-PT-F, p<0.001) in patients missing the 1-year follow-up visit. The PT-F and TT-PT-F lead to a reduction in physician visits in comparison to P-F (5.2% and 8.9% vs 100%, p<0.001) with no differences in time to the first follow-up visit, CPAP efficacy, and patients' adherence among the three periods. More device-related problems were found in the PT-F (57.8%), compared with the PF (25.6%) period (p<0.001); the most common troubles were mask problems evaluated in 26.2% of cases. In conclusion, different follow-up models offer similar efficacy and short-term adherence for CPAP leading to a significant reduction in physician visits under the PT-F with or without tele-titration, being mask problems as the most commonly treated. Further analysis should be useful to define the best cost-efficacy follow-up intervention.
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Affiliation(s)
- Carla Simonelli
- Cardio-Respiratory Rehabilitation, ICS Maugeri IRCCS, Institute of Lumezzane (BS).
| | - Michele Vitacca
- Respiratory Rehabilitation, ICS Maugeri IRCCS, Institute of Lumezzane (BS).
| | - Beatrice Salvi
- Cardio-Respiratory Rehabilitation, ICS Maugeri IRCCS, Institute of Lumezzane (BS).
| | - Manuela Saleri
- Cardio-Respiratory Rehabilitation, ICS Maugeri IRCCS, Institute of Lumezzane (BS).
| | - Mara Paneroni
- Cardio-Respiratory Rehabilitation, ICS Maugeri IRCCS, Institute of Lumezzane (BS).
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2
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Delijaj F, Lindberg E, Johnsson L, Kristiansson P, Tegelmo T, Theorell-Haglöw J. Effects of telemonitoring follow-up, side effects, and other factors on CPAP adherence. J Clin Sleep Med 2023; 19:1785-1795. [PMID: 37323036 PMCID: PMC10546003 DOI: 10.5664/jcsm.10686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 06/07/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023]
Abstract
STUDY OBJECTIVES This study aimed to investigate the effect of telemonitoring compared with standard clinic visits on adherence to continuous positive airway pressure (CPAP) treatment after 6 months. In addition, the impact of other factors including CPAP side effects on treatment adherence were assessed. METHODS Consecutive patients (n = 217) who were prescribed CPAP treatment for obstructive sleep apnea were randomized to either telemonitoring or standard-care follow-up. All patients were followed up 6 months after treatment started. Clinical/anthropometric variables, socioeconomical and lifestyle factors, psychological distress, daily function, and personality traits along with CPAP side effects were assessed. Differences between groups were analyzed using 2-sample t-test, chi-square test, or Fisher's exact test. Regression modeling was used to explore associations between dependent and independent variables. RESULTS There were no differences in CPAP adherence between telemonitoring and standard-care groups after 6 months (53.2% vs 48.7%; P = .54). CPAP side effects such as dry throat (odds ratio = 2.17; 95% confidence interval = 1.25-3.70), increased awakenings (2.50; 1.31-4.76), and exhaling problems (3.70; 1.25-10.1) were independently associated with low CPAP adherence, although these associations were weakened when adding smoking to the model. No other baseline or follow-up factors were associated with CPAP adherence at 6 months. CONCLUSIONS We could not show that telemonitoring follow-up improved adherence levels. Dry throat, increased awakenings, exhaling problems, and smoking had negative effects on CPAP adherence. Preventing side effects and assessing smoking status is therefore of importance when wanting to improve CPAP adherence. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Benefits of Telemedicine in CPAP Treatment; URL: https://clinicaltrials.gov/ct2/show/NCT03202602; Identifier: NCT03202602. CITATION Delijaj F, Lindberg E, Johnsson L, Kristiansson P, Tegelmo T, Theorell-Haglöw J. Effects of telemonitoring follow-up, side effects, and other factors on CPAP adherence. J Clin Sleep Med. 2023;19(10):1785-1795.
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Affiliation(s)
- Florim Delijaj
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
- Centre for Clinical Research Sörmland (CKFD), Eskilstuna, Sweden
- Department of Patient Safety, Region Sörmland, Sweden
| | - Eva Lindberg
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Linus Johnsson
- Centre for Research Ethics and Bioethics (CRB), Uppsala University, Uppsala, Sweden
| | - Per Kristiansson
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Tove Tegelmo
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - Jenny Theorell-Haglöw
- Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
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Sawunyavisuth B, Ngamjarus C, Sawanyawisuth K. Adherence to Continuous Positive Airway Pressure Therapy in Pediatric Patients with Obstructive Sleep Apnea: A Meta-Analysis. Ther Clin Risk Manag 2023; 19:143-162. [PMID: 36761690 PMCID: PMC9904217 DOI: 10.2147/tcrm.s358737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 12/22/2022] [Indexed: 02/05/2023] Open
Abstract
Introduction Obstructive sleep apnea (OSA) is a public health problem that affects children. Although continuous positive airway pressure (CPAP) therapy is effective, the CPAP adherence rate in children is varied. This study aimed to evaluate the CPAP adherence rate and factors associated with CPAP adherence in children with OSA using a systematic review. Methods The inclusion criteria were observational studies conducted in children with OSA and assessed adherence of CPAP using objective evaluation. The literature search was performed in four databases. Meta-analysis using fixed-effect model was conducted to combine results among included studies. Results In all, 34 studies that evaluated adherence rate and predictors of CPAP adherence in children with OSA were included, representing 21,737 patients with an average adherence rate of 46.56%. There were 11 calculations of factors predictive of CPAP adherence: age, sex, ethnicity, body mass index, obesity, income, sleep efficiency, the apnea-hypopnea index (AHI), severity of OSA, residual AHI, and lowest oxygen saturation level. Three different factors were linked to children with adherence and non-adherence to CPAP: age, body mass index, and AHI. Conclusion The CPAP adherence rate in children with OSA was 46.56%. Young age, low body mass index, and high AHI were associated with acceptable CPAP adherence in children with OSA.
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Affiliation(s)
- Bundit Sawunyavisuth
- Department of Marketing, Faculty of Business Administration and Accountancy, Khon Kaen University, Khon Kaen, Thailand
| | - Chetta Ngamjarus
- Department of Epidemiology and Biostatistics, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand,Correspondence: Kittisak Sawanyawisuth, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand, Tel +66-43-363664, Fax +66-43-348399, Email
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4
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Baba RY, Dandawate N. Factors influencing automatic PAP compliance: what really matters? J Clin Sleep Med 2023; 19:1-2. [PMID: 36377841 PMCID: PMC9806779 DOI: 10.5664/jcsm.10356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Affiliation(s)
- Ridhwan Y. Baba
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
| | - Nupur Dandawate
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, New York University Grossman School of Medicine, New York, New York
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5
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Park SI, Kim BK, Lee KE, Hong SD, Jung YG, Kim HY. Predictors for short-term and long-term automatic PAP compliance. J Clin Sleep Med 2023; 19:17-26. [PMID: 35962941 PMCID: PMC9806787 DOI: 10.5664/jcsm.10236] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 08/06/2022] [Accepted: 08/09/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES Positive airway pressure (PAP) is considered a standard treatment for obstructive sleep apnea (OSA), but there are compliance issues. As compliance to PAP tends to decrease with time, it is necessary to consider reasons affecting compliance at each period. Therefore, this study aimed to define factors affecting short-term and long-term compliance to PAP therapy. METHODS One hundred eighty-seven patients with OSA who started PAP treatment between July 2018 to March 2020 were included. Acceptance and compliance rates were monitored. Demographics, polysomnography (PSG) profiles, cephalometric data, and physical examination results were analyzed to identify factors predictive of PAP compliance at short-term (3 months) and long-term (12 months) periods. RESULTS The acceptance rate of PAP was 92.5%. Compliance at 3 months and 12 months was 79.1% and 51.3%, respectively. Higher apnea-hypopnea index (odds ratio [OR] 1.018, P = .049) and older age (OR 1.032, P = .039) were predictive factors of good automatic PAP (APAP) compliance at 3 months. However, long-term compliance was affected by the percentage of duration with O2 desaturation of < 90% (CT90; OR 1.032, P = .011) and baseline self-reported symptom scores such as nasal obstruction (OR 0.819, P = .038) and awakening (OR 0.796, P = .045). CONCLUSIONS In PAP use, indicators of OSA severity such as apnea-hypopnea index affect short-term compliance. On the other hand, the mandibular plane to hyoid distance and self-reported symptoms such as nasal obstruction and awakening can affect long-term compliance. CITATION Park SI, Kim BK, Lee KE, Hong SD, Jung YG, Kim HY. Predictors for short-term and long-term automatic PAP compliance. J Clin Sleep Med. 2023;19(1):17-26.
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Affiliation(s)
- Song I. Park
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung Kil Kim
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Eun Lee
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Gi Jung
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology, Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Dzierzewski JM, Perez E, Ravyts SG, Dautovich N. Sleep and Cognition: A Narrative Review Focused on Older Adults. Sleep Med Clin 2022; 17:205-222. [PMID: 35659074 DOI: 10.1016/j.jsmc.2022.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Little is known regarding sleep's association with the traditional developmental course of late-life cognitive functioning. As the number of older adults increases worldwide, an enhanced understanding of age-related changes in sleep and cognition is necessary to slow decline and promote optimal aging. This review synthesizes the extant literature on sleep and cognitive function in healthy older adults, older adults with insomnia, and older adults with sleep apnea, incorporating information on the potential promising effects of treating poor sleep on cognitive outcomes in older adults. Unifying theories of the sleep-cognition association, possible mechanisms of action, and important unanswered questions are identified.
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Affiliation(s)
- Joseph M Dzierzewski
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Room 306, Box 842018, Richmond, VA 23284-2018, USA.
| | - Elliottnell Perez
- Department of Psychology, Virginia Commonwealth University, Box 842018, Richmond, VA 23284-2018, USA
| | - Scott G Ravyts
- Department of Psychology, Virginia Commonwealth University, Box 842018, Richmond, VA 23284-2018, USA
| | - Natalie Dautovich
- Department of Psychology, Virginia Commonwealth University, 800 West Franklin Street, Room 203, Box 842018, Richmond, VA 23284-2018, USA
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7
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Dunietz GL, Yu Y, Levine RS, Conceicao AS, Burke JF, Chervin RD, Braley TJ. Obstructive sleep apnea in older adults: geographic disparities in PAP treatment and adherence. J Clin Sleep Med 2021; 17:421-427. [PMID: 33094720 DOI: 10.5664/jcsm.8914] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is prevalent among older adults. Although treatment with positive airway pressure (PAP) lowers subsequent morbidity, PAP adherence is inconsistent. Socioeconomic disparities have been observed in OSA treatment, but regional differences in OSA care are unknown. This study examined geographic variations in PAP treatment and adherence among older Americans. METHODS This study utilized a representative 5% sample of all Medicare fee-for-service beneficiaries aged 65+ years. An OSA diagnosis, treatment, and PAP adherence were confirmed with International Classification of Diseases, Ninth Revision, HCPCS (Health Care Common Procedure Coding System) codes, and ≥2 HCPCS claims for PAP supplies respectively. Descriptive statistics were used to examine proportions of Medicare beneficiaries who obtained and adhered to PAP. Maps described the proportion of treated and adherent beneficiaries by state and hospital referral region. RESULTS For state-level data, PAP treatment and adherence proportions among beneficiaries with an OSA diagnosis ranged between 54-87% and 59-81%, respectively. Proportions of treated patients were higher in Midwest states (>80%), in comparison to Northwest, Northeast, and Southern states (<73%). Southern states and California had lowest proportions of PAP adherence (<70%). Within-state variability in treatment patterns were apparent along the East and West coasts. Correlations of PAP treatment and adherence proportions were low in Washington, DC, New York, and New Jersey. Discordant treatment and adherence proportions were observed in Alabama and Mississippi. CONCLUSIONS Significant state-level and regional disparities of PAP treatment and adherence among Medicare beneficiaries with OSA suggest gaps in delivery of OSA care for older Americans.
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Affiliation(s)
- Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Yue Yu
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Rivkah S Levine
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Alan S Conceicao
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Ronald D Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Tiffany J Braley
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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8
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Wickwire EM, Jobe SL, Oldstone LM, Scharf SM, Johnson AM, Albrecht JS. Lower socioeconomic status and co-morbid conditions are associated with reduced continuous positive airway pressure adherence among older adult medicare beneficiaries with obstructive sleep apnea. Sleep 2021; 43:5861663. [PMID: 32575113 DOI: 10.1093/sleep/zsaa122] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
STUDY OBJECTIVES To examine rates of adherence to continuous positive airway pressure (CPAP) therapy among a representative sample of older adult Medicare beneficiaries with obstructive sleep apnea (OSA), and to identify demographic and health-related factors associated with CPAP adherence. METHODS Using a 5% sample of Medicare claims data, we utilized Medicare policy and CPAP machine charges as a proxy for CPAP adherence. A cumulative logit model was used to identify demographic, medical, and psychiatric predictors of CPAP adherence status. RESULTS Of beneficiaries who initiated CPAP (n = 3,229), 74.9% (n = 2,417) met the so-called "90-day Medicare adherence criteria," but only 58.8% of these individuals (n = 1,420) continued to use CPAP throughout the entire 13-month rent-to-own period. Anxiety, anemia, fibromyalgia, traumatic brain injury, and lower socioeconomic status (SES) were all associated with reduced CPAP adherence. CONCLUSIONS These results provide the first national estimates of CPAP adherence among older adult Medicare beneficiaries in the United States. In addition, findings highlight the salience of medical and psychiatric comorbidity, as well as SES, as important markers of CPAP adherence among older adults in the United States. Future studies should seek to evaluate interventions to improve CPAP adherence among older adults of lower SES.
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Affiliation(s)
- Emerson M Wickwire
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD.,Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Sophia L Jobe
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | | | - Steven M Scharf
- Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Abree M Johnson
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, MD
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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9
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Dunietz GL, Chervin RD, Burke JF, Conceicao AS, Braley TJ. Obstructive Sleep Apnea Treatment and Dementia Risk in Older Adults. Sleep 2021; 44:6189102. [PMID: 33769542 DOI: 10.1093/sleep/zsab076] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 01/27/2021] [Indexed: 12/11/2022] Open
Abstract
STUDY OBJECTIVES To examine associations between PAP therapy, adherence and incident diagnoses of Alzheimer's disease (AD), mild cognitive impairment (MCI), and dementia not-otherwise-specified (DNOS) in older adults. METHODS This retrospective study utilized Medicare 5% fee-for-service claims data of 53,321 beneficiaries, aged 65+, with an OSA diagnosis prior to 2011. Study participants were evaluated using ICD-9 codes for neurocognitive syndromes [AD(n=1,057), DNOS(n=378), and MCI(n=443)] that were newly-identified between 2011-2013. PAP treatment was defined as presence of ≥1 durable medical equipment (HCPCS) code for PAP supplies. PAP adherence was defined as ≥2 HCPCS codes for PAP equipment, separated by≥1 month. Logistic regression models, adjusted for demographic and health characteristics, were used to estimate associations between PAP treatment or adherence and new AD, DNOS, and MCI diagnoses. RESULTS In this sample of Medicare beneficiaries with OSA, 59% were men, 90% were non-Hispanic whites and 62% were younger than 75y. The majority (78%) of beneficiaries with OSA were prescribed PAP (treated), and 74% showed evidence of adherent PAP use. In adjusted models, PAP treatment was associated with lower odds of incident diagnoses of AD and DNOS (OR=0.78, 95% CI:0.69-0.89; and OR=0.69, 95% CI:0.55-0.85). Lower odds of MCI, approaching statistical significance, were also observed among PAP users (OR=0.82, 95% CI:0.66-1.02). PAP adherence was associated with lower odds of incident diagnoses of AD (OR=0.65, 95% CI:0.56-0.76). CONCLUSIONS PAP treatment and adherence are independently associated with lower odds of incident AD diagnoses in older adults. Results suggest that treatment of OSA may reduce risk of subsequent dementia.
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Affiliation(s)
- Galit L Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Ronald D Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - James F Burke
- Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Alan S Conceicao
- Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
| | - Tiffany J Braley
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
- Division of Neuroimmunology, Department of Neurology, University of Michigan, Michigan Medicine, Ann Arbor, MI, USA
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10
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Dhanda Patil R, Hong MP, Ishman SL. Hypoglossal Nerve Stimulation in Veterans With Comorbid Insomnia and Sleep Apnea. Otolaryngol Head Neck Surg 2021; 164:1345-1353. [PMID: 33399502 DOI: 10.1177/0194599820982638] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Insomnia and sleep apnea frequently co-occur, with additive effects of both disorders presenting clinicians with unique treatment challenges compared to one disorder alone. The hypoglossal nerve stimulator (HNS) is a promising treatment for patients with comorbid insomnia and sleep apnea (COMISA), many of whom have positive airway pressure (PAP) intolerance. Our aim was to determine adherence to and efficacy of HNS in veterans with COMISA refractory to PAP therapy compared to those with obstructive sleep apnea alone (OSA only). STUDY DESIGN Retrospective case series. SETTING A single, academic Veterans Affairs medical center. METHODS Review of clinical records, pre- and postoperative polysomnography, and clinical measures of obstructive sleep apnea (OSA), sleepiness, and insomnia was conducted in 53 consecutive cases of veterans with OSA undergoing HNS implantation. HNS adherence was obtained at postoperative visits. HNS adherence and efficacy were compared between individuals with COMISA and OSA only. RESULTS COMISA was noted in 30 of 53 (56.6%) veterans studied. There was no significant difference between HNS adherence in patients with COMISA and OSA only (5.6 vs 6.4 h/night, P = .17). HNS implantation improved polysomnographic and clinical measures of OSA and sleepiness in both COMISA and OSA only, and 56.5% (13/23) of patients with COMISA self-reported improvement in insomnia after surgery. CONCLUSION HNS was successful in treating a complex veteran population with COMISA refractory to PAP when examining measures of treatment adherence and efficacy. Future studies of patients with COMISA undergoing HNS will examine effective combination therapy targeting insomnia and a multidisciplinary effort to optimize treatment adherence.
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Affiliation(s)
- Reena Dhanda Patil
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Michael P Hong
- University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stacey L Ishman
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati Medical Center, Cincinnati, Ohio, USA.,Cincinnati Children's Hospital Medical Center, Divisions of Pediatric Otolaryngology and Pulmonary Medicine, Cincinnati, Ohio, USA
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11
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Dickerson SS, TenBrock E, Smith P, Kwon M, Chacko T, Li CS, Dean GE. Mixed methods feasibility study of Breathe2Sleep™ a peer modeling approach to PAP self-management. Heart Lung 2020; 49:949-958. [PMID: 32473747 DOI: 10.1016/j.hrtlng.2020.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 04/15/2020] [Accepted: 04/20/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Suzanne S Dickerson
- The State University of New York, University at Buffalo, School of Nursing, Wende hall, 3435 Main Street, Buffalo, NY 14214, United States.
| | - Eric TenBrock
- The State University of New York, University at Buffalo, School of Medicine, Buffalo, NY 14214, United States
| | - Patricia Smith
- The State University of New York, University at Buffalo, School of Medicine, Buffalo, NY 14214, United States
| | - Misol Kwon
- The State University of New York, University at Buffalo, School of Nursing, Wende hall, 3435 Main Street, Buffalo, NY 14214, United States
| | - Thomas Chacko
- The State University of New York, University at Buffalo, School of Nursing, Wende hall, 3435 Main Street, Buffalo, NY 14214, United States
| | - Chin-Shang Li
- The State University of New York, University at Buffalo, School of Nursing, Wende hall, 3435 Main Street, Buffalo, NY 14214, United States
| | - Grace E Dean
- The State University of New York, University at Buffalo, School of Nursing, Wende hall, 3435 Main Street, Buffalo, NY 14214, United States
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12
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Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications. Sleep Med Clin 2020; 15:227-240. [PMID: 32386697 DOI: 10.1016/j.jsmc.2020.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
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13
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Zhou J, Li DH, Zhu PF, Yi CY, Chang L, Zhang Y, Yang XH. Effect of mandibular advancement device on the stomatognathic system in patients with mild-to-moderate obstructive sleep apnoea-hypopnoea syndrome. J Oral Rehabil 2020; 47:889-901. [PMID: 32306424 PMCID: PMC7318685 DOI: 10.1111/joor.12982] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 03/13/2020] [Accepted: 04/06/2020] [Indexed: 11/30/2022]
Abstract
Objective This study was conducted to evaluate the changes of temporomandibular joints (TMJs) through magnetic resonance imaging (MRI) scanning and the electrical changes in mandibular movement and masticatory muscle surface of mild‐to‐moderate obstructive sleep apnoea‐hypopnoea syndrome (OSAHS) patients before and after treatment with mandibular advancement device (MAD). Methods This was a single‐centre, prospective study recruiting OSAHS patients undergoing treatment with MAD in Department of Stomatology, Yannan Hospital, Kunming, China. Patients were recruited from February 2015 to October 2015, and TMJ changes were observed in MRI scanning before and after 18 months of treatment with MAD in cohort 1. The second cohort of the patients were recruited from January 2014 to September 2015 and electrical changes in mandibular movement and masticatory muscle surface of patients before and after 6 months of treatment with MAD. Results In the cohort 1, TMJ changes analysed through MRI scanning, before and after 18‐month treatment with MAD, there was no significant deviation in the angle of joint disc position. A minor change in the position relationship between condylar process, articular disc and articular fossa but not significant was observed. There was no significant difference in the shape and magnitude of mandibular incision edge movement, percussion movement, masticatory movement and condylar central trajectory among the recruited OSAHS patients, before and after 6 months of MAD treatment as analysed through electromyography. Conclusion In this study, from the results it was evident that the effect of MAD on the stomatognathic system of OSAHS patients is minimal.
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Affiliation(s)
- Jing Zhou
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - De-Hong Li
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - Peng-Fei Zhu
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - Chun-Yan Yi
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - Lin Chang
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - Yanan Zhang
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
| | - Xiang-Hong Yang
- Department of Stomatology, Kunming Yan'an Hospital, Kunming City, China
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14
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Sarber KM, Chang KW, Ishman SL, Epperson MV, Dhanda Patil R. Hypoglossal Nerve Stimulator Outcomes for Patients Outside the U.S. FDA Recommendations. Laryngoscope 2020; 130:866-872. [DOI: 10.1002/lary.28175] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/28/2019] [Accepted: 06/18/2019] [Indexed: 01/26/2023]
Affiliation(s)
- Kathleen M. Sarber
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical Center Cincinnati Ohio U.S.A
- Division of Pediatric Otolaryngology Head and Neck SurgeryCincinnati Children's Hospital Medical Center Cincinnati Ohio U.S.A
| | | | - Stacey L. Ishman
- Division of Pediatric Otolaryngology Head and Neck SurgeryCincinnati Children's Hospital Medical Center Cincinnati Ohio U.S.A
- Department of Otolaryngology–Head & Neck SurgeryUniversity of Cincinnati College of Medicine Cincinnati OH USA
| | | | - Reena Dhanda Patil
- Department of Otolaryngology–Head & Neck SurgeryUniversity of Cincinnati College of Medicine Cincinnati OH USA
- Department of OtolaryngologyCincinnati Veterans Affairs Medical Center Cincinnati Ohio U.S.A
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15
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Kendzerska T, Wilton K, Bahar R, Ryan CM. Short- and long-term continuous positive airway pressure usage in the post-stroke population with obstructive sleep apnea. Sleep Breath 2019; 23:1233-1244. [DOI: 10.1007/s11325-019-01811-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/30/2019] [Accepted: 02/19/2019] [Indexed: 12/17/2022]
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16
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Mehrtash M, Bakker JP, Ayas N. Predictors of Continuous Positive Airway Pressure Adherence in Patients with Obstructive Sleep Apnea. Lung 2019; 197:115-121. [PMID: 30617618 DOI: 10.1007/s00408-018-00193-1] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/29/2018] [Indexed: 01/23/2023]
Abstract
Obstructive sleep apnea (OSA) is a common disease which impacts quality of life, mood, cardiovascular morbidity, and mortality. Continuous positive airway pressure (CPAP) is the first-line treatment for patients with moderate to severe OSA. CPAP ameliorates respiratory disturbances, leading to improvements in daytime sleepiness, quality of life, blood pressure, and cognition. However, despite the high efficacy of this device, CPAP adherence is often sub-optimal. Factors including: socio-demographic/economic characteristics, disease severity, psychological factors, and side-effects are thought to affect CPAP adherence in OSA patients. Intervention studies have suggested that augmented support/education, behavioral therapy, telemedicine and technological interventions may improve CPAP adherence. In this paper, we will extensively review the most common factors including age, gender, race/ethnicity, socioeconomic status, smoking status, severity of OSA, severity of OSA symptoms, psychological variables, social support, marital status/bed partner involvement, dry nose and mouth, mask leak, and nasal congestion that may predict CPAP adherence. We will also extensively review interventions that may increase adherence to CPAP.
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Affiliation(s)
- M Mehrtash
- Experimental Medicine Program, Department of Medicine, University of British Columbia (UBC), Vancouver, BC, Canada
- Sleep Disorders Program, UBC Hospital, Vancouver, BC, Canada
| | - J P Bakker
- Division of Sleep & Circadian Disorders, Brigham and Women's Hospital, Boston, MA, USA
| | - N Ayas
- Sleep Disorders Program, UBC Hospital, Vancouver, BC, Canada.
- Respiratory and Critical Care Divisions, Department of Medicine, UBC, Vancouver, BC, Canada.
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17
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Benca RM, Teodorescu M. Sleep physiology and disorders in aging and dementia. HANDBOOK OF CLINICAL NEUROLOGY 2019; 167:477-493. [PMID: 31753150 DOI: 10.1016/b978-0-12-804766-8.00026-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sleep problems occur commonly in normal and pathologic aging. Older adults typically have more difficulty falling asleep and remaining asleep, report more daytime napping, and have an increased prevalence of primary sleep disorders such as insomnia, parasomnias, sleep apnea, and sleep-related movement disorders. Medical and psychiatric disorders as well as medications used to treat them also contribute to sleep disturbances in aging. Patients with mild cognitive impairment and dementia have more severe sleep problems, and disturbed sleep and sleep disorders contribute to earlier onset and more rapid progression of neurodegenerative disorders. Approaches to diagnosing and treating sleep disorders in the elderly are discussed.
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Affiliation(s)
- Ruth M Benca
- Department of Psychiatry and Human Behavior, University of California, Irvine, CA, United States.
| | - Mihai Teodorescu
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
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Baratta F, Pastori D, Bucci T, Fabiani M, Fabiani V, Brunori M, Loffredo L, Lillo R, Pannitteri G, Angelico F, Del Ben M. Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome. Sleep Med 2018; 43:66-70. [PMID: 29482815 DOI: 10.1016/j.sleep.2017.09.032] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/07/2017] [Accepted: 09/20/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP. METHODS CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP. RESULTS Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46-0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13-2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03-3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome. CONCLUSIONS In our cohort of patients with moderate/severe OSAS who were prescribed CPAP therapy, long-term compliance to treatment was present in less than half of the patients. Adherence was positively associated with OSAS severity and negatively associated with cigarette smoking and previous cardiovascular events at baseline.
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Affiliation(s)
- Francesco Baratta
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy; Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Italy
| | - Daniele Pastori
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy; Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Italy
| | - Tommaso Bucci
- Department of Internal Medicine and Hepatology Unit, Salerno University, Italy
| | - Mario Fabiani
- Department of Sense Organs, Sapienza University of Rome, Italy
| | - Valerio Fabiani
- Department of Neurosciences, Mental Health and Sensory Functions, Sapienza University of Rome, Italy
| | - Marco Brunori
- Department of Cardiovascular, Respiratory, Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Lorenzo Loffredo
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Rossella Lillo
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Gaetano Pannitteri
- Department of Cardiovascular, Respiratory, Nephrologic, Anaesthesiologic and Geriatric Sciences, Sapienza University, Rome, Italy
| | - Francesco Angelico
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy.
| | - Maria Del Ben
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
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Gibson R, Campbell A, Mather S, Neill A. From diagnosis to long-term management: the experiences of older New Zealanders with obstructive sleep apnoea. J Prim Health Care 2018; 10:140-149. [DOI: 10.1071/hc17072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
ABSTRACT INTRODUCTION In New Zealand (NZ), access to public sleep services is limited to people deemed with the highest need. The prevalence of obstructive sleep apnoea (OSA) increases with age, but the symptoms and the treatment pathway is expected to differ for older compared to younger patients. This study explored the experience of older people regarding diagnosis and treatment services for OSA in order to inform considerations required in primary health and sleep services. METHODS Patients who were initiated on Continuous Positive Airway Pressure (CPAP) therapy at the age of 65 years or older were invited to one of three 1.5-h focus group discussions. In total, 16 patients attended; nine were accompanied by their spouse or partner. Discussions were semi-structured and explored experiences with the OSA pathway, from diagnosis through to long-term management. RESULTS Thematic analysis highlights the key symptoms of OSA. Patients’ experiences with diagnostic and treatment services were generally positive. However, there was an overarching need for greater knowledge and follow up regarding OSA and CPAP therapy. Most patients were happy with CPAP treatment. Issues associated with long-term use, comfort and daily management were highlighted, and strategies used to overcome them discussed. DISCUSSION Focus groups reported similar experiences, positively endorsing the health value of OSA diagnosis and CPAP therapy. Mechanisms and resources are required at a primary healthcare level in order to raise awareness around sleep and aging, OSA and CPAP. This would aid earlier and more appropriate diagnosis and management of OSA and help overcome some of the gaps identified in this study.
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Abstract
Increased age is associated with normative declines in both sleep and cognitive functioning. Although there are some inconsistencies in the literature, negative sleep changes are associated with worse cognitive functioning. This negative relationship holds true across normal-sleeping older adults, older adults with insomnia, older adults with sleep disordered breathing, cognitively healthy older adults, and older adults with dementia. There are mixed results regarding potential benefits of sleep treatments on cognitive functions; however, this line of research deserves added attention because the potential mechanisms of action are likely distinct from other interventions to improve cognition.
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Affiliation(s)
- Joseph M Dzierzewski
- Department of Psychology, Virginia Commonwealth University, 806 West Franklin Street, Room 306, Box 842018, Richmond, VA 23284-2018, USA.
| | - Natalie Dautovich
- Department of Psychology, Virginia Commonwealth University, 800 West Franklin Street, Room 203, Box 842018, Richmond, VA 23284-2018, USA
| | - Scott Ravyts
- Department of Psychology, Virginia Commonwealth University, Box 842018, Richmond, VA 23284-2018, USA
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Abstract
Sleep-disordered breathing (SDB) is a highly prevalent chronic disease in older adults. A growing body of evidence demonstrates that SDB in older adults is linked to many adverse cardiovascular, neurocognitive, and metabolic sequelae. However, several unanswered questions remain regarding the diagnosis, consequences, and treatment of SDB in older adults. This review presents the current evidence pertaining to the management of SDB in older adults and identifies crucial gaps in knowledge that need further investigation.
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Affiliation(s)
- Susmita Chowdhuri
- Sleep Medicine Section, John D. Dingell VA Medical Center, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI 48201, USA.
| | - Pragnesh Patel
- Department of Medicine, Wayne State University, Detroit, MI 48201, USA
| | - M Safwan Badr
- Sleep Medicine Section, John D. Dingell VA Medical Center, Detroit, MI 48201, USA; Department of Medicine, Wayne State University, Detroit, MI 48201, USA
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Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications. Sleep Med Clin 2017; 12:551-564. [PMID: 29108610 DOI: 10.1016/j.jsmc.2017.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
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Batool-Anwar S, Baldwin CM, Fass S, Quan SF. ROLE OF SPOUSAL INVOLVEMENT IN CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) ADHERENCE IN PATIENTS WITH OBSTRUCTIVE SLEEP APNEA (OSA). SOUTHWEST JOURNAL OF PULMONARY AND CRITICAL CARE 2017; 14:213-227. [PMID: 28725492 PMCID: PMC5512877 DOI: 10.13175/swjpcc034-17] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Little is known about the impact of spousal involvement on continuous positive airway pressure (CPAP) adherence. The aim of this study was to determine whether spouse involvement affects adherence with CPAP therapy, and how this association varies with gender. METHODS 194 subjects recruited from Apnea Positive Pressure Long Term Efficacy Study (APPLES) completed the Dyadic Adjustment Scale (DAS). The majority of participants were Caucasian (83%), and males (73%), with mean age of 56 years, mean BMI of 31 kg/m2. & 62% had severe OSA. The DAS is a validated 32-item self-report instrument measuring dyadic consensus, satisfaction, cohesion, and affectional expression. A high score in the DAS is indicative of a person's adjustment to the marriage. Additionally, questions related to spouse involvement with general health and CPAP use were asked. CPAP use was downloaded from the device and self-report, and compliance was defined as usage ≥ 4 h per night. RESULTS There were no significant differences in overall marital quality between the compliant and noncompliant subjects. However, level of spousal involvement was associated with increased CPAP adherence at 6 months (p=0.01). After stratifying for gender these results were significant only among males (p=0.03). Three years after completing APPLES, level of spousal involvement was not associated with CPAP compliance even after gender stratification. CONCLUSION Spousal involvement is important in determining CPAP compliance in males in the 1st 6 months after initiation of therapy but is not predictive of longer-term adherence. Involvement of the spouse should be considered an integral part of CPAP initiation procedures. SUPPORT HL068060.
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Affiliation(s)
| | - Carol M. Baldwin
- Arizona State University College of Nursing and Health Innovation and College of Health Solutions, Phoenix, AZ
| | - Shira Fass
- Case Western Reserve University, Cleveland, Ohio
| | - Stuart F. Quan
- University of Arizona College of Medicine, Tucson, AZ
- Brigham and Women’s Hospital, Boston, MA
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24
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Luyster FS. Impact of Obstructive Sleep Apnea and Its Treatments on Partners: A Literature Review. J Clin Sleep Med 2017; 13:467-477. [PMID: 28095973 DOI: 10.5664/jcsm.6504] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/19/2016] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVES Many adults sleep with a significant other; thus, sleep disorder symptoms and treatments of one partner are likely to impact the other partner's health. A literature review was conducted to examine the impact of obstructive sleep apnea (OSA) and OSA treatments on partner-assessed sleep and daytime functioning and partner involvement in OSA treatment. METHODS MEDLINE, EMBASE, and CINAHL searches yielded 38 pertinent quantitative and qualitative studies that described sleep and/or daytime functioning assessed in partners of patients with untreated OSA, sleep and/or daytime functioning assessed in partners who were referred for OSA treatment, including continuous positive airway pressure (CPAP) therapy, oral appliance (OA), or surgery, and/or associations between partner involvement and OSA treatment use. RESULTS The majority of studies found untreated OSA to have a negative impact on partners' objective and subjective sleep and daytime functioning, in particular mood, quality of life, and relationship quality. Improvements in partner-assessed sleep quality were reported for CPAP, OA, and surgery. Conflicting results were reported for partners' mood, quality of life, daytime sleepiness, and relationship quality. Perceived partner support was associated with greater CPAP use. CONCLUSIONS Symptoms associated with OSA can negatively impact partners' sleep and daytime functioning. Treatment of OSA with CPAP, OA, or surgery can have health benefits for not only patients but also partners. Collaborative partner involvement may be a useful strategy for interventions promoting CPAP adherence.
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Metta RVVS, Zaka A, Lee VC, Mador MJ. Continuous Positive Airway Pressure Adherence In Patients with Obstructive Sleep Apnea & Symptomatic BPH. Lung 2017; 195:255-261. [PMID: 28204876 DOI: 10.1007/s00408-017-9981-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 01/29/2017] [Indexed: 10/20/2022]
Abstract
Purpose To determine the short-term and long-term adherence rates with continuous positive airway pressure (CPAP) therapy in sleep apnea patients with benign prostatic hyperplasia (BPH) compared to matched controls. Methods A case-control retrospective analysis was performed in a veterans affairs hospital. All symptomatic patients with BPH (n = 107) ever started on CPAP therapy between 2006 and 2012 were compared with controls matched for severity of sleep apnea (AHI). Adherence measures were obtained at the third and twelfth month visits. The cases included symptomatic BPH patients on active medical therapy. Diuretic use among cases and controls, and severity of nocturia among the cases were also analyzed. Results The mean AHI among cases and controls was 35.6 ± 27.3 and 35.5 ± 31 (p = 0.96). The population was male and predominantly Caucasian. There was no statistically significant difference in percent days CPAP device use ≥4 h. between symptomatic BPH patients and controls at 3-month (51.6 ± 38 vs. 47.2 ± 36; p = 0.43) and 1-year (64 ± 40.5 vs. 64.7 ± 31.3; p = 0.90) visits. The use of diuretics in the cases and controls, and the severity of nocturia in the cases did not influence adherence with CPAP therapy. Conclusions BPH or diuretic use did not affect adherence with CPAP therapy in obstructive sleep apnea. Severity of nocturia did not have any influence on adherence among the cases. BPH, regardless of the severity of nocturia, and diuretic use does not influence CPAP adherence in patients with OSA.
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Affiliation(s)
- Ramesh V V S Metta
- The Veterans Affairs Western New York Healthcare System, University at Buffalo, 3495 Bailey Avenue, Buffalo, NY, 14215, USA. .,Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo, 3495 Bailey Avenue, Buffalo, NY, 14215, USA.
| | - Awais Zaka
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - Vincent C Lee
- Department of Medicine, University at Buffalo, Buffalo, NY, USA
| | - M Jeffery Mador
- The Veterans Affairs Western New York Healthcare System, University at Buffalo, 3495 Bailey Avenue, Buffalo, NY, 14215, USA.,Division of Pulmonary, Critical Care, and Sleep Medicine, University at Buffalo, 3495 Bailey Avenue, Buffalo, NY, 14215, USA
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27
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Exuberant inflammatory reaction to occlusion of topical 5-fluorouracil (FU) under a continuous positive airway pressure (CPAP) mask: A warning to dermatologists and patients. JAAD Case Rep 2016; 2:278-80. [PMID: 27486594 PMCID: PMC4949501 DOI: 10.1016/j.jdcr.2016.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Jeong JI, Kim HY, Hong SD, Ryu G, Kim SJ, Lee KE, Dhong HJ, Chung SK. Upper Airway Variation and Frequent Alcohol Consumption Can Affect Compliance With Continuous Positive Airway Pressure. Clin Exp Otorhinolaryngol 2016; 9:346-351. [PMID: 27334512 PMCID: PMC5115154 DOI: 10.21053/ceo.2015.01984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 01/26/2016] [Accepted: 02/02/2016] [Indexed: 12/02/2022] Open
Abstract
Objectives Compliance with continuous positive airway pressure (CPAP) treatment remains a primary concern for improving treatment outcomes of obstructive sleep apnea. There are few studies that have considered the role of upper airway anatomy on the compliance with CPAP. We hypothesized that upper airway anatomy would influence the compliance with CPAP. Methods One hundred out of 161 consecutive patients were enrolled in this study. The following possible determinants were tested against CPAP use: demographic and anthropometric data, minimal cross-sectional area on acoustic rhinometry, cephalometric and polysomnographic data, questionnaires of Epworth sleepiness scale and Beck depression index, and histories of previous upper airway surgery, degree of nasal obstruction, daily cigarette consumption, and weekly frequency of alcohol intake. Results Univariate analysis showed that histories of previous upper airway surgery and less frequent alcohol consumption, and longer mandibular plane-hyoid length (MP-H) on cephalometry were associated with longer average daily CPAP use. After adjustment for the confounding factors with multiple linear regression analysis, alcohol consumption and MP-H were still associated with the compliance with CPAP significantly. Conclusion To improve compliance with CPAP, careful evaluations of upper airway problems and life style are important before initiating CPAP.
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Affiliation(s)
- Jong In Jeong
- Department of Otolaryngology, Keimyung University School of Medicine, Daegu, Korea
| | - Hyo Yeol Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang Duk Hong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gwanghui Ryu
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Jin Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyung Eun Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hun-Jong Dhong
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung-Kyu Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Shastri A, Bangar S, Holmes J. Obstructive sleep apnoea and dementia: is there a link? Int J Geriatr Psychiatry 2016; 31:400-5. [PMID: 26266479 DOI: 10.1002/gps.4345] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2014] [Revised: 07/12/2015] [Accepted: 07/17/2015] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Obstructive sleep apnoea is a common sleep disturbance in people of all ages, while dementia is an increasing entity among the ageing population of the world. Recent studies have established a link between sleep apnoea and cognitive decline. This literature review explores this relationship and examines the mechanisms, neurobiology and treatment modalities. DESIGN The study was conducted with the use of narrative literature overview. RESULTS AND CONCLUSIONS While there are numerous studies that establish a clear relationship between obstructive sleep apnoea, cognitive decline and dementia, more work is needed in understanding the mechanism and processes involved. A detailed understanding of pathophysiology of sleep and the relationship with cognitive decline will be vital in addressing the possibility of averting a likely reversible cause of dementia or cognitive decline.
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Affiliation(s)
| | - Santosh Bangar
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - John Holmes
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK.,Leeds Institute of Medical Education, School of Medicine, University of Leeds, Leeds, UK
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McMillan A, Bratton DJ, Faria R, Laskawiec-Szkonter M, Griffin S, Davies RJ, Nunn AJ, Stradling JR, Riha RL, Morrell MJ. A multicentre randomised controlled trial and economic evaluation of continuous positive airway pressure for the treatment of obstructive sleep apnoea syndrome in older people: PREDICT. Health Technol Assess 2016; 19:1-188. [PMID: 26063688 DOI: 10.3310/hta19400] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND The therapeutic and economic benefits of continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnoea syndrome (OSAS) have been established in middle-aged people. In older people there is a lack of evidence. OBJECTIVE To determine the clinical efficacy of CPAP in older people with OSAS and to establish its cost-effectiveness. DESIGN A randomised, parallel, investigator-blinded multicentre trial with within-trial and model-based cost-effectiveness analysis. METHODS Two hundred and seventy-eight patients, aged ≥ 65 years with newly diagnosed OSAS [defined as oxygen desaturation index at ≥ 4% desaturation threshold level for > 7.5 events/hour and Epworth Sleepiness Scale (ESS) score of ≥ 9] recruited from 14 hospital-based sleep services across the UK. INTERVENTIONS CPAP with best supportive care (BSC) or BSC alone. Autotitrating CPAP was initiated using standard clinical practice. BSC was structured advice on minimising sleepiness. COPRIMARY OUTCOMES Subjective sleepiness at 3 months, as measured by the ESS (ESS mean score: months 3 and 4) and cost-effectiveness over 12 months, as measured in quality-adjusted life-years (QALYs) calculated using the European Quality of Life-5 Dimensions (EQ-5D) and health-care resource use, information on which was collected monthly from patient diaries. SECONDARY OUTCOMES Subjective sleepiness at 12 months (ESS mean score: months 10, 11 and 12) and objective sleepiness, disease-specific and generic quality of life, mood, functionality, nocturia, mobility, accidents, cognitive function, cardiovascular risk factors and events at 3 and 12 months. RESULTS Two hundred and seventy-eight patients were randomised to CPAP (n = 140) or BSC (n = 138) over 27 months and 231 (83%) patients completed the trial. Baseline ESS score was similar in both groups [mean (standard deviation; SD) CPAP 11.5 (3.3), BSC 11.4 (4.2)]; groups were well balanced for other characteristics. The mean (SD) in ESS score at 3 months was -3.8 (0.4) in the CPAP group and -1.6 (0.3) in the BSC group. The adjusted treatment effect of CPAP compared with BSC was -2.1 points [95% confidence interval (CI) -3.0 to -1.3 points; p < 0.001]. At 12 months the effect was -2.0 points (95% CI -2.8 to -1.2 points; p < 0.001). The effect was greater in patients with increased CPAP use or higher baseline ESS score. The number of QALYs calculated using the EQ-5D was marginally (0.005) higher with CPAP than with BSC (95% CI -0.034 to 0.044). The average cost per patient was £1363 (95% CI £1121 to £1606) for those allocated to CPAP and £1389 (95% CI £1116 to £1662) for those allocated to BSC. On average, costs were lower in the CPAP group (mean -£35; 95% CI -£390 to £321). The probability that CPAP was cost-effective at thresholds conventionally used by the NHS (£20,000 per QALY gained) was 0.61. QALYs calculated using the Short Form questionnaire-6 Dimensions were 0.018 higher in the CPAP group (95% CI 0.003 to 0.034 QALYs) and the probability that CPAP was cost-effective was 0.96. CPAP decreased objective sleepiness (p = 0.02), increased mobility (p = 0.03) and reduced total and low-density lipoprotein cholesterol (p = 0.05, p = 0.04, respectively) at 3 months but not at 12 months. In the BSC group, there was a fall in systolic blood pressure of 3.7 mmHg at 12 months, which was not seen in the CPAP group (p = 0.04). Mood, functionality, nocturia, accidents, cognitive function and cardiovascular events were unchanged. There were no medically significant harms attributable to CPAP. CONCLUSION In older people with OSAS, CPAP reduces sleepiness and is marginally more cost-effective than BSC over 12 months. Further work is required in the identification of potential biomarkers of sleepiness and those patients at increased risk of cognitive impairment. Early detection of which could be used to inform the clinician when in the disease cycle treatment is needed to avert central nervous system sequelae and to assist patients decision-making regarding treatment and compliance. Treatment adherence is also a challenge in clinical trials generally, and adherence to CPAP therapy in particular is a recognised concern in both research studies and clinical practice. Suggested research priorities would include a focus on optimisation of CPAP delivery or support and embracing the technological advances currently available. Finally, the improvements in quality of life in trials do not appear to reflect the dramatic changes noted in clinical practice. There should be a greater focus on patient centred outcomes which would better capture the symptomatic improvement with CPAP treatment and translate these improvements into outcomes which could be used in health economic analysis. TRIAL REGISTRATION Current Controlled Trials ISRCTN90464927. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 40. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alison McMillan
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
| | - Daniel J Bratton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Rita Faria
- Centre for Health Economics, University of York, York, UK
| | | | - Susan Griffin
- Oxford University and Oxford Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | - Robert J Davies
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - John R Stradling
- Oxford Respiratory Trials Unit, University of Oxford, Churchill Hospital, Oxford, UK
| | - Renata L Riha
- Department of Sleep Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Mary J Morrell
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
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Abstract
KEY POINTS Sleep disordered breathing (SDB) is common and its prevalence increases with age. Despite this high prevalence, SDB is frequently unrecognised and undiagnosed in older people.There is accumulating evidence that SDB in older people is associated with worsening cardio- cerebrovascular, cognitive and functional outcomes.There is now good evidence to support the use of continuous positive airway pressure therapy in older patients with symptomatic SDB. EDUCATIONAL AIMS To highlight the prevalence and presentation of sleep disordered breathing (SDB) in older people.To inform readers about the risk factors for SDB in older people.To explore the impact of SDB in older people.To introduce current evidence based treatment options for SDB in older people. Sleep disordered breathing (SBD) increases in prevalence as we age, most likely due to physiological and physical changes that occur with ageing. Additionally, SDB is associated with comorbidity and its subsequent polypharmacy, which may increase with increasing age. Finally, the increased prevalence of SDB is intrinsically linked to the obesity epidemic. SDB is associated with serious outcomes in younger people and, likewise, older people. Thus, identification, diagnosis and treatment of SDB is important irrelevant of age. This article reviews the age-related changes contributing to SDB, the epidemiology and the risk factors for SDB in older people, the association of SDB with adverse outcomes, and diagnostic and treatment options for this population.
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Affiliation(s)
- Alison McMillan
- Sleep and Respiratory Dept, East and North Hertfordshire NHS Trust, Stevenage, UK
| | - Mary J. Morrell
- Academic Unit of Sleep and Ventilation, National Heart and Lung Institute, Imperial College, London, UK
- Respiratory Disease Biomedical Research Unit at the Royal Brompton Hospital and Harefield NHS Foundation Trust, London, UK
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López-Padilla D, Alonso-Moralejo R, Martínez-García MÁ, De la Torre Carazo S, Díaz de Atauri MJ. Continuous positive airway pressure and survival of very elderly persons with moderate to severe obstructive sleep apnea. Sleep Med 2015; 19:23-9. [PMID: 27198943 DOI: 10.1016/j.sleep.2015.10.015] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 09/27/2015] [Accepted: 10/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There is evidence of a beneficial effect of long-term continuous positive airway pressure (CPAP) on survival in elderly persons with obstructive sleep apnea (OSA), although the usual age cut off is between 60 and 70 years of age. Our objective was to determine this effect in very elderly patients (ie, those ≥80 years of age). METHODS An observational study of a historic cohort of very elderly persons with moderate to severe OSA (apnea-hypopnea index ≥20) and the effect of long-term CPAP on their survival was performed. Two groups were formed: one prescribed CPAP treatment (≥4 hours per night), and one without CPAP treatment. Survival analyses, including Kaplan-Meier curves and Cox models, were carried out to determine the association of long-term CPAP with longer survival, RESULTS A total of 155 very elderly persons (84 men and 71 women, mean age 81.5 ± 1.5 years) were followed up for 53 months (interquartile range, 41-77 months); 83 deaths occurred. CPAP was prescribed to 132 patients, and adherence was observed in 79 (60%). Kaplan-Meier curves showed longer survival in the treated OSA group (91 months, 95% confidence interval [CI] = 76-106) than in the untreated OSA group (52 months, 95% CI 41-64), which was statistically significant (log-rank 16.9, p < 0.0001). Although history of stroke was significantly associated with higher mortality (hazard ratio [HR] = 2.18, 95% CI = 1.14-4.17, p = 0.02), CPAP treatment was associated with higher survival rates (HR = 0.46, 95% CI = 0.27-0.78, p = 0.004) in an adjusted Cox analysis. CONCLUSIONS CPAP treatment might be associated with a longer survival in very elderly persons with moderate to severe OSA.
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Affiliation(s)
| | - Rodrigo Alonso-Moralejo
- Respiratory Department, 12 de Octubre University Hospital, Madrid, Spain; Instituto de Investigación, 12 de Octubre i+12, Madrid, Spain
| | - Miguel Ángel Martínez-García
- Respiratory Department, La Fe University and Polytechnic Hospital, Valencia, Spain; CIBER de Enfermedades Respiratorias, Bunyola, Spain
| | | | - María Josefa Díaz de Atauri
- Respiratory Department, 12 de Octubre University Hospital, Madrid, Spain; Instituto de Investigación, 12 de Octubre i+12, Madrid, Spain; CIBER de Enfermedades Respiratorias, Bunyola, Spain
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33
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Vinogradov OI, Kulagina AM. [Insomnia and sleep-related breathing disturbances are the new risk factors for ischemic stroke]. Zh Nevrol Psikhiatr Im S S Korsakova 2015; 115:40-47. [PMID: 26120996 DOI: 10.17116/jnevro20151153240-47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sleep disorders have an extremely negative impact on human vital functioning, encompassing both mental and somatic sphere. A large number of clinical trials have shown an increased risk of cardiovascular diseases and their complications, including the risk of ischemic stroke, in patients suffering from insomnia or sleep-related breathing disturbances. These types of sleep disorders are the most common in the structure of all violations of sleep. Obstructive sleep apnea syndrome is the most clinically significant type of sleep-related breathing disturbances. A number of pathophysiological mechanisms that may be responsible for the negative impact of sleep disorders was identified. In order to treat insomnia, behavioral techniques, including the normalization of sleep hygiene, behavioral and cognitive therapy, medication treatment, are used. Continuous Positive Airway Pressure (CPAP) therapy is currently the method of choice in the treatment of obstructive sleep apnea syndrome of any etiology.
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Affiliation(s)
| | - A M Kulagina
- Pirogov National Center of Therapy and Surgery, Moscow
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34
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Tan KB, Toh ST, Guilleminault C, Holty JEC. A Cost-Effectiveness Analysis of Surgery for Middle-Aged Men with Severe Obstructive Sleep Apnea Intolerant of CPAP. J Clin Sleep Med 2015; 11:525-35. [PMID: 25700871 PMCID: PMC4410926 DOI: 10.5664/jcsm.4696] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Accepted: 12/09/2014] [Indexed: 12/11/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is associated with increased cardiovascular morbidity and mortality. Conventional OSA therapy necessitates indefinite continuous positive airway pressure (CPAP). Although CPAP is an effective treatment modality, up to 50% of OSA patients are intolerant of CPAP. We explore whether surgical modalities developed for those intolerant of CPAP are cost-effective. METHODS We construct a lifetime semi-Markov model of OSA that accounts for observed increased risks of stroke, cardiovascular disease, and motor vehicle collisions for a 50-year-old male with untreated severe OSA. Using this model, we compare the cost-effectiveness of (1) no treatment, (2) CPAP only, and (3) CPAP followed by surgery (either palatopharyngeal reconstructive surgery [PPRS] or multilevel surgery [MLS]) for those intolerant to CPAP. RESULTS Compared with the CPAP only strategy, CPAP followed by PPRS (CPAP-PPRS) adds 0.265 quality adjusted life years (QALYs) for an increase of $2,767 (discounted 2010 dollars) and is highly cost effective with an incremental cost-effectiveness ratio (ICER) of $10,421/QALY for a 50-year-old male with severe OSA. Compared to a CPAP-PPRS strategy, the CPAP-MLS strategy adds 0.07 QALYs at an increase of $6,213 for an ICER of $84,199/QALY. The CPAP-PPRS strategy appears cost-effective over a wide range of parameter estimates. CONCLUSIONS Palatopharyngeal reconstructive surgery appears cost-effective in middle-aged men with severe OSA intolerant of CPAP. Further research is warranted to better define surgical candidacy as well as short-term and long-term surgical outcomes. COMMENTARY A commentary on this article appears in this issue on page 509.
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Affiliation(s)
- Kelvin B. Tan
- Stanford University, Management Science and Engineering Department, Stanford, CA
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
| | | | | | - Jon-Erik C. Holty
- Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA
- Pulmonary, Critical Care and Sleep Section, VA Palo Alto Healthcare System, Palo Alto, CA
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Martin F, Gagnadoux F, Onen F, Onen SH. [S.AGES Study. Collection and follow-up of new sleep apnea cases in patients over 70 years of age and diagnosed in pulmonary and geriatric units]. Rev Mal Respir 2015; 32:768-72. [PMID: 25595879 DOI: 10.1016/j.rmr.2014.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/23/2014] [Indexed: 10/24/2022]
Abstract
RATIONALE S.AGES is a prospective cohort of >70-years-old patients with obstructive sleep apnea syndrome having been diagnosed in a pulmonary or a geriatric medical unit. OBJECTIVES The main objective of S.AGES is to get a description of older patients with OSAS in France. The secondary objectives will be to prospectively describe the management and the treatment of these patients, to describe their 5-years outcome as compared to younger patients in the literature. It will also contribute to better characterize the compliance and tolerance of the treatment and the incidence of comorbidities like respiratory diseases and cardiovascular disorders. METHODS All consecutive ≥70-years-old patients having received a diagnosis of OSAS (after polygraphy or polysomnography) will be included in the study. All patients will be followed in a pulmonary or a geriatric department. EXPECTED RESULTS S.AGES should better characterize the OSAS in the elderly patients, the specific management of this disease and its related risk factors. It may also identify the 5-years mortality and morbidity rates in this population.
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Affiliation(s)
- F Martin
- Unité des pathologies du sommeil, CHI Compiègne-Noyon, 60200 Compiègne, France.
| | - F Gagnadoux
- Service de pneumologie, CHU d'Angers, Angers, 49100 France
| | - F Onen
- Service de gériatrie, CHU Bichat-Claude-Bernard, 75018 Paris, France
| | - S H Onen
- Centre gériatrique de médecine du sommeil, HEH, pavillon E, 69003 Lyon, France
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36
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Ketata W, Feki W, Yangui I, Msaad S, Ayoub A. [Obstructive sleep apnea syndrome in the elderly]. REVUE DE PNEUMOLOGIE CLINIQUE 2014; 70:223-232. [PMID: 24894966 DOI: 10.1016/j.pneumo.2014.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 01/22/2014] [Accepted: 02/05/2014] [Indexed: 06/03/2023]
Abstract
Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a common disease in the general population. However, original works on the SAHS in the elderly are few and their results are discordant. Studies show an increased prevalence of OSAHS with age, and despite this high prevalence, it remains under-diagnosed due to lack of knowledge of geriatric features of this disease and the frequency of comorbidities that may worsen as a result of nocturnal breathing problems but can also mask the symptoms necessary for positive diagnosis. The functional symptoms are dominated by neurological signs such as daytime hypersomnia and cognitive impairment often reported by those around the patient. The treatment is based mainly on continuous positive airway pressure which tolerance in elderly patients suffering from sleep apnea is similar to that of younger patients. Mandibular implants can be discussed depending on the severity of the condition. Surgical treatment is not indicated because of the increased frequency of complications.
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Affiliation(s)
- W Ketata
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie.
| | - W Feki
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - I Yangui
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - S Msaad
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
| | - A Ayoub
- Service de pneumo-allergologie, CHU Hédi Chaker, 3029 Sfax, Tunisie
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Gooneratne NS, Vitiello MV. Sleep in older adults: normative changes, sleep disorders, and treatment options. Clin Geriatr Med 2014; 30:591-627. [PMID: 25037297 PMCID: PMC4656195 DOI: 10.1016/j.cger.2014.04.007] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.
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Affiliation(s)
- Nalaka S Gooneratne
- Division of Geriatric Medicine, Department of Medicine, University of Pennsylvania, 3615 Chestnut Street, Philadelphia, PA 19104, USA; Division of Sleep Medicine, Center for Sleep and Circadian Neurobiology, School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Michael V Vitiello
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, USA
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The Role of Severity of Obstructive Sleep Apnea Measured by Apnea–Hypopnea Index in Predicting Compliance With Pressure Therapy, a Meta-analysis. Am J Ther 2014; 21:260-4. [DOI: 10.1097/mjt.0b013e318249a09d] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Crawford MR, Espie CA, Bartlett DJ, Grunstein RR. Integrating psychology and medicine in CPAP adherence – New concepts? Sleep Med Rev 2014; 18:123-39. [DOI: 10.1016/j.smrv.2013.03.002] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 03/07/2013] [Accepted: 03/08/2013] [Indexed: 12/11/2022]
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40
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Long-term adherence to nasal continuous positive airway pressure therapy by hypertensive patients with preexisting sleep apnea. J Cardiol 2013; 63:281-5. [PMID: 24148860 DOI: 10.1016/j.jjcc.2013.08.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/23/2013] [Accepted: 08/18/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Although positive screening for and treatment of obstructive sleep apnea (OSA) have been recommended for patients with cardiovascular problems, patient adherence to nasal continuous positive airway pressure (CPAP) therapy primarily for a cardiovascular concern is unknown. Therefore, this study aimed to determine the adherence to CPAP therapy by hypertensive patients with OSA after a screening test performed regardless of OSA-related symptoms. SUBJECTS AND METHODS CPAP therapy was administered to 194 of the 1365 hypertensive patients who underwent the screening. The monthly dropout from CPAP therapy and the adequate use level (4h every night, 70% days in a month) were assessed using the Kaplan-Meier analysis over a 3-year follow-up period. RESULTS Of the patients, 106 (55%) refused or abandoned the therapy by the end of the follow-up period (adherence, 45%). An adequate use level was maintained by 76 patients (39%). Most of the patients' background characteristics, including age, sex, Epworth sleepiness scale scores, and parameters obtained on polysomnography, were not related to adherence or adequate use level. The good-compliance level on the first visit after CPAP therapy introduction was most strongly related to adherence (95% CI, 0.05-0.32; p<0.001) and adequate use level (95% CI, 0.06-0.33; p<0.05). Fourth quartile of apnea hypopnea index value (greater than 67/h) was also related to adherence (95% CI, 0.21-0.98; p<0.02) and adequate use level (95% CI, 0.19-0.88; p<0.05). CONCLUSIONS The adherence and use level in this population may not be satisfactory but are comparable with those in previous sleep center reports treating symptomatic OSA patients. Thus, the present results would encourage hypertensive patients to undergo positive screening for OSA, regardless of OSA-related symptoms. However, an outcomes study with the same cohort is needed.
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41
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Wickwire EM, Lettieri CJ, Cairns AA, Collop NA. Maximizing Positive Airway Pressure Adherence in Adults. Chest 2013; 144:680-693. [DOI: 10.1378/chest.12-2681] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Martin S, Lange K, Haren MT, Taylor AW, Wittert G. Risk factors for progression or improvement of lower urinary tract symptoms in a prospective cohort of men. J Urol 2013; 191:130-7. [PMID: 23770136 DOI: 10.1016/j.juro.2013.06.018] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2013] [Indexed: 11/24/2022]
Abstract
PURPOSE We determined the metabolic, lifestyle and physical factors associated with progression or improvement of storage and voiding lower urinary tract symptoms in a population based cohort of men. MATERIALS AND METHODS After the exclusion of men with prostate or bladder cancer and/or surgery from the study, progression and improvement of storage and voiding lower urinary tract symptoms was assessed using the AUA-SI (American Urological Association symptom index) in 780 men, age 35 to 80 years at baseline, who attended 5-year followup clinics. RESULTS Storage and voiding lower urinary tract symptoms progressed in 39.8% (308) and 32.3% (250) of men, and improved in 33.1% (256) and 23.4% (181), respectively. In final adjusted regression models greater bother and physical activity at baseline predicted improvement in storage and voiding lower urinary tract symptoms, while greater income, high-density lipoprotein cholesterol and lower triglycerides predicted improvement of storage lower urinary tract symptoms only. Being widowed, higher plasma estradiol and depression at baseline predicted the progression of storage and voiding lower urinary tract symptoms, while greater abdominal fat mass and obstructive sleep apnea risk predicted the progression of storage lower urinary tract symptoms only. Older age, lower high-density lipoprotein cholesterol, testosterone, income, previous benign prostatic hyperplasia and erectile dysfunction at baseline predicted the progression of voiding lower urinary tract symptoms only. The initiation or continued use of α-blockers or anticholinergics (storage lower urinary tract symptoms), and 5α-reductase inhibitors (voiding lower urinary tract symptoms), were associated with symptom improvement. CONCLUSIONS Lower urinary tract symptoms may progress or remit. Even accounting for medication use, progression may be associated with modifiable disease, or metabolic or behavioral factors, which are also risk factors for type 2 diabetes and cardiovascular disease. These factors should be looked for and managed.
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Affiliation(s)
- Sean Martin
- Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, South Australia; School of Medicine, University of Adelaide, Adelaide, South Australia
| | - Kylie Lange
- School of Medicine, University of Adelaide, Adelaide, South Australia
| | - Matthew T Haren
- Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, South Australia; Population Research and Outcome Studies, University of Adelaide, Adelaide, South Australia
| | - Anne W Taylor
- SANSOM Institute, Division of Health Sciences, University of South Australia, Adelaide, South Australia
| | - Gary Wittert
- Freemasons Foundation Centre for Men's Health, University of Adelaide, Adelaide, South Australia; School of Medicine, University of Adelaide, Adelaide, South Australia.
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Skinner T, McNeil L, Olaithe M, Eastwood P, Hillman D, Phang J, de Regt T, Bucks RS. Predicting uptake of continuous positive airway pressure (CPAP) therapy in obstructive sleep apnoea (OSA): a belief-based theoretical approach. Sleep Breath 2013; 17:1229-40. [PMID: 23516025 DOI: 10.1007/s11325-013-0828-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Revised: 02/06/2013] [Accepted: 03/04/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE Obstructive sleep apnoea (OSA) is a common disorder, for which continuous positive airway pressure (CPAP) therapy is a standard treatment. Despite its well-established efficacy, many patients choose not to initiate CPAP treatment. The present study investigated the degree to which biological measures (e.g. Apnoea-Hypopnoea Index [AHI]), symptom experiences (e.g. fatigue) and illness representations (e.g. perceived consequences) predict the decision of individuals newly diagnosed with OSA to undergo a trial of CPAP therapy. METHODS Four hundred forty-nine individuals (316 males) newly diagnosed with OSA. Epworth sleepiness scale (ESS), Fatigue Severity Scale, Depression Anxiety Stress Scale and Illness Perception Questionnaire-Revised (IPQ-R) were administered at time of sleep study. These, patient demographics and sleep study variables were used to determine factors predicting patient decision to proceed with a trial of CPAP. RESULTS The participants were most likely to attribute their OSA to unchangeable and psychological factors. For those with moderate OSA (AHI, 15 to 30) IPQ-R illness consequence was predictive of decision to initiate CPAP (p = 0.002). For severe OSA (AHI >30) age, ESS and IPQ illness causal beliefs were predictive of decision to initiate CPAP (p < 0.001). CONCLUSIONS Illness beliefs are important determinants of the choice of recently diagnosed OSA patients whether or not to undertake a trial of CPAP therapy. Concerns about illness consequences were important in those with moderate OSA. In severe OSA, sleepiness symptoms are more prominent and a more significant determinant of CPAP uptake along with age and causal beliefs.
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Affiliation(s)
- Timothy Skinner
- Psychological and Clinical Sciences, Charles Darwin University, Darwin, Northern Territory, 0909, Australia,
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Balachandran JS, Yu X, Wroblewski K, Mokhlesi B. A brief survey of patients' first impression after CPAP titration predicts future CPAP adherence: a pilot study. J Clin Sleep Med 2013; 9:199-205. [PMID: 23493772 DOI: 10.5664/jcsm.2476] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND CPAP adherence patterns are often established very early in the course of therapy. Our objective was to quantify patients' perception of CPAP therapy using a 6-item questionnaire administered in the morning following CPAP titration. We hypothesized that questionnaire responses would independently predict CPAP adherence during the first 30 days of therapy. METHODS We retrospectively reviewed the CPAP perception questionnaires of 403 CPAP-naïve adults who underwent in-laboratory titration and who had daily CPAP adherence data available for the first 30 days of therapy. Responses to the CPAP perception questionnaire were analyzed for their association with mean CPAP adherence and with changes in daily CPAP adherence over 30 days. RESULTS Patients were aged 52 ± 14 years, 53% were women, 54% were African American, the mean body mass index (BMI) was 36.3 ± 9.1 kg/m(2), and most patients had moderate-severe OSA. Four of 6 items from the CPAP perception questionnaire- regarding difficulty tolerating CPAP, discomfort with CPAP pressure, likelihood of wearing CPAP, and perceived health benefit-were significantly correlated with mean 30-day CPAP adherence, and a composite score from these 4 questions was found to be internally consistent. Stepwise linear regression modeling demonstrated that 3 variables were significant and independent predictors of reduced mean CPAP adherence: worse score on the 4-item questionnaire, African American race, and non-sleep specialist ordering polysomnogram and CPAP therapy. Furthermore, a worse score on the 4-item CPAP perception questionnaire was consistently associated with decreased mean daily CPAP adherence over the first 30 days of therapy. CONCLUSIONS In this pilot study, responses to a 4-item CPAP perception questionnaire administered to patients immediately following CPAP titration independently predicted mean CPAP adherence during the first 30 days. Further prospective validation of this questionnaire in different patient populations is warranted.
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Affiliation(s)
- Jay S Balachandran
- Sleep Disorders Center, Section of Pulmonary and Critical Care, Department of Medicine, Chicago, IL, USA
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Effectiveness of a group education session on adherence with APAP in obstructive sleep apnea—a randomized controlled study. Sleep Breath 2012. [DOI: 10.1007/s11325-012-0789-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Berkani K, Dimet J, Breton P, Bizieux-Thaminy A, Berruchon J. Prise en charge du syndrome d’apnées du sommeil dans un hôpital général. Étude rétrospective de 1718patients appareillés du 1er janvier 1994 au 1er janvier 2010. Rev Mal Respir 2012; 29:871-7. [DOI: 10.1016/j.rmr.2012.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 01/27/2012] [Indexed: 11/24/2022]
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Samson P, Casey KR, Knepler J, Panos RJ. Clinical characteristics, comorbidities, and response to treatment of veterans with obstructive sleep apnea, Cincinnati Veterans Affairs Medical Center, 2005-2007. Prev Chronic Dis 2012; 9:E46. [PMID: 22280961 PMCID: PMC3337849 DOI: 10.5888/pcd9.110117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction Obstructive sleep apnea (OSA) is a common disorder that is associated with significant morbidity. Veterans may be at an elevated risk for OSA because of increased prevalence of factors associated with the development and progression of OSA. The objective of this study was to determine the clinical characteristics, comorbidities, polysomnographic findings, and response to treatment of veterans with OSA. Methods We performed a retrospective chart review of 596 patients undergoing polysomnography at the Cincinnati Veterans Affairs Medical Center from February 2005 through December 2007. We assessed potential correlations of clinical data with polysomnography findings and response to treatment. Results Polysomnography demonstrated OSA in 76% of patients; 30% had mild OSA, 23% moderate OSA, and 47% severe OSA. Increasing body mass index, neck circumference, Epworth Sleepiness Scale score, hypertension, congestive heart failure, and type 2 diabetes correlated with increasing OSA severity. Positive airway pressure treatment was initiated in 81% of veterans with OSA, but only 59% reported good adherence to this treatment method. Of the patients reporting good adherence, a greater proportion of those with severe OSA (27%) than with mild or moderate disease (0%-12%) reported an excellent response to treatment. Conclusion The prevalence of metabolic and cardiovascular comorbidities increased with increasing OSA severity. Only 59% of treated patients reported good adherence to treatment with positive airway pressure, and response to treatment correlated with OSA severity.
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Affiliation(s)
- Pamela Samson
- Cincinnati Veterans Affairs Medical Center, Cincinnati, OH 45220, USA
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Vearrier D, Phillips B, Greenberg MI. Addressing obstructive sleep apnea in the emergency department. J Emerg Med 2011; 41:728-740. [PMID: 20227230 DOI: 10.1016/j.jemermed.2010.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2009] [Revised: 10/15/2009] [Accepted: 01/05/2010] [Indexed: 05/28/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a prevalent, serious disease that is under-recognized and under-treated. It results from a combination of increased pharyngeal collapsibility and impaired compensatory pharyngeal muscle dilator activity. OSA causes serious morbidity and mortality. OSA is also a public health problem in that it is an independent cause of car crashes, at great cost to society in dollars and lives. OSA is conservatively estimated to affect 2-4% of Americans; however, recent estimates are much higher. OBJECTIVES To educate emergency physicians on the pathophysiology, epidemiology, diagnosis, and management of OSA and discuss diagnostic approaches and recommendations that can be made from the emergency department (ED). DISCUSSION Emergency physicians can play an important role in the recognition and referral of patients at risk for OSA. A focused history and physical examination or the use of a structured evaluation can identify patients at risk for OSA. In addition to referring patients at risk for OSA for further diagnostic work-up, emergency physicians can offer recommendations such as weight loss, moderation of alcohol use and certain medications, and smoking cessation. CONCLUSION OSA is a common disease in the United States that is under-recognized and under-treated. ED patients who do not regularly see a primary care provider or have no primary care provider are particularly at risk for undiagnosed OSA. Emergency physicians can play an important role in recognizing patients at risk for OSA, referring them for further diagnostic work-up, and offering recommendations from the ED.
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Affiliation(s)
- David Vearrier
- Department of Emergency Medicine, Division of Medical Toxicology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
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Woehrle H, Graml A, Weinreich G. Age- and gender-dependent adherence with continuous positive airway pressure therapy. Sleep Med 2011; 12:1034-6. [PMID: 22033117 DOI: 10.1016/j.sleep.2011.05.008] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 05/27/2011] [Accepted: 05/29/2011] [Indexed: 01/30/2023]
Abstract
BACKGROUND Several studies have analysed adherence to continuous positive airway pressure (CPAP) therapy but little is known on the effects of age and gender. METHODS Data from 4281 patients with obstructive sleep apnea (OSA) treated with CPAP (S8, ResMed, Sydney, Australia) were analysed, including apnea-hypopnea index (AHI), mask pressure, leakage, period of use (hours of use/night), and efficiency (days of use/total days). Patterns of use and treatment efficacy were compared between different age groups and genders. RESULTS Average numbers of days used per week (range of the subgroups 5.8±1.6 to 6.3±1.2 days/week) and period of use (range 363±88 to 395±120 min) increased with age. Residual AHI(CPAP) (range 4.8±3.4 to 11.1±9.0/h), leakage (range 0.09±0.11 to 0.27±0.32l/s) increased significantly with age. Males had statistically significantly higher average hours of use (377±94 vs. 370±96 min), AHI(CPAP) (6.4±4.9 vs. 5.4±4.5/h), mask pressure (8.8±2.0 vs. 8.4±1.9 cm H(2)O), and leakage (0.13±0.16 vs. 0.11±0.15l/s) than females. CONCLUSION Adherence to therapy is high and therapeutic efficacy is excellent in long-term CPAP users. Adherence is both age- and gender-dependent, but the differences are small and not clinically relevant.
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Affiliation(s)
- Holger Woehrle
- ResMed Science Center, ResMed Germany Inc., Martinsried, Germany.
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Schlafbezogene Atmungsstörungen beim Hochbetagten. SOMNOLOGIE 2011. [DOI: 10.1007/s11818-011-0519-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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