Dementia Patient using CPAP

We are preparing my 84-year-old father-in-law for assisted living. He is currently hospitalized in a geriatric psychiatric evaluation facility with mild/moderate dememtia. When we speak with him he acknowledges that he is aware he has sleep apnea but almost daily he forgets what the CPAP machine is for, sometimes mistaking it for a machine to clear his sinuses. He once awakened during the night wide-eyed and alarmed, questioning what that machine was and what he needed to do with it. He currently continues to experience cognitive difficulties and confusion during his hospitalization.

He has only had the CPAP machine since July 7th, and early on his compliance was good with using it. We began with simple nasal pillows after trying on a nasal gel mask and not getting a good seal due to his mustache. He complained about feeling as though he was fighting the machine while exhaling through his nose and was a bit confused on the breathing in through the nose and out through the mouth business. After noticing an elevated AHI we took the SD card to his doctor and a problem with leakage was noted so we switched to a full-faced mask, thinking this would alleviate the mouth/nose issue.

Now hospitalized, he is non-compliant with using the CPAP mask, complaining of feeling he can't breathe with the mask on. He uses it off and on, but apparently not enough to register consistent usage on the SD card. We have worked with the staff to try to increase compliance and on Monday his doctor will reduce the flow from 6cm H2O to 4cm. We are thinking that perhaps the mask is making him claustrophobic and are thinking again of trying the nasal pillows. We are eager to increase his compliance 1) because it will make him feel better and maximize O2 to his already compromised brain, but also 2) Medicare will only cover the cost of the machine if he maintains an average useage of 4 hours per night over 90 days.

I'm looking for a recommendation from you experts on a comfortable, good-fitting nasal pillow to try on him. Anyone have a suggestion? Thanks for your help.

Takoda911 wrote:was a bit confused on the breathing in through the nose and out through the mouth business

I'm a bit confused, too. I can't tell whether he was breathing though his mouth and you told him not to, or vice-versa. I hope you were telling him NOT to breathe through his mouth. Unless he had a full face mask, which is what you indicate at one point, breathing out through his mouth is making his therapy useless. If the system is not closed and air is coming out his mouth with a nasal mask or nasal pillows, it's not holding his airway open, and he's still going to have apneas. It would also explain the large leaks you're talking about. If I misunderstood, sorry about that.

I can't recommend any particular nasal pillows, as I've never used them. However, I do have a moustache and get a good seal with the mask you see listed in my profile below. Good luck.

Hi - i have to question reducing his pressure from 6 to 4 cm as most of us would find even 6 difficult at best to breathe with, let alone 4 (the default low setting for machines) as no one can get enough air in and he may really panic at that setting. I would try to get them to raise the pressure to 7 or 8, as most of us are actually using about 10 cm.

Hi - i have to question reducing his pressure from 6 to 4 cm as most of us would find even 6 difficult at best to breathe with, let alone 4 (the default low setting for machines) as no one can get enough air in and he may really panic at that setting. I would try to get them to raise the pressure to 7 or 8, as most of us are actually using about 10 cm.

As for mask fitting, it is so personal and it's very difficult to say what will work and be comfortable for another person - only trial and error over time will tell.

Takoda911 wrote: ...and on Monday his doctor will reduce the flow from 6cm H2O to 4cm. We are thinking that perhaps the mask is making him claustrophobic and are thinking again of trying the nasal pillows.

Surely a challenging situation. Just want to comment that taking his pressure down may be the wrong direction to go. Is this pressure change based on the doctor reading data from his machine that tells him this is what's needed? Every mask has a recommended minimum pressure at which the mask will adequately vent exhaled air. If the pressure is too low to be effective, that can also cause one to feel the need to remove the mask as an instinctual relex in trying to breathe. I would be very concerned about a pressure of 4 with a full face mask. If his pressure is sub-therapeutic, he will have a hard time being compliant. I would suggest you ask the doctor for fact based adjustments. Also, if his machine is set to use the ramp feature and it is set too low, that will get his night off to a bad start. If machine data shows a pattern in when he takes the mask off at night, that could be a clue too. Because of his dementia it is even more important to utilize technology to tell you what he can't.

P.S. I see while I was typing another poster has the same feelings about low pressure.

Hi

A few thoughts come to mind -

What was his original non-cpap AHi (was a sleep study or was some other method used)

Have you monitored his SpO2 overnight in the hospital. If so, what does it indicate.

You need to educate yourself about the pro's and cons of mask/cpap use, as the advice you are getting sounds questionable.

Good Luck

Mars

You actually need to use the machine to achieve compliance data, otherwise people could just turn on their machines and let them blow all night without using them.
I had a pressure of 4/8 prescribed and didn't feel as though I was suffocating. I tolerated the four pressure with no problems.

I live in Texas and the medicare compliance here is at least 4 hrs. using the machine for 21 days in a 30 day period. You might check again on your compliance with medicare.

I am also concerned about turning his pressure down, the lower pressure could be what is making him feel claustrophobic.

Paula J wrote:I live in Texas and the medicare compliance here is at least 4 hrs. using the machine for 21 days in a 30 day period. You might check again on your compliance with medicare.

I think that medicare compliance is a national standard and not a local one, but I could be wrong. I was curious and did a little internet research this morning and most sites are in agreement on this. Below is one I found that is in agreement with the others but is in a pdf format as a form to be filled by the managing provider;

http://www.sleephealth.com/Collateral/D ... e-form.pdf

I also checked last May with CMS which is also a governmental agency acting as a TPA (third party administrator) for Medicare and that was what they told me then on the phone. I guess I should have asked for that in writing as I am sure they must have spent a few thousand dollars of our tax money for some nice brochures.


Roger

kteague wrote:

Takoda911 wrote: ...and on Monday his doctor will reduce the flow from 6cm H2O to 4cm. We are thinking that perhaps the mask is making him claustrophobic and are thinking again of trying the nasal pillows.

I would be very concerned about a pressure of 4 with a full face mask. If his pressure is sub-therapeutic, he will have a hard time being compliant.

Question, would a lower pressure also make the volume of air moved in the mask go down? Mine is set at 9 per the sleep study but sometimes I too feel like I am not getting enough air, especially if I awaken early in the morning like around 4:30 or 5 am.

Roger

I agree with those here who are positing that a pressure of 6 or 4 might be too low; I remember during my sleep test they started me out at 8 and I didn't feel like I was getting enough air. At my prescribed setting of 14 my breathing is comfortable and I don't feel like I'm suffocating.

If he says he can't breathe at 6, 4 will be worse.

A patient with dementia will always be a challenge because the sense of disorientation they experience especially upon waking will often result in a situation like you described -- he has no idea why this mask is strapped to his face, etc. While a nightly sedative or sleeping pill might help, often doctors won't prescribe them to older people because they can have a depressive effect on respiration, and can exacerbate the symptoms of dementia. Some drugs like Seroquel are prescribed however, and can help with sleep.

I hope you both will soon get some relief, maybe the doctor try something that works.

I agree with everyone who has suggested that dropping the pressure lower would probably not be a good idea.

Now I'll step out on a limb and express a personal opinion that many (perhaps most) would disagree with.

84 years old, mild/moderate dementia... I would not worry about having him do CPAP therapy. I'd leave the machine with him until the day Medicare stops reimbursing -- for him to use or not use as the mood (and comprehension) strikes him. If he doesn't use it, or takes the mask off, or has horrendous leaks, I would not worry about that.

Takoda911 wrote:We are eager to increase his compliance 1) because it will make him feel better and maximize O2 to his already compromised brain,

I do understand what you're saying. You're right. But my feeling is that it's probably too late in his life and in his condition for that to matter enough to warrant putting him through using CPAP. Too much has probably already been destroyed.

At this point (and condition) of that good man's life, I just wouldn't try to get him to use it. There will be enough things to cause him panic, distress, and discomfort in how he will be spending his life now, without adding a CPAP mask to what he will be going through.

I do applaud you for wanting to do the right things and best things for your father-in-law. I just think the problems a CPAP mask -- any mask -- could cause him at this point are not worth it. Not if the goal is to let him have as peaceful and easy a time as possible in living the remaining years of his life.

That (probably very unpopular opinion of mine) said...
Turning to what you actually asked --
"I'm looking for a recommendation from you experts on a comfortable, good-fitting nasal pillow to try on him. Anyone have a suggestion?"

The Swift FX nasal pillows would probably be the easiest mask for him to cope with putting on and taking off.

If he does CPAP for part of the day when he's awake as "CPAP practice", it may help him get used to it. It will also count towards compliance hours, wink, wink.

A nasal mask is probably better psychologically, as well as in several other ways, but if you can't solve leak problems, you may need a FFM. You could also use a nasal mask during the day for CPAP practice and FFM at night if necessary.

rested gal wrote: Now I'll step out on a limb and express a personal opinion that many (perhaps most) would disagree with.

84 years old, mild/moderate dementia... I would not worry about having him do CPAP therapy. I'd leave the machine with him until the day Medicare stops reimbursing -- for him to use or not use as the mood (and comprehension) strikes him. If he doesn't use it, or takes the mask off, or has horrendous leaks, I would not worry about that.

But my feeling is that it's probably too late in his life and in his condition for that to matter enough to warrant putting him through using CPAP. Too much has probably already been destroyed.

At this point (and condition) of that good man's life, I just wouldn't try to get him to use it. There will be enough things to cause him panic, distress, and discomfort in how he will be spending his life now, without adding a CPAP mask to what he will be going through.

I do applaud you for wanting to do the right things and best things for your father-in-law. I just think the problems a CPAP mask -- any mask -- could cause him at this point are not worth it. Not if the goal is to let him have as peaceful and easy a time as possible in living the remaining years of his life.

As someone who has just spent 2 months looking after my mother with dementia and a host of other issues I agree 110% with you. If mom knew what was really happening right now she would have jumped off a bridge while she could. But we can't let go, we have to "fix things" so we have her a bit longer.