Abstract
Study objectives:
The goal of this study was to examine feasibility, acceptability, and preliminary efficacy of WePAP, a novel, couples-based treatment to promote positive airway pressure adherence in patients with obstructive sleep apnea and sleep quality in patients and partners.
Methods:
Patients who were recently diagnosed with obstructive sleep apnea and intended to start positive airway pressure and their partners completed pre-treatment self-report measures of study constructs and actigraphy. Couples were randomly assigned to WePAP or information control groups. Post-PAP assessments and adherence downloads were completed at 1 month and 3 months. Primary analyses evaluated feasibility, acceptability, and preliminary efficacy between the WePAP and information control groups. Secondary analyses examined between- and within-group changes in sleep, mood, and quality of life.
Results:
The study enrolled 37 midlife and older adults (n = 74, age m = 62.97; SD = 9.04). WePAP couples were 100% adherent with the 3 sessions. Compared with the information control group, patients and partners in WePAP rated the intervention more favorably and were more satisfied. Positive airway pressure adherence was high in both groups and the difference was not statistically significant (PAP use ≥4 h = 76% in WePAP and 72% in information control at 3 months). There were significant within-group differences for sleep quality, such that patients in both groups showed significant improvements in self-reported sleep, mood, and quality of life at 3 months. Patients in both groups showed improvements in sleep-related daytime impairment; however, only partners in the WePAP group showed improvement in sleep-related daytime impairment.
Conclusions:
The results demonstrate that WePAP is feasible and well-liked by patients and partners, but it did not demonstrate greater adherence or improved sleep quality in this sample of highly adherent patients. Future studies should examine longer-term outcomes and enroll patients at greater risk for nonadherence to positive airway pressure.
Keywords: Obstructive sleep apnea, Couples, Dyadic, Adherence, Bedpartner, Transdiagnostic
Introduction
Obstructive sleep apnea (OSA) is a serious health condition that affects over 25 million U.S. adults, including over 30% of older adults,1,2 and is associated with substantial morbidity. For example, individuals with OSA have double the risk of cardiovascular disease mortality,3 depression,4 and 5 times the risk of Alzheimer’s disease.5 However, emerging evidence suggests that the consequences of OSA extend beyond the individual with OSA, also affecting the bedpartner or spouse. In particular, given that sleep is a shared behavior with 61% of adults reporting that they regularly sleep with a partner,6 bedpartners of individuals with OSA may be considered the secondary “casualties” of untreated or poorly treated OSA.7,8 For example, partners of snorers or those with OSA are at 3 times greater risk of insomnia, with greater likelihood of depression, anxiety, and reduced quality of life.7–9
Positive airway pressure (PAP), the first-line treatment for most patients with OSA, is highly effective at treating OSA symptoms in the patient and also is associated with benefits for the bedpartner.10 For example, there is a dose-response relationship between PAP adherence and improvements in both patient and bedpartner sleep, daytime sleepiness, and quality of life,7,11,12 as well as reductions in the patients’ cardiometabolic and dementia risk factors, including hypertension.13 Despite this promising evidence concerning the downstream benefits of OSA therapy for both patients and partners, 50%-80% of patients are nonadherent,14–16 highlighting the urgent need for efficacious interventions that promote PAP adherence.
Substantial prior work has focused on interventions designed to promote PAP adherence.17–19 However, prior work has been focused almost exclusively on the individual patient while neglecting to consider the impact of the disorder on the bedpartner and the potential role of the partner in promoting PAP adherence. Nevertheless, there is a strong scientific premise for targeting PAP adherence at the couple-level.8,20,21 First, a consistent body of evidence demonstrates that couples’ sleep is highly interdependent, meaning that sleep in one partner affects and is affected by the other partner’s sleep.21 In fact, the bedpartner’s sleep disruption is a primary motivator for patients to seek evaluation and treatment for OSA.22,23 In contrast, 50% of OSA patients reported they would not use PAP if it disrupted their partners’ sleep (e.g., due to concerns about noise from the equipment).24 Evidence from other chronic illness populations (e.g., cancer, HIV, and diabetes) further supports the premise that couples-based interventions are more effective than individual treatments at improving adherence, symptom management, and patient and partner health outcomes.25–27 Finally, other work has demonstrated that partner support (e.g., helping with the PAP machine)28 or partner29 or caregiver30 engagement predicts better PAP adherence, whereas relationship conflict predicts lower adherence.31
Despite the strong scientific rationale for incorporating the bedpartner into PAP adherence interventions, to date, there are only a handful of interventions that have incorporated the partner or caregiver into a PAP adherence intervention.29,30,32 Of these studies, only one also addressed bedpartner sleep quality.32 Specifically, in a small pilot study (n = 10 couples) of a couples’-based behavioral intervention, Luyster and colleagues reported improvements in patient PAP adherence and sleep quality, and reductions in daytime sleepiness in patients and partners. However, only 6 out of 10 couples randomized to this condition completed this brief intervention, potentially highlighting the challenges in having both members of the couple attend in-person intervention sessions or other reasons for noncompletion of the intervention.
Recognizing the critical importance of the bedpartner in promoting PAP adherence, as well as the scarcity of interventions to address the partners’ sleep disturbances, our team developed WePAP, a novel, couples-based sleep health intervention, that can be delivered via telehealth. WePAP aims to improve PAP adherence in the individual with OSA and sleep health more generally in both the individual with OSA and the partner.33 We have previously described the treatment development process for this intervention as well as a description of the randomized clinical trial protocol.33 The goal of this paper is to present the primary outcomes from the WePAP randomized clinical trial (feasibility and acceptability of the treatment), and preliminary efficacy data on key study outcomes, including patient PAP adherence, and patient and partner objective and self-reported sleep. We also report secondary analyses of within-group changes in outcomes.
Methods
Participants and procedure
The detailed description of the study protocol is described in our published protocol and the full protocol is available by contacting the corresponding author.33 This was a 2-arm, parallel-group, single-blind (outcomes assessor), randomized controlled pilot trial to evaluate the feasibility and preliminary effectiveness of the WePAP intervention compared with an information control (IC). Participants included patients who were newly diagnosed with OSA and starting PAP therapy and their partners. Patients undergoing sleep apnea testing (in-lab polysomnography, PSG, or home sleep testing) at the University of Utah Health Sleep Centers were contacted by study staff about the study and if interested, were screened for study eligibility using an online form. Sleep apnea scoring was determined using CMS scoring criteria (criteria of 4% desaturation for hypopneas).34
Eligibility criteria
Inclusion criteria patient included: 1) Age 50–85 years; 2) Mixed or same-sex couples who are married or living with a partner for at least 1 year; 3) Patient is PAP-naive or reinitiating PAP after 3 or more years; 4) Able to read and write in English; and 5) Able to access online, video conference capabilities (Wi-Fi or cellular plan).
Patient exclusion criteria include: 1) Self-reported diagnosis of severe comorbid sleep disorders other than insomnia (e.g., moderate or severe restless legs syndrome, narcolepsy); 2) Presence of severe medical and psychiatric disorders that would interfere with participation in treatment (e.g., schizophrenia, bipolar disorder, hemodialysis, severe depression in that required hospitalization or electroconvulsive therapy in the past year); and 3) Patient use of supplemental oxygen or adaptive servo-ventilation.
Partners’ eligibility included: 1) Age > 18; 2) Responded “yes” to the question “are you interested in improving your sleep”; 3) Able to read and write in English; and 4) Able to access online, video conference capabilities (Wi-Fi or cellular plan). Partners who were already using PAP were permitted to enroll if interested.
Procedure
After completing screening, couples scheduled a session via a HIPAA-compliant video conference platform (Zoom) to review and sign the online consent form and arrange to complete the baseline assessment. At the baseline or pre-treatment assessment, couples completed questionnaires, 7 days of wrist actigraphy, and daily sleep diaries, and a brief cognitive testing battery. Patients and partners completed follow-up assessments at post treatment (approximately 1 month after starting PAP) and 3 months after starting PAP treatment. The primary study endpoint was defined as 3 months. Approval for this study was provided by the University of Utah Institutional Review Board (IRB_000135927). The study is registered with ClinicalTrials.gov (NCT04759157, 2/13/2021).
Usual care procedures for OSA diagnosis and follow-up
Participants in both groups continued to receive usual care at the University of Utah Sleep Clinics. Usual care was determined by each individual provider; there was no standard follow-up. Typically, providers discussed the potential diagnosis and treatment at the initial assessment, before the sleep study. Then, following the results, providers delivered results and treatment recommendations via phone call or a secure message (Mychart). If patients had questions about their diagnosis, they either discussed those questions with their provider over the phone or via secure messaging. In patients who had an in-lab titration, they were able to try several masks at the titration visit. Patients who underwent home sleep testing would receive a mask according to the DME recommendation. The specific process of selecting a mask for at-home use varied between the different companies and insurances, there was no standard procedure. Patients received follow-up regarding their machine usage according to each DME company’s protocol. In addition, each patient received a phone call from a sleep technician from our clinic approximately 2–4 weeks after beginning PAP.
Randomization and blinding
Upon completion of the baseline assessment, couples were randomly assigned to either WePAP or IC using the REDCap randomization algorithm using a 1:1 ratio of WePAP to IC with equal strata for male and female patients. The randomization tables were created by the study statistician using a random number generator and the sequence was concealed by the REDCap randomization module. This was a single-blind study, as participants were informed of their group assignment; however, assessments were conducted by study staff who were blind to study assignments and only investigators directly associated with the intervention were unblinded (e.g., WT supervised the therapist and conducted fidelity ratings but was not involved in conducting assessments, data entry, or analysis). When the blinded study research staff completed a baseline assessment, they confirmed completion of key baseline data. When those data were entered, the interventionist then completed a REDCAP case report form and the program generated the next treatment assignment. User privileges were set in the program to allow only the interventionist access to the randomization assignment form. The interventionist contacted the participant via phone and email with their treatment group assignment.
Intervention description
Session-by-session content is listed in Table 1. WePAP is a brief, 3-session intervention (75 m, 60 m, and 60 m) delivered via zoom that integrates evidence-based practices for enhancing partner support for PAP with behavioral strategies to improve the couples’ sleep health.33 Sessions were designed to begin within the first 2 weeks of PAP initiation if possible. It is considered a “transdiagnostic” intervention, as it recognizes and addresses the multidimensional nature of sleep health problems among midlife and older adult couples in which one partner has OSA (e.g., sleep disruptions due to insomnia or other sleep problems such as circadian rhythm sleep disorder). Furthermore, WePAP focuses on the sleep health of the couple, rather than only the patient’s sleep apnea. The treatment seeks to address common challenges faced by couples as they adjust to the new PAP treatment and enhance communication and collaboration for problem-solving initial challenges with PAP. WePAP provides education about OSA and dyadic techniques to promote PAP adherence based on communication therapy, self-efficacy theory, and motivational enhancement. In addition, couples are provided with tools to improve overall sleep health using techniques drawn from Brief Behavioral Treatment for Insomnia (e.g., consistent wake-up times, limiting time in bed not asleep).35–37 Consistent with the transdiagnostic model, the core information was delivered to all participants but it could be tailored depending on the nature of the couples’ sleep challenges. For example, participants without significant awakenings were instructed about stimulus control techniques but it did not need to be listed in their goals for the next session. The couples assigned to WePAP each received a binder with sleep diaries and copies of the session slides. Session content was delivered to individual couples by a trained PhD-level study interventionist using standardized materials. There were opportunities for interaction or discussion of topics in each session and tailoring toward couples’ specific concerns. The therapist attended supervision meetings twice per month to review sessions and discuss cases. In addition, the interventionist completed intervention fidelity ratings after each session using a fidelity checklist developed for this study, and checklists were reviewed in supervision. The intervention supervisor or trainer (WT) also conducted quarterly on a random sample of 10% of sessions to ensure treatment fidelity and retraining would be initiated if fidelity ratings fell below 80% (which did not occur).
Table 1.
Session content
| Session | Content |
|---|---|
|
| |
| 1 | • Program overview: Impact of OSA on the patient and partner, what to expect in the sessions, and treatment goals • Assessment: Main symptoms or sleep challenges, current sleep routine, and goals (individual- and couple-focused) • Education: Background about sleep apnea and PAP, common problems with PAP, couple collaboration for troubleshooting PAP issues, and communicating about PAP problems • Homework: Review goals, reminder to complete sleep diaries |
| 2 | • Review homework: Review goals, homework, sleep diaries, and PAP download; discuss and strategize any PAP problems • Sleep health: Defining sleep health and techniques for improving sleep health based on BBTI (consistent wake-time, stimulus control, sleep compression [as appropriate], and sleep hygiene) • Homework: Set action plan for sleep health improvement, complete sleep diaries |
| 3 | • Review homework: Review sleep diaries and PAP download, strategize any PAP problems • Sleep health: Adjusting the sleep schedule (increase or decrease sleep opportunity window based on sleep efficiency) • Evening routines: Discuss the role of hyperarousal or stress in contributing to sleep disturbance, both in general and specific to PAP anxiety; delivery of relaxation techniques, including establishing a wind-down together and PAP desensitization |
Cross-cutting themes (in each session): education, dyadic coping, and enhancing communication.
OSA, obstructive sleep apnea; PAP, positive airway pressure; BBTI, Brief Behavioral Treatment of Insomnia.
Information control (IC)
In this group, patients received usual care with additional materials provided by the study to ensure standardized educational content. Study participants who are assigned to the information control were provided with a printed copy of information about sleep apnea and PAP from the website sleepeducation.org. Intervention participants were not provided with the same handout because their materials were tailored to match the session content. The interventionist contacted the patients to notify them of their study assignment and then provided a second call to ensure they received the study materials. If the couple had questions about PAP, the interventionist referred couples to direct questions to their sleep medicine provider or durable medical equipment (DME) company.
Measures
Sample characteristics
At baseline, web-based surveys were used to assess sociodemographic and relationship characteristics, including, age, sex, race or ethnicity, household income, length of relationship, and number of nights bed-sharing with partner. Apnea-hypopnea index (AHI) at baseline was determined by polysomnography or home sleep apnea test (Noxturnal, Nox Medical, USA) using the criteria determined by the AASM criteria: apnea defined as cessation of airflow for at least 10 seconds and hypopnea defined as a 30% reduction in thoracoabdominal movement or airflow as compared with baseline with at least a 3% oxygen desaturation and reports also calculated AHI according to the Centers for Medicare and Medicaid Services criteria that include a 4% desaturation criteria for hypopneas.38,39
Primary outcome measures
Our primary outcomes included feasibility of enrollment and retention, including: 1) Recruiting our target sample in the study period and 2) Percentage of participants completing all 3 intervention sessions. We also collected other quantitative ratings of feasibility and acceptability of the treatment, including ratings of ease of participation in the telehealth visits, and perceived benefits of the intervention and enjoyment of the sessions.33 Additionally, we collected qualitative data via open-ended questions about the format, content, materials, and suggestions for improving the interventions. Success was defined as meeting recruitment goals (enrolling 100% of the planned sample) and retention of 85% of our participants in the intervention.
Primary efficacy outcome
PAP adherence was the primary efficacy measure. Adherence was measured continuously and remotely downloaded at 3 months post-PAP initiation. PAP adherence measures included percent of nights used, average hours of use per night, and percent of nights with use > 4 hours.
Secondary outcome measures
Objective sleep variables were estimated using the Actiwatch Spectrum Plus (Philips Respironics, Murrysville, PA, USA). Actiwatches were configured with default settings using 30-second epochs. Rest intervals were manually set with assistance of a sleep diary (to indicate bedtimes and wake times) using a standardized protocol.40 We used the Actiware software to derive actigraphy-assessed additional outcomes, including total sleep time (TST), wakefulness after sleep onset (WASO), and sleep efficiency (for both partners and both conditions) at baseline and 3-month time points.
All participants completed the PROMIS sleep disturbance and sleep-related daytime impairment adaptive measures to measure self-reported sleep quality.41 Raw scores on this measure are converted to a t-score, with a mean of 50 and SD of 10, with higher scores indicating more sleep disturbances or greater impairment, respectively.
Functional Outcomes of Sleep Questionnaire 10-item (FOSQ-10): The FOSQ-1016 is a 10-item assessment that assesses the impact of sleep on daily functioning, such as driving and working, and was used as a measure of quality of life. Each item was scored on a 4-point Likert scale and summed. Lower scores suggest greater impairment due to sleep-related issues.
Patient Health Questionnaire 8: The Patient Health Questionnaire 819 is an 8-item assessment to determine the degree to which a respondent experiences depressive symptoms. Each item corresponds to diagnostic criteria for major depressive disorder, such as little interest in doing things, or trouble concentrating. Scores ≥ 10 indicate the presence of depressive symptoms.
Statistical analysis
Statistical analyses were conducted using Stata v17. First, descriptive analyses were used to characterize the sample and evaluate whether there were any baseline group differences. Second, t-tests and chi-square analyses were used to evaluate feasibility and acceptability, including comparing ratings of acceptability and treatment satisfaction measures between WePAP and IC. Responses to open-ended questions about feasibility were evaluated for common themes. Next, multilevel models for each outcome tested the preliminary efficacy of WePAP compared with IC for patient PAP adherence and patient and partner actigraphy and self-reported sleep. We also conducted exploratory analyses of changes within group. Our analysis plan included controlling for any significant difference at baseline between groups. Our main criteria for continuing to a fully powered trial were feasibility of recruitment and retention. Given the pilot nature of the proposed study, significance tests of study hypotheses were performed using 1-sided tests with α = 0.10.
Sample size
Our targeted enrollment goal was 40 couples (20 per arm) to allow us to provide sufficient power to: 1) evaluate the feasibility of enrollment and retention needed to conduct a successful fully powered clinical trial and 2) evaluate preliminary efficacy of our main sleep outcome of interest (% of nights with PAP use ≥ 4 hour per night). Description of power analysis was reported previously.33
Results
Enrollment occurred between June 2021 and October 2023 at the University of Utah and follow-up occurred until January 2024. The CONSORT diagram is depicted in Figure 1. Participant characteristics are presented in Table 2. A total of 84 participants consented to the study but 10 participants (5 couples) withdrew before randomization due to various reasons (4 couples became ineligible for reasons such as not starting PAP or starting oxygen and one couple declined to continue after baseline). The final sample included 37 couples (74 individuals; mean age 63 years; 20 couples in the intervention arm and 17 couples in the control arm). As shown, the sample was predominantly non-Hispanic White, and well-educated (64% had college degree or greater), with roughly equal proportions of male and female patients. Over 90% of couples had been together for 16 years or more and 94% shared a bed 4 or more nights per week. Overall, 53% of patients were in the moderate-to- severe range for OSA based on AHI > =15. There were no significant differences in any sociodemographic or clinical characteristics between WePAP or IC groups.
Fig. 1.
CONSORT diagram
Table 2.
Participant characteristics
| Variable | Total sample (n = 74) | WePAP patient (n = 20) | WePAP partner (n = 20) | Control patient (n = 17) | Control partner (n = 17) |
|---|---|---|---|---|---|
|
|
|||||
| Mean (SD) or N (%) | Mean (SD) or N (%) | Mean (SD) or N (%) | Mean (SD) or N (%) | Mean (SD) or N (%) | |
|
| |||||
| Sex | |||||
| Female | 37(50.0%) | 9 (45.0%) | 11 (55.0%) | 8 (47.1%) | 9 (52.9%) |
| Male | 37(50.0%) | 11 (55.0%) | 9 (45.0%) | 9 (52.9%) | 8 (47.1%) |
| Age | 62.97 (9.04) | 62.2 (7.45) | 59.9 (7.68) | 66.12 (8.75) | 64.35 (11.63) |
| Education level | |||||
| < 12 grade | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| High school diploma or GED | 7 (9.5%) | 1 (5.0%) | 1 (5.0%) | 2 (11.8%) | 3 (17.6%) |
| Some college or associate’s (2-year) degree | 20 (27.0%) | 7 (35.0%) | 4 (20.0%) | 6 (35.3%) | 3 (17.7%) |
| Bachelor’s (4-year) degree | 16 (21.6%) | 3 (15.0%) | 7 (35.0%) | 2 (11.8%) | 4 (23.5%) |
| Graduate degree or more | 31 (41.9%) | 9 (45.0%) | 8 (40.0%) | 7 (41.2%) | 7 (41.2%) |
| Race | |||||
| American Indian or Alaskan Native | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Asian | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| Native Hawaiian or Pacific Islander | 3 (4.1%) | 0 (0.0%) | 0 (0.0%) | 1 (5.9%) | 2 (11.8%) |
| Black or African American | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| White | 64 (86.5%) | 18 (19.0%) | 17 (85.0%) | 16 (94.1%) | 13 (76.5%) |
| More than one | 3 (4.1%) | 2 (10.0%) | 1 (5.0%) | 0 (0.0%) | 0 (0.0%) |
| Choose not to answer | 4 (5.4%) | 0 (0.0%) | 2 (10.0%) | 0 (0.0%) | 2 (11.8%) |
| Ethnicity | |||||
| Not Hispanic or Latino | 65 (87.8%) | 18 (90.0%) | 16 (80.0%) | 16 (94.1%) | 15 (88.2%) |
| Choose not to answer | 4 (5.4%) | 0 (0.0%) | 2 (10.0%) | 0 (0.0%) | 2 (11.8%) |
| Missing | 2 (2.7%) | 1 (5.0%) | 1 (5.0%) | 1 (5.9%) | 0 (0.0%) |
| Income | |||||
| < $10,000 | 2 (2.7%) | 1 (5.0%) | 1 (5.0%) | 0 (0.0%) | 0 (0.0%) |
| $10,000-$25,000 | 1 (1.4%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 1 (5.9%) |
| $26,000-$50,000 | 5 (6.8%) | 0 (0.0%) | 1 (5.0%) | 2 (11.8%) | 2 (11.8%) |
| $51,000-$75,000 | 11 (14.9%) | 4 (20.0%) | 3 (15.0%) | 2 (11.8%) | 2 (11.8%) |
| $76,000-$100,000 | 9 (12.2%) | 1 (5.0%) | 3 (15.0%) | 2 (11.8%) | 3 (17.7%) |
| > $101,000 | 41 (55.4%) | 13 (65.0%) | 12 (60.0%) | 9 (52.9%) | 7 (41.2%) |
| Missing | 5 (6.8%) | 1 (5.0%) | 0 (0.0%) | 2 (11.8%) | 2 (11.8%) |
| BMI | 30.29 (6.19) | 32.73 (5.94) | 28.76 (6.42) | 30.62 (5.49) | 28.89 (6.43) |
| Years together | |||||
| 6–10 | 6 (8.1%) | 2 (10.0%) | 2 (10.0%) | 1 (5.9%) | 1 (5.9%) |
| 11–15 | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| 16–20 | 10 (13.5%) | 4 (20.0%) | 4 (20.0%) | 1 (5.9%) | 1 (5.9%) |
| 21+ | 58 (78.4%) | 14 (70.0%) | 14 (70.0%) | 15 (88.2%) | 15 (88.2%) |
| Bed-sharing | |||||
| 0–1 | 4 (5.4%) | 1 (5.0%) | 1 (5.0%) | 1 (5.9%) | 1 (5.9%) |
| 2–3 | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) | 0 (0.0%) |
| 4+ | 70 (94.6) | 19 (95.0%) | 19 (95.0%) | 16 (94.1%) | 16 (94.1%) |
| AHI | |||||
| Mild 5–14 | 16 (43.2%) | 9 (45.0%) | 7 (41.2%) | ||
| Moderate 15–29 | 7 (18.9%) | 5 (25.0%) | 2 (11.8%) | ||
| Severe > =30 | 14 (37.8%) | 6 (30.0%) | 8 (47.1%) | ||
Feasibility and acceptability (primary outcomes)
Results supported the feasibility of WePAP; we achieved our enrollment goals within 93% of our target (37 couples enrolled; target enrollment of 40 couples) and all couples in the WePAP group attended each of the 3 telehealth sessions.The timing of the sessions was slightly later than the planned 2-week period of starting PAP. The average duration between PAP initiation and WePAP first session was 24 days and SD of 12 days, with a range of 8–45 days. The results also demonstrated that WePAP had higher acceptability ratings compared with the IC group. As shown in Table 3, compared with patients in IC, WePAP patients had higher ratings on all program evaluation measures, including the degree to which the program was logical, acceptable, or useful. In addition, patients in WePAP were significantly more likely to recommend the treatment as compared with patients in IC. Treatment satisfaction ratings were also significantly higher for patients in WePAP as compared with patients in IC, including greater enjoyment, understandability, improvement in their adjustment to PAP, communication, and sleep quality. As shown in Table 4, a similar pattern was also observed for partners in WePAP versus partners in IC, with WePAP partners having significantly higher ratings on nearly all program evaluation and treatment satisfaction measures. In response to open-ended questions about what was most liked about the WePAP program, patients and partners reported enjoying the time to discuss their PAP treatment and sleep quality with a knowledgeable person and enjoying the opportunity to learn more about sleep, PAP therapy, and improving sleep quality. Patients and partners had few criticisms of the program, but the most frequent comment was the dislike of filling out daily sleep diaries. Suggestions for changes to the program included adding videos of the presentations, not using the paper copies of the presentations, and having the study team involved in the initial PAP setup process.
Table 3.
Acceptability and feasibility: patients
| WePAP patient mean (SD) | IC patient mean (SD) | 90% CI | |
|---|---|---|---|
|
| |||
| Program evaluation a | |||
| How logical does the program offered to you seem? | 7.76 (1.20) | 6.20 (2.46) | [−2.50, −0.47] |
| How acceptable does the program offered to you seem in terms of increasing your CPAP use and supporting both of your sleep health? | 7.71 (1.45) | 5.47 (2.20) | [−2.36, −0.25] |
| At this point, how useful do you think this program will be in terms of increasing your CPAP use and supporting both of your sleep health? | 7.47 (1.37) | 4.73 (2.43) | [−2.86, −0.85] |
| How confident would you be in recommending this program to a friend who experiences similar sleep apnea problems? | 7.82 (1.47) | 5.47 (2.67) | [−2.37, −0.21] |
| Treatment satisfaction b | |||
| How much did you enjoy the program? | 4.00 (0.79) | 2.93 (0.96) | [−1.37, −0.20] |
| How easy was it to understand the information that was presented? | 4.71 (0.59) | 3.93 (1.03) | [−1.33, −0.16] |
| How much did the program help you adjust to using CPAP? | 3.94 (0.90) | 2.07 (1.10) | [−0.03, 1.07] |
| How much did the program help you communicate with your spouse or partner about CPAP? | 4.41 (0.80) | 2.47 (1.30) | [−0.54, −0.04] |
| How much did the program improve your sleep quality? | 4.06 (0.77) | 2.13 (1.25) | [−1.71, −0.36] |
Note: IC, information control. The analysis was conducted using the 2-sided Student T-test.
Program evaluation measures are on a scale of 1–9 with higher average scores indicating program approval among patients.
Treatment satisfaction measures are on a scale of 1–5 with higher average scores indicating satisfaction with the intervention among patients.
Table 4.
Acceptability and feasibility: partners
| WePAP partner mean (SD) | IC partner mean (SD) | 90% CI | |
|---|---|---|---|
|
| |||
| Program evaluation a | |||
| How logical does the program offered to you seem? | 6.35 (1.93) | 5.47 (2.59) | [−1.89, 0.48] |
| How acceptable does the program offered to you seem in terms of increasing your partner’s CPAP use and supporting both of your sleep health? | 7.00 (1.32) | 5.40 (2.50) | [−3.04, −0.82] |
| At this point, how useful do you think this program will be in terms of increasing your partner’s CPAP use and supporting both of your sleep health? | 7.18 (1.59) | 5.00 (2.10) | [−3.43, −1.18] |
| How confident would you be in recommending this program to a friend who experiences similar sleep apnea problems? | 7.00 (1.80) | 5.40 (2.13) | [−3.09, −0.68] |
| Treatment satisfaction b | |||
| How much did you enjoy the program? | 3.73 (1.03) | 2.73 (0.96) | [−1.43, −0.45] |
| How easy was it to understand the information that was presented? | 4.40 (0.74) | 3.53 (1.36) | [−1.19, −0.31] |
| How much did the program help your partner adjust to using CPAP? | 3.53 (1.30) | 2.31 (1.03) | [0.37, 1.36] |
| How much did the program help you communicate with your spouse or partner about CPAP? | 3.87 (1.19) | 2.79 (1.25) | [−0.39, −0.01] |
| How much did the program improve your sleep quality? | 3.47 (1.25) | 2.93 (1.14) | [−2.37, −1.29] |
Note: IC, information control.
Program evaluation measures are on a scale of 1–9 with higher average scores indicating program approval among partners.
Treatment satisfaction measures are on a scale of 1–5 with higher average scores indicating satisfaction with the intervention among partners.
PAP use: Table 5 presents adherence results at 1-month and 3-month follow-up for patients receiving WePAP versus those in the IC groups. As shown, PAP adherence was high in both groups. Although the WePAP group had higher use in all the measures recorded, there were no significant between-group differences in PAP adherence. For instance, at 3 months, patients in WePAP, on average, used PAP 30 more minutes per night compared with IC, but this did not reach statistical significance (6.06 hours in WePAP compared with 5.56 hours in IC).
Table 5.
PAP adherence at 1 and 3 months
| PAP adherence | One month |
Three months |
||||
|---|---|---|---|---|---|---|
| WePAP patients | IC patients | 90% CI | WePAP patients | IC patients | 90% CI | |
|
| ||||||
| Percent of total days used (%) | 0.91 (0.15) | 0.81 (0.28) | [−0.01, 0.26] | 0.84 (0.27) | 0.81 (0.27) | [−0.07, 0.19] |
| Percent of # nights used > 4 h (%) | 0.76 (0.29) | 0.71 (0.32) | [−0.03, 0.09] | 0.76 (0.32) | 0.72 (0.30) | [−0.07, 0.24] |
| Average hours used for total nights (h) | 6.21 (1.42) | 5.65 (2.50) | [−0.77, 1.89] | 6.06 (1.79) | 5.56 (2.13) | [−0.82, 1.83] |
Note: IC, information control. All comparisons are P > .10.
Secondary outcome measures
Sleep outcomes: Tables 6 and 7 present results for patients and partners in both groups for actigraphy, self-reported sleep outcomes, sleep-related quality of life, and depressive symptoms. There were no within- or between-group differences in actigraphy-assessed sleep efficiency, TST, or WASO. For subjective sleep measures, there were no significant between-group differences. However, there were significant within-group differences in these measures, with patients in both the WePAP and IC groups showing significant reductions in sleep disturbance from baseline to 3 months and improvements in sleep-related quality of life and depressive symptoms. For sleep-related daytime impairment, there were significant within-group reductions for patients in both groups and among partners in the WePAP group only.
Table 6.
Patient actigraphy, PROMIS sleep disturbance, and PROMIS sleep-related impairment at baseline and 3 months
| Sleep measure | WePAP patients |
Control patients |
||||
|---|---|---|---|---|---|---|
| Baseline | 3 Months | Baseline | 3 Months | 95% CI for within-group mean difference | 95% CI for between- group mean difference | |
|
| ||||||
| Sleep efficiency, % | 83.00 (10.33) | 84.73 (8.80) | 85.10 (8.49) | 85.93 (8.57) | [−0.22, 4.96]; [−0.19, 5.01] | [−3.60, 3.53] |
| Total sleep time, h | 6.96 (1.05) | 7.06 (0.97) | 7.01 (1.01) | 7.20 (1.08) | [−0.17, 0.46]; [−0.01, 0.67] | [−0.64, −0.28] |
| WASO, m | 43.76 (23.85) | 42.91 (25.78) | 40.58 (17.29) | 42.16 (22.70) | [−9.41, 6.38]; [−4.98, 12.15] | [−16.76, 6.55] |
| PROMIS sleep disturbance, t-score | 55.21 (6.75) | 48.61 (5.47) w | 55.96 (7.64) | 51.08 (6.45) w | [−8.19, −2.68]; [−8.32, −2.32] | [−4.18, 3.96] |
| PROMIS sleep impairment, t-score | 59.70 (10.31) | 50.61 (7.80) w | 53.97 (8.07) | 50.21 (7.23) w | [−10.95, −3.96]; [−7.56, 0.01] | [−8.83, 1.47] |
| FOSQ | 29.76 (6.64) | 34.65 (5.37) w | 31.38 (6.85) | 34.60 (5.21) w | [1.77, 5.83]; [0.53, 4.92] | [−1.91, 4.06] |
| PHQ-8 | 8.06 (5.94) | 3.94 (3.29) w | 5.54 (5.32) | 2.93 (2.46) w | [−5.67, −1.41]; [−4.98, −0.45] | [−3.94, 2.28] |
Note: WASO, wake after sleep onset; FOSQ, functional outcomes of sleep questionnaire 10-item; PHQ-8, patient health questionnaire 8-item. P < .05.
b = change from baseline to 3 months between the patients or partner groups, P < .05.
change within the groups from baseline to 3 months.
Table 7.
Partner actigraphy, PROMIS sleep disturbance, and PROMIS sleep-related impairment at baseline and 3 months
| Sleep measure | WePAP partners |
Control partners |
||||
|---|---|---|---|---|---|---|
| Baseline | 3 Months | Baseline | 3 Months | 95% CI for within-group mean difference | 95% CI for between-group mean difference | |
|
| ||||||
| Sleep efficiency, % | 87.50 (3.60) | 87.78 (5.12) | 86.84 (4.43) | 88.11 (3.67) | [−1.15, 3.52]; [−1.63, 3.54] | [−3.29, 3.65] |
| Total sleep time, h | 7.10 (0.60) | 7.21 (0.68) | 7.28 (0.95) | 7.27 (0.87) | [−0.12, 0.50]; [−0.33, 0.34] | [−0.27, 0.64] |
| WASO, m | 31.19 (12.61) | 30.48 (13.92) | 38.25 (16.79) | 33.98 (11.14) | [−7.66, 2.78]; [−8.05, 3.27] | [−7.75, 7.65] |
| PROMIS sleep disturbance, t-score | 50.54 (6.05) | 48.03 (5.94) | 48.50 (6.32) | 47.24 (5.82) | [−5.01, 0.38]; [−2.66, 3.21] | [−6.58, 1.39] |
| PROMIS sleep impairment, t-score | 54.26 (7.79) | 50.02 (7.95) w | 46.61 (8.62) | 44.55 (9.67) | [−6.95, −0.16];[−5.35, 2.00] | [−6.88, 3.12] |
| FOSQ | 34.76 (5.01) | 35.59 (3.64) | 37.20 (3.84) | 36.73 (4.57) | [−1.00, 1.90]; [−2.04, 1.10] | [−1.22, 3.06] |
| PHQ-8 | 4.24 (3.19) | 2.71 (2.31) | 1.62 (1.96) | 1.53 (1.92) | [−2.60, 0.39]; [−1.39, 1.00] | [−2.83, 0.42] |
Note: WASO, wake after sleep onset; FOSQ, functional outcomes of sleep questionnaire 10-item; PHQ-8, patient health questionnaire 8-item. P < .05.
b = change from baseline to 3 months between the patients or partner groups, P < .05.
change within the groups from baseline to 3 months.
Discussion
Drawing on the theoretical premise of the interdependent nature of sleep20,21 and promising preliminary data concerning the importance of integrating the bedpartner into PAP adherence treatment,8,12,28–32 the goal of this study was to develop and test WePAP, a transdiagnostic, couples-based intervention to promote PAP adherence in OSA patients and sleep quality in both patient and partner.
The results of this study provide support for the acceptability and feasibility of a dyadic intervention for patients initiating PAP treatment and their partners, with adequate recruitment and engagement of couples in the intervention. Overall, couples rated WePAP as beneficial for their sleep, easy to participate in, and worthy of recommending to a friend. In addition, the remote sessions increased the feasibility for couples, who were often fitting this program in with their jobs and other responsibilities. However, in terms of preliminary efficacy, there was not a statistically significant difference between groups in PAP adherence.
There are several potential reasons for the lack of significant results for PAP adherence. First, it is also important to note that both patient groups had exceptionally high adherence rates. Participants in our study used PAP ≥ 4 hours 76% of nights and the average usage per night in the current study was approximately 6 hours. These data are comparable to other data from our clinic. A published study of 940 new PAP users from our clinic in their first year, PAP usage was 5.4 hours per night and 61% met the > 4-hour criteria for adherence.42 In addition, a recent query of our clinic database of over 30,000 existing patients using PAP demonstrates 71% met the adherence criteria of > 4 hours per night. These data suggest PAP usage in our clinic is higher than many other clinics and clinical trials, which often report approximately 4 hours of PAP use per night.18,43–46 Although there was not a statistically significant difference between groups, the WePAP treatment group had a nonsignificant higher mean in all PAP use metrics. Given the preliminary nature of the trial, it is possible that lack of statistical power contributed to the null findings. In addition, there are several contextual factors that may have contributed to the high PAP adherence in this sample overall. For example, a number of other clinic-related factors such as visit with sleep provider prior to testing, patient education, organization of sleep facility, and follow-up communication with patient during the 1st month after PAP initiation can also affect adherence.47 Our sleep center conducts close follow-up (e.g., communication with a sleep technologist after PAP initiation), which may have also contributed to greater adherence in the both groups compared with other studies of PAP use. In addition, this study was also recruiting concurrent with a large PAP device recall that and during the COVID-19 pandemic, which caused lab shutdowns and delays in care. Although studies seem to suggest that PAP adherence was not affected by the pandemic, we cannot rule out a cohort effect of these 2 major events that affected the timeliness of care and patient perceptions of OSA treatment.48,49 Education and socioeconomic status of our sample also likely played a role in the high adherence in both groups.50 Finally, enrolling patients in the intervention and control groups who had partners willing to participate is likely to have led to a selection effect. That is, regardless of condition, patients who had partners willing to do the intervention were already receiving support, which could have led to ceiling effects. This suggests that a critical future step for such interventions is reaching more diverse patients who have poor partner support, may have less trust in the medical system, and potentially applying this intervention to include other types of supportive family members, particularly among those who do not have a partner. Such adaptations may be especially useful for culturally tailoring the intervention for specific racial or ethnic groups, for whom other supportive family relationships (e.g., parent and adult child) may play a crucial role in healthcare engagement and adherence.51 It is also important to note that while our intervention contained content aimed at improving insomnia symptoms, few of our participants (patients or partners) reported clinically elevated symptoms (e.g., pre-treatment sleep disturbance score was average). As evidence grows for the importance of identifying comorbid sleep apnea and insomnia,52,53 it may be even more critical to identify couples where either partner is experiencing insomnia symptoms, because they may have more potential to benefit from this treatment.
Given that WePAP included principles from an evidence-based insomnia treatment, Brief Behavioral Treatment for Insomnia,35 we expected to see improvements in sleep outcomes among WePAP patients and partners; however, we did not find statistically significant changes in any of the actigraphy-measured sleep outcomes. As with PAP adherence, sleep efficiency was high in this sample of older adults, among both patients and partners in both conditions. Thus, there may have been a ceiling effect with regard to actigraphy sleep outcomes. We did, however, observe improvements in subjective sleep quality among patients in both conditions, which is likely attributable to use of PAP and notable given that sleep quality was not substantially impaired among participants in this study. In addition, WePAP partners showed significant reductions in sleep-related impairment. Together, these findings are consistent with other behavioral sleep medicine trials that generally find stronger effects for subjective sleep measures than objective ones.54 Future applications of WePAP with larger and more diverse samples and greater variability in sleep outcomes may yield different results. Nevertheless, from a couples-framework, we believe there is utility in having treatment targets for both the patient and the partner to make the treatment more collaborative and less stigmatizing on the patient with OSA.
Several limitations of this investigation are worth noting. Although the primary aim of our study was feasibility and acceptability, the small sample size limited our ability to observe differences between groups. Our study was powered to observe only moderate-to-large effect sizes. The limited follow-up period also did not allow us to observe maintenance of adherence over time. In addition, the study was not designed to control for attention, and it is unknown whether the results are specifically due to therapist attention or couples’ aspect of the treatment. Finally, our sample was collected at a single academic sleep center, among a primarily White sample with high educational attainment, which limits generalizability and focused the intervention among participants who were more likely to have good adherence. Our study was focused on middle-aged and older couples, and enrolled both male and female patients, but we were not able to delve into sex or age differences on the influence of the intervention. For example, although there is not a sex difference in adherence overall, female participants tend to have less severe OSA and in particular, younger women (but not older) have lower adherence.55 We should also note, the use of a transdiagnostic model allowed us to address insomnia symptoms however, most of our partners reported good sleep quality overall, and we did not have information about whether they qualified for other sleep disorders. In our next steps, we are currently addressing these limitations by creating a culturally adapted WePAP intervention for Hispanic couples, to increase the socioeconomic diversity of the sample and address the unique needs of this under-represented population in PAP adherence research. We also plan to conduct fully powered trials of WePAP in the future, with adaptations to reach a more diverse population.
These limitations notwithstanding, a considerable strength in our study was the ability to recruit female patients. Despite the fact that OSA is less common among females compared with males,56 we easily enrolled female patients in this study. This observation raises the possibility that a couples-intervention may be particularly appealing for this population. Additional strengths include the strong theoretical foundation of the transdiagnostic model and the interdependence of sleep, and the focus on both patient and partner treatment targets and outcomes. This dyadic focus may contribute to the high engagement among enrolled couples, which is critical for health behavior change.57 A design consideration for future studies is that we would have hoped to deliver the first session of the intervention sooner, ideally in the first week of PAP treatment. Although we completed the assessment prior to PAP initiation, scheduling the sessions was often delayed due to the challenges of aligning the couples’ schedule in the context of work and childcare responsibilities. In future studies, we will consider shortening the first session to reduce the burden and allow it to be delivered sooner.
In summary, this study adds to the literature demonstrating that addressing sleep and sleep disorders at the level of the couple has the potential to positively impact the health and well-being of both partners. Engaging the patient and partner together in their goals for their sleep as a couple has the potential to improve interaction around PAP treatment as well as sleep and health of the couple as a whole.
Supplementary Material
Statement of significance.
WePAP is a novel, transdiagnostic and couples-based intervention to improve PAP adherence and sleep quality for patients with OSA and their partners. The results of this study comparing WePAP to information control demonstrated that WePAP is feasible and well-liked by patients and their partners. Adherence was high in both conditions, but there were no significant differences between the groups. Among patients, self-reported sleep mood and quality of life improved in both the WePAP and information control groups, but only partners in WePAP showed improvements in sleep-related daytime impairment. Further research is needed in populations in larger and more diverse samples, with individuals at-risk for low PAP adherence.
Acknowledgments
The authors would like to express their gratitude to the University of Utah Sleep Wake Center providers and staff, Allyson Gilles (interventionist), Giulia DeVetorri (graduate student), Shilpy Kharidia and Saydra Galloway (undergraduate student volunteers), and the couples who enrolled in this research study to make this work possible.
Funding
The research reported in this publication was supported (in part or in full) by the National Center on Aging under award numbers R21AG067183 (PIs: Baron and Troxel), 3R21AG067183–01A1S1 (Baron/DeVettori), and for Advancing Translational Sciences of the National Institutes of Health under award numbers UL1TR002538 and UM1TR004409. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Appendix A. Supporting information
Supplementary data associated with this article can be found in the online version at doi:10.1016/j.sleh.2025.08.006.
Footnotes
Declaration of conflicts of interest
Dr. Troxel is author of the book “Sharing the Covers: Every Couple’s Guide to Better Sleep” for which she receives royalties and serves on the advisory board for National Sleep Foundation and OneCare Media. Dr. Sundar is co-founder of Hypnoscure LLC, software for population management for sleep apnea (developed through the University of Utah technology commercialization office) with no monies to date received. He has been past member of Advisory Board for Resmed Inc. with last involvement in October 2021.
Use of generative AI and AI-assisted technologies
AI was not used in this manuscript.
Trial name: WePAP: A couples-based intervention for sleep apnea, URL: https://classic.clinicaltrials.gov/ct2/show/NCT04759157, Registration: Clinicaltrials.gov.
Data sharing
All authors do not have conflicts of interest to disclose date and data will be made available upon request.
References
- 1.Franklin KA, Lindberg E. Obstructive sleep apnea is a common disorder in the population-a review on the epidemiology of sleep apnea. J Thorac Dis. 2015;7(8):1311–1322. 10.3978/j.issn.2072-1439.2015.06.11 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Braley TJ, Dunietz GL, Chervin RD, et al. Recognition and diagnosis of obstructive sleep apnea in older Americans. J Am Geriatr Soc. 2018;66(7):1296–1302. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Fu Y, Xia Y, Yi H, et al. Meta-analysis of all-cause and cardiovascular mortality in obstructive sleep apnea with or without continuous positive airway pressure treatment. Sleep Breath. 2017;21(1):181–189. 10.1007/s11325-016-1393-1 [DOI] [PubMed] [Google Scholar]
- 4.Jackson ML, Tolson J, Bartlett D, et al. Clinical depression in untreated obstructive sleep apnea: examining predictors and a meta-analysis of prevalence rates. Sleep Med. 2019;62:22–28. 10.1016/j.sleep.2019.03.011 [DOI] [PubMed] [Google Scholar]
- 5.Emamian F, Khazaie H, Tahmasian M, et al. The association between obstructive sleep apnea and Alzheimer’s disease: a meta-analysis perspective. Front Aging Neurosci. 2016;8:78. 10.3389/fnagi.2016.00078 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.National Sleep Foundation. 2005. Sleep in America Poll. 2005. [Google Scholar]
- 7.Beninati W, Harris CD, Herold DL, Shepard JW Jr. The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc. 1999;74(10):955–958. [DOI] [PubMed] [Google Scholar]
- 8.Luyster FS. Impact of obstructive sleep apnea and its treatments on partners: a literature review. J Clin Sleep Med JCSM Offl Publ Am Acad Sleep Med. 2017;13(3):467–477. 10.5664/jcsm.6504 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Doherty LS, Kiely JL, Lawless G, McNicholas WT. Impact of nasal continuous positive airway pressure therapy on the quality of life of bed partners of patients with obstructive sleep apnea syndrome. Chest. 2003;124(6):2209–2214. [DOI] [PubMed] [Google Scholar]
- 10.Epstein LJ, Kristo D, Strollo PJ Jr, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med JCSM Offl Publ Am Acad Sleep Med. 2009;5(3):263–276. [PMC free article] [PubMed] [Google Scholar]
- 11.Parish JM, Lyng PJ. Quality of life in bed partners of patients with obstructive sleep apnea or hypopnea after treatment with continuous positive airway pressure. Chest. 2003;124(3):942–947. 10.1378/chest.124.3.942 [DOI] [PubMed] [Google Scholar]
- 12.Lai AY, Ip MS, Lam JC, et al. A pathway underlying the impact of CPAP adherence on intimate relationship with bed partner in men with obstructive sleep apnea. Sleep Breath. 2016;20(2):543–551. 10.1007/s11325-015-1235-6 [DOI] [PubMed] [Google Scholar]
- 13.Huang Z, Liu Z, Luo Q, et al. Long-term effects of continuous positive airway pressure on blood pressure and prognosis in hypertensive patients with coronary heart disease and obstructive sleep apnea: a randomized controlled trial. Am J Hypertens. 2015;28(3):300–306. 10.1093/ajh/hpu147 [DOI] [PubMed] [Google Scholar]
- 14.Wolkove N, Baltzan M, Kamel H, et al. Long-term compliance with continuous positive airway pressure in patients with obstructive sleep apnea. Can Respir J. 2008;15(7):365–369. 10.1155/2008/534372 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178. 10.1513/pats.200708-119MG [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Rosenberg R, Doghramji P. Optimal treatment of obstructive sleep apnea and excessive sleepiness. Adv Ther. 2009;26(3):295–312. 10.1007/s12325-009-0016-7 [DOI] [PubMed] [Google Scholar]
- 17.Bakker JP, Wang R, Weng J, et al. Motivational enhancement for increasing adherence to CPAP: a randomized controlled trial. Chest. 2016;150(2):337–345. 10.1016/j.chest.2016.03.019 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Aloia MS, Arnedt JT, Strand M, et al. Motivational enhancement to improve adherence to positive airway pressure in patients with obstructive sleep apnea: a randomized controlled trial. Sleep. 2013;36(11):1655–1662. 10.5665/sleep.3120 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Labarca G, Schmidt A, Dreyse J, et al. Telemedicine interventions for CPAP adherence in obstructive sleep apnea patients: systematic review and meta-analysis. Sleep Med Rev. 2021;60:101543. 10.1016/j.smrv.2021.101543 [DOI] [PubMed] [Google Scholar]
- 20.Troxel WM. It’s more than sex: exploring the dyadic nature of sleep and implications for health. Psychosom Med. 2010;72(6):578–586. 10.1097/PSY.0b013e3181de7ff8 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Troxel WM, Robles TF, Hall M, Buysse DJ. Marital quality and the marital bed: examining the covariation between relationship quality and sleep. Sleep Med Rev. 2007;11(5):389–404. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Luyster FS, Dunbar-Jacob J, Aloia MS, et al. Patient and partner experiences with obstructive sleep apnea and CPAP treatment: a qualitative analysis. Behav Sleep Med. 2016;14(1):67–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Ye L, Antonelli MT, Willis DG, et al. Couples’ experiences with continuous positive airway pressure treatment: a dyadic perspective. Sleep Health. 2017;3(5):362–367. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Ye L, Malhotra A, Kayser K, et al. Spousal involvement and CPAP adherence: a dyadic perspective. Sleep Med Rev. 2015;19:67–74. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Baucom DH, Porter LS, Kirby JS, Hudepohl J. Couple-based interventions for medical problems. Behav Ther. 2012;43(1):61–76. 10.1016/j.beth.2011.01.008 [DOI] [PubMed] [Google Scholar]
- 26.Regan TW, Lambert SD, Girgis A, et al. Do couple-based interventions make a difference for couples affected by cancer?: A systematic review. 2012/07/06 BMC Cancer. 2012;12(1):279. 10.1186/1471-2407-12-279 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Martire LM, Schulz R, Helgeson VS, et al. Review and meta-analysis of couple-oriented interventions for chronic illness. Ann Behav Med. 2010;40(3):325–342. 10.1007/s12160-010-9216-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Baron KG, Smith TW, Berg CA, et al. Spousal involvement in CPAP adherence among patients with obstructive sleep apnea. Sleep Breath. 2011;15(3):525–534. 10.1007/s11325-010-0374-z [DOI] [PubMed] [Google Scholar]
- 29.Gentina T, Bailly S, Jounieaux F, et al. Marital quality, partner’s engagement and continuous positive airway pressure adherence in obstructive sleep apnea. Sleep Med. 2019;55:56–61. 10.1016/j.sleep.2018.12.009 [DOI] [PubMed] [Google Scholar]
- 30.Khan NNS, Todem D, Bottu S, et al. Impact of patient and family engagement in improving continuous positive airway pressure adherence in patients with obstructive sleep apnea: a randomized controlled trial. J Clin Sleep Med JCSM Offl Publ Am Acad Sleep Med. 2022;18(1):181–191. 10.5664/jcsm.9534 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Baron KG, Smith TW, Czajkowski LA, et al. Relationship quality and CPAP adherence in patients with obstructive sleep apnea. Behav Sleep Med. 2009;7(1):22–36. [DOI] [PubMed] [Google Scholar]
- 32.Luyster FS, Aloia MS, Buysse DJ, et al. A couples-oriented intervention for positive airway pressure therapy adherence: a pilot study of obstructive sleep apnea patients and their partners. Behav Sleep Med. 2018:1–12. 10.1080/15402002.2018.1425871 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Baron KG, Gilles A, Sundar KM, et al. Rationale and study protocol for We-PAP: a randomized pilot/feasibility trial of a couples-based intervention to promote PAP adherence and sleep health compared to an educational control. Pilot Feasibility Stud. 2022;8(1):171. 10.1186/s40814-022-01089-x [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Sleep Testing for Obstructive Sleep Apnea (2009). [Google Scholar]
- 35.Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–895. 10.1001/archinternmed.2010.535 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36.Germain A, Richardson R, Stocker R, et al. Treatment for insomnia in combat-exposed OEF/OIF/OND military veterans: preliminary randomized controlled trial. Behav Res Ther. 2014;61:78–88. 10.1016/j.brat.2014.07.016 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Meyer N, Harvey AG, Lockley SW, Dijk D-J. Circadian rhythms and disorders of the timing of sleep. Lancet. 2022;400(10357):1061–1078. 10.1016/S0140-6736(22)00877-7 [DOI] [PubMed] [Google Scholar]
- 38.Services CfMaM. CPAP For Obstructive Sleep Apnea. 〈https://www.cms.gov/medicare/coverage/evidence/cpap〉.
- 39.Berry RB, Brooks R, Gamaldo C, et al. AASM scoring manual updates for 2017 (version 2.4). American Academy of Sleep Medicine; 2017:665–666. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Patel SR, Weng J, Rueschman M, et al. Reproducibility of a standardized actigraphy scoring algorithm for sleep in a US Hispanic/Latino population. Sleep. 2015;38(9):1497–1503. 10.5665/sleep.4998 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Buysse DJ, Yu L, Moul DE, et al. Development and validation of patient-reported outcome measures for sleep disturbance and sleep-related impairments. Sleep. 2010;33(6):781–792. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Locke BW, Neill SE, Howe HE, et al. Electronic health record–derived outcomes in obstructive sleep apnea managed with positive airway pressure tracking systems. J Clin Sleep Med. 2022;18(3):885–894. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43.Patil SP, Ayappa IA, Caples SM, et al. Treatment of adult obstructive sleep apnea with positive airway pressure: an American Academy of Sleep Medicine Systematic Review, Meta-Analysis, and GRADE Assessment. J Clin Sleep Med JCSM Offl Publ Am Acad Sleep Med. 2019;15(2):301–334. 10.5664/jcsm.7638 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Kushida CA, Berry RB, Blau A, et al. Positive airway pressure initiation: a randomized controlled trial to assess the impact of therapy mode and titration process on efficacy, adherence, and outcomes. Sleep. 2011;34(8):1083–1092. 10.5665/sleep.1166 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Fridriksson B, Berndtson M, Hammered H, et al. Beneficial effects of early intervention telemedicine-based follow-up in sleep apnea - a randomized controlled multi-center trial. Ann Am Thorac Soc. 2023;20(10):1499–1507. 10.1513/AnnalsATS.202208-723OC [DOI] [PubMed] [Google Scholar]
- 46.McEvoy RD, Antic NA, Heeley E, et al. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375(10):919–931. 10.1056/NEJMoa1606599 [DOI] [PubMed] [Google Scholar]
- 47.Shapiro GK, Shapiro CM. Factors that influence CPAP adherence: an overview. Sleep Breath. 2010;14(4):323–335. 10.1007/s11325-010-0391-y [DOI] [PubMed] [Google Scholar]
- 48.Jo S, Cho J. Impact of the COVID-19 pandemic on adherence to positive airway pressure treatment in patients with obstructive sleep apnea: systematic review and meta-analysis. Ther Adv Respir Dis. 2023;17 17534666231214040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49.Bouloukaki I, Pataka A, Mauroudi E, et al. Impact of the COVID-19 pandemic on positive airway pressure adherence and patients’ perspectives in Greece: the role of telemedicine. J Clin Sleep Med. 2023;19(10):1743–1751. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Billings ME, Auckley D, Benca R, et al. Race and residential socioeconomics as predictors of CPAP adherence. Sleep. 2011;34(12):1653–1658. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 51.Alcántara C, Giorgio Cosenzo L, McCullough E, et al. Cultural adaptations of psychological interventions for prevalent sleep disorders and sleep disturbances: a systematic review of randomized controlled trials in the United States. Sleep Med Rev. 2021;56:101455. 10.1016/j.smrv.2021.101455 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 52.Sweetman AM, Lack LC, Catcheside PG, et al. Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev. 2017;33:28–38. 10.1016/j.smrv.2016.04.004 [DOI] [PubMed] [Google Scholar]
- 53.Kaffenberger TM, Chandna M, Kaki P, et al. Reduced usage of upper airway stimulation therapy in patients with comorbid insomnia and obstructive sleep apnea. J Clin Sleep Med. 2023;19(12):1997–2004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 54.Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med JCSM Offl Publ Am Acad Sleep Med. 2021;17(2):255–262. 10.5664/jcsm.8986 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 55.Patel SR, Bakker JP, Stitt CJ, et al. Age and sex disparities in adherence to CPAP. Chest. 2021;159(1):382–389. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 56.Lin CM, Davidson TM, Ancoli-Israel S. Gender differences in obstructive sleep apnea and treatment implications. Sleep Med Rev. 2008;12(6):481–496. 10.1016/j.smrv.2007.11.003 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 57.Ho Y-CL, Mahirah D, Ho CZ-H, Thumboo J. The role of the family in health promotion: a scoping review of models and mechanisms. Health Promot Int. 2022;37(6) 10.1093/heapro/daac119 [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
All authors do not have conflicts of interest to disclose date and data will be made available upon request.