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Background and Purpose— Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea may improve stroke recovery, but adherence is poor. We assessed the effectiveness of an intensive CPAP adherence program during and after inpatient stroke rehabilitation on 3-month adherence and stroke recovery. Methods— In a single-arm study, 90 stroke rehabilitation patients were enrolled into an intensive CPAP adherence program. CPAP was continued after a run-in among qualifying patients with evidence of obstructive sleep apnea. The primary outcome was CPAP adherence, defined as ≥4 hours of use on ≥70% of days, over 3 months. Results— A total of 62 patients qualified for continued CPAP and 52 of these were willing to continue CPAP after discharge from rehabilitation. At 3 months, the average daily CPAP use was 4.7 hours (SD 2.6), and 32/52 (62%) patients were adherent. Factors significantly associated with adherence included more severe stroke, aphasia, and white race. Compared with nonadherent patients, adherent patients experienced greater improvements in the cognitive component of the Functional Independence Measure ( P =0.02) and in the National Institutes of Health Stroke Scale ( P =0.03). Conclusions— This intensive CPAP adherence program initiated during stroke rehabilitation can lead to CPAP adherence in the majority of patients with evidence of obstructive sleep apnea, including those with more severe stroke and aphasia, and may promote recovery. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02809430.

Background: Continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA) may improve stroke recovery but prior studies have been limited by poor adherence. In a single-arm study of stroke rehabilitation patients treated with CPAP, we evaluated environmental, behavioral and social factors associated with CPAP adherence. Methods: As part of an intensive CPAP adherence protocol, stroke rehabilitation patients were assessed for OSA based on CPAP device download. Qualifying patients underwent motivational interviewing (MI) sessions to set goals and address barriers for CPAP use. Patients who planned to continue CPAP after rehabilitation unit discharge were asked after 3-months to detail facilitators or barriers to continued CPAP use. We conducted a thematic analysis of the MI and 3-month interview notes, with four authors each coding modifiable and less modifiable barriers and facilitators. Results: Among 52 subjects who planned to continue CPAP over 3-months, 32 (62%) were adherent, defined as ≥ 4 hours on ≥ 70% of days. Adherent patients were less likely to complain of claustrophobia than non-adherent patients (13% vs. 42%, p =0.02). Facilitators for adherence were improved sleep quality and daytime function, self-efficacy with CPAP, social support, and positive expectations of treatment benefit. Common modifiable barriers included discomfort using a new health technology, common CPAP side effects and anxiety. Several patients described more complex and less modifiable barriers such as social stressors, sleep disturbance, lack of social support and competing health issues. Conclusions: An intensive CPAP adherence protocol with MI sessions during rehabilitation yielded a high rate of adherence even outside of the supportive inpatient environment. Adherence programs for CPAP after stroke should focus on interventions to address modifiable barriers, including early desensitization to improve anxiety or claustrophobia and continued education or training to address perceived self-efficacy and importance of CPAP therapy. Future studies should assess the effectiveness of MI to identify factors associated with CPAP adherence and to design interventions to improve long-term adherence by modifying these factors.

Introduction: Obstructive sleep apnea (OSA) is associated with worse outcome after stroke. Treatment with continuous positive airway pressure (CPAP) may improve recovery after stroke but has been limited by poor adherence. Methods: In a single-arm ongoing study, adults with stroke underwent an intensive CPAP adherence protocol during inpatient rehabilitation, including motivational interviewing and help with CPAP by nurses and respiratory therapists. A 3-night run-in period of auto-titrating CPAP was used to test for tolerance and to diagnose OSA, based upon the apnea-hypopnea index and flow resistance. Qualifying patients were asked to continue CPAP for 3 months. The outcomes included CPAP adherence, defined as ≥ 4 hours of use on ≥ 70% of nights, and stroke recovery, measured by change in NIH Stroke scale (NIHSS) and Functional Independence Measure (FIM) over 3 months. Results: During the run-in, 39 of 60 (65%) patients had presumed OSA, 5 (8%) had no evidence of OSA, 4 (7%) had evidence of central sleep apnea, and 12 (20%) were intolerant of CPAP. Among the 34 of 39 patients who chose to continue CPAP after the run-in, the median use per night was 5.3 hours (IQR 4.1, 6.0) with 56% (n=19) adherent during rehabilitation. The median CPAP use per night for the 22 who completed the study was 5.1 hours (IQR 2.5, 6.4) with 54% (n=12) adherent over the 3-month period. Unadjusted for baseline factors, there was a significant change in the NIHSS in adherent patients (n=10) vs. non-adherent patients (n=10) [5 (SD 3) vs. 2 (SD 2), p =0.02]. Comparing adherent (n=7) to non-adherent patients (n=5), the change for total FIM trended towards significant [42 (SD 18) vs. 30 (SD 11), p =0.20] and the change for cognitive component of the FIM was significant [10 (SD 7) vs. 2 (SD 3), p =0.05]. Conclusion: After an intensive adherence intervention, over half of stroke patients with presumed OSA and CPAP tolerance were adherent over 3 months. CPAP adherent patients had greater improvement in NIHSS and the cognitive component of the FIM, although the associations may be confounded by patients’ characteristics influencing both adherence and outcomes. Future studies are needed to evaluate in a randomized trial if the intensive intervention will lead to long-term CPAP adherence and improved stroke recovery.