FROM THE CLINICAL KNOWLEDGE CENTER
Obstructive Sleep Apnea: A Wake Up Call

by Michelle Ostrander, PhD

Last week, June 11-17th was Men's Health Week, which is designed to heighten the awareness of preventable health problems and encourage early detection and treatment of disease among men and boys. One disorder that often goes undiagnosed in men is obstructive sleep apnea (OSA) -- a condition affecting more than 12 million Americans that is characterized by complete or partial obstruction of the airway that causes loud snoring and severely fragmented sleep. OSA is more common in men than in women -- one out of 25 middle-aged men have sleep apnea that causes them to be very sleepy during the day. Other risk factors for OSA include being overweight, having a large neck circumference (> 17 inches), hypertension, a narrowed airway, age, family history, use of sedating substances (e.g., alcohol, sedatives or tranquilizers), and smoking.

The most common symptoms of OSA are loud snoring, choking or gasping during sleep, excessive sleepiness during the day. Other symptoms of sleep apnea may include morning headaches, cognitive difficulties, irritability, inability to concentrate, mood swings, dry throat upon wakening, frequent urination at night. Frequently, family members will notice symptoms of sleep apnea before the patient does as the patient is usually not aware that he/she is experiencing breathing problems during sleep.

Prompt and effective treatment of OSA is very important as serious consequences may arise from untreated OSA. Untreated OSA is associated with an elevated risk of heart disease and stroke, and untreated OSA is also a common underlying cause of sleepiness-related motor vehicle accidents. Unfortunately, OSA frequently goes undiagnosed, and therefore untreated – it is estimated that only 10% to 20% of OSA cases are diagnosed and treated.

Treatment goals in OSA patients are the restoration of regular nighttime breathing and the relief of symptoms such as snoring and excessive sleepiness. Treatment also reduces the risk of associated medical problems such as hypertension, heart attack, and stroke. Treatment of mild sleep apnea may involve lifestyle changes such as losing weight, avoiding smoking, alcohol, and sedative medications, and changing sleep positions (side sleeping is preferred over back sleeping). Dental mouthpieces may also be of benefit in patients with mild OSA. The gold standard of treatment for moderate to severe OSA is continuous positive airway pressure (CPAP). Surgical interventions may also need to be considered for some patients with OSA.

CPAP is a highly efficacious treatment for OSA, but low adherence rates limit the effectiveness of CPAP. Adherence to CPAP is defined as using the device for 5 nights per week, for more than 4 hours per night. Interventions that enhance adherence to CPAP are sorely needed as emerging data indicate that longer periods of nightly use of CPAP are associated with improved cognitive function, reduced excessive sleepiness, and improved glycemic control.

A recent randomized, controlled study from the journal Sleep sought to determine whether an educational intervention based in part on social cognitive theory and using cognitive behavioral therapy (CBT) would increase acceptance and adherence to CPAP in patients with OSA. One hundred individuals (96 men, age range: 32 to 81 years) were randomly assigned to either the CBT intervention or treatment as usual (TAU). The CBT intervention consisted of two 1-hour sessions spaced one week apart with approximately 10 participants and their partners. Components of the CBT intervention sessions included: 1) an educational slide presentation on sleep, consequences of OSA, and effectiveness of CPAP, 2) display of CPAP machine, 3) demonstration of relaxation techniques, 4) a video with “role-model” users of CPAP, and 5) an educational booklet on sleep, OSA/CPAP, and general health. All participants (including CBT group) participated in the TAU group education session on CPAP. During this session, the CPAP-titration process was explained, participants were familiarized with the CPAP equipment, side effects of CPAP were discussed, and patients were fitted for their CPAP mask. The primary outcomes measurement was mean hours of CPAP usage (mask-on time) at 28 days, with mean usage at 7 days and the proportion of patients adherent to treatment at 7 and 28 days as additional secondary outcomes.

The CBT intervention significantly improved adherence to CPAP treatment as mean nightly mask usage at both 7 d and 28 d was 2.9 hours longer in the CBT group than the TAU group (p’s < .0001). At 7 d, 88% of the individuals in the CBT group used the CPAP for more than 4 hours per night whereas only 39% of the individuals in the TAU group attained this level of adherence, and this difference was statistically significant (p < .001). The beneficial effects of CBT persisted for at least one month, because at 28 d a greater proportion of the CBT group used CPAP for 4 hours or more per night than the TAU group (77% vs. 31%, respectively), and this difference was statistically significant (p = .0002). In addition, 50% of the CBT group utilized CPAP for at least 6 hours per night whereas only 15% of the TAU group achieved this level of adherence. Logistic regression modeling indicated that after adjusting for the effect of sex, participants in the CPAP group were 6.9 times more likely to adhere to CPAP than the TAU group. Finally, the number needed to treat is low at 2.2 (CI 1.3-3.2).

These are the first data from a randomized trial indicating that CBT combined with TAU increases both acceptance of and adherence to CPAP therapy. The authors suggest that this intervention could have a high economic return given the low number needed to treat, as well as the fact that the CBT can be successfully administered in a group setting. The authors do note two limitations to this study: the lack of a placebo group and the one-month follow-up period. Adherence to CPAP markedly drops off after one month, so future longitudinal studies are necessary to determine whether CBT has a persistent beneficial effect.

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