Elsevier

Sleep Medicine Reviews

Volume 15, Issue 6, December 2011, Pages 343-356
Sleep Medicine Reviews

Clinical Review
A systematic review of CPAP adherence across age groups: Clinical and empiric insights for developing CPAP adherence interventions

https://doi.org/10.1016/j.smrv.2011.01.003Get rights and content

Summary

Continuous positive airway pressure (CPAP) is a highly efficacious treatment for obstructive sleep apnea (OSA) but adherence to the treatment limits its overall effectiveness across all age groups of patients. Factors that influence adherence to CPAP include disease and patient characteristics, treatment titration procedures, technological device factors and side effects, and psychological and social factors. These influential factors have guided the development of interventions to promote CPAP adherence. Various intervention strategies have been described and include educational, technological, psychosocial, pharmacological, and multi-dimensional approaches. Though evidence to date has led to innovative strategies that address adherence in CPAP-treated children, adults, and older adults, significant opportunities exist to develop and test interventions that are clinically applicable, specific to sub-groups of patients likely to demonstrate poor adherence, and address the multi-factorial nature of CPAP adherence. The translation of CPAP adherence promotion interventions to clinical practice is imperative to improve health and functional outcomes in all persons with CPAP-treated OSA.

Introduction

Continuous positive airway pressure therapy (CPAP), a first-line medical treatment in adults with obstructive sleep apnea (OSA) and an increasingly common treatment option in children with OSA, effectively reduces the apnea hypopnea index (AHI), normalizes oxyhemoglobin saturation, and reduces cortical arousals associated with apneic/hypopneic events.1, *2 A significant limitation of CPAP treatment is adherence. After the first description of CPAP,3 studies on adult patients’ use of CPAP clearly identified adherence as a problem.4, 5, 6 Similarly, in children treated with CPAP, sub-optimal use of CPAP has recently been identified.*2, 7 Since these initial reports of CPAP nonadherence, particularly in adults with OSA, many studies have been conducted to identify salient factors of CPAP adherence and effective strategies to promote adherence. The purpose of this review is to summarize the evidence focused on CPAP adherence, identify similarities and differences in factors associated with CPAP adherence across age groups, and suggest strategies to promote CPAP use among all patients with a particular focus on children and older adults.

Section snippets

Can CPAP adherence be accurately measured?

Early studies on patients’ use of CPAP relied on self-report. With the development of technological advances in the CPAP industry, hour meter readings (i.e., device powered on) emerged as a more accurate measure of patients’ use of CPAP. Several studies substantiated that self-reports overestimated CPAP use by approximately 1 h/night when compared with objectively measured CPAP use.4, 8, 9 Although hour meter recordings of use were superior to self-report, there was no assurance that the device

What amount (i.e., dose) of CPAP use constitutes adherence?

CPAP is routinely prescribed for use during all sleep periods with the clinical expectation that patients will use CPAP for the duration of sleep. Yet, there is great inconsistency in how CPAP adherence is defined, both empirically and clinically. Three seminal papers reporting CPAP adherence rates in adults were published in the mid-1990s.4, 5, 6 These papers collectively suggested average CPAP use was 4.7 h/night in adults in the U.S. and the U.K. Although the authors of these papers did not

What factors influence CPAP adherence?

In order to better understand patients’ decisions to adhere to CPAP treatment, many studies have been conducted to identify factors that influence or predict CPAP use. These studies can be categorized as examining the following factors: 1) disease and patient characteristics; 2) treatment titration procedures; 3) technological device factors and side effects; and 4) psychological and social factors (Table 1).

What interventions promote CPAP adherence?

Recognizing the importance of adherence to CPAP in terms of health and functional outcomes in the OSA population, there is a growing body of literature reporting the effect of interventions on CPAP adherence. Strategies that have been tested are broadly categorized as educational, technological, psychosocial, pharmacological, and multi-dimensional (Table 3). Although some of the interventions have been effective in improving CPAP use, the clinical applicability and cost-effectiveness of any

Childhood CPAP-treated OSA and adherence

Although the standard treatment of childhood OSA is adenotonsillectomy, CPAP is increasingly used in children who do not respond to surgery or in those for whom surgery is not recommended. Because CPAP has only more recently been used in children with OSA, the empiric evidence to date regarding CPAP adherence is limited. It is also difficult to extrapolate from adult studies of CPAP adherence to this population. The average sleep need in the pediatric population exceeds that of adults, varies

Older adults with OSA and CPAP adherence

Adherence rates in older adults are generally similar to those observed in other age groups.82 Russo-Magno and colleagues noted that 64% of older adult males from a Veterans Affairs cohort (33 subjects total, retrospective chart review) were adherent with CPAP as defined by at least 5 h of use per night,57 while Pelletier-Fleury and colleagues noted a one-year adherence rate of 71.9% (defined as at least 3 h/night) in a prospective study that included 70 adults, >60 years.83 In older adults

What are critical components of CPAP adherence interventions across and within age groups?

The evidence to date suggests critical components of intervention strategies to promote CPAP adherence in the OSA population likely include: 1) patient education about OSA, diagnostic information, symptoms, CPAP treatment, expectancies for treatment response, expectancies for daily management of CPAP; 2) goals for treatment and use of CPAP; 3) anticipatory guidance for troubleshooting common problems and experiences with CPAP; 4) assisted initial exposure to CPAP; 5) inclusion of support

Acknowledgments

This work was supported by a grant from National Institutes of Health, National Institute of Nursing Research K99NR011173 (Sawyer AM).

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