CPAP Basics - 22 - Compliance

mollete wrote:These guys note that when it's the partner's idea to seek treatment, adherence drops (Wow. What a BF surprise.):

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679572/

I find this surprising, because my personal experience for myself and friends and associates has been entirely the opposite.

I never would have gone to my first sleep evaluation had it not been for the begging, pleading and encouragement of my girlfriend; and even when we got there and were interviewed, the record of the meeting noted that I insisted that I could not possibly have sleep apnea because, accordingly to me, I slept well for 8 hours every night and woke up feeling well-rested and refreshed and anxious to start my day! Only reluctantly and because of the presence and encouragement of my girlfriend did I agree to take the first night's test! Once I read the results of my three tests, I accepted my diagnosis and the machine and have been 100% compliant. Surely had I been living alone, it never would have entered my mind to consider that I had sleep apnea with centrals.

I have friends and associates who have been treated for various health problems and who acknowledge that, but for the encouragement of a loving and caring partner, they would never have sought treatment or, had they started it, they would not have persisted in continuing it faithfully.

Perhaps the difference is the key words I used above: "loving and caring partner" - not every person with a partner is that fortunate, sad to say. That makes the difference, IMO. Those of us who do must count ourselves as very fortunate, including those whose partners are the ones who participate on this forum on their behalf.

Regards, Nate

mollete wrote:These guys note that when it's the partner's idea to seek treatment, adherence drops (Wow. What a BF surprise.):

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2679572/

I don't have time right now to more than just quickly skim, so I didn't readily see where it says that (other than citing another study that showed that without stating to what degree it was different). One statistic I'd like to see is the correlation between sleepiness and who initiates treatment. We know that with greater daytime EDS comes greater compliance, so perhaps those whose partners prod them to do it are not necessarily experiencing as much impairment in daytime functioning. Just a thought.

I'm hoping that I can get some advice on just exactly what is "compliance" for my father, in dealing with my mother. He's trying to find out when the "more than 4 hours per night" begins or ends. He's confused what constitutes a "night."
Is it 12:01 am to 12:01 am the next day? So sleeping from 9-12 that night and 12-1 the next morning would meet the four-hour minimum?
Or is it when she puts the machine on when she goes to bed until the following day when she goes to bed? That from 9-1 would meet the four-hour minimum?
He's also wondering if naps during the day using the machine will count towards the four hour goal.

My mother has dementia, and frequently resists the Bi-PAP machine. Sometimes she swears that she's so far gone it will make no difference, sometimes she swears that there is no problem. Neither of which are true. He notices that her mental acuity is diminished when she hasn't used the machine. She's never gone more than 5 hours on the machine, and that's with her taking it off midway and him coaxing her back onto it in the middle of the night. If the "night" starts when she goes to bed, then it would be worth trying to get her to put it back on for another hour to make four hours. However, if the "night" starts at 12:01, she'd have to wear it for longer and it would be at least two times of trying to get her to wear it longer, which is exhausting for him.

She also wears it maybe 4-5 nights most weeks, sometimes less. So she's not always meeting the "70% of the time" rule either.

I know that wearing it every night for almost the whole night would be best. Having to parse out what "night" means indicates that she's not very compliant, regardless of the official definition. However, that's where he (and she) are at now.

Thanks for your help.

christine13 wrote:I'm hoping that I can get some advice on just exactly what is "compliance" for my father, in dealing with my mother. He's trying to find out when the "more than 4 hours per night" begins or ends. He's confused what constitutes a "night."
Is it 12:01 am to 12:01 am the next day? So sleeping from 9-12 that night and 12-1 the next morning would meet the four-hour minimum?
Or is it when she puts the machine on when she goes to bed until the following day when she goes to bed? That from 9-1 would meet the four-hour minimum?
He's also wondering if naps during the day using the machine will count towards the four hour goal.

My mother has dementia, and frequently resists the Bi-PAP machine. Sometimes she swears that she's so far gone it will make no difference, sometimes she swears that there is no problem. Neither of which are true. He notices that her mental acuity is diminished when she hasn't used the machine. She's never gone more than 5 hours on the machine, and that's with her taking it off midway and him coaxing her back onto it in the middle of the night. If the "night" starts when she goes to bed, then it would be worth trying to get her to put it back on for another hour to make four hours. However, if the "night" starts at 12:01, she'd have to wear it for longer and it would be at least two times of trying to get her to wear it longer, which is exhausting for him.

She also wears it maybe 4-5 nights most weeks, sometimes less. So she's not always meeting the "70% of the time" rule either.

I know that wearing it every night for almost the whole night would be best. Having to parse out what "night" means indicates that she's not very compliant, regardless of the official definition. However, that's where he (and she) are at now.

Thanks for your help.

The machine programming (with virtually all manufacturers) uses "Noon to Noon" as the 24 hour period. Four hours and 70% of the nights is really the bare minimum, but that's typically the requirement for insurance. That would amount to approximately 5 nights per week and 21 nights in a 30-day month.
How long has she been on the machine? (How long ago was it prescribed?)

Hope that helps.

Den

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Thanks Den, that is very helpful. My father has been trying to pin this down from the provider without much success. He complains that for someone who explains things for a living, the provider rep seems to have lost touch with what other people don't know.

So if my mother has it on when she takes a nap from 2pm to 3pm, then wears at night from 10pm to 1am, that would mean she met the 4 hour minimum, correct?

My mother has had the machine for about 6 weeks, although for the first week they didn't use it as it was "too complicated" and they needed the provider to come out and explain it again with me there (there's an on button and a ramp button). The doctor who prescribed the sleep study and who she just went in to see last week seems pretty apathetic, according to my father, although the sleep study showed pronounced sleep apnea. This fuels my mother's belief that she doesn't really need it, it's all a con to sell machines. Although the study was done a year ago, my mother refused to allow anyone to follow up on it then. When she was recently evaluated by a neuro-psychologist, that doctor strongly emphasized that treating her sleep apnea and depression would help retain the mental abilities she still has, although not recover what she's lost.

It is frustrating that she's so far gone that she can't discern what she needs to do in order to stay healthy--and even fights attempts to establish any kind of order or pattern. I cannot get my father to give her the sleeping pill the doctor prescribed, although I argue that she needs to reestablish healthier sleeping patterns. My dad always says, "well, your mother never had a regular pattern," but now she sometimes goes to bed at 8, but usually stays up til 11 or 12, then sleeps til noon or later (without the machine). He can't convince her to take her regular evening pills at the same time every night--it's got to be reinvented each evening (and the pill box tracked down from where she last insisted it be kept). When she doesn't use the machine she becomes even more irrational/inconsistent, which is rapidly turning into a downward spiral, I'm afraid.

Sorry if I'm whining!

christine13 wrote:Thanks Den, that is very helpful. My father has been trying to pin this down from the provider without much success. He complains that for someone who explains things for a living, the provider rep seems to have lost touch with what other people don't know.

So if my mother has it on when she takes a nap from 2pm to 3pm, then wears at night from 10pm to 1am, that would mean she met the 4 hour minimum, correct?

My mother has had the machine for about 6 weeks, although for the first week they didn't use it as it was "too complicated" and they needed the provider to come out and explain it again with me there (there's an on button and a ramp button). The doctor who prescribed the sleep study and who she just went in to see last week seems pretty apathetic, according to my father, although the sleep study showed pronounced sleep apnea. This fuels my mother's belief that she doesn't really need it, it's all a con to sell machines. Although the study was done a year ago, my mother refused to allow anyone to follow up on it then. When she was recently evaluated by a neuro-psychologist, that doctor strongly emphasized that treating her sleep apnea and depression would help retain the mental abilities she still has, although not recover what she's lost.

It is frustrating that she's so far gone that she can't discern what she needs to do in order to stay healthy--and even fights attempts to establish any kind of order or pattern. I cannot get my father to give her the sleeping pill the doctor prescribed, although I argue that she needs to reestablish healthier sleeping patterns. My dad always says, "well, your mother never had a regular pattern," but now she sometimes goes to bed at 8, but usually stays up til 11 or 12, then sleeps til noon or later (without the machine). He can't convince her to take her regular evening pills at the same time every night--it's got to be reinvented each evening (and the pill box tracked down from where she last insisted it be kept). When she doesn't use the machine she becomes even more irrational/inconsistent, which is rapidly turning into a downward spiral, I'm afraid.

Sorry if I'm whining!

Regarding your example of compliance hours......"theoretically"......YES.
If this is a Philips/Respironics System One Bi-PAP, there should be reporting capabilities in the machine that show compliance with "Days >4", "Seven-day average" and "Thirty-day average". (from the LCD information windows) In the past and older machines, it may not have shown the >4 numbers unless there was at least a contiguous period of greater than four hours.
However, if the DME or whomever, downloads the information on the data card, that should show when it's being used within those time periods. Downloading the data on the card is always preferred as it can show how well the therapy is working.

It's long been known that there's a link between "depression" and Sleep Apnea. And, I believe I've also read where "dementia" and Sleep Apnea also share some cause and effect relationship.
So, if you can get her to get comfortable with using it, that would be great.


Den

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Regarding hourly compliance Wulfman is exactly right. Another point to make involves a doctor's follow up visit between the 30th and 90th day after start of treatment. It's the second part of compliance, mainly for the purposes of insurance coverage, that people tend to forget. Basically any treating physician, not necessarily the sleep doctor will meet face to face with the patient and indicate "pt is using and benefitting from the pap device" or something similar.

Regarding dementia, a few studies done in 2009 might be of interest. I'll paste them below. Not only should pressure therapy help your mother, it should indirectly help her caregiver, AKA your dad.

Good luck!

Jim

20275201 PMID: 19699148 Record Identifier: NIHMS140024; PMC2783482
Continuous positive airway pressure deepens sleep in patients with Alzheimer's disease and obstructive sleep apnea.
Cooke Jana R; Ancoli-Israel Sonia; Liu Lianqi; Loredo Jose S; Natarajan Loki; Palmer Barton S; He Feng; Corey-Bloom Jody
Department of Medicine, University of California San Diego, La Jolla, Ca 92093-0733, USA.
Sleep medicine ( Netherlands ) Dec 2009 , 10 (10) p1101-6 , OBJECTIVE: Patients with Alzheimer's disease (AD) and obstructive sleep apnea (OSA) experience disrupted sleep. This study examined the effect of continuous positive airway pressure (CPAP) on sleep parameters in AD patients with OSA. METHODS: A randomized placebo-controlled trial of 3 weeks of therapeutic CPAP (tCPAP) vs. 3 weeks placebo CPAP (pCPAP) followed by 3 weeks tCPAP in patients with AD and OSA. Polysomnography data from screening after one night and after 3 weeks of treatment were analyzed. Records were scored for percent of each sleep stage, total sleep time (TST), sleep efficiency (SE), sleep period (SP), time in bed (TIB), sleep onset (SO), wake time after sleep onset (WASO), and arousals. A randomized design comparing one night of pCPAP to tCPAP and a paired analysis combining 3 weeks of tCPAP were performed. RESULTS: Fifty-two participants (mean age=77.8 years, SD=7.3) with AD and OSA were included. After one treatment night, the tCPAP group had significantly less % Stage 1 (p=0.04) and more % Stage 2 sleep (p=0.02) when compared to the pCPAP group. In the paired analysis, 3 weeks of tCPAP resulted in significant decreases in WASO (p=0.005), % Stage 1 (p=0.001), arousals (p=0.005), and an increase in % Stage 3 (p=0.006). CONCLUSION: In mild to moderate AD patients with OSA, the use of tCPAP resulted in deeper sleep after just one night, with improvements maintained for 3 weeks.

Sustained use of CPAP slows deterioration of cognition, sleep, and mood inpatients with Alzheimer's disease and obstructive sleep apnea: a preliminary study.

Cooke JR, Ayalon L, Palmer BW, Loredo JS, Corey-Bloom J, Natarajan L, Liu L,
Ancoli-Israel S.
Department of Medicine, University of California, San Diego, CA, USA.
J Clin Sleep Med. 2009 Aug 15;5(4):305-9.
Comment in
J Clin Sleep Med. 2009 Aug 15;5(4):310.
INTRODUCTION: Obstructive sleep apnea (OSA) is common among patients with
Alzheimer's disease (AD). Untreated OSA exacerbates the cognitive and functional
deficits. Continuous positive airway pressure (CPAP) has recently been shown to
have beneficial effects on cognition in AD. Little attention has focused on the
long-term benefits of CPAP in these patients.
METHODS: This was an exploratory study of sustained CPAP use (mean use = 13.3
months, SD = 5.2) among a subset of participants from an initial 6-week
randomized clinical trial (RCT) of CPAP in patients with mild to moderate AD.
Follow-up included 5 patients who continued CPAP (CPAP+) after completion of the
RCT and 5 patients who discontinued CPAP (CPAP-), matched by time of completion
of the initial study. A neuropsychological test battery and sleep/mood
questionnaires were administered and effect sizes were calculated.
RESULTS: Even with a small sample size, sustained CPAP use resulted in
moderate-to-large effect sizes. Compared to the CPAP- group, the CPAP+ group
showed less cognitive decline with sustained CPAP use, stabilization of
depressive symptoms and daytime somnolence, and significant improvement in
subjective sleep quality. Caregivers of the CPAP+ group also reported that their
own sleep was better when compared to the final RCT visit and that their patients
psychopathological behavior was improved.
CONCLUSION: The results of this preliminary study raise the possibility that
sustained, long-term CPAP treatment for patients with AD and OSA may result in
lasting improvements in sleep and mood as well as a slowing of cognitive
deterioration. Prospective randomized controlled research trials evaluating these
hypotheses are needed.

DH quit smoking because of me. Good Friday, 1970.

Thanks for that post and information, Jim ("SleepWellCPAP").


Den

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Thanks to everyone for their help and information. My mother just received a different anti-depressant and a higher dose of the Exelon patch for dementia, so I'm hoping that with an upturn in the depression and dementia she'll be able to see the benefit of treating the apnea. She swings between recognizing there's a problem but feeling she's too close to death to do anything and not believing there's a problem. Which makes treating the problem kind of difficult. Still working on my dad to use half a sleeping pill that's been prescribed so she (and he) can get some sleep. I'm a bit concerned about the physical and mental effects on him of this cycle they've gotten into of sleeping for an hour, then talking her down for a few, repeated throughout the night.

There was an article in the NY Times from August 2011 about the link between sleep apnea and depression as well. I can't post the link but the link includes the phrase "common-sleep-problem-raises-dementia-risk/"

Thanks!