Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older Veterans

老年退伍军人共病失眠和睡眠呼吸暂停的新疗法

• 批准号: 8595191
• 负责人: Cathy A Alessi
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2014
• 资助国家: 美国
• 起止时间: 2014-02-01 至 2017-06-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/8595191
• 关键词: Address; Adherence; Adverse effects; Age; Allied Health Personnel; Attention; Attitude; Behavior Therapy; Behavioral; Belief; Breathing; Chronic; Chronic Insomnia; Clinic; Cognitive Therapy; Comorbid Insomnia; Diagnosis; Diagnostic; Disease; Early treatment; Education; Elderly; Fatigue; Future; General Population; Goals; Guidelines; Health; Health Care Costs; Healthcare Systems; High Prevalence; Impaired cognition; Impairment; Intervention; Los Angeles; Measures; Mental Health; Moods; Obstructive Sleep Apnea; Outcome; Outpatients; Participant; Patient Self-Report; Patients; Pattern; Pharmaceutical Preparations; Practice Management; Prevalence; Quality of Care; Quality of life; Randomized; Randomized Controlled Trials; Recruitment Activity; Reporting; Research; Sampling; Sleep; Sleep Apnea Syndromes; Sleep disturbances; Sleeplessness; Specialist; Symptoms; Testing; Veterans; Work; adverse outcome; aged; airway obstruction; base; cardiovascular disorder risk; clinical care; compliance behavior; depressive symptoms; experience; falls; follow-up; health care service utilization; health related quality of life; improved; innovation; meetings; mortality; novel; population based; pressure; programs; response; standard care; success; treatment trial

DESCRIPTION (provided by applicant): Obstructive sleep apnea (OSA) is a disorder characterized by repetitive episodes of complete or partial upper airway obstruction occurring during sleep. OSA increases in prevalence with age, and is associated with increased risk of cardiovascular disease, decreased quality of life, and increased mortality. Insomnia also increases in prevalence with age, and is associated with numerous adverse outcomes, including decreased quality of life, increased healthcare costs and increased mortality. The diagnostic criteria for insomnia include a decreased ability to fall asleep or stay asleep, frequent nighttime awakening or poor quality sleep that is associated with daytime impairment such as fatigue, impaired attention, or daytime sleepiness. Recent evidence suggests that insomnia often coexists with OSA, particularly in older adults, and predicts worse outcomes of OSA. Both OSA and insomnia have an even higher prevalence among Veterans compared to the general population. Little is known of the best approaches to manage the large number of patients with coexisting OSA and comorbid insomnia. Guidelines for best practice typically address these conditions separately, where positive airway pressure (PAP) therapy is the standard for the treatment of OSA, and cognitive behavioral therapy for insomnia (CBT-I) is considered first-line treatment for chronic insomnia. In fact, most CBT-I trials have excluded participants with evidence of OSA, and most PAP treatment trials do not address coexisting insomnia. CBT-I is particularly recommended for insomnia in older adults, where adverse effects of sleeping medications are most problematic. Adherence rates to PAP therapy in patients with OSA are very low (particularly among Veterans), and coexisting insomnia predicts lower adherence with PAP. Several studies have demonstrated that early adherence to PAP therapy (i.e., how adherent the OSA patient is with PAP therapy early in the course of treatment) is one of the strongest predictors of long-term PAP adherence. Unfortunately, in many patients, once OSA is identified and PAP therapy initiated, insomnia symptoms are either not addressed at all, or are only considered once the patient has established a long-term pattern of nonadherence with PAP. Based on this evidence, and findings from our own extensive prior work, we believe that a novel, integrated, behavioral treatment approach which addresses both OSA and insomnia early in the course of PAP therapy is needed to maximize patient adherence and treatment success when these conditions coexist. We propose a randomized controlled trial to test a novel, behavioral approach integrating best practices among older Veterans (aged > 60 years, N=120) diagnosed with OSA who are prescribed PAP therapy and have comorbid insomnia. Participants will be recruited among older Veterans referred to sleep clinics in the VA Greater Los Angeles Healthcare System who are diagnosed with OSA and prescribed PAP therapy, and also meet diagnostic criteria for insomnia. The intervention will combine CBT-I with a behavioral PAP adherence program, provided by allied health personnel and initiated early during PAP treatment. Participants randomized to the control condition will receive an active, attention control program including general sleep and OSA education. Our specific aims are to test whether this combined, integrated CBT-I and behavioral PAP intervention improves sleep, PAP adherence, mood and health-related quality of life among older Veterans with OSA and comorbid insomnia. We will also explore participants' experiences, attitudes and adherence with key aspects of the intervention, which may act as potential facilitators or barriers to future implementation of the intervention into routine clinical care.

描述（由申请人提供）： 阻塞性睡眠呼吸暂停（OSA）是一种疾病，其特征是睡眠期间发生的完整或部分上呼吸道阻塞的重复发作。 OSA随着年龄的增长而增加患病率，并且与心血管疾病的风险增加，生活质量降低和死亡率增加有关。失眠症的患病率也随着年龄的增长而增加，并且与许多不良后果有关，包括生活质量降低，医疗保健成本增加和死亡率增加。失眠的诊断标准包括降低入睡或入睡的能力，夜间觉醒或与白天障碍相关的频繁觉醒或质量差，例如疲劳，注意力受损或白天嗜睡。最近的证据表明，失眠症经常与OSA共存，尤其是在老年人中，并预测OSA的结果较差。与普通人群相比，OSA和失眠的退伍军人的患病率更高。 对管理大量共存OSA和合并症失眠的患者的最佳方法知之甚少。最佳实践指南通常分别解决这些疾病，其中阳性气道压力（PAP）疗法是治疗OSA的标准，而失眠症的认知行为疗法（CBT-I）被认为是慢性失眠症的一线治疗。实际上，大多数CBT-1试验都排除了具有OSA证据的参与者，并且大多数PAP治疗试验都无法解决共存的失眠症。 CBT-I特别建议在老年人中失眠，因为睡眠药物的不良影响最有问题。 OSA患者对PAP治疗的依从率很低（尤其是在退伍军人中），并且共存的失眠症预测与PAP的依从性较低。几项研究表明，早期遵守PAP疗法（即，在治疗过程中，OSA患者对PAP治疗的依从性如何）是长期PAP依从性的最强预测指标之一。不幸的是，在许多患者中，一旦确定了OSA并开始使用PAP治疗，根本就无法解决失眠症状，或者只有在患者建立长期不遵守PAP的长期模式后才被考虑。基于这些证据以及我们自己广泛的先前工作的发现，我们认为，在PAP治疗过程中，需要一种新颖的，综合的行为治疗方法，该方法在PAP疗法的早期需要解决OSA和失眠症，以最大程度地提高患者的依从性和治疗成功。 我们提出了一项随机对照试验，以测试一种新型的行为方法，该试验整合了老年退伍军人（> 60岁，n = 120岁）的最佳实践，这些实践被诊断为OSA，这些OSA被处方为PAP疗法并具有合并症的失眠症。参与者将被招募在大洛杉矶医疗体系中被诊断为OSA和处方PAP疗法的VA大诊所的老年退伍军人中，并且还符合失眠症的诊断标准。该干预措施将结合CBT-I与Allied Health人员提供的行为PAP依从性计划，并在PAP治疗期间开始。随机分配到控制条件的参与者将获得一个积极的注意力控制计划，包括一般睡眠和OSA教育。我们的具体目的是测试这种结合，整合的CBT-I和行为PAP干预是否可以改善患有OSA和合并症的老年退伍军人的睡眠，PAP依从性，情绪和与健康相关的生活质量。我们还将探讨参与者的经验，态度和遵守干预措施的关键方面，这可能是潜在的促进者或将来将干预措施实施到常规临床护理中的障碍。