clinical management, adult Flashcards
Cognitive therapy indications and rationale
Primary or co-morbid insomnia, acute or chronic
Indication: those with dysfunctional beliefs about sleep
More helpful for those with psychophysiological or paradoxical insomnia, rather than idiopathic insomnia
Rationale: target sleep-related beliefs that are presumed to contribute to maintenance or exacerbation of insomnia
Appraisal of a situation (sleeplessness) can trigger negative emotions (fear, anxiety) that are incompatible with sleep
What are the Steps of Cognitive therapy?
Steps:
Identifying negative automatic thoughts
Connections between cognitions, emotions, thoughts
Examine evidence
Substitute more realistic interpretations
learn to identify and modify core beliefs
DBAS
Dysfunctional beliefs and attitudes about sleep
30 item scale
16 item short form
Pick strongly held beliefs
What are outcomes for cognitive therapy
Key component of multi-component therapy
Plays a role in positive outcomes and long term remission
What do we know about CPAP adherence?
Self report is unreliable
Use across studies averages ~5hrs/night mean of use
29-83% reported to be nonadherent
Half the patients are consistent users averaging ~6hrs/night
Patients decide early to be nonadherent (~4 nights in)
If you skip 1 night of CPAP, back to baseline on many variables
~25% patients d/c treatment within 1st year of use
How long do you need to use CPAP?
For Daytime sleepiness: ~4 hrs Objective sleepiness (commercial driver, ~6hrs). MSLT <7 to MSLT >7
What is not a strong determinant of CPAP adherence?
Age, gender, disease severity, BMI, symptom severity
Other aspects of CPAP adherence
Split night study: no difference in adherence form split night vs full night
ADX vs UDX study does matter
Best predictor is change in SE
The mask does not make a difference: no difference in nasal vs FFM
Better quality sleep and less pressure discomfort with AutoPAP
Better QOL with auto-titrating
Flexible pressure: pt can set pressure within a range
can work because it can build self-efficacy and control
Not a psychological abnormality
If it’s the the patient’s idea, then more likely to be active in treatment
Active but not passing coping (confrontive coping, planful problem solving)
Person’s perception and opinion matter
Maladaptive behavior (social isolation, emotional reactions)
Claustrophobic tendencies
What are predictors of adherence in 1st week?
3 main factors:
Race (Black less adherent, ?SES factors)
Residual events
Risk perception (if thought they were at risk, then would use CPAP)
Does the nose make a difference? Volume
Claustrophobia and adherence to PAP:
higher claustrophobia scored 2x likely poor adherence (avg use <2hrs/night)
claustrophobia scores decreased over time in some
Humidification: conflicting data
What domains make up the bio psychosocial model?
Psychological domain: person, illness, treatment
Social domain
Biomedical domain
Education alone does not work to improve adherence
Component you have to have, but won’t work on its own
What medication can you use for residual sleepiness and adherence
Modafanil can help
What are the critical elements of CPAP adherence?
Pretreatment: Who referred patient? Knowledge of OSA/perception of treatment degree and awareness symptoms How do they handle challenges? Assess claustrophobic tendencies Consult ENT Mask selection Early exposure to treatment spousal involvement
On-treatment: Humidification, if needed phone call/follow-up visit 1st week Assessment of use and outcome: use of apps/software perception of treatment Bed partner experience Troubleshoot problems immediately: telehealth Treat residual sleepiness
What is Motivational Enhancement Therapy?
MET is for motivating adherence to PAP therapy in OSA
Specific indication:
Recent dx of OSA
judged to be good responders to PAP: AHI<10 on PAP titration study, remission of snoring,
arousal index<10; PLM index <15
What are contraindications to MET?
Serious medical condition: (COPD, ESRD, severe COPD, severe asthma). These conditions cause increased EDS and no improvement with PAP therapy
Hx of or current Dx of major psychiatric illness (including current substance abuse) with exception of depression. Makes it hard to participate in Tx.
Cognitive impairment due to dementia
What is rationale for MET?
25% of patients d/c PAP within 1st year of use
Willingness and motivation fluctuate for Tx
Motivational interviewing, help to resolve ambivalence,
Focus on perceived importance of change and their confidence that they can maintain a new behavior
What is the “Elicit-Provide-Elicit” strategy in MET?
Used during feedback
Designed to reduce likelihood of patient denial and defensiveness
Therapist asks an open-ended question (“elicit”), shares information (“Provide”), and follow up with another open-ended question (“Elicit”) to learn the patient’s reaction
Adopt curious, eliciting and non-judgemental tone, calibrating session to patient’s level of readiness to change, and exploring patient ambivalence about change.
Goal is to develop intrinsic motivation to use Tx, enhance long-term adherence
Session 1 for MET
Patient assessment of PAP during titration night
Patient assessment of PAP during titration night
Ask re: experience of using PAP in sleep study
Assessment of motivation to use PAP (1-10)
Info exchange (video clip of OSA pt)
Review pre-treatment PSG
Place AHI on graph, mild/mod/severe
graph of oxygen sat
Review of sx (primary sx that let to seek tx)
Mortality graph: cumulative survival rates according to categories of PAP compliance:
significantly higher cumulative survival rates for those who use PAP>6 hrs and those who use it 1-6 hrs, compared to those who use it <1 hr
Session 2
Patient’s subjective appraisal of adherence to PAP
Values assessment Decisional balance Review of reaction time on and off Tx PAP benefits for health and functioning Cognitive benefits of SA treatment Assess motivation and confidence Explore and identify experienced or anticipated barriers to PAP use Renegotiate plan based on readiness and confidence
Phone call in MET
Self-report PAP use
Building confidence to use PAP
Summary
Research MET
MET vs standard care vs education
ED and MET > SC at 3 mos
MET= best for ambivalence (used 2-5 hrs/night in 1st week
6 months only MET demonstrated significance
Exposure therapy for Claustrophobic reactions to PAP therapy
Claustrophobia = extreme anxiety/panic in situations such as tunnels, elevators, person feels trapped
Rachmaninov and Taylor 2 core fears: fear of restriction, fear of suffocation
Development of fears explained by 2 factor model by Mowrer (fear reactions initially developed by classical conditioning and maintained through operant conditioning
CPAP can elicit memories of original UCS or set of circumstances that elicit claustrophobic response (military vets, trauma, bad exp w/ pap)
Exposure breaks the link between anxiety and avoidance response
What is the Procedure for Exposure therapy
1-6 sessions over 1-3 months
Session 1: assessment, education, implement exposure therapy (Tx rationale, exposure hierarchy,
goal setting/homework
Sessions 2-6: assess adherence to homework, monitor progress, problem solve, in-session exposure trial (if indicated) provide feedback
Research: 1/3 of people report claustrophobic reactions to CPAP
Exposure yields large effect size
Sleep Apnea self-management program
Need referral to claustrophobia protocol if that is the presenting concern
Focus is on education, sleep testing, sleep apnea, CPAP therapy
How is chronic illness defined?
Gradual onset Lengthy or indefinite duration Multivariate causation (which may change over time) Focus on functional status rather than individual diagnoses OSA better characterized as chronic rather than acute disease
What is chronic disease self-management?
Systematic behavioral approach to help patients with chronic conditions participate actively in self-monitoring of systems or physiologic processes, decision making (i.e. managing the disease or its impact, based on self-monitoring), and problem-solving
disease, medication, and health management
Role management
emotional management
How is Self management program carried out?
Group size 3-6 patients
4 sessions 1-2 hrs each
CBT to increase adherence to CPAP
Psychoeducation in presentation format (discussion, emphasis questions)
Social cognitive therapy (how people learn by modeling)
self efficacy
outcome expectations
Stages of change
Video and discussion for modeling
Stages of Change from Transtheoretical Model
Precontemplation: no intention to change, i.e. snorer can’t see the problem, can’t see “what all the fuss is about”
Contemplation: “fence sitting”, some recognition there may be a problem with snoring/apneas, May need to do something about it. Change often triggered by bed partner moving out of shared bed.
Preparation: change in both intention and behavior. Consult w/ PCP re: snoring/apneas is example of patient showing that he understands the problem and is now prepared to take some action. Referral to sleep specialist, PSG, etc.
Action: relates to how patient modifies his behavior, experience, and/or environment to make the necessary change. Learning about OSA, learning about CPAP, what it does, undergoing titration study, being committed to Tx for specific time period, learning to seek help.
Maintenance: undertaking CPAP for at least 6 mos. Patient taking ownership of having OSA and the undertaking that this Tx intervention gives health and life choices. Continually update and seek help when there are mask/machine problems
Relapse: needs to be seen as normal, generally not possible to use mask/machine all the time. What is important is what the patient does during the relapse period, how can get back on track, for example cold/flu/traveling has been resolved. Relapse if the rule, not the exception
Avoid of supine posture during sleep for patients with supine-related sleep apnea
Positional therapy
Recommended for patients with any breathing abnormality during sleep:
obstructive apnea
mixed/central apnea
UARS, most of breathing issues while sleeping in supine position
Sleeping in other positions, the severity of events reduces to AHI <5-10
patients w/o OSA, but snore supine
patients who have not responded to other treatments and mainly struggle while supine
Rationale for Avoidance of supine posture during sleep
Supine problems are high (55.9% had at least twice as many breathing problems while supine)
Prevalence of supine disturbance is much higher (65-69%) in patients with mild/mod. OSA
Mild OSA is less likely to succeed with CPAP
What is the Procedure for positional supine therapy?
Any form of therapy with will help patients roll back onto their side at night
Tennis ball technique: Tennis ball in wide cloth band or belt attached to waist, when patient
rolls over onto back, pressure causes them to roll back over
An Alarm system: momentarily wake up when rolling onto back
The Sleep positioner: Device consists of foam block placed on back
The positioner
The BPOD unit: located on midline of chest and will detect position
Thoracic anti-supine board
The supine position prevention vest
Zoma positional sleeper
Vest-type design
