Elsevier

Clinical Psychology Review

Volume 28, Issue 8, December 2008, Pages 1355-1371
Clinical Psychology Review

Adherence to Continuous Positive Airway Pressure Therapy in Obstructive Sleep Apnoea sufferers: A theoretical approach to treatment adherence and intervention

https://doi.org/10.1016/j.cpr.2008.07.004Get rights and content

Abstract

Obstructive Sleep Apnoea (OSA) is a common sleep disorder associated with significant health, quality of life and psychosocial problems. The aims of this review are to investigate the contribution of psychological constructs and theory to the assessment and treatment of OSA. Adherence to CPAP treatment remains a primary concern for improving treatment outcomes for OSA. Modifiable, psychological constructs of self-efficacy, coping, social support, treatment satisfaction and self-reported daytime sleepiness improve the prediction of CPAP adherence. These predictors are particularly robust in the context of a theoretical model. Social Cognition Theory (SCT) and Health Belief Model (HBM) are emerging as promising psychological models for understanding patient acceptance and adherence to CPAP treatment. An overview of psychologically informed interventions for CPAP use is presented. Education-based interventions have promise, but the strongest and robust findings are emerging from theory-driven interventions. Specifically, Cognitive-Behaviourally informed interventions and Motivational Interventions demonstrate consistent and large effect sizes in improving CPAP adherence rates.

Section snippets

Clinical presentation and health consequences of Obstructive Sleep Apnoea

Obstructive Sleep Apnoea (OSA) is associated with obstructions of the upper airway during sleep, which are caused by collapse of the dilator muscles and soft tissues of the pharyngeal wall. OSA may be diagnosed based on the presence of 5 or more of these respiratory events (Apnoea–Hypopnoea Index > 5) with concurrent evidence of OSA symptoms (daytime sleepiness, snoring and choking arousals from sleep). Alternatively, OSA is also diagnosed when patients display an AHI of greater than 15 events

Prevalence of OSA

The prevalence of OSA varies according to the defined criteria (ICSD-2, 2005). When the criteria for diagnosis requires an AHI > 5 and self-reported daytime sleepiness, snoring and/or choking arousals, the estimated American prevalence of OSA is 4% for men and 2% for women. Up to 24% of men and 9% of women in the population have an AHI > 5 without any associated symptoms of sleepiness, snoring or choking arousals (American Academy of Sleep Medicine, 1999, ICSD-2, 2005, Malhotra and White, 2002,

Treatment of OSA

The current “Gold Standard” treatment for OSA is CPAP therapy. Pressurised air is administered through a nasal (nCPAP) or full face mask. This pressurised air functions as a pneumatic splint for the upper airway, preventing it from collapse. The pressure is titrated to a level that reduces the individual patient's AHI to less than 5 events per hour (Malhotra et al., 2000, Stepnowsky and Moore, 2003).

CPAP use reduces the risk of several adverse outcomes of OSA. There is a general reduction in

Adherence to CPAP

CPAP treatment of OSA can be awkward, and requires considerable alteration to a patient's lifestyle (Malhotra et al., 2000). It has been estimated that 15–30% of patients do not accept CPAP treatment from the outset, that is, before or during their titration study (Collard et al., 1997, Fletcher and Luckett, 1991). This early pattern of CPAP use is critical for determining continued patterns of use (Weaver, Grunstein, 2008). Of those who do initially accept the treatment and take it home,

Patient-reported reasons for not using CPAP

The reasons reported by patients for not using CPAP are usually associated with the side effects of the treatment. The most common side effects, reported in 15 to 45% of patients, are skin irritation, nose stuffiness and air leaks around the mask (Zozula & Rosen, 2001). Less common, but equally significant reported problems, are claustrophobic reactions to the mask, problems with spontaneous intimacy with the bed partner, and the noise of the machine (Engleman et al., 1996, Hui et al., 2001,

Physiological and demographic predictors of adherence

Many empirical studies have investigated general predictors of CPAP adherence. CPAP use may be associated with demographic factors such as male gender (Lewis et al., 2004, McArdle et al., 1999, Popescu et al., 2001, Zozula and Rosen, 2001) lower age (McArdle et al., 1999, Zozula and Rosen, 2001) and the absence of a comorbid pulmonary disease (Lewis et al., 2004, McArdle et al., 1999). There is large variability in the literature regarding the predictive power of physiological indices of OSA

Motivational/psychological factors in adherence to treatment

In a variety of chronic disorders requiring consistent adherence to a treatment regime (for example: diabetes, asthma and heart disease), social, emotional, personality and cognitive factors have been found to enhance the prediction of adherence (Connor and Norman, 1996, Kavanagh et al., 1993). Inclusion of psychological variables to physiological variables in predicting CPAP adherence has been found to substantially improve prediction (Edinger et al., 1994, Olsen et al., 2008, Stepnowsky et

Psychological predictors of adherence

Physiological indices of the severity of sleep disordered breathing (for example, AHI) are not reliably correlated with patients' reported subjective symptom severity and quality of life (Chervin and Aldrich, 1999, ICSD-2, 2005, Zezirian et al., 2007). This indicates that a patients' subjective perception of the problem may not necessarily reflect the objective severity of the illness. Thus, objective severity may not reflect their need for treatment. The impact of these beliefs and motivations

Psychological symptoms and CPAP adherence

Fewer symptoms of anxiety and depression at pre-treatment may be associated with better subsequent CPAP adherence (Edinger et al., 1994, Lewis et al., 2004). Edinger et al. (1994) administered the MMPI to 28 male OSA patients as well as measures of daytime sleepiness and sleep quality before they had experienced CPAP. At six months follow-up, 63% of the variance in self-reported use of CPAP was explained by a combination of the MMPI hypochondriasis and depression scales, as well as BMI,

Social support and CPAP adherence

A large proportion of OSA patients are married or in long-term relationships (McFadyen et al., 2001, Stepnowsky et al., 2002, Wild et al., 2004). Spousal support has been identified as a potential mediating variable relating to treatment adherence in other health domains (Doherty et al., 1983, Jones, 2002). Of particular importance may be the spouse's self-reported acceptance of a treatment (Doherty et al., 1983) and improvements in marital satisfaction with CPAP use (Kiely and McNicholas, 1997

Theoretical models of CPAP adherence

A limited number of studies have investigated explicit psychological models of adherence derived from other health domains (Aloia et al., 2005, Olsen et al., 2008, Sage et al., 2001, Stepnowsky et al., 2002, Wild et al., 2004). Prediction of CPAP adherence from a theory-driven perspective has reduced some of the inconsistency noted in previous research. As outlined in Table 1, Stepnowsky, Marler et al. (2002) and Aloia et al. (2005) have applied Bandura's Social Cognitive Theory (SCT) (Bandura,

Social Cognitive Theory (SCT) and Transtheoretical Model (TTM)

Bandura's SCT proposes that a patient's expectations for good or bad outcomes if the appropriate health behaviour is undertaken, and their belief in their ability to engage in the necessary behaviours to affect change (self-efficacy), are predictive of their subsequent engagement in these behaviours (Bandura, 1998, Britt et al., 2004, Clark and Becker, 1998). SCT also emphasises the importance of knowledge and social support in adherence (Stepnowsky et al., 2002). TTM proposes that a patient's

Social Learning Theory

Wallston's modified SLT emphasises that the patient's perception about the level of control they have over their illness will determine whether they change their behaviour to improve their health. Health Locus of Control is the central concept of this theory. This construct is subdivided into subscales of internality, powerful others and change. Patients who have a higher internal locus of control (i.e. they believe that they have control over their health) are more likely to adhere to

The Health Belief Model

The Health Belief Model (HBM) has been successfully applied to the prediction of compliance to several disease models (Clark and Becker, 1998, Connor and Norman, 1996, Juniper et al., 2004) and has been applied to CPAP adherence prediction (Olsen et al., 2008, Sage et al., 2001). HBM allows for the inclusion of demographic, psychological and psychosocial influences on adherence (Connor & Norman, 1996). Although developed for the prediction of engaging in preventative health behaviours (such as

A new model of CPAP acceptance and adherence

Our research group has attempted to overcome the limitations of this previous research and utilise the HBM in prediction of both CPAP acceptance and adherence (Olsen et al., 2008). We utilised a theoretically grounded, conceptual model of CPAP acceptance and adherence developed from HBM constructs. Fig. 1 presents this new model.

The previous adherence literature available (see Table 1) indicates that biomedical and psychological variables (such as depression and anxiety) do not directly

Psychological interventions for improving CPAP adherence

Psychological constructs are most powerful in predicting CPAP use, and a number of these constructs have the potential to be changed or modified. As CPAP modifications are now known to not improve adherence rates, resource allocation may be better targeted towards the identification of these modifiable, psychological predictors and then the development of interventions to specifically target them (Haniffa et al., 2004). Behavioural and cognitive-behavioural interventions, as well as home

Motivational Interviewing

Motivational Interviewing (MI) has gained recognition as an efficacious treatment for enhancing health behaviour for a variety of disorders, including reducing addictive behaviour such as smoking and alcohol dependence, and increasing treatment compliance (Burke et al., 2003, Miller and Rollnick, 2002). MI is a client-centered therapy designed to enhance a patient's readiness to change, or in the case of CPAP adherence, readiness to initiate and adhere to treatment.

MI appears to be particularly

Directions for future research

Psychological constructs and theory have a lot to offer the real problem of poor adherence in this very serious disorder. However, there remains large gaps and inconsistencies in the psychological literature. Table 3 presents the directions for research in the psychology of OSA identified in this review. First, the successful treatment of OSA is limited by suboptimal adherence rates to CPAP. However, there is limited validation for “optimal adherence” guidelines. The dosage of CPAP needed for

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