Behavioral sleep medicine techniques for sleep apnea … · Behavioral sleep medicine techniques...

© Associated Professional Sleep Societies, LLC 1

Behavioral sleep medicine techniques for sleep apnea patients

Jack D. Edinger, Ph.D., C.B.S.M.National Jewish Health, Denver, CO

Duke University Medical Center, Durham, NC


Conflict of Interest Disclosures for Speakers1. I do not have any relationships with any entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, OR

x 2. I have the following relationships with entities producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

Type of Potential Conflict Details of Potential Conflict

Grant/Research Support National Institutes of Health; Merck; Philips Respironics

Consultant

Speakers’ Bureaus

Financial support

Other Oxford University Press; Springer Press (Book Royalties)

3. The material presented in this lecture has no relationship with any of these potential conflicts, OR

x 4. This talk presents material that is related to one or more of these potential conflicts, and the following objective references are provided as support for this lecture:

1. Bjornsdottir E, Janson C, Sigurdsson JF, Gehrman P, Perlis M, Juliusson S, Arnardottir ES, Kuna ST, Pack AI, Gislason T, Benediktsdottir B. Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013;36(12):1901-9. doi: 10.5665/sleep.3226. PubMed PMID: 24293765; PubMed Central PMCID: PMC3825440.

2. Guilleminault C, Davis K, Huynh NT. Prospective Randomized Study of Patients with Insomnia and Mild Sleep Disordered Breathing. Sleep. 2008;31(11):1527-33. PubMed PMID: WOS:000260550100011.


Presentation Objectives/OutlineWhat the BSM specialist has to offer OSA patients

Techniques for Promoting CPAP Adherence Graded Exposure Therapy for CPAP related claustrophobia Motivational Interviewing Risk Perception Enhancement through Personalized Videos

Interventions for Insomnia Disorder occurring comorbid to OSA

[Weight reduction interventions] – not discussed


*Stepnowsky CJ, Jr., Moore, PJ. Nasal CPAP treatment for obstructive sleep apnea:

developing a new perspective on dosing strategies and compliance. J Psychosom Res. 2003

Jun;54(6):599-605.

• PAP is safe, effective non-invasive 1st line therapy• However PAP adherence remains a challenge

– Initial acceptance rate is 70-75%*– > 50% patients started on CPAP not using it after 1 year*– Most of those using PAP at 1 year, use it < prescribed*

• < entire night• < nightly use

PAP Adherence ‐ Background


PAP Usage Across 12‐Month RCT

4.8

73.6

34.4

7

0

10

20

30

40

50

60

70

80

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 Month 9 Month 10 Month 11 Month 12

Percen

t of sam

ple

Degrees of PAP Adherence Across 12 Months

0 hours per night > 0 & < 2 Hrs 2 to 4 Hrs 4 to 6 Hrs >= 6 hours

0

60

120

180

240

300

MONTH 1 MONTH 2 MONTH 3 MONTH 4 MONTH 5 MONTH 6 MONTH 7 MONTH 8 MONTH 9 MONTH 10 MONTH 11 MONTH 12

Minutes of U

se

PAP Mean Hrs Used/Night N = 273


Factors determining PAP adherence

PhysicalComfort

Psychological Factors

Social Factors

Mechanical Problems


Psychological factors affecting PAP use• Anxiety reactions

– Claustrophobia– fear of suffocation– sense of being trapped - panic

• Comorbid Psychiatric Conditions• Beliefs/Attitudes about OSA Risks and PAP

– “My OSA is not that serious”– “PAP does little to improve my symptoms”


Conditioned Arousal

Panic/Anxiety

+ BellMeat powder

Drooling

UCSCS

UCR

Drooling

CR

ConfinementRestricted breathing

UCS

+ CS

UCR CR

Panic/Anxiety


Mask Removal(PAP Avoidance)

= immediate anxiety

decrease

Reinforcement of Mask Removal

Anxiety

Anxiety


Case Example


Graded Exposure Treatment of PAP Anxiety ReactionsSample PAP Exposure Hierarchy

1. Connect the mask and hose to the PAP unit. Hold the mask over your face and turn on the PAP. Practice breathing with the machine on while you are awake.

2. Strap the mask on your head, and turn on the CPAP. Practice breathing with the mask on, starting with 5 to 10 min and gradually increasing time for longer periods up to 20 to 30 min.

3. Take a short daytime nap with PAP. Start with 5-10 minute nap and gradually increase up to 30 minutes +.

4. Reintroduce PAP into nighttime sleep. You can begin using it a portion of the night and gradually increase up to entire night.

*Proceed from one step to the next only when you are completely comfortable. If you feel any anxiety or discomfort, return to previous step, then proceed again when comfortable.


Graded PAP Exposure: Tracking Progress


Objective Measures of Practice Adherence


Efficacy of PAP Graded Exposure Protocol Means & Edinger, Behavioral Sleep Medicine, 2007

%


Efficacy of PAP Graded Exposure Protocol Means & Edinger, Behavioral Sleep Medicine, 2007


Case Example

• 60 year old African American Female• Marital status: Divorced• Hx of OSA since 2003 – AHI = 11• Hx of treatment with CPAP and BiPAP• Referred due to PAP intolerance


Medical HistoryProblems Medication

List• Diabetes Ambien Albuterol• HTN Amlodipine• Obesity – BMI = 35.2 ASA• Osteoarthritis Wafarin• Renal Disease Cozaar• Asthma Allopurinol Zocar• GERD Insulin


Psychiatric History

• PTSD related to hx of domestic violence• Engaged in active treatment (UCMC)

– Group and individual therapy– Sertraline for PTSD & Depression

• Benefiting from treatment but has recurrent memories of domestic abuse


OSA Treatment History• Given Trials of CPAP & BiPAP• Most recent titration shows BiPAP @ 26/21

most effective• Patient intolerant to therapy

– Reminds her of ex-husband trying to suffocate her

– Gets palpitations when she hears PAP machine on

– Anxious when in same room as PAP• Longest usage per night = 3 hours• Not using PAP at all at time of referral


Treatment Approach

• Graded Exposure • 6 visits between July 2013 and April 2014

– First visit (1 hr.) = assessment + treatment introduction

– Subsequent visits (30 min) = follow-up & support


PAP Exposure Hierarchy

1. Get comfortable with CPAP in same room2. Connect the mask and hose to the PAP unit. Hold the mask over your face and

turn on the PAP. Practice breathing with the machine on while you are awake.

3. Strap the mask on your head, and turn on the CPAP. Practice breathing with the mask on, starting with 5 to 10 min and gradually increasing time for longer periods up to 20 to 30 min.

4. Take a short daytime nap with PAP. Start with 5‐10 minute nap and gradually increase up to 30 minutes +.

5. Reintroduce PAP into nighttime sleep. You can begin using it a portion of the night and gradually increase up to entire night.

*Proceed from one step to the next only when you are completely comfortable. If you feel any anxiety or discomfort, return to previous step, then proceed again when comfortable.


Treatment Outcome


In‐Lab Protocol to Enable PAP Titration

1 2

3


Motivational Interviewing Intervention for PAP Adherence

Aloia et al, Sleep, 2013


Use of Personalized Videos to Enhance Risk Perception

Aloia et al., Sleep (suppl) 2013

Average CPAP Hourly Adherence By Group

2

4

6

8

week1

month1

month2

month3

allmon

ths

Date

Hour

s pe

r nig

ht

BPVNPV

6.2 hrs

4.2 hrs


Management of the OSA Patient with Comorbid Insomnia Disorder


Relative Disease Risk: OSA+I vs. OSA‐IGupta & Knapp, PLoS ONE 9(3): e90021. doi:10.1371/

journal.pone.0090021


Impact of comorbid apnea on insomnia patients’ medical and mental health

Data from Edinger et al. Archives of General Psychiatry, 2011

43.1

29.3

010

20304050607080

Insomnia +Apnea

Insomnia Only

%

DepressionNo Depression

N = 304 adults who met RDC for insomnia disorder


ISI & Epworth Score RangesClinic Data – 65 OSA + Insomnia vs. 64 Insomnia only

0

25

50

75

100

Insomnia+OSA Insomnia Other

Daytime Sleepiness and Insomnia Diagnosis

ESS <= 10 ESS > 10

0

25

50

75

100

Insomnia+OSA Insomnia Other

ISI Score Ranges by Insomnia Grouping

ISI< 8 ISI 8-14 ISI 15-21 ISI >=22

P = .05P = .02


ANCOVA (controlling for age, medical and psychiatric conditions, service connection, AHI, PAP pressure, BMI, days of having PAP, medication, caffeine and nicotine use).

Effects of Insomnia & PAP Adherence on daytime sleepiness and quality of life

Wohlgemuth et al., Sleep, 2012N = 442 Veterans at Miami VAMC

P < .001


Wohlgemuth et al. 2013 WASM

CPAP ADHERENCE AS A MEDIATOR BETWEEN CO‐MORBID INSOMNIA,OSA AND SUBJECTIVE DAYTIME SLEEPINESS


What is known about treating patients with comorbid insomnia & OSA?


Efficacy of CBT with Comorbid insomnia &OSALack et al, Sleep, 2011

• N= 344 consecutive patients in an insomnia treatment program who met the criteria of chronic insomnia

• A full home diagnostic PSG was conducted pre-treatment. • Sample characteristics

• 219 with primary insomnia • 92 with co-morbid mild OSA (apnea/hypopnea index, 15<AHI<30) • 33 patients with moderate to severe OSA (AHI>30).

• Outpatient treatment program for insomnia • stimulus control therapy & bedtime restriction therapy • cognitive therapy (sleep education, sleep perception re-training, relaxation) • bright light therapies appropriate to needs of each patient.

• Measures = 7-day sleep diaries & daytime functioning questionnaires • Baseline, after 5 weeks and at 3 month follow-up.


Sleep and Waking FunctionLack et al, Sleep, 2011

No OSA

Mod/Severe OSA

Mild OSA

No OSA

Mild OSA

Mod/Severe OSA


Sequential Treatment CBT for Insomnia and OSA TherapyKrakow et al., Sleep and Breathing, 2004

ISI FOSQ

Results from 17 patients who received either PAP (n=14); Oral appliance (n=2); or surgical (n=1) OSA therapy after CBT


CBT + Surgical Treatment of Comorbid OSA & InsomniaGuilleminault et al., Sleep, 2008


Overall ConclusionsGuilleminault, et al., Sleep 2008

OSA treatment alone eliminated insomnia complaints in only 5 of 15 patients

CBT did not improve most sleep variables

Combined therapy needed to normalize sleep and associated complaints in the majority of subjects


Clinical Considerations & Case Vignettes


Sizing up the case

• What are presenting symptoms?– Are they specifically insomnia symptoms? Or….– Could they result from under-treated OSA?

• What is usage pattern and tolerance for OSA therapy?• What benefits does patient derive from OSA therapy?• Are there behavioral targets for CBT?• Does OSA therapy contribute to sleep disruption?• How should the treatment be sequenced?

– PAP then CBT– CBT then PAP– Simultaneous CBT + PAP


Perpetuating Mechanisms + Treatment Approach

= Insomnia

and/or

and/or

Low sleep drive

Improper circadian timing

Excessive bedtime arousal

Napping

↑ TIB

Variable sleep schedules

Performance anxiety

Attentional bias

Active mind

Conditioned arousal

Unhelpful sleep beliefs

Cognitive therapies

Stimulus control

Sleep restriction


The game of mix and match……..

CBT +


Insomnia Symptom Improvements in PAP Users and Nonusers (N = 705 w OSA + Insomnia pre PAP)

Björnsdóttir et al. Sleep, 2013


Insomnia Before and After PAP InitiationCaetano Mota et al. Rev Port Pneumol. 2012;18(1):15---21

24

56

80

13 12

25

0

30

60

90

Insomnia Pre‐PAP No Insomnia Pre‐PAP Total

# of Patients

Insomnia Before and After PAP

Group Pre‐ PAP # with Insomnia After PAP


Special Consideration:OSA Patients who remain sleepy

• Modify SRT so that initial TIB = TST + 30 min.• Recommend short naps• Reassess OSA and treatment adequacy• Use counter-control instead of strict SC

– Less effective in beginning of night– Equally effective in middle of night


Case 1:• 63-year-old single male BMI = 35 • Referred due to sleep onset/maintenance complaints• Medical Conditions:

– asthma, – hypertension, – aortic valve disease, – benign prostatic hypertrophy, – chronic migraine headaches, – gastroesophageal reflux disease, – chronic back pain.– Prior dx (10 yrs. ago) of OSA PAP trial but discontinued after 1

month• No Psychiatric history


Case 1 continued:• Current findings

– His bedtime varied between 9:30 p.m. and 10:30 p.m.his rising time varied between 5:15 a.m. and 7:15 a.m.

– No pattern of napping– watches TV in bed 2 to 3 nights a week and reads in bed one

night per week– take Ambien CR, 12.5 m.g., and Melatonin, 10 m.g. to aid his

sleep and he reports that this medication is helpful.– Insomnia Severity Index = 11; Epworth = 2– Sleep study conducted the week before my consultation showed

a baseline AHI = 36; PAP @ 12 cm H2O reduced AHI to 1. • Assessment & Plan

– Mild insomnia but severe OSA– Allow patient to restart PAP therapy – Keep sleep diary for 2 weeks once using PAP on regular basis

and return to clinic to re-evaluate sleep symptoms


Sleep Diary Post PAP Initiation


Case 2• 37 yr. old married male• 2 year history of insomnia – mostly sleep onset difficulty• Insomnia began with suicide of co-worker/friend• Recently moved to Denver for work with charitable

organization – directs youth center • Work stressful – long hours & dysfunctional staff• Medical conditions = chronic bronchitis, GERD, and

cough all effectively treated. Patient does not view as contributory to sleep problems

• No history of mental/emotional problems• MSE – mildly anxious mood but otherwise normal• ISI = 20; Epworth Scale = 13• Diagnostic PSG showed AHI = 10 events/hour


Case 2 ‐ continued• Reported sleep schedule: bedtime = 9:30 PM;

rise time = 5:00 AM• Works 10-12 hour days 6 days per week• Sundays works as pastor ½ of day• Usually watches TV in bed nightly• Has active mind in bed – thinks about work• Uses over the counter sleep aides intermittently

to manage sleep


Case 2 ‐ continued


Treatment Plan:• Standard SC and SRT• Increase exercise for stress release• One hour buffer time prior to bed• Initiate CPAP concurrent to behavioral treatment

Case 2 ‐ continued


Case 2 – after 6 weeks of CBT + PAP therapy


Managing comorbid insomnia & OSA

• Emerging area of sleep medicine focus• CBT has proven effective alone and with OSA

therapies• Combined therapy presumed optimal but adherence to

therapies a challenge • Future studies should ascertain:

– Optimal therapies for sleep-wake and health outcomes– Strategies for making therapies acceptable/tolerable– Best treatment sequence

• Assure dissemination/translation of findings so patients have access to best treatment practices

Behavioral sleep medicine techniques for sleep apnea … · Behavioral sleep medicine techniques...

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