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OBJECTIVE To examine whether a social cognitive therapy ( SCT ) intervention increases continuous positive airway pressure ( CPAP ) use compared to equivalent social interaction ( SI ) time . PARTICIPANTS Individuals with obstructive sleep apnea ( OSA ) referred for CPAP therapy . INTERVENTION Participants received a 30-min group education session regarding OSA and CPAP . Groups of three to four participants were then r and omly assigned to an SCT session or social interaction . MEASUREMENTS CPAP usage was assessed at 7 nights , then 1 , 3 , and 6 months . The two primary outcomes were adherence , usage ≥ 4 h per night at 6 months , and uptake of CPAP . Question naires were given pretreatment and posttreatment . RESULTS Two hundred six individuals were r and omized to SI ( n = 97 ) or SCT ( n = 109 ) . CPAP uptake was not different between groups ( 82 % in SI , 88 % in SCT groups , P = 0.35 ) . There were no differences between groups in adherence : 63 - 66 % at 1 week , and at 6 months 55 - 47 % ( P = 0.36 ) . Higher pretreatment apnea-hypopnea index , higher baseline self-efficacy , and use of CPAP ( ≥ 4 h ) at 1 week were independent predictors of CPAP adherence at 6 months . CPAP adherence increased by a factor of 1.8 ( odds ratio = 1.8 , 95 % confidence interval 1.1 - 3.0 ) for every one-unit increase in self-efficacy . There was no difference between groups postintervention in self-efficacy scores , sleepiness , mood , or sleep quality . CONCLUSIONS In this r and omized trial , a single SCT application did not increase adherence when compared with SI time . Although self-efficacy scores prior to CPAP predicted adherence , self-efficacy was not increased by the interventions . Increasing intensity and underst and ing of SCT interventions may be needed to improve CPAP adherence . CLINICAL TRIALS REGISTRATION Australian New Zeal and Clinical Trials Registry , ACTRN12607000424404 OBJECTIVES To study the effects of augmentation of continuous positive airway pressure ( CPAP ) education and support on compliance and outcome in patients with obstructive sleep apnea ( OSA ) . DESIGN A r and omized , controlled , parallel study of basic vs augmented CPAP education and support . SETTING A university teaching hospital . PATIENTS A total of 108 OSA patients r and omized into  basic-support ( BS ) and augmented-support ( AS ) groups . INTERVENTIONS Patients in the BS group ( n = 54 ) were given educational brochures on OSA and CPAP , CPAP education by nurses , CPAP acclimatization , and were review ed by physicians and nurses at weeks 4 and 12 . Patients in the AS group ( n = 54 ) received more education , including a videotape , telephone support by nurses , and early review at weeks 1 and 2 . MEASUREMENTS Objective CPAP compliance , Calgary sleep apnea quality of life index ( SAQLI ) , and cognitive function after 1 month and 3 months ; and Epworth sleepiness scale ( ESS ) after 3 months of CPAP treatment . RESULTS At 4 weeks , CPAP usage was 5.3 + /- 0.2 h/night ( mean + /- SEM ) vs 5.5 + /- 0.2 h/night in the BS and AS groups , respectively ( p = 0.4 ) . At 12 weeks , CPAP usage was 5.3 + /- 0.3 h/night vs 5.3 + /- 0.2 h/night in the two groups , respectively ( p = 0.98 ) . There was greater improvement of SAQLI at 4 weeks ( p = 0.008 ) and at 12 weeks ( p = 0.047 ) in the AS group . There was no significant difference between BS and AS groups in terms of improvement of ESS and cognitive function . CONCLUSION Augmentation of CPAP education and support does not increase CPAP compliance , but leads to a greater improvement of quality of life during the reinforced period Objective To evaluate whether follow-up of patients with obstructive sleep apnoea ( OSA ) undergoing CPAP treatment  could be performed in primary care ( PC ) setting s. Design Non-inferiority , r and omised , prospect i ve controlled study . Setting s Sleep unit ( SU ) at the University Hospital and in 8 PC units in Lleida , Spain . Participants Patients with OSA were r and omised to be followed up at the SU or PC units over a 6-month period . Main outcomes measured The primary outcome was  CPAP compliance at 6 months . The secondary outcomes were Epworth Sleep Scale ( ESS ) score , EuroQoL , patient satisfaction , body mass index ( BMI ) , blood pressure and cost-effectiveness . Results We included 101 patients in PC ( ( mean±SD ) apnoea – hypopnoea index ( AHI ) 50.8±22.9/h , age 56.2±11 years , 74 % male ) and 109 in the SU ( AHI 51.4±24.4/h , age 55.8±11 years , 77 % male ) ) . The CPAP compliance was ( mean ( 95 % CI ) 4.94 ( 4.47 to 5.5 ) vs 5.23 ( 4.79 to 5.66 ) h , p=0.18 ) in PC and SU groups , respectively . In the SU group , there were greater improvements in ESS scores ( mean change 1.79 , 95 % CI + 0.05 to + 3.53 , p=0.04 ) and patient satisfaction ( −1.49 , 95 % CI −2.22 to −0.76 ) ; there was a significant mean difference in BMI between the groups ( 0.57 , 95 % CI + 0.01 to + 1.13 , p=0.04 ) . In the PC setting , there was a cost saving of 60 % , with similar effectiveness , as well as a decrease in systolic blood pressure ( −5.32 ; 95 % CI −10.91 to + 0.28 , p=0.06 ) . Conclusions For patients with OSA , treatment provided in a PC setting did not result in worse CPAP compliance compared with a specialist model and was shown to be a cost-effective alternative . Trial registration number Clinical Trials NCT01918449 OBJECTIVE  Weight loss  can decrease the severity of obstructive sleep apnea ( OSA ) in many obese individuals ; however , very few studies have investigated the effects of behavioral weight loss interventions for patients with OSA . The aims of this pilot study were to determine the feasibility and initial effects on weight and continuous positive airway pressure ( CPAP ) use of a brief minimal-contact self-monitoring-based weight loss intervention ( SM ) . An additional aim was to investigate the association between weight loss and CPAP adherence . METHODS Forty obese men and women diagnosed with mild or moderate OSA were r and omized to either the SM or an attention-control ( AC ) condition . SM participants completed daily dietary logs for 6 weeks . Participants were weighed at baseline , post-treatment ( 6 weeks ) , and at a 6-week follow up . RESULTS Recruitment and retention were good in this study and attrition rates did not differ significantly by group . Intent to treat repeated measures ANOVA indicated a main effect of time ( but not group ) , such that both groups lost weight over time . Pearson r correlations between weight change and CPAP adherence indicated that among SM participants , 6-week weight loss was correlated with CPAP adherence at post-treatment and follow-up , such that SM participants with greater weight loss at 6 weeks had greater CPAP adherence at 6 and 12 weeks . CONCLUSION This study provides initial support for the beneficial effects of a minimal-contact weight loss intervention for patients with obstructive sleep apnea and highlights a possible association between weight loss and CPAP adherence Background Continuous Positive Airway Pressure ( CPAP ) remains the reference treatment for moderate to severe forms of the Sleep Apnea/Hypopnea Syndrome ( SAHS ) . Compliance to the treatment appears to be a key factor to improving health status of these patients . Methods We conducted a multicenter , prospect i ve , r and omized , controlled , parallel group trial of st and ard support completed or not within 3 months of coaching sessions for newly diagnosed SAHS patients starting CPAP therapy .  This study has been recorded by AFSSAPS with the RCB number : 2009-A01127 - 50 and received favourably by the Human Studies Committee in France . The coaching session consisted of 5 sessions of telephone-based counselling by competent staff . The primary outcome was the proportion of patients using CPAP more than 3 h per night for 4 months ; the secondary outcome was mean hours of CPAP usage in the 2 groups . Results Three hundred and seventy-nine patients fulfilled the inclusion criteria and were r and omized . The percentage of patients using CPAP more than 3 h per night for 4 months was 65 % for the st and ard support group and 75 % for the coached group . This difference reached a statistical significance ( χ2 = 3.97 ) . The mean CPAP usage was increased in the coached group versus st and ard group . A difference of 26 min was observed ( 4 h34+/−2 h17 and 4 h08+/−2 h25 respectively , p = 0.04 ) . Conclusion This study shows that SAHS patients who benefit from phone coaching  are statistically more compliant to CPAP than a st and ard support group is . A simple phone coaching procedure based on knowledge of the disease and reinforcement messages about treatment benefits helps to improve CPAP adherence in SAHS patients .Trial registration STUDY OBJECTIVES To identify factors before a trial of nasal continuous positive airway pressure ( CPAP ) treatment that are associated with lower compliance . DESIGN A prospect i ve cohort study . Initial Hospital Anxiety and Depression Scale scores and other demographic data were noted . Machine use was recorded by clock timer after a 1-month trial of treatment . SETTING District General Hospital sleep-disordered breathing clinic . PATIENTS OR PARTICIPANTS Eighty consecutive patients with symptoms of sleep apnea-hypopnea syndrome and a 4 % Sao2 desaturation index greater than 10 events per hour . INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Those reporting ' initial problems ' with CPAP went on to have an average of 2.4 hours of on time per night , while those not reporting initial problems had an on time of 5.0 hours per night ( P < .001 ) . Those living alone had a machine on time of 3.2 hours compared with 4.5 hours for those with partners ( P = .04 ) . Pearson 's correlations between hours on time were -0.08 ( P = .48 ) for initial Anxiety score and 0.10 ( P = .37 ) for initial Depression score . CONCLUSIONS There was no association between baseline anxiety and depression scores , as measured by the Hospital Anxiety and Depression Scale , and subsequent machine use . Other factors observable prior to commencing treatment , in particular , ' initial problems ' ( reported at autotitration ) , ' recent life-events ' and ' living alone ' were associated with lower machine use . Regarding all initial variables , reporting problems after the first night of nCPAP seems the most important predictor of ensuing machine use . A single screening question immediately after autotitration is useful in identifying those at high risk of treatment failure Context Approaches that improve adherence to continuous positive airway pressure ( CPAP ) therapy are needed . Contribution In this trial , 160 adults with severe obstructive sleep apnea were r and omly assigned to eszopiclone or placebo for the first 14 nights of CPAP . Adherence to CPAP was then measured weekly for 24 weeks . Patients receiving eszopiclone were less likely to discontinue CPAP and used CPAP more nights and for longer periods per night than did patients receiving placebo . Implication Eszopiclone given during the first 2 weeks of therapy may help improve long-term adherence and use of CPAP in some patients with severe obstructive sleep apnea . The Editors Untreated obstructive sleep apnea ( OSA ) is associated with adverse effects on both health and quality of life ( 1 , 2 ) . Continuous positive airway pressure ( CPAP ) is recommended as first-line therapy for most patients to improve sleep quality , reduce daytime sleepiness , and enhance quality of life . It may also mitigate the increased risk for cardiovascular events ( 36 ) . However , adherence to CPAP is often poor , which limits its efficacy . Of patients who initiate CPAP , approximately 50 % discontinue use within the first year , most within the first month . The initial experience with CPAP influences who accepts and continues treatment ( 7 ) . Patients who experience initial discomfort , intolerance , or lack of perceived benefit are more likely to discontinue therapy ( 8) . Some studies suggest that psychosocial factors may also affect short- and intermediate-term adherence ( 9 , 10 ) . The only consistently reliable predictor of long-term adherence has been the use of  CPAP  during the initial treatment period ( 11 ) . The average nightly CPAP use during the first 3 months of therapy can predict use at 6 and 12 months ( 12 ) . Furthermore , long-term adherence patterns may be determined within the first few days of therapy ( 13 ) . Therefore , strategies aim ed at improving adherence with therapy should focus on the initial experience with CPAP . In theory , robust patient education , regular follow-up , and improvements in device comfort ( for example , autoadjustable units with heated humidifiers and better- design ed , better-fitted masks ) should increase CPAP tolerance and use . However , intensive support and technological interventions have not consistently or reliably predicted which patients will successfully transition to CPAP ( 1418 ) . Nonbenzodiazepine sedative-hypnotic agents promote sleep onset and continuity without altering sleep architecture . They can safely be used in patients with OSA , especially those already using CPAP ( 19 ) . We hypothesized that a short course of the nonbenzodiazepine sedative-hypnotic eszopiclone during the first 2 weeks of treatment would improve patients ' initial tolerability and use of CPAP and subsequently increase long-term adherence . Methods Study Design Overview We conducted a parallel- design , r and omized , placebo-controlled trial to assess the effects of eszopiclone on CPAP adherence among patients with newly diagnosed OSA who were initiating CPAP . Patients received eszopiclone , 3 mg , or matching placebo every night for the initial 14 nights of CPAP and were followed serially for 24 weeks ( Figures 1 and 2 ) . Patient enrollment began in March 2007 , and final data were collected by December 2008 . Our study is part of the CPAP ASAP ( CPAP Promotion and PrognosisThe Army Sleep Apnea Program ) Trial , which will examine several outcomes related to OSA . Figure 1 . Study flow diagram . CPAP = continuous positive airway pressure . Figure 2 . Study design overview . CPAP = continuous positive airway pressure . Walter Reed Army Medical Center 's Department of Clinical Investigation ( Scientific Review Committee , Human Use Committee , and Institutional Review Board ) , as well as the United States Army Center for Investigational Research Organization , approved our protocol . We obtained informed consent from all study participants . Setting s and Participants We recruited all patients from a single academic sleep medicine center . Our center is part of Walter Reed Army Medical Center , which is a quaternary-care facility providing care to a wide range of patient demographic groups , including active-duty service members , their dependents , and retirees . Consecutive patients between 18 and 64 years of age , with newly diagnosed OSA , and not previously receiving CPAP therapy were approached for enrollment .  Obstructive sleep apnea  was diagnosed on the basis of an attended , overnight level I polysomnography in all patients . All polysomnograms were interpreted by the study investigators and authors . We established the diagnosis and defined the severity of OSA in accordance with American Academy of Sleep Medicine criteria by using the apneahypopnea index ( 20 ) . We excluded patients with long-term use of hypnotic medications , those who consumed more than 2 alcoholic beverages per night , and those who had hepatic dysfunction or an underlying psychiatric condition that would preclude completion of the study . We also excluded pregnant women . R and omization and Interventions We r and omly assigned patients to receive eszopiclone , 3 mg ( n= 80 ) , or matching placebo ( n= 80 ) . The Walter Reed Army Medical Center 's investigational pharmacy central ly administered and distributed study medications to the patients at the time of enrollment . The referring physician , investigators , and patients were blinded to the r and omization order and treatment group assignment ( eszopiclone or placebo ) . R and omization was implemented by using a computerized program ( R and omization.com , seed 3565 ) and was performed by using 16 fixed blocks ( 10 patients per block ) without stratification by patient criteria or polysomnogram results . The pharmacy maintained r and omization and blinding until after the final data were collected . All persons initiating CPAP at our institution participate in a comprehensive educational program to familiarize them with OSA , its effects , and the available treatment options . Patients undergo formal mask-fitting and receive telephone follow-up after 2 weeks to ensure proper fit . A clinical evaluation is conducted after 1 month of therapy to measure CPAP use and assess clinical response to therapy . Additional follow-up is provided as needed . Nonpharmacologic interventions , including changes in pressures , assessment of leaks , mask changes , or adjustments to and education on proper sleep hygiene and stimulus control , are individualized to promote better CPAP tolerance and adherence . All patients enrolled in this study were also assessed after 3 and 6 months of therapy . Otherwise , study participants were not treated differently from other patients receiving care at our center . After the initial 4 weeks of enrollment , open-label sedatives could be prescribed at the discretion of the physician seeing the patient during follow-up . It is common practice for providers in our clinic to offer a sedative-hypnotic agent to patients who are having difficulties using the CPAP machine despite nonpharmacologic interventions . All enrolled patients received the same model of CPAP ( RemStar Pro M Series with C-Flex and integrated heated humidifiers , Phillips Respironics , Murrysville , Pennsylvania ) . We prescribed CPAP devices for long-term use . We did not use any autoadjustable positive airway pressure devices . Outcomes and Measurements For each participant , we recorded demographic data , information regarding OSA severity , degree of symptoms , and objective measures of CPAP use . The primary outcome measured was CPAP adherence at 24 weeks . Specifically , we computed the percentage of nights used , the mean hours per night for total study nights , and the mean hours per night that CPAP was used during each week of the 24-week study . We also compared the rate of regular use of CPAP between groups , defined as more than 4 hours per night on more than 70 % of nights ( 21 ) . We obtained objective measures of CPAP use from a downloadable smart card adherence-monitoring device ( Encore Pro smart card , Phillips Respironics ) . These cards , which are integrated into the CPAP units , record all use of the devicespecifically , the date , time , and duration that CPAP is used . These cards also record data on mask leaks and residual airflow limitations , data that are useful to troubleshoot barriers to therapeutic adherence . We collected all measured variables at the time of enrollment ( baseline ) and again at 1 , 3 , and 6 months after initiating CPAP .  In addition , we collected smart cards at 1 , 3 , and 6 months and recorded and analyzed the downloaded data for each night in 1-week blocks . Secondary outcomes were the rate of CPAP discontinuation and the use of open-label sedative-hypnotic agents between the 2 groups . Because our primary aim was to promote better CPAP adherence , we allowed the open-label use of sedative-hypnotic agents after the first 4 weeks of treatment . These were prescribed at the discretion of the ordering physician and only when nonpharmacologic interventions were unsuccessful . All such prescriptions were monitored and recorded by using a closed electronic medical records system . In addition , we compared the change in Epworth Sleepiness Scale ( ESS ) score , fatigue , and Functional Outcomes of Sleep Question naire score between baseline and the end of the study to determine whether a greater use of CPAP was associated with improvements in symptoms and quality of life . We assessed degree of somnolence by using the ESS and visual analogue fatigue scale ( 22 ) . The ESS score ranges from 0 to 24 . Higher scores indicate greater daytime somnolence , and scores less than 10 are considered normal . We assessed sleep-related quality -of-life scores by using the Functional Outcomes of Sleep Question naire ( 23 ) . The score ranges from 5 to 20 . Higher scores , particularly those greater than 17.9 , suggest improved quality of life . We collected additional data related to mood and depression , libido and erectile dysfunction , and quality of life that will be Background : Continuous positive airway pressure ( CPAP ) is an effective therapy for obstructive sleep apnea syndrome ( OSAS ) , although many patients have difficulty adhering to this therapy . The purpose of this study was to investigate the effectiveness of totally automated telephone technology in improving adherence to prescribed CPAP therapy . Research Design : This pilot study was a r and omized clinical trial in 30 patients being started on CPAP therapy for OSAS . Patients were r and omly assigned to use of a computer telephone system design ed to improve CPAP adherence ( telephone-linked communications for CPAP [ TLC-CPAP ] ) in addition to usual care ( n = 15 ) or to usual care alone ( n = 15 ) for a period of 2 months . TLC-CPAP is a computer-based system that monitors patients ’ self-reported behavior and provides education and reinforcement through a structured dialogue . Measures : A sleep symptoms checklist and the Functional Outcomes of Sleep Question naire were administered at study entry and at 2-month follow up . Hours of CPAP use at effective mask pressure were measured by the CPAP device , stored in its memory , and retrieved at the 2-month visit . Results : At 2 months , patients r and omized to TLC-CPAP had fewer reported sleep-related symptoms ( 9.4 vs. 13.4 , P = 0.047 ) than those receiving usual care . The average nightly CPAP use in the TLC-CPAP group was 4.4 hours compared with 2.9 hours ( P = 0.076 ) in the usual-care group . Conclusions : This pilot study suggests that patients with OSAS started on CPAP and a concurrently administered automated education and counseling system had better CPAP adherence and better control of OSAS symptoms Background Continuous positive airway pressure ( CPAP ) is widely recommended for the treatment of sleep apnea/hypopnea syndrome ( SAHS ) , but its usage by patients is very low . The aim of this study was to assess intensive educational programs and nursing support for the improvement of CPAP use and outcomes in SAHS patients . Methods Eighty new SAHS patients were r and omized to receive nurse-led intensive interventions or usual support  at hospital and home . The main outcome measure was  CPAP use ; changes in sleeping , symptoms , mood , and quality of life were also assessed after 12 months of treatment . Results All outcome measures were improved after treatment in both groups . However , patients receiving intensive support with significantly higher CPAP use ( higher daily CPAP usage by 2.2 hours/day ) had greater improvements in SAHS symptoms and mood ( P<0.05 ) . The intervention group further showed an improvement in the Short Form-36 domains of mental and physical health ( P<0.05 ) . Conclusion The CPAP usage and quality of life can be significantly improved by nurse-led intensive program in obstructive sleep apnea patients The present study objective was to establish whether pretreatment social cognitive variables may contribute to the explanation of variance in adherence to continuous positive airway pressure ( CPAP ) treatment for patients with obstructive sleep apnoea/hypopnoea syndrome ( OSAHS ) . A total of 119 of 180 consecutive OSAHS patients were recruited to the study prior to initial CPAP titration . Patients completed psychological measures of health value , health locus of control ( incorporating internality , chance , powerful others ) and self-efficacy prior to CPAP titration . Objective adherence data were measured by CPAP unit time clocks and collected at 3-month follow-up . Average nightly use was calculated over this period . Logistic regression of prospect i ve predictors of adherence produced a model comprising psychological ( health value , internality , powerful others ) , as well as clinical variables ( Epworth score , body mass index , apnoea/hypopnoea index , CPAP pressure ) . This model explained 24 % of the variance in CPAP use , and correctly identified 75 % of adherers and 53 % of nonadherers . Although the psychological variables explained only a small amount of the overall variance in adherence behaviour , this result provides further support for the hypothesis that psychological variables contribute , in part , to continuous positive airway pressure adherence . Future research should focus on highlighting discrete variables , which may helpfully inform psychologically based interventions aim ed at improving the use of continuous positive airway pressure by patients with obstructive sleep apnoea/hypopnoea syndrome at risk of discontinuance The present study examined the efficacy of a cognitive-behavioral intervention at improving compliance with CPAP  and vigilance in older adults with obstructive sleep apnea/hypopnea syndrome ( OSAHS ) . Participants included 12 subjects who were r and omized into one of two groups controlling for age , education , disease severity , and vigilance . The experimental group received two 45-min sessions design ed to educate subjects on the consequences of OSAHS and the efficacy of CPAP . The control group received the same extent of therapist contact but did not receive information on OSAHS or CPAP . All subjects were administered a test of vigilance both before and after the study . Compliance data were collected using CPAP devices with internal microprocessors at were read at 1 , 4 , and 12 weeks after treatment initiation . The results showed that the experimental condition did not enhance compliance after 1 week of treatment but did so by the 12-week follow-up . Subjects in the experimental condition had a run time of 3.2-h per night longer than did those in the control group . Those using CPAP more regularly at 12 weeks also showed greater improvement on vigilance at follow-up . Performance on vigilance testing before the introduction of CPAP was predictive of CPAP use at 12 weeks . In conclusion , a modest cognitive-behavioral intervention may substantially increase  CPAP use and vigilance in older adults RATIONALE It is unknown whether obstructive sleep apnea ( OSA ) may be a risk factor for  incident cardiovascular events in women . OBJECTIVES We sought to investigate whether OSA increases the incidence of a composite of stroke or coronary heart disease ( CHD ) in women , and the role of continuous positive airway pressure ( CPAP ) treatment on this association . METHODS This was a prospect i ve , observational study conducted in two Spanish teaching hospitals between 1998 and 2007 . Consecutive women referred for suspected OSA and free of previous stroke and CHD were analyzed . Women with an apnea-hypopnea index ( AHI ) less than 10 comprised the control group , and those with an AHI greater than or equal to 10 were diagnosed with OSA and classified as CPAP-treated ( adherence ≥ 4 h/d ) or untreated ( adherence < 4 h/d or not prescribed ) . The follow-up ended in December 2010 . MEASUREMENTS AND MAIN RESULTS A total of 967 women were studied ( median follow-up , 6.8 yr ; interquartile range , 5.2 - 8.2 ) . The untreated OSA group showed a greater incidence rate of the composite outcome than the control group ( 2.19 vs. 0.54 per 100 person-years ; P < 0.0005 ) . Compared with the control group , the fully adjusted hazard ratios for the composite outcome incidence were 2.76 ( 95 % confidence interval [ CI ] , 1.35 - 5.62 ) for the untreated OSA group , and 0.91 ( 95 % CI , 0.43 - 1.95 ) for the CPAP-treated group . When the type of cardiovascular event was separately assessed , untreated OSA showed a stronger association with incident stroke ( adjusted hazard ratio , 6.44 ; 95 % CI , 1.46 - 28.3 ) than with CHD ( adjusted hazard ratio , 1.77 ; 95 % CI , 0.76 - 4.09 ) . CONCLUSIONS In women , untreated OSA is associated with increased incidence of serious cardiovascular outcomes , particularly incident stroke . Adequate CPAP treatment seems to reduce this risk CONTEXT Few prospect i ve intervention studies have examined the effect of continuous positive airway pressure ( CPAP ) therapy on cardiovascular disease ( CVD ) risk factors in diabetes . OBJECTIVE Our objective was to determine whether CPAP improves CVD risk factors in patients with type 2 diabetes and obstructive sleep apnea ( OSA ) . DESIGN AND SETTING This was a r and omized parallel group intervention trial in an urban Australian community . PATIENTS Fifty-nine participants of the Fremantle Diabetes Study Phase II at high risk for OSA consented to confirmatory polysomnography followed by r and omization to a 3-month CPAP intervention initiated early ( < 1 wk ) or late ( 1 - 2 months ) . MAIN OUTCOME MEASURES Patients were assessed before and 1 and 3 months after CPAP started . Tests for repeated measures were used to compare variables of interest over time . RESULTS Forty-four patients ( 75 % ) completed the study . Their mean ± sd age was 66.1 ± 8.8 yr , and 61.4 % were male . Completers and noncompleters had similar age , sex , diabetes duration , apnea-hypopnea index , and Epworth Sleepiness Scale ( P ≥ 0.29 ) . There were no differences in outcome between early and late r and omization , and the data were pooled . The Epworth Sleepiness Scale decreased between entry and 1 month [ -4.8 ( -6.5 to -3.1 ) , P < 0.001 ] . Blood pressure improved between entry and 3 months ( from 149 ± 23/80 ± 12 to 140 ± 18/73 ± 13 mm Hg ; P ≤ 0.007 ) . Pulse rate declined within the first month [ -6 ( -10 to -2 ) beats/min , P = 0.002 ] . Glycemic control and serum lipids , which were mostly within recommended target ranges at entry , did not change . CONCLUSIONS Three months of CPAP  in community-based people with type 2 diabetes  significantly decreased blood pressure and pulse rate but did not influence metabolic control BACKGROUND AND PURPOSE Interventions to improve treatment outcomes in  sleep apnoea-hypopnoea syndrome ( SAHS ) have had mixed success . Most have concentrated on following the use of a continuous positive airway pressure ( CPAP ) machines ; poorer users may not return for machine readings , so any compliance study must take into account rates of attendance rates . We hypothesised that a series of additional , early support measures would improve re-attendance over a sustained period . PATIENTS AND METHODS Prospect i ve , single-blinded interventional study . Seventy-two consecutive patients starting CPAP for SAHS were r and omised to receive st and ard follow-up or extra early support .  Attendance rates , CPAP use , Epworth scores , side-effects scores and number of changes to equipment were compared , by intent to treat , in both groups at 1 and 12 months . RESULTS Re-attendance rates were higher in the intervention group at 1 month ( P=0.04 ) , 6 months ( P=0.07 ) and 12 months ( P=0.12 ) . Those who defaulted tended previously to be poor users of the CPAP machine . For those who re-attended there was no difference in machine use or other outcomes . CONCLUSIONS Simple interventions while commencing CPAP improve re-attendance with maximal benefit early on . This could provide more opportunities for solving problems early or considering alternative treatments . By confirming that poorer CPAP users eventually have higher default rates we recommend that future studies on CPAP compliance should first account for re-attendance rates INTRODUCTION Apnea is a common disorder in older adults and has been shown to affect cognition . Some studies suggest that treatment for apnea improves certain cognitive deficits , but few studies have examined the relationship between compliance and cognitive improvement . We design ed a study to answer the following questions about sleep apnea , cognition and treatment in older adults : ( 1 ) Which neuropsychological ( NP ) variables are differentially associated with measures of sleep fragmentation and oxygen desaturation ? ( 2 ) Does compliant use of CPAP provide a cognitive advantage over noncompliant use ? ( 3 ) Does NP performance at baseline predict compliance at 3 months ? METHOD Twelve participants were recruited for the study . All had polysomnographically defined sleep apnea with an RDI of 10 or greater . All were also at least 55 years of age , had no other diagnosable sleep disorder and had no previous treatment for sleep apnea syndrome ( SAS ) . Participants were administered a full NP battery before and 3 months after treatment with CPAP . RDI at baseline was associated with delayed verbal recall , while oxygen desaturation was associated with both delayed recall and constructional abilities . Compliant use of CPAP at 3 months was associated with greater improvements in attention , psychomotor speed , executive functioning and nonverbal delayed recall . Finally , attention measures predicted compliance at 3 months suggesting that those who were least vigilant at baseline were more likely to comply with treatment . DISCUSSION Results are discussed in terms of the relevance to targeting special population s for compliance interventions , the ways that treatment may specifically affect older adults and the possible dose-response relationship of CPAP CONTEXT Continuous positive airway pressure ( CPAP ) is the first-line treatment for patients with symptomatic obstructive sleep apnea ( OSA ) . However , its indication for all patients with sleep-disordered breathing , regardless of daytime symptoms , is unclear . OBJECTIVE To evaluate the effect of CPAP treatment on the incidence of hypertension or cardiovascular events in a cohort of nonsleepy patients with OSA . DESIGN , SETTING , AND PATIENTS Multicenter , parallel-group , r and omized controlled trial in 14 teaching hospitals in Spain . Between May 2004 and May 2006 , 725 consecutive patients were enrolled who had an apnea-hypopnea index of 20 h(-1 ) or greater and an Epworth Sleepiness Scale score of 10 or less ( scores range from 0 - 24 , with values < 10 suggesting no daytime sleepiness ) . Exclusion criteria were previous cardiovascular event , physical or psychological incapacity , chronic disease , or drug or alcohol addiction . Follow-up ended in May 2009 . INTERVENTION Patients were allocated to receive CPAP treatment or no active intervention . All participants received dietary counseling and sleep hygiene advice . MAIN OUTCOME MEASURES Incidence of either systemic hypertension ( taking antihypertensive medication or blood pressure greater than 140/90 mm Hg ) or cardiovascular event ( nonfatal myocardial infa rct ion , nonfatal stroke , transient ischemic attack , hospitalization for unstable angina or arrhythmia , heart failure , or cardiovascular death ) . RESULTS Seven hundred twenty-three patients underwent follow-up for a median of 4 ( interquartile range , 2.7 - 4.4 ) years ( 1 patient from each group did not receive allocated treatment ) ; 357 in the CPAP group and 366 in the control group were included in the analysis . In the CPAP group there were 68 patients with new hypertension  and 28 cardiovascular events ( 17 unstable angina or arrhythmia , 3 nonfatal stroke , 3 heart failure , 2 nonfatal myocardial infa rct ion , 2 transient ischemic attack , 1 cardiovascular death ) . In the control group there were 79 patients with new hypertension and 31 cardiovascular events ( 11 unstable angina or arrhythmia , 8 nonfatal myocardial infa rct ion , 5 transient ischemic attack , 5 heart failure , 2 nonfatal stroke ) . The hypertension or cardiovascular event incidence density rate was 9.20 per 100 person-years ( 95 % CI , 7.36 - 11.04 ) in the CPAP group and 11.02 per 100 person-years ( 95 % CI , 8.96 - 13.08 ) in the control group . The incidence density ratio was 0.83 ( 95 % CI , 0.63 - 1.1 ; P = .20 ) . CONCLUSIONS In patients with OSA without daytime sleepiness , the prescription of CPAP compared with usual care did not result in a statistically significant reduction in the incidence of hypertension or cardiovascular events . However , the study may have had limited power to detect a significant difference . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00127348 STUDY OBJECTIVES To determine long-term compliance rates to continuous positive airway pressure ( CPAP ) therapy in patients with obstructive sleep apnea enrolled in a comprehensive CPAP program in the community . DESIGN Prospect i ve cohort longitudinal study . SETTING University sleep disorders center . PATIENTS Two hundred ninety-six patients with an apnea-hypopnea index ( AHI ) > or = 20/h on polysomnography .  INTERVENTIONS A CPAP device equipped with a monitoring chip was supplied . Within the first week , daily telephone contacts were made . Patients were seen at 2 weeks , 4 weeks , 3 months , and 6 months . RESULTS Of the 296 subjects enrolled , 81.1 % were males . Mean + /- SD AHI was 64.4 + /- 34.2/h of sleep ; age , 51 + /- 11.7 years ; and body mass index , 35.2 + /- 7.9 kg/m(2 ) . The mean duration of CPAP  use was 5.7 h/d at 2 weeks , 5.7 h/d at 4 weeks , 5.9 h/d at 3 months , and 5.8 h/d at 6 months . The percentage of patients using CPAP  > or = 3.5 h/d was 89.0 % at 2 weeks , 86.6 % at 4 weeks , 88.6 % at 3 months , and 88.5 % at 6 months . There was a decrease in the Epworth Sleepiness Scale ( ESS ) score of 44 % by 2 weeks of therapy . The patients continue to improve over the follow-up period , with the lowest mean ESS score observed at 6 months . With multiple regression analysis , three variables were found to be significantly correlated with increased CPAP use : female gender , increasing age , and reduction in ESS score . CONCLUSION A population -based CPAP program consisting of consistent follow-up , " troubleshooting , " and regular feedback to both patients and physicians can achieve CPAP compliance rates of > 85 % over 6 months Obstructive sleep apnoea syndrome ( OSAS ) is characterised by repetitive collapse of the upper airway during sleep . Continuous positive airway pressure ( CPAP ) applied via a mask is the st and ard treatment for OSAS . CPAP adherence is crucial in therapy to prevent the deleterious consequences of OSAS . We hypothesised that a combination of supervision by telemetry together with targeted telephone support in the first month of CPAP would increase CPAP adherence and treatment success . A total of 113 OSAS patients followed by telemetry-triggered interventions used the device for 5.3 h/night on 28/30 nights , significantly more than the 110 OSAS patients in the control group with 4.6 h/night and 27/30 nights . Telemetry-triggered interventions have a significant impact on adherence rate in early CPAP treatment . These results can be reached with an acceptable additional effort Purpose The purpose of this study is to explore the effects of patient education and progressive muscle relaxation ( PMR ) alone or combined on adherence to continuous positive airway pressure ( CPAP ) treatment in obstructive sleep apnea ( OSA ) patients . Methods One hundred and fifty-two Han Chinese OSA patients were r and omly assigned to a control group ( C ) , an education group ( E ) , a PMR group ( P ) , and an education + PMR group ( E + P ) , with 38 patients each group . The adherence to CPAP was defined as 4 or more hours of CPAP usage per night and at least 9 of each 14 nights of ventilator use . The CPAP adherence rates , cumulative patient dropout rates , CPAP usage , and scores of daytime sleepiness , sleep quality , anxiety , and depression were compared among the groups at 4 , 8 , and 12 weeks of intervention . Results All study groups were comparable in baseline characteristics . Group E + P showed significant improvement in CPAP adherence , daytime sleepiness , and sleep quality compared with group C at 4 , 8 , and 12 weeks of intervention . Compared with group C , group E only showed significant improvement in CPAP adherence , daytime sleepiness , and sleep quality at 4 weeks of intervention , while group P showed no significant improvement over time . Scores of anxiety and depression were significantly improved in group E + P compared with group C at 12 weeks of intervention . Conclusions Combined intervention with patient education and PMR can significantly improve CPAP adherence in OSA patients for at least 12 weeks . The intervention paradigm may serve as an important reference for future studies on CPAP adherence STUDY OBJECTIVES We tested whether providing adults with obstructive sleep apnea ( OSA ) with daily Web-based access to their positive airway pressure ( PAP ) usage over 3 mo with or without a financial incentive in the first week improves adherence and functional outcomes . SETTING Academic- and community-based sleep centers . PARTICIPANTS One hundred thirty-eight adults with newly diagnosed OSA starting PAP treatment . INTERVENTIONS Participants were r and omized to : usual care , usual care with access to PAP usage , or usual care with access to PAP usage and a financial incentive . PAP data were transmitted daily by wireless modem from the participants ' PAP unit to a website where hours of usage were displayed . Participants in the financial incentive group could earn up to $ 30/day in the first week for objective PAP use ≥ 4 h/day . MEASUREMENTS AND RESULTS Mean hours of daily PAP use in the two groups with access to PAP usage data did not differ from each other but was significantly greater than that in the usual care group in the first week and over 3 mo ( P < 0.0001 ) . Average daily use ( mean ± st and ard deviation ) during the first week of PAP intervention was 4.7 ± 3.3 h in the usual care group , and 5.9 ± 2.5 h and 6.3 ± 2.5 h in the Web access groups with and without financial incentive respectively . Adherence over the 3-mo intervention decreased at a relatively constant rate in all three groups . Functional Outcomes of Sleep Question naire change scores at 3 mo improved within each group ( P < 0.0001 ) but change scores of the two groups with Web access to PAP data were not different than those in the control group ( P > 0.124 ) . CONCLUSIONS Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment . Inclusion of a financial incentive in the first week had no additive effect in improving adherence RATIONALE Home portable monitor testing is increasingly being used to diagnose patients with obstructive sleep apnea ( OSA ) and to initiate them on continuous positive airway pressure ( CPAP ) treatment . OBJECTIVES To compare functional outcome and treatment adherence in patients who receive ambulatory versus in-laboratory testing for OSA . METHODS Veterans with suspected OSA were r and omized to either home testing or st and ard in-laboratory testing . Home testing consisted of a type 3 portable monitor recording followed by at least three nights using an automatically adjusting positive airway pressure apparatus . Participants diagnosed with OSA were treated with CPAP for 3 months . MEASUREMENTS AND MAIN RESULTS We measured the change in Functional Outcomes of Sleep Question naire score , with an a priori noninferiority delta of -1 , and the mean daily hours of objective ly measured CPAP adherence , with an a priori noninferiority delta of -0.75 hour/day . Of the 296 subjects enrolled , 260 ( 88 % ) were diagnosed with OSA , and 213 ( 75 % ) were initiated on CPAP . Mean ± SD functional outcome score improved 1.74 ± 2.81 in the home group ( P < 0.001 ) and 1.85 ± 2.46 in the in-laboratory group ( P < 0.0001 ) . The lower bound of the one-sided 95 % noninferiority confidence interval was -0.54 . Mean ± SD hours of daily CPAP adherence were 3.5 ± 2.5 hours/day in the home group and 2.9 ± 2.3 hours/day in the in-laboratory group ( P = 0.08 ) . The lower bound of the one-sided 95 % noninferiority confidence interval was 0.03 . CONCLUSIONS Functional outcome and treatment adherence in patients evaluated according to a home testing algorithm is not clinical ly inferior to that in patients receiving st and ard in-laboratory polysomnography Objectives : To examine if reported  obstructive sleep apnea ( OSA )  symptom improvement , baseline depressive symptoms , or polysomnographically measured sleep parameters are associated with adherence to continuous positive airway pressure ( CPAP ) . CPAP is a highly effective treatment for OSA . Low adherence to CPAP therapy is common and poorly understood . Depression and lack of perceived benefits from CPAP are possible reasons for low adherence . Methods : Seventy-eight patients evaluated for OSA at a sleep medicine center agreed to participate in the study ; 54 patients completed all study assessment s. The Beck Depression Inventory ( BDI ) and the functional outcomes of sleep question naire ( FOSQ ) were administered before polysomnographic evaluation . A card embedded in the CPAP device electronically recorded adherence . The BDI and FOSQ were administered 1 to 2 months after the baseline measurements were obtained . Results : Baseline depressive symptoms were not correlated with mean duration of CPAP use per night . Reported improvements in OSA symptoms were correlated positively with CPAP adherence . There were significant positive correlations between improvement in depressive symptoms and OSA symptoms after initiation of CPAP therapy . The polysomnographic variables measured did not predict improvement in daytime OSA symptoms or CPAP adherence . Post hoc analyses suggested that those individuals with baseline Apnea Hypopnea Index ( AHI ) between 40 and 80 experienced more symptom improvement than those with AHI < 40 or > 80 . Conclusions : Patients with the greatest level of CPAP adherence also reported the greatest improvement in OSA symptoms . Patients who continued to experience OSA symptoms after CPAP treatment also tended to have more depressive symptoms after CPAP treatment . AHI = Apnea Hypopnea Index ; BDI = Beck Depression Inventory ; CPAP = continuous positive airway pressure ; FOSQ = functional outcomes of sleep question naire ; OSA = obstructive sleep apnea Incomplete patient adherence with nasal continuous positive airway pressure ( CPAP ) limits the effectiveness of treatment and results in suboptimal  obstructive sleep apnea ( OSA ) outcomes . An interactive website specifically design ed for patients with OSA was design ed and utilized in a r and omized clinical trial to test its effect on increasing CPAP adherence . The goal of this paper is to report on CPAP adherence , internet use , privacy concerns and user satisfaction in using the website . The original project was design ed as a r and omized , controlled clinical trial of Usual Care ( UC , control ) versus MyCPAP group ( intervention ) . Question naires were administered to evaluate the patient perspective of using the MyCPAP website . Participation in the MyCPAP intervention result ed in higher CPAP adherence at the two-month time point relative to participation in the UC group ( 3.4 ± 2.4 and 4.1 ± 2.3 hrs/nt ; P = 0.02 ; mean ± SD ) . Participants r and omized to the MyCPAP website increased their use of the internet to obtain OSA related information , but did not increase their use of the internet to get information on general health or medical conditions . Users had very little concern about their CPAP data being viewed daily or being sent over the internet . Future studies should consider the use of newer evaluation criteria for collaborative adaptive interactive technologies The aim of this study to evaluate the efficacy of a home-based programme on clinical response , continuous positive airway pressure ( CPAP ) compliance and cost in a population of high pre-test probability of suffering obstructive sleep apnoea syndrome ( OSAS ) . Patients were r and omised into the following three groups . Group A : home respiratory polygraphy ( RP ) and home follow-up ; group B : hospital polysomnography and hospital follow-up ; and group C : home RP and hospital follow-up . Evaluation during 6 months included Epworth Sleepiness Scale ( ESS ) , Functional Outcomes Sleep Question naire ( FOSQ ) , and daily activity and symptom question naires . Compliance was assessed by memory cards ( group A ) and using an hourly counter ( groups B and C ) . 66 patients were included ( 22 per branch ) , 83 % were males , aged mean±sd 52±10 yrs , body mass index 34±7kg·m−2 , apnoea/hypopnoea index 43±20 h−1 , CPAP pressure 8±2 cmH2O , with no between-group differences . Clinical response showed an ESS of mean±sd 15±3 to 6±4 , a FOSQ of 16±3 to 18±2 , symptoms of 43±7 to 25±7 , and activity of 37±11 to 25±8 . At the end of the study , compliance was : group A 73 % , group B 68 % and group C 57 % . The cost per patient was : group A € 590±43 , group B € 894±11 and group C € 644±93 ( p<0.001 ) . In conclusion , patients with a high initial probability of having OSAS can be diagnosed and treated in a home setting , with a high level of CPAP compliance and lower cost than using either a hospital-based approach or home RP/hospital follow-up CONTEXT Systemic hypertension is prevalent among patients with obstructive sleep apnea ( OSA ) . Short-term studies indicate that continuous positive airway pressure ( CPAP ) therapy reduces blood pressure in patients with hypertension and OSA . OBJECTIVE To determine whether CPAP therapy is associated with a lower risk of incident hypertension . DESIGN , SETTING , AND PARTICIPANTS A prospect i ve cohort study of 1889 participants without hypertension who were referred to a sleep center in Zaragoza , Spain , for nocturnal polysomnography between January 1 , 1994 , and December 31 , 2000 .  Incident hypertension was documented at annual follow-up visits up to January 1 , 2011 . Multivariable models adjusted for confounding factors , including change in body mass index from baseline to censored time , were used to calculate hazard ratios ( HRs ) of incident hypertension in participants without OSA ( controls ) , with untreated OSA , and in those treated with CPAP therapy according to national guidelines . MAIN OUTCOME MEASURE Incidence of new-onset hypertension . RESULTS During 21,003 person-years of follow-up ( median , 12.2 years ) , 705 cases ( 37.3 % ) of incident hypertension were observed . The crude incidence of hypertension per 100 person-years was 2.19 ( 95 % CI , 1.71 - 2.67 ) in controls , 3.34 ( 95 % CI , 2.85 - 3.82 ) in patients with OSA ineligible for CPAP therapy , 5.84 ( 95 % CI , 4.82 - 6.86 ) in patients with OSA who declined CPAP therapy , 5.12 ( 95 % CI , 3.76 - 6.47 ) in patients with OSA nonadherent to CPAP therapy , and 3.06 ( 95 % CI , 2.70 - 3.41 ) in patients with OSA and treated with CPAP therapy . Compared with controls , the adjusted HRs for incident hypertension were greater among patients with OSA ineligible for CPAP therapy ( 1.33 ; 95 % CI , 1.01 - 1.75 ) , among those who declined CPAP therapy ( 1.96 ; 95 % CI , 1.44 - 2.66 ) , and among those nonadherent to CPAP therapy ( 1.78 ; 95 % CI , 1.23 - 2.58 ) , whereas the HR was lower in patients with OSA who were treated with CPAP therapy ( 0.71 ; 95 % CI , 0.53 - 0.94 ) . CONCLUSION Compared with participants without OSA , the presence of OSA was associated with increased adjusted risk of incident hypertension ; however , treatment with CPAP therapy was associated with a lower risk of hypertension Background Continuous positive airway pressure ( CPAP ) is the most widely prescribed treatment for obstructive sleep apnoea syndrome ( OSAS ) . Although it has been shown to improve the symptoms of OSAS , many patients have difficulty adhering to this treatment . The purpose of this study was to investigate the effectiveness of an automated telemedicine intervention to improve adherence to CPAP . Methods A r and omised clinical trial was undertaken in 250 patients being started on CPAP therapy for OSAS . Patients were r and omly assigned to use a theory-driven interactive voice response system design ed to improve CPAP adherence ( telephone-linked communications for CPAP ( TLC-CPAP ) , n=124 ) or to an attention placebo control ( n=126 ) for 12 months . TLC-CPAP monitors patients ' self-reported behaviour and CPAP-related symptoms and provides feedback and counselling through a structured dialogue to enhance motivation to use CPAP . A Sleep Symptoms Checklist , the Functional Outcomes of Sleep Question naire , the Center for Epidemiological Studies Depression Scale and the Psychomotor Vigilance Task were administered at study entry and at 6-month and 12-month follow-up . Hours of CPAP usage at effective mask pressure were measured by the CPAP device stored in its memory and retrieved at each visit . Results Median observed CPAP use in patients r and omised to TLC-CPAP was approximately 1 h/night higher than in the control subjects at 6 months and 2 h/night higher at 12 months . Using generalised estimating equation modelling , the intervention had a significant effect on CPAP adherence . For secondary analysis , the effect of CPAP adherence on the secondary outcomes was analysed . CPAP adherence was significantly associated with a greater reduction in sleep apnoea symptoms and depressive symptoms and a greater improvement in functional status . No significant association was observed between CPAP adherence and reaction time . Conclusions The TLC-CPAP intervention result ed in improved CPAP adherence , which was associated with improved functional status and fewer depressive symptoms . Clinical trial.gov NCT00232544 Continuous positive airway pressure ( CPAP ) is an effective treatment for obstructive sleep apnoea syndrom ( OSAS ) but therapy adherence is often low . The hypothesis that CPAP-adherence and clinical outcomes can be improved by either using an autoadjusting-CPAP ( APAP ) device or an intensive support was tested . A controlled parallel group study was performed with 100 newly diagnosed OSAS patients , r and omised into 4 groups ( n = 25 each ) : st and ard or intensive support plus either APAP or CPAP . Intensive support included education and monthly home visits for 6 months . Clinical outcome was monitored by polysomnography at CPAP initiation and , after 3 and 9 months , compliance data were downloaded from the CPAP devices . After 9 months , intensively supported patients returned for follow-up in 88 versus 68 % in the st and ard-support-group . Daily usage ( mean±sem 5.7±0.2 for intensive support versus 4.6±0.4 h for st and ard support ) , percentage of days used ( 80.4±2.8 versus 57.0±5.9 % ) and proportion of individual sleep time ( 80.6±3.2 versus 64.9±6.2 % ) were also higher . There was no significant difference  between APAP or CPAP , ( daily usage 5.2±0.4 versus 5.1±0.3 h , percentage of days 67.9±5.0 versus 69.2±4.9 % , proportion of sleep time 72.5±5.0 % versus 72.1±5.2 % , for APAP and CPAP ) but retention rate was higher with CPAP . In summary , intensive support after continuous positive airway pressure initiation , rather than the application of autoadjusting-continuous positive airway pressure , increased therapy adherence We aim ed to compare the effect of intensive versus st and ard interventions on continuous positive airway pressure ( CPAP ) adherence 2 years after CPAP initiation , as well as on sleepiness , quality of life , depression , hospitalisation and death rate due to cardiovascular disease ( CVD ) . 3100 patients with newly diagnosed sleep apnoea were r and omised into the st and ard group , with usual follow-up care , or the intensive group , with additional visits , telephone calls and education .  Subjective daytime sleepiness ( Epworth Sleepiness Scale ; ESS ) , quality of life ( 36-item Short Form Health Survey ; SF-36 ) and the patient ’s level of depression ( Beck Depression Inventory ; BDI ) were recorded before and 2 years after CPAP initiation , together with CVD hospitalisations and death rate . 2 years after CPAP initiation , the intensive group used CPAP  significantly more than the st and ard group ( 6.9 versus 5.2 h per night ; p<0.001 ) . ESS , SF-36 and BDI scores were also significantly better in the intensive group . Furthermore , the st and ard group had significantly more deaths and hospitalisations due to CVD . CPAP usage can be improved by both intensive and st and ard patient support . However , the patients who received intensive CPAP support had significantly better ESS , BDI and SF-36 scores , and lower cardiovascular morbidity and mortality , suggesting that an intensive programme could be worthwhile . Intensive CPAP support improves sleepiness , quality of life , depression , hospitalisation and death rate Background Compliance with continuous positive airway pressure ( CPAP ) therapy is essential in patients with obstructive sleep apnoea ( OSA ) , but adequate control is not always possible . This is clinical ly important because CPAP can reverse the morbidity and mortality associated with OSA . Telemedicine , with support provided via a web platform and video conferences , could represent a cost-effective alternative to st and ard care management . Aim To assess the telemedicine impact on treatment compliance , cost-effectiveness and improvement in quality of life ( QoL ) when compared with traditional face-to-face follow-up . Methods A r and omised controlled trial was performed to compare a telemedicine-based CPAP follow-up strategy with st and ard face-to-face management .  Consecutive OSA patients requiring CPAP treatment , with sufficient internet skills and who agreed to participate , were enrolled . They were followed-up at 1 , 3 and 6 months and answered surveys about sleep , CPAP side effects and lifestyle . We compared CPAP compliance , cost-effectiveness and QoL between the beginning and the end of the study . A Bayesian cost-effectiveness analysis with non-informative priors was performed . Results We r and omised 139 patients . At 6 months , we found similar levels of CPAP compliance , and improved daytime sleepiness , QoL , side effects and degree of satisfaction in both groups . Despite requiring more visits , the telemedicine group was more cost-effective : costs were lower and differences in effectiveness were not relevant . Conclusions A telemedicine-based strategy for the follow-up of CPAP treatment in patients with OSA was as effective as st and ard hospital-based care in terms of CPAP compliance and symptom improvement , with comparable side effects and satisfaction rates . The telemedicine-based strategy had lower total costs due to savings on transport and less lost productivity ( indirect costs ) . Trial register number NCT01716676 INTRODUCTION The most commonly used treatment for obstructive sleep apnea syndrome ( OSA ) is the application of continuous positive airway pressure ( CPAP ) during sleep . However compliance with this treatment is frequently below 70 % . METHODS The main aim of this study was to evaluate the feasibility of an educational intervention ( EI )  delivered in phone calls made to OSA patients ( n=66 ) treated with CPAP by a home care provider ( SADIR ) . The educational intervention consisted of five sessions of telephone based counseling intervention by appropriately trained staff delivered on day 3 , 10 , 30 , 60 and 90 after initiation of treatment . Secondary objectives were to compare , using a case-control design , CPAP compliance of OSA patients ( n=133 )  with or without EI . RESULTS Ninety-eight percent of patients accepted the intervention to participate in the study . Fifty-seven patients ( 86 % ) received the full intervention program and 44 patients ( 66 % ) strictly respected the pre-defined timings per protocol . A higher adherence to CPAP at six months was observed in the EI group compared to patient without EI ( 94 % versus 81 % ) ( P<0.05 ) . CPAP compliance at three months was 54minutes higher in the EI group compared to the control group ( 4h39±2h17 and 3h45±2h45 respectively ) but this difference was not statistically significant . CONCLUSION An educational intervention dispensed by phone is applicable and would have an impact on CPAP compliance . Its efficacy on long-term compliance has to be confirmed in a larger group using a r and omized procedure IMPORTANCE Due to increasing dem and for sleep services , there has been growing interest in ambulatory models of care for patients with obstructive sleep apnea . With appropriate training and simplified management tools , primary care physicians are ideally positioned to take on a greater role in diagnosis and treatment . OBJECTIVE To compare the clinical efficacy and within-trial costs of a simplified model of diagnosis and care in primary care relative to that in specialist sleep centers . DESIGN , SETTING , AND PATIENTS A r and omized , controlled , noninferiority study involving 155 patients with obstructive sleep apnea that was treated at primary care practice s ( n=81 ) in metropolitan Adelaide , 3 rural regions of South Australia or at a university hospital sleep medicine center in Adelaide , Australia ( n = 74 ) , between September 2008 and June 2010 . INTERVENTIONS Primary care management of obstructive sleep apnea vs usual care in a specialist sleep center ; both plans included continuous positive airway pressure , m and ibular advancement splints , or conservative measures only . MAIN OUTCOME AND MEASURES The primary outcome was 6-month change in Epworth Sleepiness Scale ( ESS ) score , which ranges from 0 ( no daytime sleepiness ) to 24 points ( high level of daytime sleepiness ) . The noninferiority margin was -2.0 . Secondary outcomes included disease-specific and general quality of life measures , obstructive sleep apnea symptoms , adherence to using continuous positive airway pressure , patient satisfaction , and health care costs . RESULTS There were significant improvements in ESS scores from baseline to 6 months in both groups . In the primary care group , the mean baseline score of 12.8 decreased to 7.0 at 6 months ( P < .001 ) , and in the specialist group , the score decreased from a mean of 12.5 to 7.0 ( P < .001 ) . Primary care management was noninferior to specialist management with a mean change in ESS score of 5.8 vs 5.4 ( adjusted difference , -0.13 ; lower bound of 1-sided 95 % CI , -1.5 ; P = .43 ) . There were no differences in secondary outcome measures between groups . Seventeen patients ( 21 % ) withdrew from the study in the primary care group vs 6 patients ( 8 % ) in the specialist group . CONCLUSIONS AND RELEVANCE Among patients with obstructive sleep apnea , treatment under a primary care model compared with a specialist model did not result in worse sleepiness scores , suggesting that the 2 treatment modes may be comparable . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12608000514303 BACKGROUND : CPAP is currently the treatment of choice for obstructive sleep apnea syndrome , but therapy adherence is poor . Many educational trials have been proposed to increase CPAP adherence . We tested the hypothesis that polysomnograph chart viewing by patients would improve CPAP adherence . METHODS : A controlled parallel group study was performed with 206 newly diagnosed obstructive sleep apnea syndrome patients , r and omized into 2 groups ( n = 103 each ) : st and ard support group , and educational support group . Each educational support group subject viewed 2 consecutive polysomnograms on the computer screen : the first recorded during a st and ard diagnostic overnight polysomnography , and the second during a full-night polysomnography with nasal CPAP . The subject 's attention was drawn only to the flow and oxyhemoglobin saturation curves . Clinical outcomes were assessed via polysomnography at CPAP initiation and after 1 , 3 , and 12 months . RESULTS : After 12 months of CPAP , 76 % of the educational support group and 52 % of the st and ard support group returned for a follow-up visit ( P < .001 ) . Statistical significance had already been reached after 1 and 3 months . Moreover , CPAP use ( measured as hours of use per night ) was higher in the educational support group at each control visit . CONCLUSIONS : Polysomnograph chart viewing by obstructive sleep apnea patients can increase CPAP adherence , as evaluated by rate of return for the follow-up visit and mean nightly CPAP use BACKGROUND This pragmatic r and omised , controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome ( SAHS ) .  Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit . METHOD One hundred and seventy-four patients were r and omised to annual review by consultant clinic appointment or by specialist nurse home visit .  SAHS symptoms , Epworth score , hospital anxiety and depression scale ( HADS ) , Short Form-36 ( SF-36 ) and hours of use of constant positive airway pressure ( CPAP ) were measured before and 3 months after review . The costs and patient preference for review were determined . RESULTS After review , both groups significantly increased CPAP use ( mean ( SD ) increase : nurse , 0.66 ( 1.71 ) h ; consultant , 0.45 ( 1.69 ) h ) and reduced symptom scores ( nurse , -2 ( 7 ) ; consultant , -3 ( 9 ) ) , compared to baseline . There were no differences between groups in these improvements , or in HADS or SF-36 scores . Average duration of a nurse home visit , excluding travel time , was 26 ( 6 ) min . Total NHS cost per visit was 52.26 UK pounds ( 49.85 ) ( $ 83.62 ( 79.76 ) ) , of which 6.57 UK pounds ( 1.43 ) ( $ 10.51 ( 2.29 ) ) reflected time spent with the patient and the remainder was travel cost . Average duration of consultant review was 10 ( 6 ) min , total NHS cost 6.21 UK pounds ( 3.99 ) ( $ 9.94 ( 6.38 ) ) . However , the cost to the patient of attending the clinic was 23.63 UK pounds ( 23.21 ) ( $ 37.81 ( 37.13 ) ) . Patient preference for review was nurse 16 % , consultant 19 % , and no preference 65 % . CONCLUSION Following annual review , use of CPAP increased and symptoms improved . Outcomes were similar for consultant and nurse led review . Home visits were expensive for the healthcare provider , whereas clinic attendance incurred substantial costs to the patient . The majority of patients would accept nurse review for their sleep apnea management OBJECTIVE As many as 50 % of patients diagnosed with obstructive sleep apnea stop adhering to the prescribed medical treatment of continuous positive airway pressure ( CPAP ) within 1 - 3 weeks of onset . Thus , a theory-based intervention using music to support habit formation was design ed to improve CPAP adherence at onset . The intervention material s included directions for CPAP nightly use , a diary for recording nightly use and writing about CPAP benefits or problems . In addition , an audiotape with softly spoken instructions for placing the CPAP mask comfortably , using deep breathing and muscle relaxation along with the slowly decreasing music tempo was provided to listen to at bedtime each night . METHODS Effects of this music intervention were tested in a r and omized , placebo-controlled trial of 97 patients with 53 males ( 55 % ) and 44 females ( 45 % ) . Moderate to severe apnea/hyponea scores ( per sleep laboratory data ) and medical diagnosis of OSA were required for study inclusion . RESULTS Compared to placebo controls , a greater proportion of experimental patients were adhering ( chi(2)=14.67 , p<0.01 ; a large difference , Phi=0.39 ) at the end of the first month of CPAP onset . There were no differences in CPAP adherence at 3 ( X(2)=0.065 , p=0.79 ) and 6 ( X(2)=.118 , p=0.73 ) months . Patients ' diary data and satisfaction survey results indicated the intervention was rated as helpful and guided formation of a relaxing , habitual routine of CPAP nightly use . CONCLUSION The intervention had a strong effect for improving adherence to CPAP at 1 month . PRACTICE IMPLICATION S Adherence at the onset of treatment is critical and the audio music intervention was easily administered . Other interventions that target problems interfering with longer-term CPAP adherence are needed BACKGROUND Obstructive sleep apnoea is associated with raised blood pressure . If blood pressure can be reduced by nasal continuous positive airway pressure ( nCPAP ) , such treatment could reduce risk of cardiovascular disease in patients with obstructive sleep apnoea . Our aim was to see whether nCPAP for sleep apnoea reduces blood pressure compared with the most robust control intervention subtherapeutic nCPAP . METHODS We did a r and omised parallel trial to compare change in blood pressure in 118 men with obstructive sleep apnoea ( Epworth score > 9 , and a > 4 % oxygen desaturation index of > 10 per h ) who were assigned to either therapeutic ( n=59 ) or subtherapeutic ( 59 ) nCPAP ( about 1 cm H(2)O pressure ) for 1 month . The primary outcome was the change in 24-h mean blood pressure . Secondary outcomes were changes in systolic , diastolic , sleep , and wake blood pressure , and relations between blood pressure changes , baseline blood pressure , and severity of sleep apnoea . FINDINGS Therapeutic nCPAP reduced mean arterial ambulatory blood pressure by 2.5 mm Hg ( SE 0.8 ) , whereas subtherapeutic nCPAP increased blood pressure by 0.8 mm Hg ( 0.7 ) ( difference -3.3 [ 95 % CI -5.3 to -1.3 ] ; p=0.0013 , unpaired t test ) . This benefit was seen in both systolic and diastolic blood pressure , and during both sleep and wake . The benefit was larger in patients with more severe sleep apnoea than those who had less severe apnoea , but was independent of the baseline blood pressure . The benefit was especially large in patients taking drug treatment for blood pressure .  INTERPRETATION In patients with most severe sleep apnoea , nCPAP reduces blood pressure , providing significant vascular risk benefits , and substantially improving excessive daytime sleepiness and quality of life Purpose The objective of the study was to evaluate the effectiveness of stage-matched intervention on adherence to continuous positive airway pressure ( CPAP ) in patients with obstructive sleep apnea syndrome . Methods One hundred and ten Chinese patients with newly diagnosed obstructive sleep apnea syndrome were enrolled in this study . They were r and omly assigned into stage-matched care ( SMC ) and st and ard care ( SC ) groups ( 55 patients in each group ) . Patients in the SMC group received stage-matched intervention at different stages of behavior changes , and the SC group received only routine care . The intervention was based on the health action process approach theory and included risk perception , outcome expectancy , and self-efficacy . Question naires included the Self-Efficacy Measure for Sleep Apnea , the Epworth Sleepiness Scale ( ESS ) , and the Pittsburgh Sleep Quality Index ( PSQI ) . Data were collected at baseline and 1 and 3 months after home CPAP treatment , and hours of CPAP usage was also recorded at 1 and 3 months of follow-up . Results At 1 month , CPAP usage was 5.59 ± 0.56 h/night ( mean ± SD ) vs 5.28 ± 0.67 h/night in the SMC and SC groups , respectively ( p = 0.016 ) . At 3 months , CPAP usage was 5.65 ± 0.50 vs 5.26 ± 0.82 h/night in the SMC and SC groups , respectively ( p = 0.006 ) . Repeated ANOVA analysis demonstrated that risk perception , outcome expectancy , and self-efficacy in the SMC group were significantly higher than those of the SC group ( p < 0.05 ) . Moreover , the time × group interaction was significant for outcome expectancy and self-efficacy , indicating that the groups differed significantly in changes in outcome expectancy and self-efficacy over the three time points . There was a significant difference between the SMC and SC groups in terms of improvement in ESS ( p < 0.001 ) and PSQI ( p = 0.013 ) after 3 months of CPAP treatment . Conclusions Stage-matched intervention could not only facilitate intention formation and enhance treatment self-efficacy but significantly improve CPAP adherence in OSA patients for the 3-month treatment OBJECTIVES To examine whether treatment of obstructive sleep apnea ( OSA ) with continuous positive airway pressure ( CPAP ) in patients with Alzheimer 's disease ( AD ) results in better cognitive function . DESIGN R and omized double-blind placebo-controlled trial . Participants were r and omized to therapeutic CPAP for 6 weeks or placebo CPAP for 3 weeks followed by therapeutic CPAP for 3 weeks . SETTING General clinical research center . PARTICIPANTS Fifty-two men and women with mild to moderate AD and OSA . INTERVENTION CPAP . MEASUREMENTS A complete neuropsychological test battery was administered before treatment and at 3 and at 6 weeks . RESULTS A comparison of subjects r and omized to 3 weeks of therapeutic versus placebo CPAP suggested no significant improvements in cognition . A comparison of pre- and posttreatment neuropsychological test scores after 3 weeks of therapeutic CPAP in both groups showed a significant improvement in cognition . The study was underpowered to make definitive statements about improvements within specific cognitive constructs , although exploratory post hoc examination of change scores for individual tests suggested improvements in episodic verbal learning and memory and some aspects of executive functioning such as cognitive flexibility and mental processing speed . CONCLUSION OSA may aggravate cognitive dysfunction in dementia and thus may be a reversible cause of cognitive loss in patients with AD . OSA treatment seems to improve some cognitive functioning . Clinicians who care for patients with AD should consider implementing CPAP treatment when OSA is present The objective of this study was to test whether a telehealth intervention could improve the compliance with continuous positive airway pressure ( CPAP ) by patients with sleep apnea . These patients had been nonadherent for the initial 3 months of therapy even after receiving the initial st and ard and then supplemental audiotaped/videotaped patient education for adhering to CPAP nightly . The material s and methods included a r and omized testing of experimental and placebo interventions . Interventions were delivered by nurses to two groups in their homes by telehealth over a 12-week period . The placebo intervention was used to control for Hawthorne effect , time and attention influences and the novelty of having telehealth in the home . Results following the telehealth interventions were that significantly more patients in the experimental group 1 ( n = 10 ) than the placebo group 2 ( n = 9 ) were adhering nightly to CPAP ( chi 2 = 4.55 , p = 0.033 ) . Group 1 patients reported greater satisfaction with their intervention . However , both groups rated telehealth delivery positively . The mean cost of each 20-minute telehealth visit was 30 dollars while the total cost of the telehealth intervention for each patient was 420 dollars . These costs included telehealth equipment , initial installation , longdistance telephone charges , nurse salary , and intervention material s. Conclusions are that telehealth interventions are a potentially cost-effective service for increasing adherence to prescribed medical treatments . Replication studies with large sample s and in other clinical groups are recommended STUDY OBJECTIVES To compare a clinical pathway using portable monitoring ( PM ) for diagnosis and unattended autotitrating positive airway pressure ( APAP ) for selecting an effective continuous positive airway pressure ( CPAP ) with another pathway using polysomnography ( PSG ) for diagnosis and treatment of obstructive sleep apnea ( OSA ) . DESIGN R and omized parallel group SETTING Veterans Administration Medical Center PATIENTS 106 patients with daytime sleepiness and a high likelihood of having OSA MEASUREMENTS AND RESULTS : The AHI in the PM-APAP group was 29.2 + /- 2.3/h and in the PSG group was 36.8 + /- 4.8/h ( P= NS ) . Patients with an AHI > or = 5 were offered CPAP treatment . Those accepting treatment ( PM-APAP 45 , PSG 43 ) were begun on CPAP using identical devices at similar mean pressures ( 11.2 + /- 0.4 versus 10.9 + /- 0.5 cm H2O ) . At a clinic visit 6 weeks after starting CPAP , 40 patients in the PM-APAP group ( 78.4 % of those with OSA and 88.8 % started on CPAP ) and 39 in the PSG arm ( 81.2 % of those with OSA and 90.6 % of those started on CPAP ) were using CPAP treatment ( P = NS ) . The mean nightly adherence ( PM-APAP : 5.20 + /- 0.28 versus PSG : 5.25 + /- 0.38 h/night ) , decrease in Epworth Sleepiness Scale score ( -6.50 + /- 0.71 versus -6.97 + /- 0.73 ) , improvement in the global Functional Outcome of Sleep Question naire score ( 3.10 + /- 0.05 versus 3.31 + /- 0.52 ) , and CPAP satisfaction did not differ between the groups . CONCLUSIONS A clinical pathway utilizing PM and APAP titration result ed in  CPAP adherence and clinical outcomes similar to one using PSG In a prospect i ve study aim ed at evaluating objective ly the compliance with nasal continuous positive airway pressure ( CPAP ) treatment , 233 obstructive sleep apnea ( OSA ) ( apnea index , > 10 apneas/hour ) patients and 36 nonapneic snorers were studied . The compliance to treatment was measured by the mean rate of use of the CPAP device , obtained from a built-in time counter . The follow-up period was 874 + /- 48 in OSA patients and 675 + /- 83 in snorers .  CPAP was proposed to all OSA patients but only to those snorers who felt improved after an initial laboratory night on CPAP . Nineteen OSA patients refused CPAP .  Of the 214 OSA patients who accepted CPAP  , 181 are still on treatment , with a mean daily rate of use of 5.6 + /- 0.1 hours ( mean + /- SEM ) ; 22 patients stopped CPAP after a variable period of time ; 10 patients died and one acromegalic patient was considered cured after hypophysectomy for a pituitary adenoma . Depending upon the definition of acceptable compliance , the compliance rate in this group was between 77 % and 89 % . The mean rate of use was correlated with indices of disease severity ( apnea index , apnea+hypopnea index , minimal SaO2 during sleep , daytime PaO2 , pulmonary artery pressure ) . Thirty-six nonapneic snorers accepted CPAP . In this group , 26 are still on CPAP , with a mean daily rate of use of 5.4 + /- 0.5 hours ; one patient died ; one underwent uvolopalatopharyngoplasty without follow-up ; and eight stopped CPAP . The compliance rate in this group was between 58 % and 78 % . This study shows that CPAP is reasonably accepted by OSA patients as well as by nonapneic snorers . ( ABSTRACT TRUNCATED AT 250 WORDS OBJECTIVE Adherence to continuous positive airway pressure ( CPAP ) therapy for obstructive sleep apnoea ( OSA ) is poor . We assessed the effectiveness of a motivational interviewing intervention ( motivational interview nurse therapy [ MINT ] ) in addition to best practice st and ard care to improve acceptance and adherence to CPAP therapy in people with a new diagnosis of OSA . METHOD One hundred six Australian adults ( 69 % male ) with a new diagnosis of OSA and a clinical recommendation for CPAP treatment were recruited from a tertiary sleep disorders center . Participants were r and omly assigned to receive either 3 sessions of a motivational interviewing intervention ( MINT ; n = 53 ; mean age = 55.4 years ) or no intervention ( control ; n = 53 ; mean age = 57.74 years ) . The primary outcome was the difference between the groups in objective CPAP adherence at 1-month , 2-month , 3-month , and 12-month follow-ups . RESULTS Fifty ( 94 % ) participants in the MINT group and 50 ( 94 % ) participants in the control group met all inclusion and exclusion criteria and were included in the primary analysis . The number of hours of CPAP use per night in the MINT group at 3 months was 4.63 hr and was 3.16 hr in the control group ( p = .005 ) . This represents almost 50 % better adherence in the MINT group relative to the control group . Patients in the MINT group were substantially more likely to accept CPAP treatment . CONCLUSIONS MINT is a brief , manualized , effective intervention that improves CPAP acceptance and objective adherence rates compared to st and ard care alone Background Obstructive sleep apnea syndrome ( OSAS ) is a serious disorder with significant health consequences . Treatment adherence to auto-titrating positive airway pressure ( APAP ) is often below expectations . We investigated the effectiveness of a brief educational intervention using motivational strategies in treatment adherence among patients with OSAS . Methods The study followed a r and omized , controlled design and included 61 patients diagnosed with OSAS , meeting the criteria for APAP therapy . Patients recruited from a Sleep Disorders Unit were r and omly allocated to an intervention group ( IG ) and two control groups ( CG1 and CG2 ) . In the IG motivational strategies were applied according to patient ’s motivation , assessed by the degree of confidence and conviction . In the CG1 , participants received exclusively st and ardized information , and in the CG2 , routine procedures were followed . Assessment included the Apnea Hypopnea Index ( AHI ) , the Epworth Sleepiness Scale ( ESS ) , and sociodemographic and clinical information . Adherence to treatment was measured after 1 ( T1 ) and 2 months ( T2 ) through the APAP software . Results The IG presented higher adherence to APAP — percentage of days of use > 4 h ( 89.8 % p = 0.013 ) , mean effective use per effective day ( 6.2 p = 0.000 ) , and lower AHI ( 2.7 p = 0.019 ) at T2 when compared with the other two groups . Confidence was higher in the IG group at T2 than at T1 ( p = 0.000 ) . The ESS presented a significant reduction ( p = 0.000 ) in the IG and in the CG1 ( p = 0.008 ) , but was higher in the CG2 ( p = 0.015 ) . Conclusions Brief interventions using motivational strategies can improve a patient ’s adherence to APAP BACKGROUND Obstructive sleep apnea ( OSA ) is associated with a variety of medical conditions . Positive airway pressure ( PAP ) is an effective treatment for improving sleep , yet adherence rates are low . The aim of the current study is to test two treatments versus st and ard care in improving adherence to PAP . METHOD Two hundred twenty-seven patients with OSA were r and omized to st and ard care ( SC ) , education ( ED ) and motivational enhancement therapy ( MET ) .  Adherence was measured objective ly and the first week of adherence ( prior to the intervention ) was used as an a priori moderator of the effect of the various interventions . Mediators of treatment response were also examined using theory-based measures of decisional balance and self-efficacy . RESULTS Adherence declined over time for all three groups . There was a significant interaction between level of adherence during the first week of treatment and treatment group . Those who had moderate levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had MET ; those who had high levels of adherence during their first week of PAP were more likely to adhere to treatment at follow-up if they had ED . MET treatment increased the perception of the positive aspects of PAP , but ED did not . CONCLUSIONS Initial adherence to positive airway pressure could help guide subsequent treatment plans . The results also support social cognitive theory in that educational approaches might be best suited for those who are ready for change whereas more motivational approaches might be best for those who are ambivalent about change Background The treatment of choice for sleep apnoea-hypopnoea syndrome ( SAHS ) is continuous positive airway pressure ( CPAP ) . However , CPAP effectiveness strongly depends on patient adherence to treatment . The aim of this study was to determine the effectiveness of a low-cost , basic intervention on improving CPAP adherence . Methods A controlled parallel-group trial . Participants were SAHS patients for whom CPAP treatment was indicated . Those in the intervention group were shown the results of their sleep test and were told the importance of treatment adherence ; the control group received neither . Outcomes for both groups were compared at 6 months . The primary outcome assessed was CPAP usage . Results One hundred fifty-four patients were included in the intervention group and 167 in the control group . At 6 months , the intervention group had 10 % more participants with CPAP usage ≥4 h , significantly higher adherence as compared to controls ( 5 ± 1.8 h vs 4.3 ± 1.7 , p = 0.031 ) , mean : 0.7 h/day and fewer discontinuations of CPAP . A multiple linear regression model showed that intervention group and daytime sleepiness were variables independently associated with treatment adherence . Conclusions An inexpensive basic intervention involving communication of sleep test results and the importance of CPAP adherence  improves adherence to CPAP therapy . In addition , greater daytime sleepiness is associated with higher CPAP adherence Effectiveness of continuous positive airway pressure ( CPAP ) as a treatment of  obstructive sleep apnea  can be limited by poor compliance , but little is known about how to improve compliance . We performed a r and omized , controlled clinical trial among 33 subjects of two interventions to improve compliance . One group of subjects received weekly phone calls to uncover any problems and encourage use , another received written information about sleep apnea and the importance of regular CPAP use , and a third served as control subjects . We found that intervention improved CPAP compliance ( p = 0.059 ) and that the effect was particularly strong when intervention occurred during the first month of CPAP treatment ( p = 0.004 ) . Although the sample size did not allow definitive investigation of other explanatory variables , subjects with lower levels of education or those with relatives who used CPAP may have benefited from intervention more than other subjects . We conclude that simple , inexpensive efforts to improve compliance with  CPAP  can be effective , especially when applied at the start of CPAP treatment , but optimal intervention may vary with certain patient characteristics STUDY OBJECTIVES To evaluate patient ratings of the acceptability of a peer buddy system ( PBS ) . To promote continuous positive airway pressure ( CPAP ) therapy adherence in patients with obstructive sleep apnea ( OSA ) . To obtain preliminary data on the effectiveness of PBS on sleep-specific health-related quality of life and CPAP adherence . DESIGN Prospect i ve , r and omized , and controlled study . SETTING Academic Center . PARTICIPANTS Thirty-nine patients with OSA and 13 patients with OSA who were experienced CPAP users . INTERVENTIONS Recently diagnosed patients with OSA were r and omly assigned to either the PBS to promote CPAP adherence ( intervention group ) or usual care ( control group ) . MEASUREMENTS Patient satisfaction , Functional Outcomes of Sleep Question naire ( FOSQ ) , CPAP adherence , vigilance , self-efficacy , and patient activation were measured . RESULTS Ninety-one percent of the subjects rated the  PBS  as very satisfactory ( 68 % ) or satisfactory ( 23 % ) . During the 90 days of therapy , weekly CPAP adherence was greater in the intervention than the usual care group ( MANOVA ; F = 2.29 ; p = 0.04 ) . Patient satisfaction was positively correlated with CPAP adherence ( R(2 ) = 0.14 ; p = 0.02 ) . We did not find any group differences for FOSQ , vigilance , self-efficacy , or patient activation in this pilot study . CONCLUSION Our pilot study suggests that the PBS intervention is feasible and received high patient satisfaction ratings . CPAP adherence may be improved by peer-driven intervention , but a larger , adequately powered study is needed . CLINICAL TRIAL INFORMATION Clinical Trials.gov identifier : NCT01164683 . COMMENTARY A commentary on this article appears in this issue on page 551 . CITATION Parthasarathy S ; Wendel C ; Haynes PL ; Atwood C ; Kuna S. A pilot study of CPAP adherence promotion by peer buddies with sleep apnea . J Clin Sleep Med 2013;9(6):543 - 550 Continuous positive airway pressure ( CPAP ) therapy is widely prescribed for patients with the sleep apnea/hypopnea syndrome ( SAHS ) , but the use of CPAP for such patients is disappointingly low . We postulated that providing intensive educational programs and nursing support to SAHS patients might improve CPAP use and outcomes . We also examined the hypothesis that CPAP use would be greater among patients who had initiated their own referral than among those asked to seek help by a partner . We r and omized 80 consecutive , new patients with SAHS to receive either usual support or additional nursing input including CPAP education at home and involving their partners , a 3-night trial of CPAP in our institution 's sleep center , and additional home visits once they had begun CPAP . The primary outcome variable was objective CPAP use ; symptoms , mood , and cognitive function were also assessed after 6 mo .  CPAP use over 6 mo was greater ( p = 0.003 ) among patients receiving intensive than among those receiving st and ard support ( 5.4 + /- 0.3 versus 3.9 + /- 0 . 4 h/night [ mean + /- SEM ] ) , with greater improvements ( p < 0.05 ) in SAHS symptoms , mood , and reaction time in the intensively supported group .  CPAP use was greater ( p = 0.002 ) among patients who initiated their own referrals .  CPAP use and outcomes of therapy can be improved by provision of a nurse-led intensive CPAP education and support program .  CPAP use is lower among patients whose partners ask them to seek treatment STUDY OBJECTIVES Obstructive sleep apnea ( OSA ) is commonly associated with cognitive and functional deficits , some of which are resolved after continuous positive airway pressure ( CPAP ) treatment . The investigation of brain structural changes before and after treatment could provide deep insights into the pathogenesis and the reversibility of this disorder . We hypothesized that severe OSA patients would have altered white matter ( WM ) integrity and cognition and that treatment would improve both the structural damage and the cognitive impairment . DESIGN Prospect i ve clinical study . SETTING The Sleep Disorders Center and the Center of Excellence in High-Field Magnetic Resonance Imaging at Vita-Salute San Raffaele University , Milan , Italy . PARTICIPANTS Seventeen never-treated consecutive OSA patients were evaluated before and after treatment ( after 3 and 12 months ) and compared to 15 matched healthy controls . INTERVENTION CPAP . MEASUREMENTS WM integrity measured by diffusion tensor imaging ( DTI ) and cognitive performance ( measured with neuropsychological testing ) before and after 3 and 12 months of CPAP . RESULTS Results in pre-treatment OSA patients showed impairments in most cognitive areas , mood and sleepiness that were associated with diffuse reduction of WM fiber integrity reflected by diminished fractional anisotropy ( FA ) and mean diffusivity ( MD ) in multiple brain areas . After 3 months of CPAP , only limited changes of WM were found . However , over the course of 12 months CPAP treatment , an almost complete reversal of WM abnormalities in all the affected regions was observed in patients who were compliant with treatment . Significant improvements involving memory , attention , and executive-functioning paralleled WM changes after treatment . CONCLUSIONS Changes of WM DTI " signatures " of brain pathology in OSA patients are appreciable over the course of 12-month treatment with CPAP in most of the regions involved . Recovery of cognitive deficits after treatment is consistent with the presence of a reversible structural neural injury in OSA in patients who were compliant with treatment Although of proven health benefit to persons with obstructive sleep apnea ( OSA ) , adherence to continuous positive airway pressure ( CPAP ) therapy is suboptimal , with patterns of use that are established early and that are not easily altered after the initial experience . In a r and omized controlled trial , 70 participants with OSA and cardiovascular disease were assigned to receive either positively or negatively framed education about CPAP . Objective adherence was measured following 30 days of home CPAP therapy .  Daytime sleepiness , dispositional optimism , self-efficacy , and depression were also evaluated at baseline and after 30 days .  CPAP use was greater in the group receiving negative message framing ( p = .015 ) The objective of this study was to compare continuous positive airway pressure ( CPAP ) use , functional status , and client satisfaction in obstructive sleep apnea syndrome ( OSAS ) patients r and omized to either telemedicine support or traditional care . In our university-affiliated sleep disorders center , patients with OSAS who were initiating CPAP therapy were r and omized to receive telemedicine support vs traditional follow-up care for 30 days . The telemedicine group received a “ Health Buddy ” computer that provided daily Internet-based informational support and feedback for problems experienced with CPAP use . At 30 days , there were no significant differences in the hours of CPAP use between groups receiving traditional care ( M=4.22 , SD±2.05 ) and telemedicine support ( M=4.29 , SD±2.15 ) , p=0.87 , or in the proportion of nights with CPAP use between the traditional ( M=50%±33.8 ) and telemedicine groups ( M=47%±34.2 ) , p=0.61 . No significant differences were found between groups in functional status ( M=2.27±4.56 vs M=2.03±3.88 , respectively , p=0.76 ) or client satisfaction ( M=28.0±3.51 vs M=28.5±3.05 , p=0.43 ) . Patients in the telemedicine and traditional groups had similar CPAP use , functional status , and client satisfaction . The data suggest that telemedicine support as provided by our model compares favorably with traditional care . As a provider-extender , telemedicine support for patients initiating use of CPAP may allow for greater practice efficiency while maintaining quality of care Effective compliance ( time spent at the effective pressure ) with nasal CPAP in obstructive sleep apnea has been reported to be poor . The aim of our study was to evaluate effective compliance in a large European multicenter study . One hundred twenty-one consecutive newly treated patients ( initial apnea-hypopnea index [ AHI ] = 62.0 + /- 29 . 5/h , AHI under CPAP = 6.4 + /- 8.1/h , CPAP pressure = 8.7 + /- 2.6 cm H(2)O , BMI = 33.1 + /- 6.8 kg/m(2 ) ) were r and omly allocated to a group with ( MC(+ ) ) ( n = 58 ) or without ( MC(- ) ) ( n = 63 ) a control unit measuring effective compliance at 1 , 2 , and 3 mo , which was compared with the built-in time counter data . MC(+ ) data were 94 + /- 10 , 98 + /- 5 , and 96 + /- 9 % of counter data at 1 , 2 , and 3 mo , respectively . Using criteria of regular use already reported in the literature ( at least 4 h of nCPAP per day of use and nCPAP administered more than 70 % of the days ) we found 77 , 82 , and 79 % compliant patients at 1 , 2 , and 3 mo , respectively , 79 % of the patients meeting these criteria each month . Although there were no pulmonary functions or polysomnographic differences between the two subgroups , the compliant patients did report a greater improvement in minor symptoms . We found a close correlation between effective use of CPAP and the machine run time . The main result of our study was a higher effective compliance than previously reported , approximately 80 % of the patients being regular users versus 46 % in a previously published study . This may result from different technical and medical follow-up BACKGROUND Obstructive sleep apnea ( OSA ) affects approximately 20 % of US adults , of whom about 90 % are undiagnosed . While OSA may increase risk of perioperative complications , its prevalence among surgical patients is unknown . We tested the feasibility of screening surgical patients for OSA and determined the prevalence of undiagnosed OSA . METHODS In a prospect i ve , observational study adult surgical patients were screened for OSA in an academic hospital . Patients without an OSA diagnosis who screened high-risk were offered a home sleep study to determine if they had OSA . The results were compared with  polysomnography ( PSG )  when available . Charts of high-risk patients were examined for postoperative complications . High-risk patients received targeted interventions as part of a hospital safety initiative . RESULTS There were 2877 patients screened ; 661 ( 23.7 % ) screened high-risk for OSA , of whom 534 ( 81 % ) did not have diagnosed OSA . The portable sleep study detected OSA in 170/207 ( 82 % ) high-risk patients without diagnosed OSA . Twenty-six PSGs confirmed OSA in 19 of these patients . Postoperatively there were no respiratory arrests , two unanticipated ICU admissions , and five documented respiratory complications . CONCLUSION Undiagnosed OSA is prevalent in adult surgical patients . Implementing universal screening is feasible and can identify undiagnosed OSA in many surgical patients . Further investigation is needed into perioperative complications and their prevention for patients with undiagnosed OSA BACKGROUND AND PURPOSE Compliance with continuous positive airway pressure ( CPAP ) treatment in obstructive sleep apnoea syndrome ( OSAS ) may be difficult . Patient education is important but strategies and their outcomes are not clear . PATIENTS AND METHODS We studied the effects of four education strategies on  compliance and quality of life changes with CPAP treatment in seven centres in the French ANTADIR homecare network . Patients received from prescribers either a simple oral explanation ( SP ) or an oral and written explanation ( RP ) of CPAP use . In addition , they received from homecare technicians either a single home visit ( SH ) at CPAP onset or repeated home visits at CPAP onset and at 1 week , 1 month and 3 months after ( RH ) . Compliance and quality of life were evaluated at CPAP onset , and at 3 , 6 and 12 months after initiation of treatment . RESULTS One hundred twelve patients with severe OSAS ( mean age 58+/-11 year , apnoea-hypopnoea index 58+/-25/h ) were allocated r and omly to groups ( SP+SH ; SP+RH ; RP+SH ; RP+RH ) with no initial differences . Quality of life , evaluated by the generic SF-36 question naire , improved in the combined emotional domains . Compliance was over 5h in all four education groups . These effects were sustained over 12 months and were not different between the four groups . We conclude that st and ard education strategies for CPAP induction in France are sufficient for good compliance and improved quality of life with CPAP . Education with reinforced input should be focussed on identified subgroups prone to problems Objective : To eluci date the predictive role of age and other pre-treatment , putative confounding factors on compliance with nasal continuous positive airway pressure ( nCPAP ) therapy . Patients and methods : This study was design ed as a prospect i ve cohort study in the setting of a sleep laboratory in a teaching hospital at Saint Antoine , Paris . One hundred and sixty-three patients referred to the sleep laboratory with complaints of snoring and excessive daytime sleepiness for whom nCPAP had been prescribed for obstructive sleep apnea syndrome ( OSAS ; defined as an apnea-hypopnea index ( AHI ) of > 15/h of sleep during a polysomnographic recording ) were followed for a median period of 887 days . The main outcome measure was the risk ratio for elderly patients associated with nCPAP compliance . Results : Four patients , who remained under treatment , died before the end of the study , and 50 patients stopped their nCPAP therapy for reasons other than death ( insomnia , equipment too noisy , etc . ) . When compliance curves were compared by univariate analysis ( log-rank test ) , the oldest group ( 57/163 patients , > 60 years old ) was significantly less compliant with nCPAP than the youngest ( P=0.01 ) . However , in the Cox 's proportional hazards model , age did not exert any independent effect on compliance with nCPAP  after controlling for confounding factors ( adjusted relative risk , 1.09 , 0.5 - 2 ; P=0.70 ) . On the other h and , female sex ( adjusted relative risk , 2.8 , 1.4 - 5.4 ; P=0.002 ) , a body mass index ( BMI ) of < /=30 kg/m(2 ) ( adjusted relative risk , 2.2 , 1.2 - 4 ; P=0.006 ) , an Epworth sleepiness scale ( ESS ) score of < /=15 ( adjusted relative risk , 3.2 , 1.1 - 8.9 ; P=0.025 ) , an AHI of < /=30/h ( adjusted relative risk , 2.2 , 1.2 - 4 ; P=0.01 ) and a nCPAP of > /=12 cmH(2)O ( adjusted relative risk , 2.3 , 1.2 - 4.4 ; P=0.011 ) were predictive factors for non-compliance . Conclusion : This study suggests that there is no independent effect of age on compliance with nCPAP therapy BACKGROUND OSA is extremely common among patients with resistant hypertension ( HTN ) . However , the impact of the treatment of OSA with CPAP on BP in patients with resistant HTN is not well established . METHODS In the current study , 40 patients with confirmed resistant HTN and moderate to severe OSA confirmed by full polysomnography were r and omized to medical therapy or to medical treatment plus CPAP for 6 months . Patients were evaluated at study baseline and after 6 months by  24-h ambulatory BP monitoring ( ABPM ) . RESULTS Thirty-five patients ( 77 % men ; age , 56 ± 1 years ; BMI , median 32 kg/m² [ 25%-75 % , 28 - 39 kg/m² ] ; apnea-hypopnea index , 29 events/h [ 24 - 48 events/h ] ; Epworth Sleepiness Scale , 10 ± 1 ; systolic/diastolic office BP , 162 ± 4/97 ± 2 mm Hg ; taking four [ four to five ] antihypertensive drugs ) completed the study . CPAP was used for 6:01 ± 0:20 h/night ( 3:42 - 7:44 h/night ) . Compared with the control group , awake systolic/diastolic ABPM decreased significantly in the CPAP group ( Δ : + 3.1 ± 3.3 /+2.1 ± 2.7 mm Hg vs -6.5 ± 3.3/-4.5 ± 1.9 mm Hg , respectively , P < .05 ) . Interestingly , the BP changes were observed only while patients were awake , but not during nocturnal ABPM ( Δ : + 2.8 ± 4.5/+1.8 ± 3.5 mm Hg vs + 1.6 ± 3.5/+0.8 ± 2.9 mm Hg , P = NS ) . CONCLUSIONS The treatment of OSA with CPAP  significantly reduces daytime BP in patients with resistant HTN . Therefore , our study reinforces the importance of recognizing and treating OSA in patients with resistant HTN . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT00812695 ; URL : www . clinical trials.gov Background Obstructive sleep apnea ( OSA ) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2 % to 4 % of working middle-aged adults . Nasal continuous positive airway pressure ( CPAP ) is the gold-st and ard treatment for OSA . Because compliance rates with CPAP therapy are disappointingly low , effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA . Objective The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data , compared to usual clinical care , results in higher CPAP compliance and improved OSA outcomes . Methods 45 patients newly diagnosed with OSA were r and omized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy . CPAP therapists were not blinded to the participants ’ treatment group . Results 20 participants in each group received the design ated intervention . Patients r and omized to telemonitored clinical care used CPAP  an average of 4.1 ± 1.8 hours per night , while the usual clinical care patients averaged 2.8 ± 2.2 hours per night ( P = .07 ) . Telemonitored patients used CPAP  on 78 % ± 22 % of the possible nights , while usual care patients used CPAP on 60 % ± 32 % of the nights ( P = .07 ) . No statistically significant differences between the groups were found on measures of CPAP efficacy , including measures of mask leak and the Apnea-Hypopnea Index . Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group . Patients in both groups were highly satisfied with the care they received and rated themselves as “ not concerned ” that their CPAP data were being wirelessly monitored . Conclusions Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative ( ie , patient and provider ) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users . This study was design ed as a pilot — larger , well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population BACKGROUND Sleep-disordered breathing is prevalent in the general population and has been linked to chronically elevated blood pressure in cross-sectional epidemiologic studies . We performed a prospect i ve , population -based study of the association between objective ly measured sleep-disordered breathing and hypertension ( defined as a laboratory-measured blood pressure of at least 140/90 mm Hg or the use of antihypertensive medications ) . METHODS We analyzed data on sleep-disordered breathing , blood pressure , habitus , and health history at base line and after four years of follow-up in 709 participants of the Wisconsin Sleep Cohort Study ( and after eight years of follow-up in the case of 184 of these participants ) . Participants were assessed overnight by 18-channel polysomnography for sleep-disordered breathing , as defined by the apnea-hypopnea index ( the number of episodes of apnea and hypopnea per hour of sleep ) . The odds ratios for the presence of hypertension at the four-year follow-up study according to the apnea-hypopnea index at base line were estimated after adjustment for base-line hypertension status , body-mass index , neck and waist circumference , age , sex , and weekly use of alcohol and cigarettes . RESULTS Relative to the reference category of an apnea-hypopnea index of 0 events per hour at base line , the odds ratios for the presence of hypertension at follow-up were 1.42 ( 95 percent confidence interval , 1.13 to 1.78 ) with an apnea-hypopnea index of 0.1 to 4.9 events per hour at base line as compared with none , 2.03 ( 95 percent confidence interval , 1.29 to 3.17 ) with an apnea-hypopnea index of 5.0 to 14.9 events per hour , and 2.89 ( 95 percent confidence interval , 1.46 to 5.64 ) with an apnea-hypopnea index of 15.0 or more events per hour . CONCLUSIONS We found a dose-response association between sleep-disordered breathing at base line and the presence of hypertension four years later that was independent of known confounding factors . The findings suggest that sleep-disordered breathing is likely to be a risk factor for hypertension and consequent cardiovascular morbidity in the general population The evidence linking sleep-disordered breathing to increased mortality and cardiovascular morbidity has been conflicting and inconclusive . We hypothesized that a potential adverse effect of disordered breathing would be more obvious in patients with established vascular disease . In a prospect i ve cohort study 408 patients aged 70 yr or younger with verified coronary disease were followed for a median period of 5.1 yr .  An apnea-hypopnea index ( AHI ) of > or = 10 and an oxygen desaturation index ( ODI ) of > or = 5 were used as the diagnostic criteria for sleep-disordered breathing . The primary end point was a composite of death , cerebrovascular events , and myocardial infa rct ion . There was a 70 % relative increase and a 10.7 % absolute increase in the primary composite end point in patients with disordered breathing defined as an ODI of > or = 5 ( risk ratio 1.70 , 95 % confidence interval [ CI ] 1.15 - 2.52 , p = 0.008 ) . Similarly , patients with an AHI of > or = 10 had a 62 % relative increase and a 10.1 % absolute increase in the composite endpoint ( risk ratio 1.62 , 95 % CI 1.09 - 2.41 , p = 0.017 ) . An ODI of > or = 5 and an AHI of > or = 10 were both independently associated with cerebrovascular events ( hazard ratio 2.62 , 95 % CI 1.26 - 5.46 , p = 0.01 , and hazard ratio 2.98 , 95 % CI 1.43 - 6.20 , p = 0.004 , respectively ) . We conclude that sleep-disordered breathing in patients with coronary artery disease is associated with a worse long-term prognosis and has an independent association with cerebrovascular events RATIONALE Obstructive sleep apnea ( OSA ) is an independent risk factor for stroke , but little is known about the role of continuous positive airway pressure ( CPAP ) on mortality in patients with stroke . OBJECTIVES To analyze the independent impact of long-term CPAP treatment on mortality in patients with ischemic stroke . METHODS Prospect i ve observational study in 166 patients with ischemic stroke .  Sleep study was performed in all of them and CPAP treatment was offered in the case of moderate to severe cases . Patients were followed-up for 5 years to analyze the risk of mortality . MEASUREMENTS AND MAIN RESULTS Of 223 patients consecutively admitted for stroke , a sleep study  was performed on 166 of them ( 2 mo after the acute event ) . Thirty-one had an apnea-hypopnea index ( AHI ) of less than 10 ; 39 had an AHI between 10 and 19 , and 96 had an AHI of 20 or greater . CPAP treatment was offered when AHI was 20 or greater . Patients were followed up in our outpatient clinic at 1 , 3 , and 6 months , and for every 6 months thereafter for 5 years ( prospect i ve observational study ) . Mortality data were recorded from our computer data base and official death certificates . The mean age of subjects was 73.3 + /- 11 years ( 59 % males ) , and the mean AHI was 26 ( for all patients with a predominance of obstructive events ) . Patients with an AHI of 20 or greater who did not tolerate CPAP ( n = 68 ) showed an increase adjusted risk of mortality ( hazards ratio [ HR ] , 2.69 ; 95 % confidence interval [ CI ] , 1.32 - 5.61 ) compared with patients with an AHI of less than 20 ( n = 70 ) , and an increased adjusted risk of mortality ( HR , 1.58 ; 95 % CI , 1.01 - 2.49 ; P = 0.04 ) compared with patients with moderate to severe OSA who tolerated CPAP ( n = 28 ) . There were no differences in mortality among patients without OSA , patients with mild disease , and patients who tolerated CPAP . CONCLUSIONS Our results suggest that long-term CPAP treatment in moderate to severe OSA and ischemic stroke is associated with a reduction in excess risk of mortality BACKGROUND CPAP remains the treatment of choice for Obstructive Sleep Apnea Hypopnea Syndrome ( OSAHS ) , but compliance with CPAP is poor . Of many interventions tried to improve CPAP compliance , only education and humidification have been shown to be of benefit . Our purpose was to develop and pilot test a video to enhance patient underst and ing of obstructive sleep apnea and of the purpose , logistics , and benefits of CPAP use in patients newly diagnosed with OSAHS . A patient 's CPAP compliance in the first few weeks after starting its use is predictive of long-term compliance with CPAP treatment . It is imperative that patients grasp at the outset both the severity of OSAHS and the effectiveness of CPAP therapy . METHODS An educational video script was written based on recommendations for patient educational video material s and covering identified misconceptions about OSAHS and perceived barriers to CPAP use . The videotape is 15 min in length and features two middle-aged males , one African-American and one Euro-American , discussing OSAHS and CPAP in a factory break room . RESULTS In a r and omized two-group design with a control group , patients with newly diagnosed OSAHS , and who viewed the CPAP educational video on their first clinic , were significantly more likely to use their machine and to return for a 1-month clinic visit than were those in the control group . CONCLUSION Viewing of a patient education video at the initial visit was found to significantly improve the rate of return for the follow-up visit BACKGROUND Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy . This r and omized controlled trial ( RCT ) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA . METHODS Subjects with newly diagnosed OSA were recruited into this RCT . The control group received usual advice on the importance of CPAP therapy and its care . The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects ' knowledge , motivation , and self-efficacy to use CPAP through the use of a 25-min video , a 20-min patient-centered interview , and a 10-min telephone follow-up  . Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months . CPAP usage data were downloaded at the completion of this 3-month study . RESULTS One hundred subjects with OSA ( mean ± SD , age 52 ± 10 years ; Epworth Sleepiness Scales [ ESS ] , 9 ± 5 ; median [ interquartile range ] apnea-hypopnea index , 29 [ 20 , 53 ] events/h ) prescribed CPAP treatment were recruited . The intervention group had better CPAP use ( higher daily CPAP usage by 2 h/d [ Cohen d = 1.33 , P < .001 ] , a fourfold increase in the number using CPAP for ≥ 70 % of days with ≥ 4 h/d [ P < .001 ] ) , and greater improvements in daytime sleepiness ( ESS ) by 2.2 units ( P = .001 ) and treatment self-efficacy by 0.2 units ( P = .012 ) compared with the control group . CONCLUSIONS 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 . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01173406 ; URL : www . clinical trials.gov Purpose Auto-titrating continuous positive airway pressure ( APAP ) is an effective treatment for obstructive sleep apnea/hypopnea syndrome ( OSAHS ) . We investigated whether a single group education session on APAP therapy is effective in promoting adherence among patients with OSAHS . Methods This prospect i ve , r and omized , controlled , parallel group study included patients newly diagnosed with OSAHS who met criteria for APAP therapy . Patients were r and omized into a study group and a control group . All patients in the study group were assigned to a single group education session , 1 month after beginning APAP therapy . Results We evaluated 146 patients . The median percentage of APAP usage days was 88.3 % , with a median duration per day of use of 6.02 h ; 59 % were classified as adherent . Overall , no significant difference in adherence was seen between the study and the control groups . Analyzing patient subgroups , the group session significantly improved APAP adherence among males and patients who were younger ( < 65 years old ) , obese ( BMI ≥35 kg/m2 ) , non-sleepy ( Epworth sleepiness scale ≤11 ) , smokers or past smokers , had hypertension or nocturia and those with non-severe OSAHS . Conclusion To maximize the impact of group education sessions and , by that , saving re sources , it may be important to select patients likely to benefit from these sessions BACKGROUND New approaches are needed to treat patients with stroke . Among acute ischemic stroke patients , our primary objectives were to describe the prevalence of sleep apnea and demonstrate the feasibility of providing auto-titrating continuous positive airway pressure ( auto-CPAP ) . A secondary objective was to examine the effect of auto-CPAP on stroke severity . METHODS Stroke patients r and omized to the intervention group received 2 nights of auto-CPAP , but only those with evidence of sleep apnea received auto-CPAP for the remainder of the 30-day period . Intervention patients received polysomnography 30 days post-stroke . Control patients received polysomnography at baseline and after 30 days . Acceptable auto-CPAP adherence was defined as ≥ 4 h/night for ≥ 75 % nights . Change in stroke severity was assessed comparing the NIH Stroke Scale ( NIHSS ) at baseline versus at 30 days . RESULTS The 2 groups ( intervention N = 31 , control N = 24 ) had similar baseline stroke severity ( both median NIHSS , 3.0 ) . Among patients with complete polysomnography data , the majority had sleep apnea : baseline , 13/15 ( 86.7 % ) control patients ; 30 days , 24/35 ( 68.6 % ) control and intervention patients . Intervention patients had greater improvements in NIHSS ( -3.0 ) than control patients ( -1.0 ) ; P = 0.03 . Among patients with sleep apnea , greater improvement was observed with increasing auto-CPAP use : -1.0 for control patients not using auto-CPAP ; -2.5 for intervention patients with some auto-CPAP use ; and -3.0 for intervention patients with acceptable auto-CPAP adherence . CONCLUSIONS The majority of acute stroke patients had sleep apnea . Auto-CPAP was well tolerated , appears to improve neurological recovery from stroke , and may represent a new therapeutic approach for selected patients with acute cerebral infa rct ion BACKGROUND Obstructive sleep apnoea ( OSA ) impairs vigilance and may lead to an increased rate of driving accidents . In uncontrolled studies accident rates and simulated steering performance improve following treatment with nasal continuous positive airway pressure ( NCPAP ) . This study seeks to confirm the improvement in steering performance in a r and omised controlled trial using subtherapeutic NCPAP as a control treatment . METHODS Fifty nine men with OSA ( Epworth Sleepiness Score ( ESS ) of > or = 10 , and > or = 10/h dips in SaO(2 ) of > 4 % due to OSA ) received therapeutic or subtherapeutic NCPAP ( approximately 1 cm H(2)O ) for one month . Simulated steering performance over three 30-minute " drives " was quantified as : st and ard deviation ( SD ) of road position , deterioration in SD across the drive , length of drive before " crashing " , and number of off-road events . The reaction times to peripheral target stimuli during the drive were also measured . RESULTS Subtherapeutic NCPAP did not improve overnight > 4 % SaO(2 ) dips/h compared with baseline values , thus acting as a control . The SD of the steering position improved from 0.36 to 0.21 on therapeutic NCPAP , and from 0.35 to 0.30 on subtherapeutic NCPAP ( p = 0.03 ) . Deterioration in SD of the steering position improved from 0.18 to 0.06 SD/h with therapeutic NCPAP and worsened from 0.18 to 0.24 with subtherapeutic NCPAP ( p = 0.04 ) . The reaction time to target stimuli was quicker after therapeutic than after subtherapeutic NCPAP ( 2.3 versus 2.7 seconds , p = 0.04 ) . CONCLUSIONS Therapeutic NCPAP improves steering performance and reaction time to target stimuli in patients with OSA , lending further support to the hypothesis that OSA impairs driving , increases driving accident rates , and that these improve following treatment with NCPAP BACKGROUND Results of clinical studies suggest that there may be a relationship between breathing-related sleep disorders and depressive disorders . This study aims to assess the impact of breathing-related sleep disorder on major depressive disorder in the general population . METHOD A cross-sectional telephone survey was carried out between 1994 and 1999 in the general population of the United Kingdom , Germany , Italy , Portugal , and Spain . A total of 18,980 r and omly selected subjects aged 15 to 100 years and representative of the general population of their respective countries participated in the study . The question naire included a series of questions about  sleep quality , breathing-related sleep disorder symptoms , mental disorders , and medical conditions . Data are presented using point prevalence . RESULTS 2.1 % of the subjects were found with  obstructive sleep apnea syndrome  at the time of the interview , and 2.5 % had some other type of DSM-IV breathing-related sleep disorder diagnosis . The association of DSM-IV breathing-related sleep disorder diagnosis and major depressive disorder diagnosis was found in 0.8 % of the sample . As many as 18 % of individuals with a major depressive disorder diagnosis also have a DSM-IV breathing-related sleep disorders diagnosis , and 17.6 % of subjects with a DSM-IV breathing-related sleep disorders diagnosis have a major depressive disorder diagnosis . Multivariate models showed that even after controlling for obesity and hypertension , the odds of having a DSM-IV breathing-related sleep disorders diagnosis was 5.26 for individuals with a major depressive disorder diagnosis . CONCLUSION About 800 of 100,000 individuals have both a breathing-related sleep disorder and a major depressive disorder . The identification of 1 of these 2 disorders should prompt the investigation of the other disorder since nearly a fifth of them have the other disorder STUDY OBJECTIVES ( 1 ) To determine the efficacy of automatically adjusted positive airway pressure ( APAP ) with a comfort feature ( A-Flex ) at reducing  apneas and hypopneas in participants with moderate to severe OSA . ( 2 ) To determine the relative difference between A-Flex , continuous positive airway pressure ( CPAP ) , and APAP-derived optimal pressure for CPAP ( CPAP(APAP ) ) on adherence to treatment . ( 3 ) To determine the relative difference between APAP with A-Flex , CPAP , and CPAP(APAP ) on long-term change in functional outcomes . DESIGN R and omized , double-blinded , 3-arm , multicenter trial . SETTING University and Veterans Affairs medical centers . PATIENTS OR PARTICIPANTS 168 participants were r and omized , and 140 completed the 180-day study . INTERVENTIONS ( 1 ) A-Flex ; ( 2 ) CPAP ; ( 3 ) APAP for 14 days and then switched to CPAP at a fixed pressure . MEASUREMENTS AND RESULTS Apnea-hypopnea indices , average and minimum oxygen saturation , time spent < 90 % were significantly poorer for A-Flex vs. CPAP at the initiation of study treatment ; with the exception of minimum oxygen saturation , these differences were absent at 180 days . A-Flex had lower average leak values at both 3 and 6 months . There were no significant differences between groups in major efficacy , adherence , and outcome ( subjective sleepiness , objective vigilance , blood pressure , quality of life ) measures . No differences between groups in attitudes toward use were observed at 3 or 6 months ; participant ratings for CPAP were significantly higher than A-Flex on treatment satisfaction and benefit , but not different for sleep quality and mask comfort . CONCLUSIONS We found that A-Flex shows equivalency , but non-superiority ( except for average leak values ) , in efficacy , adherence , and functional outcomes compared to CPAP after either 3 or 6 months . CLINICAL TRIAL REGISTRY Positive Pressure Treatment of Obstructive Sleep Apnea , http://www . clinical trials.gov , NCT00636181 STUDY OBJECTIVES Obstructive sleep apnea ( OSA ) has been associated with hypertension , which is one of the intermediary mechanisms leading to increased cardiovascular morbidity . This study aim ed at evaluating the effects of a combination of continuous positive airway pressure ( CPAP ) and telemedicine support on blood pressure ( BP ) reduction in high cardiovascular risk OSA patients . DESIGN A multi-center r and omized controlled trial that compared st and ard CPAP care and CPAP care and a telemedicine intervention . SETTING Sleep clinics in France . PATIENTS OR PARTICIPANTS 107 adult ( 18 - 65 years old ) OSA patients ( AHI > 15 events/h ) with a high cardiovascular risk ( cardiovascular SCORE > 5 % or secondary prevention ) . INTERVENTIONS Patients were r and omized to either  st and ard care CPAP ( n = 53 ) or CPAP and telemedicine ( n = 54 ) . Patients assigned to telemedicine were equipped with a smartphone for uploading  BP measurements , CPAP adherence , sleepiness , and quality of life data  ; in return , they received pictograms containing health-related messages . MEASUREMENTS The main outcome was home self-measured BP and secondary outcomes were cardiovascular risk evolution , objective physical activity , CPAP adherence , sleepiness and quality of life . RESULTS Self-measured BP did not improve in either group ( telemedicine or st and ard care ) . Patients in primary prevention showed greater BP reduction with CPAP treatment than those in secondary prevention . CONCLUSIONS CPAP treatment supported by telemedicine alone did not improve blood pressure and cardiovascular risk in high cardiovascular risk OSA patients . This study emphasizes the need for diet and physical activity training programs in addition to CPAP when aim ing at decreasing cardiometabolic risk factors in these patients . CLINICAL TRIALS REGISTRATION Clinical Trials.gov identifier : NCT01226641 Previous reports have described compliance with nasal continuous positive airway pressure ( nCPAP ) for the treatment of obstructive sleep apnea ( OSA ) only in terms of the number of patients able to use it beyond their initial trial night or those continuing after some home use . Because of a possible difference between the level of compliance ( mean number of hours of use per 24 h ) needed for symptomatic relief of OSA versus cardiovascular improvement , the level of hourly compliance in chronic nCPAP users may be important . The first part of this study prospect ively examines compliance in a stable population of OSA patients already using nCPAP for 6 months to 2 yr . The second part is a prospect i ve r and omized , crossover study examining the effect of weekly ( three times ) then monthly ( twice ) positive reinforcement on hourly compliance of new  nCPAP users for 3 months versus no reinforcement for 3 months . Positive reinforcement consisted of telephone discussion s with the patients about the severity or complications of OSA , benefits of  nCPAP  , and suggestions about minimizing side effects . Using self- assessment scales , each patient reported the perceived level of improvement from the untreated to the treated condition and the prevalence and severity of side effects from the nCPAP therapy . The level of compliance in stable , chronic nCPAP users with OSA was 6.1 + /- 2.2 h/24 h ( n = 9 ) . For the new nCPAP users during the nonreinforced period , the mean compliance was 6.0 + /- 2.8 h/24 h ; that during the reinforcement period was 6.0 + /- 2.7 h/24 h ( NS ) . There was no significant correlation between perceived improvement in OSA symptoms or between the perceived side effects of nCPAP versus hourly compliance . ( ABSTRACT TRUNCATED AT 250 WORDS BACKGROUND Obstructive sleep apnea is a prevalent condition with potentially serious medical and psychosocial consequences . Nasal continuous positive airway pressure ( CPAP ) is the treatment-of-choice and has been shown to reduce the frequency of nocturnal respiratory events , improve sleep architecture and decrease daytime sleepiness . Patient compliance with CPAP is disappointingly low . Previous studies examining determinants of CPAP compliance have limited the variables studied to patient ( sociodemographic ) , disease status , and treatment variables , with few reliable determinants found . METHODS The purpose of the current study was to investigate the relationship between objective ly measured CPAP compliance and variables from social cognitive theory ( SCT ) and the transtheoretical model ( TM ) . Scales that measure variables from each model were developed and reliability evaluated . The relationship between the  SCT and TM variables and compliance at 1-month post-CPAP-fitting was prospect ively evaluated on 51 first-time CPAP users .  SCT and TM variables were measured on the day of CPAP-fitting , at 1-week post-CPAP-fitting , and at 1-month post-CPAP-fitting . RESULTS SCT variables measured 1-week post-CPAP-fitting ( R(2)=0.261 , P=0.001 ) and TM variables measured 1-week post-CPAP-fitting ( R(2)=0.17 , P=0.002 ) accounted for a statistically significant amount of variance in objective CPAP compliance measured at 1 month . The decisional balance index ( from TM ) individually accounted for a significant amount of variance in objective CPAP compliance in the above analyses . CONCLUSIONS The ability of these new behavior change scales to predict CPAP compliance provides us with a new direction of research to better underst and factors associated with compliance . The principal advantage of these theory-driven and empirically vali date d scales are that they measure modifiable factors that can provide the basis for sound interventions to improve CPAP compliance BACKGROUND AND PURPOSE To evaluate ( a ) whether an active weight reduction strategy based on the cognitive-behavioral approach and an initial very-low-calorie diet might lead to short- and long-term weight loss and alleviation of OSAS ; and ( b ) whether the results of this intervention could be enhanced by combining it with nasal continuous positive airway pressure ( CPAP ) treatment during the first 6 months . PATIENTS AND METHODS Thirty-one obese male symptomatic sleep apnea patients underwent a 2-year weight reduction program with total follow-up of 36 months from baseline . The mean age ( + /-SD ) was 49.1+/-7.9 years , body mass index 43.8+/-5.4 , and oxygen desaturation index ( ODI4 ) 51.3+/-31.1 . The patients were r and omized to CPAP ( 17 patients ) and non-CPAP groups ( 14 patients ) . RESULTS The mean weight loss was 19.1+/-10.2 kg ( 14 % of the original weight ) for the whole group at 6 months , 18.3+/-13.2 ( 13 % ) at 12 months and 12.6+/-14.7 kg ( 9 % ) at 24 months . Excellent or good treatment results , as defined in terms of an ODI4 ( average number of oxygen desaturation events p/h>4 % from baseline ) reduction of at least 50 % from the baseline , were seen in 61 % of patients at 6 months and were still observable in 42 % of patients at 24 months . The correlations between changes in weight and in ODI4 were 0.59 ( P<0.01 ) at 6 months , 0.68 ( P<0.01 ) and 0.75 ( P<0.01 ) at 24 months . Adding CPAP treatment to the weight reduction therapy for the first 6 months did not result in greater weight loss or diminution of desaturation indices ( without CPAP ) at any time point . One year after the termination of the program the mean weight loss was 6.6+/-12.9 kg , and 42 % of patients still showed at least 5 % weight loss as compared with their original weight . CONCLUSION Satisfactory weight loss associated with improvement of OSAS could be achieved by means of a cognitive-behavioral weight loss program . Adding CPAP in the initial phase of the weight reduction program did not result in significantly greater weight loss RATIONALE Obstructive sleep apnea ( OSA ) is a risk factor for cardiovascular death in middle-aged subjects , but it is not known whether it is also a risk factor in the elderly . OBJECTIVES To investigate whether OSA is a risk factor for cardiovascular death and to assess whether continuous positive airway pressure ( CPAP ) treatment is associated with a change in risk in the elderly . METHODS Prospect i ve , observational study of a consecutive cohort of elderly patients ( ≥65 yr ) studied for suspicion of OSA between 1998 and 2007 . Patients with an apnea-hypopnea index ( AHI ) less than 15 were the control group . OSA was defined as mild to moderate ( AHI , 15 - 29 ) or severe ( AHI , ≥30 ) . Patients with OSA were classified as CPAP-treated ( adherence ≥ 4 h/d ) or untreated ( adherence < 4 h/d or not prescribed ) . Participants were monitored until December 2009 . The end point was cardiovascular death . A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on cardiovascular mortality . MEASUREMENTS AND MAIN RESULTS A total of 939 elderly were studied ( median follow-up , 69 mo ) . Compared with the control group , the fully adjusted hazard ratios for cardiovascular mortality were 2.25 ( confidence interval [ CI ] , 1.41 to 3.61 ) for the untreated severe OSA group , 0.93 ( CI , 0.46 to 1.89 ) for the CPAP-treated group , and 1.38 ( CI , 0.73 to 2.64 ) for the untreated mild to moderate OSA group . CONCLUSIONS Severe OSA not treated with CPAP is associated with cardiovascular death in the elderly , and adequate CPAP treatment may reduce this risk STUDY OBJECTIVE To improve adherence to continuous positive airway pressure ( CPAP ) treatment in participants with obstructive sleep apnea ( OSA ) using a cognitive behavioral therapy ( CBT ) intervention . DESIGN A r and omized controlled trial . SETTING A major teaching hospital in Sydney ( 2005 ) . PARTICIPANTS One hundred individuals ( 96 men ) , ranging in age from 32 to 81 years , diagnosed with OSA . INTERVENTION Two 1-hour CBT interventions ( including a video of real CPAP users ) plus treatment as usual ( mask fitting and information ) or treatment as usual only . MEASUREMENTS AND RESULTS Hours of CPAP usage was assessed at 7 nights and 28 nights . Adherence was defined as usage at least 4 hours per night . Question naires measuring self-efficacy , social support , and expectancy ( mediators of adherence ) were given after intervention or after usual treatment . A higher adherence to CPAP therapy was found in the CBT group ( 2.9 hours difference ) relative to treatment as usual ( P < 0.001 ) at 28 days . Only 4 participants in the CBT group did not initiate treatments after their titration study , compared with 15 in the treatment as usual group ( P < 0.02 ) . The CBT group had significantly higher scores for self-efficacy ( P < 0.001 ) and social support P < 0.008 ) but not for expectancy . CONCLUSIONS The CBT intervention result ed in both increased adherence and " uptake " of CPAP and therefore would be expected to reduce the social , economic , and health-related consequences of untreated OSA CONTEXT Sleep-disordered breathing ( characterized by recurrent arousals from sleep and intermittent hypoxemia ) is common among older adults . Cross-sectional studies have linked sleep-disordered breathing to poor cognition ; however , it remains unclear whether sleep-disordered breathing precedes cognitive impairment in older adults . OBJECTIVES To determine the prospect i ve relationship between sleep-disordered breathing and cognitive impairment and to investigate potential mechanisms of this association . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve sleep and cognition study of 298 women without dementia ( mean [ SD ] age : 82.3 [ 3.2 ] years ) who had overnight polysomnography measured between January 2002 and April 2004 in a sub study of the Study of Osteoporotic Fractures . Sleep-disordered breathing was defined as an apnea-hypopnea index of 15 or more events per hour of sleep . Multivariate logistic regression was used to determine the independent association of sleep-disordered breathing with risk of mild cognitive impairment or dementia , adjusting for age , race , body mass index , education level , smoking status , presence of diabetes , presence of hypertension , medication use ( antidepressants , benzodiazepines , or nonbenzodiazepine anxiolytics ) , and baseline cognitive scores . Measures of hypoxia , sleep fragmentation , and sleep duration were investigated as underlying mechanisms for this relationship . MAIN OUTCOME MEASURES Adjudicated cognitive status ( normal , dementia , or mild cognitive impairment ) based on data collected between November 2006 and September 2008 . RESULTS Compared with the 193 women without sleep-disordered breathing , the 105 women ( 35.2 % ) with sleep-disordered breathing were more likely to develop mild cognitive impairment or dementia ( 31.1 % [ n = 60 ] vs 44.8 % [ n = 47 ] ; adjusted odds ratio [ AOR ] , 1.85 ; 95 % confidence interval [ CI ] , 1.11 - 3.08 ) . Elevated oxygen desaturation index ( ≥15 events/hour ) and high percentage of sleep time ( > 7 % ) in apnea or hypopnea ( both measures of disordered breathing ) were associated with risk of developing mild cognitive impairment or dementia ( AOR , 1.71 [ 95 % CI , 1.04 - 2.83 ] and AOR , 2.04 [ 95 % CI , 1.10 - 3.78 ] , respectively ) . Measures of sleep fragmentation ( arousal index and wake after sleep onset ) or sleep duration ( total sleep time ) were not associated with risk of cognitive impairment . CONCLUSION Among older women , those with sleep-disordered breathing compared with those without sleep-disordered breathing had an increased risk of developing cognitive impairment BACKGROUND Despite the increasing aging population and the high prevalence of OSA in elderly adults , little is known about cognitive effects of OSA and the effectiveness of CPAP treatment . Therefore , this study investigated whether elderly patients with OSA present cognitive deficits and functional and structural alterations of the brain that could be improved by CPAP treatment . METHODS This r and omized , evaluator-blinded , parallel-group , single-center pilot study involved patients aged ≥ 65 years with newly-diagnosed severe OSA syndrome . Thirty-three patients were assigned to receive either conservative care ( CC ) or CPAP plus CC for 3 months . At baseline and 3 months after treatment , patients underwent a  neuropsychologic evaluation and a functional and structural MRI study of connectivity within the default mode network ( DMN ) and of cortical thickness . RESULTS Neuropsychologic evaluation revealed no differences in cognitive performance between OSA groups at baseline . By contrast , after CPAP treatment , patients showed a significant improvement in episodic ( between-group difference in change , 7.60 ; 95 % CI , 1.66 - 13.55 ; P = .014 ) and short-term memory ( between-group difference in change , 1.06 ; 95 % CI , 0.10 - 2.01 ; P = .032 ) and in executive function ( speed of mental processing , 5.74 ; 95 % CI , 1.69 - 9.79 ; P = .007 ; mental flexibility , -47.64 ; 95 % CI , -81.83 to -13.45 ; P = .008 ) , whereas no changes were observed in the CC group . Neuroimaging revealed an increase in the connectivity in the right middle frontal gyrus after 3 months of CPAP treatment and a higher percentage of cortical thinning in the CC group . No association was seen between cognition and brain functional connectivity changes within the DMN . CONCLUSIONS Elderly patients with severe OSA who present with cognitive difficulties  could benefit from CPAP treatment . Moreover , CPAP treatment increases the connectivity of the DMN and attenuates cortical thinning . TRIAL REGISTRY Clinical Trials.gov ; No. : NCT01826032 ; URL : www . clinical trials.gov STUDY OBJECTIVES First-line therapy for patients with moderate to severe obstructive sleep apnea ( OSA ) is positive airway pressure ( PAP ) . Although PAP is a highly efficacious treatment , adherence to PAP is still a substantial clinical problem . The objective of this study was to determine whether PAP adherence can be improved with a telemedicine monitoring system . DESIGN A nonblinded , single-center , r and omized controlled trial that compared st and ard PAP treatment versus PAP treatment and a telemedicine monitoring system SETTING University sleep disorders program in British Columbia , Canada PATIENTS Adult patients ( ≥ 19 yr of age ) with moderate to severe OSA ( apnea hypopnea index ( AHI ) ≥ 15 events/hr determined by polysomnography ) prescribed PAP INTERVENTIONS : Patients were r and omized to either st and ard care with an autotitrating PAP machine or an autotitrating PAP machine that transmitted physiologic information ( i.e. , adherence , air leak , residual AHI ) daily to a website that could be review ed . If problems were identified from information from the website , the patient was contacted by telephone as necessary . MEASUREMENTS PAP adherence after 3 mo , subjective sleep quality , and side effects RESULTS Seventy-five patients were enrolled ; 39 were r and omized to telemedicine and 36 to st and ard care . The mean age ± st and ard deviation ( SD ) was 53.5 ± 11.2 yr , mean AHI was 41.6 ± 22.1 events/hr , and 80 % of patients were male . After 3 mo , mean PAP adherence was significantly greater in the telemedicine arm ( 191 min per day ) versus the st and ard arm ( 105 min per day ; mean difference = 87 min , 95 % confidence interval ( CI ) : 25 - 148 min , P = 0.006 , unpaired t test ) . On days when PAP was used , mean adherence was 321 min in the telemedicine arm and 207 min in the st and ard arm ( difference = 113 min , 95 % CI : 62 - 164 min , P < 0.0001 ) . Significant independent predictors of adherence included age , baseline Epworth Sleepiness Scale score , and use of telemedicine . On average , an additional 67 min of technician time was spent on patients in the telemedicine arm compared with the st and ard arm ( P = 0.0001 ) . CONCLUSIONS PAP adherence can be improved with the use of a web-based telemedicine system at the initiation of treatment RATIONALE Obstructive sleep apnea ( OSA ) is a prevalent disease . Often limited clinical re sources result in long patient waiting lists . Simpler vali date d methods of care are needed . OBJECTIVES To demonstrate that a nurse-led model of care can produce health outcomes in symptomatic moderate-severe OSA not inferior to physician-led care . METHODS A r and omized controlled multicenter noninferiority clinical trial was performed . Of 1,427 potentially eligible patients at 3 centers , 882 consented to the trial . Of these , 263 were excluded on the basis of clinical criteria . Of the remaining 619 , 195 met home oximetry criteria for high-probability moderate-severe OSA and were r and omized to 2 models of care : model A , the simplified model , using home autoadjusting positive airway pressure to set therapeutic continuous positive airway pressure ( CPAP ) , with all care supervised by an experienced nurse ; and model B , involving two laboratory polysomnograms to diagnose and treat OSA , with clinical care supervised by a sleep physician . The primary end point was change in Epworth Sleepiness Scale ( ESS ) score after 3 months of CPAP . Other outcome measures were collected . MEASUREMENTS AND MAIN RESULTS For the primary outcome change in ESS score , nurse-led management was no worse than physician-led management ( 4.02 vs. 4.15 ; difference , -0.13 ; 95 % confidence interval : -1.52 , 1.25 ) given a prespecified noninferiority margin of -2 for the lower 95 % confidence interval . There were also no differences between both groups in CPAP adherence at 3 months or other outcome measures . Within-trial costs were significantly less in model A. CONCLUSIONS A simplified nurse-led model of care has demonstrated noninferior results to physician-directed care in the management of symptomatic moderate-severe OSA , while being less costly . Clinical trial registered with http://www.anzctr.org.au ( ACTRN012605000064606 )
BACKGROUND Although effective in the treatment of obstructive sleep apnoea ( OSA ) , continuous positive airway pressure ( CPAP ) is not universally accepted by users .
Educational , supportive and behavioural interventions may help people with OSA recognise the need for regular and continued use of CPAP .
OBJECTIVES To assess the effectiveness of strategies that are educational , supportive or behavioural in encouraging people who have been prescribed CPAP  to use their machines .