A role for the peak-end rule in improving CPAP adherence?

The ramp feature in continuous positive airway pressure devices is designed to incrementally increase air pressure, facilitating a smoother transition for patients during the initial phases of therapy. This functionality is believed to have potential benefits in improving patients’ compliance by aiding individuals in adjusting to the prescribed pressure settings.

An intriguing psychological heuristic known as the peak-end rule posits that people tend to evaluate and remember an event based on its most intense moment (peak) and its conclusion.¹ This principle has implications in the realm of sleep disturbance, as demonstrated in both laboratory and field studies, though its recognition may not be explicit in the literature. A study involving 12 women and 12 men residing in a sleep laboratory for 2 weeks explored the effects of different noise scenarios during distinct timeframes of the night.² Polysomnograms revealed that early-night noise hindered the onset of sleep, but this impact was mitigated if noise restrictions were in place. Conversely, even brief late-night noise periods were found to disrupt sleep.

This discovery aligns with observations in transportation noise studies, suggesting that noise exposure significantly affects self-reported sleep quality in the morning when sleep pressure is lowest. In studies from Norway and Switzerland modeled nighttime traffic noise exposure was primarily associated with self-reported early awakenings, whereas associations with other sleep-quality parameters, such as waking during the night or difficulty falling asleep, were less prominent.^3,4

Considering that over two thirds of individuals use alarms for waking, we propose extending the investigation of the peak-end rule to continuous positive airway pressure therapy.⁵ Introducing a short reverse-ramp or pressure slide immediately before an anticipated wake-up time may positively affect patients’ satisfaction. This approach could provide a gentler pressure shift as patients approach waking, potentially mitigating discomfort and fostering a more positive perception of the overall continuous positive airway pressure experience. This consideration addresses a common challenge associated with continuous positive airway pressure therapy and warrants further exploration in the context of improving patient outcomes.

DISCLOSURE STATEMENT

All authors have seen and approved this manuscript. Work for this study was performed at St. Vincent’s University Hospital, Elm Park, Dublin. The authors report no conflicts of interest.