Addressing insufficient positive airway pressure use among older Veterans with obstructive sleep apnea

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Background: The most frequently diagnosed sleep disorder among older Veterans is obstructive sleep apnea (OSA), which is associated with serious adverse effects on health, quality of life and survival. Positive airway pressure (PAP) is recommended as first-line treatment (particularly for moderate to severe OSA), but sustained use is difficult to achieve, including among older Veterans, and nearly half of patients with OSA who begin PAP therapy discontinue use within a year. Significance/Impact: Although OSA is a chronic condition, research to date has primarily focused on increasing initial PAP use in patients with newly diagnosed OSA. In addition, most research has not addressed PAP use in older adults, which is unfortunate given the high prevalence and important adverse effects of OSA on their health and well-being. Prior work suggests that behavioral interventions are effective in improving initial PAP use, but little is known of how to address insufficient use over time. Innovation: To address this problem, we developed and pilot-tested a structured, manual-based approach to address insufficient PAP use among older adults with previously diagnosed OSA. The intervention (5 sessions over 8 weeks, then monthly contact for up to 6 months) is designed so it can be provided by individuals (“sleep coaches”) from various disciplines (supervised remotely by a psychologist) in a variety of settings for maximal implementation. Core components of the intervention include: 1) educational and behavioral approaches to improve PAP use, 2) individualized self-management and troubleshooting techniques to address factors contributing to insufficient PAP use, and 3) ongoing review of objective PAP use (via remote monitoring). Specific Aims: Primary Aim 1 will test the efficacy of this intervention for improving PAP usage among older Veterans with previously diagnosed OSA who have insufficient PAP use. Our hypotheses are that the intervention will increase objectively measured PAP use at 6-months follow-up, with effects sustained at 12 months. Secondary Aim 2 will test for effects on sleep quality, daytime sleepiness and sleep-related function; and Exploratory Aim 3 will test for effects on health-related quality of life. Our hypotheses are that these outcomes will also improve at 6 months, and effects will be sustained at 12 months. Methodology: We propose a randomized, controlled trial to test this new intervention in older Veterans (aged > 65 years, N=90) with previously diagnosed OSA (moderate to severe) who were prescribed PAP 1-5 years in the past, but have insufficient PAP use (defined as no PAP use over the prior 30 days). Given prior growing interest in telehealth and remote monitoring approaches to optimize PAP use, and the ongoing COVID-19 pandemic, all aspects of the study will be performed virtually in keeping with the latest VA COVID-era guidance for the remote testing and treatment of OSA. Participants will be randomized to the intervention or a control program that mirrors “optimal usual care” for OSA plus general sleep education (attention control). Structured assessments at baseline, post-treatment (after session 5) and 6- and 12-months follow-up include objectively measured PAP use (via remote telemonitoring), sleep quality (Pittsburgh Sleep Quality Index), daytime sleepiness (Epworth Sleepiness Scale), sleep-related function (Functional Outcomes of Sleep-10) and health- related quality of life (PROMIS-29 v2.1 Physical and Mental Health Summary Scores). We will collect participant experiences and attitudes related to the intervention, and implementation outcome measures (acceptability, appropriateness, fidelity and staff time as an estimate of cost) to inform future implementation. Implementation/Next Steps: The long-term goal of this work is to effectively address insufficient PAP use among older Veterans with OSA to improve their health and quality of life. If successful, we will implement the intervention at our institution, and develop and disseminate an implementation package with actual tools needed to promote wider implementation of this model of care into clinical practice.