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

背景：老年退伍军人中最常见的睡眠障碍是阻塞性睡眠呼吸暂停 (阻塞性睡眠呼吸暂停)，这与对健康、生活质量和生存的严重不良影响有关。正压气道 建议将压力(PAP)作为一线治疗(特别是对中度至重度OSA)，但 持续使用很难实现，包括在老年退伍军人中，以及近一半的阻塞性睡眠呼吸暂停综合征患者 开始PAP治疗，一年内停止使用。 意义/影响：尽管阻塞性睡眠呼吸暂停综合征是一种慢性疾病，但迄今为止的研究主要集中在增加 在新诊断的阻塞性睡眠呼吸暂停患者中首次使用PAP。此外，大多数研究都没有涉及PAP的使用 在老年人中，这是不幸的，因为OSA的高流行率和对他们的 健康和幸福。先前的工作表明，行为干预在改善初始PAP方面是有效的 使用，但对于如何随着时间的推移解决使用不足的问题知之甚少。 创新：为了解决这个问题，我们开发了一种结构化的、基于手动的方法并进行了试点测试，以 解决之前诊断为阻塞性睡眠呼吸暂停综合征的老年人使用PAP不足的问题。干预(5期 超过8周，然后每月接触长达6个月)的设计使其可以由个人提供(睡眠 教练“)来自不同学科(由心理学家远程监督)，在各种环境中最大限度地 实施。干预措施的核心组成部分包括：1)采取教育和行为方法 提高PAP使用率，2)个性化自我管理和故障排除技术，以应对各种因素 造成PAP使用不足，以及3)持续审查目标PAP使用情况(通过远程监测)。 具体目标：主要目标1将测试这种干预措施在改善老年人PAP使用率方面的有效性 患有先前诊断的阻塞性睡眠呼吸暂停综合征但PAP使用不足的退伍军人。我们的假设是 干预将在6个月的随访中增加客观测量的PAP使用量，效果持续12个月 月份。次级目标2将测试对睡眠质量、日间困倦和睡眠相关功能的影响； 探索性目标3将测试对健康相关生活质量的影响。我们的假设是这些 结果也将在6个月后改善，效果将在12个月后持续。 方法：我们提出了一项随机对照试验，在老年退伍军人中测试这种新的干预措施(老年组和GT组； 65岁，N=90)，以前诊断为OSA(中到重度)，在 过去，但PAP使用不足(定义为在之前30天内未使用PAP)。考虑到之前的增长 对远程健康和远程监控方法以优化PAP使用的兴趣，以及正在进行的新冠肺炎 在大流行期间，研究的所有方面都将几乎与退伍军人管理局COVID时代的最新指南保持一致 用于阻塞性睡眠呼吸暂停综合征的远程检测和治疗。参与者将被随机分为干预组或对照组 该计划反映了针对阻塞性睡眠呼吸暂停综合征的“最佳日常护理”加上一般睡眠教育(注意力控制)。结构化 在基线、治疗后(在第5次会议之后)以及6个月和12个月随访时的评估客观上包括 测量的PAP使用情况(通过远程远程监护)、睡眠质量(匹兹堡睡眠质量指数)、白天 嗜睡(Epworth嗜睡量表)、与睡眠相关的功能(睡眠-10的功能结果)和健康- 相关生活质量(PROMIS-29 v2.1身心健康总分)。我们会收集 参与者与干预相关的经历和态度，以及实施结果措施 (可接受性、适当性、保真度和工作人员时间作为成本估算)，以便为今后的实施提供信息。 实施/后续步骤：这项工作的长期目标是有效解决PAP使用不足的问题 在患有阻塞性睡眠呼吸暂停综合征的老年退伍军人中，改善他们的健康和生活质量。如果成功，我们将实现 在我们的机构进行干预，并制定和传播具有实际工具的实施一揽子计划 需要推动将这一护理模式更广泛地应用于临床实践。

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.