The Reluctant Patient: Simplified Motivational Enhancement Therapy to Improve CPAP Adherence

It is generally accepted that continuous positive airway pressure (CPAP) adherence is considered more than four hours per night during at least 70% of the nights in a 90-day trial and maintaining this adherence for as long as CPAP is prescribed.¹ While wearing CPAP longer than four hours each night does improve the signs and symptoms of obstructive sleep apnea (OSA), it is advised to wear the CPAP mask all the hours that the patient sleeps, including naps.

It’s estimated that between 20% to 50% of CPAP users have poor or no adherence.²  A great part of this lack of adherence is due to poor mask fit, incorrect pressure or algorithm, lack of education, not understanding the purpose of CPAP use, lack of family support and the absence of follow-up by the medical professionals involved in the diagnosis and initial CPAP setup.

Once it is ascertained that a patient has the correct mask and prescribed pressure, education and behavioral interventions become a priority.

The American Academy of Sleep Medicine (AASM) suggests that behavioral and/or troubleshooting interventions be given during the initial period of positive airway pressure (PAP) therapy in adults with OSA.³ A simplified version of motivational enhancement therapy (MET) can be very effective for these interventions, and take less time compared to standard follow-up.

 MET is a treatment often used by psychologists for drug and alcohol addiction.⁴ It is a behavioral intervention devised on the principles of motivational interviewing and used to invoke inwardly motivated change.

An example of the success and simplicity of simplified MET was a 2013 study⁵ using a brief, simplified protocol based on MET principals. The study included 83 patients randomized to a control group and a group that underwent the simplified MET protocol. The control group had standard education provided by a sleep technologist. The intervention group had the standard education provided by a sleep technologist but also had a simplified protocol of MET delivered by a psychologist during two, 20-minute appointments and six, 10-minute phone calls over a 32-week period. Patients in the MET group increased CPAP use by 99 minutes per night. Average nightly adherence for six months was 99.0 min/night higher with CPAP and MET compared with CPAP only. In a number of cases it was enough to get them past the four-hour requirement that Medicare and some insurances require.

Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment with greater improvements in treatment self-efficacy and daytime sleepiness. This difference in adherence remained consistent in a subset of patients followed for 12 months, suggesting that the beneficial effect of MET was retained after the intervention had been withdrawn. (For additional studies, see the related studies list at the end of this article.)

A Simplified MET Program

Sleep technologists and clinical sleep educators interested in adding a simplified MET program to the usual education offered to patients must first understand the basics of MET before determining if it would be a good fit for their patients. The basic outline of a simplified MET program is as follows:

Maintain a collaborative — rather than educational — style of interaction with the patient. Patients that have a hard time adjusting to CPAP often perceive the situation to be such that the technologist is telling them what to do instead of realizing that the technologist is simply trying to help the patient.

Discuss the patient’s readiness to begin CPAP. The patient may feel an entire night of CPAP is overwhelming. As long as the patient continues to add minutes each night, start with a few hours, perhaps while sitting up reading.

Confirm the patient understands the health risks of OSA. There are a surprising number of patients that don’t actually believe that they could succumb to any of the risks of untreated OSA. Some patients even have a risk factor such as Type 2 diabetes and still think it isn’t related to OSA.

Determine if the patient believes CPAP reduces these risks. Once the patient accepts that the risks are real, do they actually believe CPAP can help reduce OSA symptoms?

Resolve the patient’s ambivalence by establishing consistent CPAP usage patterns. Discuss the minimum time that CPAP needs to be used to be considered adherence. The patient should understand that it is Medicare and insurance companies dictating these numbers. Further discuss the benefits of using CPAP regularly or throughout the entire night.

Increase the patient’s confidence toward using CPAP regularly. Share success stories of CPAP users that started out just like they did. Set goals for CPAP that the patient feels comfortable with. Perhaps start with a few hours with a schedule building up to four hours. Then celebrate reaching four hours and set a schedule to add more minutes little by little.

Determine a reward for accomplishing these goals. The patient may be more motivated by treating themselves to a manicure or spa treatment, buying a new tool or going to a movie. Sometimes just praise from the sleep technologist is enough.

Express empathy. Sleep technologists need to build trust and show that they understand that CPAP isn’t always easy.  

Develop discrepancy. Recognize the distance the patient needs to emotionally cover to meet their goal of wearing CPAP. Avoid arguments. This is not easy. Give positive answers whenever possible.

Roll with resistance. If the patient is exhibiting resistance, try to go along with it rather than push back.

Support self-efficacy. Self-efficacy is defined as the way people view their own competence and achieve their own goals. Encourage the patient to realize they are capable of many things, including wearing a CPAP device.

As a last resort, ask the patient to just try wearing the mask. Ask them to wear it while watching television, reading a book or during a nap. CPAP treatment is intimidating because it is never ending and patients often ask if they will ever get off CPAP. Even with substantial weight loss, it’s unlikely an OSA patient will be able to discontinue treatment. They may need a lower pressure or may have a bit of a respite, but as age and weight increase, so does OSA. As this can be a shock to patients, rather than presenting CPAP as a forever treatment, consider presenting it as a trial at first — something to try over the next 30 to 90 days.

The Importance of Understanding Medicare and Insurance Requirements   It’s imperative to explain the Medicare or other insurance requirements to your patients. It’s also important to explain the ramifications of failing the 90-day trial. If the patient decides at the end of the trial period they liked the CPAP experience but didn’t complete enough hours to keep the CPAP device, Medicare won’t pay for it. The important thing to keep in mind here is to first get through the trail, get it paid for and then worry about utilizing a CPAP device for the rest of their life.

Patients will give push back and might even say, “I’ll just have the surgery.” Explain that CPAP usage is still the first line treatment for OSA irrespective of the severity of the OSA.⁶ Patients that prefer to try alternative treatments may not qualify for an oral appliance, surgery or other treatment due to weight, the severity of their OSA or other factors. CPAP is noninvasive and reversible.⁴ Some of the other options are not and may not be covered by their insurance.

Conclusion

Patients can always try an alternative if CPAP isn’t working for them. Implementing MET into the CPAP treatment can be and has been proven successful in improving adherence, as well as save both the sleep technologist and patient a great deal of time. 

References

1. Centers for Medicare & Medicaid Services. Positive Airway Pressure (PAP) Devices for the Treatment of Obstructive Sleep Apnea. Retrieved from https://www.cms.gov/medicare-coveragedatabase/view/lcd.aspx?lcdid=33718
2. Weaver TE & Sawyer AM. Adherence to Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea: Implications for Future Interventions. Indian J Med Res. 2010 Feb;131:245–258.
3. Patil SP et al. Treatment of Adult Obstructive Sleep Apnea with Positive Airway Pressure: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2019 Feb 15;15(2):335-343. doi: 10.5664/jcsm.7640.
4. Miller WR. Motivational Enhancement Therapy: Description of Counseling Approach in Boren JJ, Onken LS, and Carroll, KM. (Eds.) Approaches to Drug Abuse Counseling. 2000. NIH Publication No. 00-4151 edition.
5. Bakker JP et al. Motivational Enhancement for Increasing Adherence to CPAP. Chest. 2016 Aug;150(2):337-45.
6. Kushida CA et al. Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients With Sleep-Related Breathing Disorders An American Academy of Sleep Medicine Report. Sleep. 2006 Mar;29(3):375-80.

Related Studies and Protocols

1. Magnon M. Using Motivational Enhancement Therapy to Achieve CPAP Compliance. Retrieved from https://scholarworks.utep.edu/cohort_9/6
2. Smith DK, Barksdale N, & Dean S. Interventions to Improve Use of CPAP Machines in Adults with Obstructive Sleep Apnea. Retrieved from https://www.aafp.org/pubs/afp/issues/2021/1000/p356.html
3. Weaver TE. Assessing and Managing Nonadherence With Continuous Positive Airway Pressure (CPAP) for Adults With Obstructive Sleep Apnea. Retrieved from https://www.uptodate.com/contents/assessing-and-managing-nonadherencewith-continuous-positive-airway-pressurecpap-for-adults-with-obstructive-sleep-apnea