In the nascent days of CPAP therapy, therapeutic options were relatively limited. CPAP adherence was a challenge, but clinicians looked forward to the day when manufacturers would catch up to the desperate need for better sleep apnea management and devices would proliferate. Years later, we now find ourselves at the promised land—hundreds of masks and highly-adjustable PAP devices are now commonplace. But with all this advancement, more can be done to tackle the CPAP adherence challenge.
While part of solving the adherence challenge lies in the titration of inspiratory/expiratory pressures, ramp settings, humidification, etc, the advent of these options combined with other interventions can help further improve adherence.
A Holistic Reframing of CPAP Adherence Strategies
Dr. Peter Nassar is a sleep physician particularly interested in the power of education and its ability to impact CPAP adherence. He noticed that comprehensive patient education was making a difference in improving his patient’s ability to stick with therapy, confirmed by a study he conducted that showed a 13% improvement in Medicare-compliant adherence.
In our interview with Dr. Nassar, he noted, “A collaborative education or training-driven focus is very different from the previous model in medicine, which relied on imploring or simply telling the patient what they needed to do in the hopes that they would just trust you enough to make the change.”
This ties into other ways of advancing patients’ capacity for change—other studies show the potential of integrating motivational interviewing (which yields a 50% increase in adherence vs. control),¹ telemedicine follow-up,² and in-person follow-ups.³ All these findings point to a central idea—the importance of approaching CPAP adherence as a psychologically-driven behavioral change problem.
Leaning into the Psychology of Behavioral Change
When considering behavioral change, one cross-specialty therapeutic technique is mentioned time and time again—motivational interviewing.¹ Motivational interviewing (MI) originated as a counseling technique used to help patients discover and pursue their own motivations for making positive changes in their behavior, rather than simply being told by a provider why it’s important for them to make a change. This is based on the principle that, when motivation comes from within—rather than without—it has a much higher likelihood of successfully changing outcomes.
Dr. Nassar pointed out that a critical component of motivational interviewing is adequately training patients on what they stand to lose in not sticking to therapy. “Positive motivators are important and powerful, but we’ve found that the fear of loss (rather than hope for gain) is much more effective in getting patients to make positive health decisions. So we teach them about the urgent sequelae of uncontrolled OSA like hypertension, increased risk of stroke, and a higher risk of re-hospitalization for various illnesses.”
When used to improve CPAP adherence, MI can aid in inspiring and motivating patients to take part in their own treatment by helping them identify and resolve their own ambivalence about (or resistance to) CPAP use. Motivational interviewing is often vaguely discussed, but it is, in fact, a deliberate process with outlined steps:
1. Establish rapport: From your very first interaction with the patient, focus on building trust by listening attentively and expressing empathy.
2. Assess the patient’s motivation: Assess the patient’s attitude and readiness to change. Ask open-ended questions and explore the patient’s reasons for pursuing PAP therapy.
3. Evoke the patient’s own motivation: Use reflective listening and mirrored statements to help the patient explore and articulate their own motivations for improving their sleep. Maybe it’s improving their comorbidities, maybe it’s improving restfulness, but the point is to elucidate the strongest driving force for the patient.
4. Create a plan: Create a personalized plan of action which integrates the patient’s motivations, perhaps with milestones that will help them measure their successfulness (a drop in hypertension, x improvement in daytime sleepiness, etc). This will help you know how and when to follow up. Discuss potential barriers along the way and offer early mitigation strategies.
For more information about motivational interviewing and to learn about the science behind it, you can visit the Motivational Interviewing website.
Establishing a Multi-Pronged Therapy On-Ramp
Motivational Interviewing and patient education are helpful tactics offered alone, but they work best in the context of a comprehensive therapy launch program. A full program should not just include a mask fitting, but should also integrate techniques like a motivational interview in your initial evaluation, a support group (perhaps online), training sessions, education modules, and scheduled text/email/phone call follow-ups.
How Somnoware Can Help
One of the main reasons launching and tracking the long-term success of a program like this sounds daunting is because many of its processes rely on manual work—especially following up with patients.
Somnoware’s Care Management platform can not only automate much of this follow-up, but it uses therapy- and patient-reported data to evaluate behaviors of your patient population and offer customized interventions that have the potential to increase patient involvement and adherence.
The technology behind PAP devices and masks has come a long way, but perhaps the secret to better adherence lies in not only leveraging the technology, but also the psychology that underpins human behavior.
Want to learn more? Schedule a demo at somnoware.com.
Nathan Costiuc is a Nurse Practitioner and Freelance Writer based in West Palm Beach, Florida. He sees disabled veterans struggling with sleep disturbances in the context of multiple comorbidities. You can find him at clinicious.com or on his LinkedIn profile.
1. Olsen S, Smith SS, Oei TP, Douglas J. Motivational interviewing (MINT) improves continuous positive airway pressure (CPAP) acceptance and adherence: a randomized controlled trial. J Consult Clin Psychol. 2012;80(1):151-163. doi:10.1037/a0026302
2. Labarca G, Schmidt A, Dreyse J, Jorquera J, Barbe F. Telemedicine interventions for CPAP adherence in obstructive sleep apnea patients: Systematic review and meta-analysis. Sleep Medicine Reviews. 2021;60:101543. doi:10.1016/j.smrv.2021.101543
3. Rueda AD, Santos-Silva R, Togeiro SM, Tufik S, Bittencourt LRA. Improving CPAP compliance by a basic educational program with nurse support for obstructive sleep apnea syndrome patients. Sleep Sci.2009;2(1):8-13