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

Abstract

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.

Figure 1

CPAP Dose and Outcomes of Subjective Sleepiness, Objective Sleepiness, and Functional Outcomes Cumulative proportion of participants obtaining normal threshold values on the Epworth Sleepiness Scale (ESS), Multiple Sleep Latency Test (MSLT), and Functional Outcomes of Sleep Questionnaire (FOSQ) by hours of continuous positive airway pressure (CPAP) use. From Weaver TE, Maislin G, Dinges DF, Bloxham T, George CFP, Greenberg H, Kader G, Mahowald M, Younger J, Pack AI. Relationship between hours of CPAP use and achieving normal levels of sleepiness and daily functioning. Sleep 2007; 30: 711–19.

Figure 2

Intervention Components to Promote CPAP* Adherence: Pediatric and Older Adult Considerations Add-on considerations (shaded diamonds, left side for children; right side for older adults and older adults with cognitive impairment) to promote CPAP use in children and older adults based on currently published studies. These suggestions extend the American Academy of Sleep Medicine’s Adult Obstructive Sleep Apnea Task Force recommendations. *CPAP – Continuous Positive Airway Pressure; PAP – Positive Airway Pressure; OSA – Obstructive Sleep Apnea; CBT – Cognitive Behavior Therapy; AASM – American Academy of Sleep Medicine. Flow diagram adapted with permission from Epstein LJ, Kristo D, Strollo PJ, Friedman N, Malhotra A, Patil SP, Ramar K, Rogers R, Schwab RJ, Weaver EM, Weinstein MD. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med 2009;5(3): 263–76.