A Qualitative Study to Investigate the Preference of Older Individuals with Obstructive Sleep Apnea on a Continuous Positive Airway Pressure Machine in Thailand: An Outpatient Setting

Introduction

Obstructive sleep apnea (OSA) is a common disease. A systematic review published in 2023 reported that the prevalence of OSA was 69% in the elderly individuals worldwide.¹ The American Heart Association (AHA) stated that up to 40–80% of patients with cardiovascular diseases such as hypertension, coronary artery disease, and stroke may have concurrent OSA.² A study of older male twins found that moderate/severe OSA was associated with myocardial perfusion abnormalities with an adjusted odds ratio of 3.6 (P = 0.005).³ If left untreated, individuals with OSA are at risk of the cardiovascular diseases stated by the AHA earlier as well as depression, or mortality.^4,5 Risks of depression and mortality were 1.34 times (95% confidence interval of 1.05, 1.70) for depression and 1.38 times (95% confidence interval of 1.09, 1.76) for mortality.

The mainstay treatment for OSA is a continuous positive airway pressure machine (CPAP).² A cohort study of older adults with OSA, median age of 73 years, showed that CPAP lower mortality and cardiovascular diseases significantly by 47% and 10%, respectively.⁶ Even though it has been shown that CPAP is beneficial for health, CPAP purchasing rate was approximately 50%.⁷ The systematic review found that several factors were predictors of CPAP purchasing such as age, education, or being sleepiness. Older adults by 1.11 years, more education by 0.93 years, or being sleepiness evidence by high Epworth Sleepiness Scale by 0.61 were likely to purchase CPAP. Another study on marketing factors and CPAP purchasing showed that informative salesperson may increase CPAP purchasing rate by 9.478 times.⁸

Even though several quantitative reports showed predictors of CPAP purchasing in patients with OSA, decision-making for CPAP purchasing is complex, particularly in older adults. Several studies showed that to identify process of decision-making in patients may require an in-depth interview or qualitative study.^9–12 A scoping review of 12 studies; mainly qualitative studies found that patients with complex care may need some specificities for decision-making.¹² Another qualitative study in older adults showed that classes and priority of decisions were related to decision-making in health-care plan.¹⁰ Additionally, there are limited data on CPAP purchasing by qualitative study, particularly in older adults. This study aimed to evaluate factors associated with CPAP purchasing in older adults with OSA by using qualitative study design.

Methods

This was a qualitative study conducted at public research hospital in Thailand. The inclusion criteria were older adults with an age of 60 years old or more who diagnosed with OSA, underwent the CPAP titration trial for at least three nights, and decided to purchase the CPAP after the CPAP titration trial. Diagnosis of OSA was made by using polysomnography with an apnea-hypopnea index of five or more events/hour.^13–16 Eligible patients were recruited from Sleep Clinic, outpatient department by a purposive sampling. The study period was between January 2024 and August 2024.

Patients who met the eligibility criteria were invited to participate in the study. An informed consent was given prior to study participation. Each patient was interviewed with structured questions to identify perspectives of CPAP purchasing. The in-depth interviews were performed until data were saturated.^17,18 Data were collected in regard to how they spend their lives currently, important factors of living as an older adults, experiences and perspectives on sleep apnea, and factors associated with CPAP purchasing. Data collection was based on three principles including data triangulation, methodological triangulation, and theory triangulation. We analyzed the data by using mix-method between Colaizzi’s method and van Kaam’s method.^19–23 There were six steps for data coding and theme identification including

Step 1: Transcription and familiarization. All interviews were transcribed, and the transcribed tape was read and re-read several times to gain a holistic understanding.

Step 2: Extracting significant statements/listing initial codes. Key phrases related to caregiving challenges were from participants’ statements.

Step 3: Formulating meanings/reducing and eliminating statements. Each statement was interpreted to derive meaning, while irrelevant or redundant statements were removed.

Step 4: Clustering themes. Similar meanings were grouped into themes.

Step 5: Developing themes/identifying core elements. Themes were categorized into overarching domains.

Step 6: Describing the essence of the experience. A synthesized description of the preference of older individuals with obstructive sleep apnea on a continuous positive airway pressure machine was written to represent participants’ shared realities.

Themes and examples of quotes of CPAP purchasing in older adults with OSA were reported.

Results

There were 15 elderly patients diagnosed with OSA and decided to purchase CPAP machine. Of those, eight patients (53.33%) were male, three patients were widowed, and most patients lived with their children, retired from the government officers, and had health insurance to cover CPAP or had no financial issue on buying CPAP. The age range was between 62 and 72 years. There were four themes related to CPAP purchasing in older adults with OSA (Figure 1).

Figure 1 Four main themes on factors associated with a decision of continuous positive airway pressure machine (CPAP) purchasing in older adults with obstructive sleep apnea (OSA).

Health and OSA Perspectives in Older Patients with OSA

Older patients wanted to live peacefully without rush, live happily, and live healthy. They experienced a lot of things in their lives, both good and bad events. The most important thing was to be healthy as they did not want to be dependent and needed one child to take care of them in the future. When diagnosed with OSA, they wanted to be treated and be healthier.

As an older adult, the most important thing is to be healthy. To live longer, I will see success of my children and grandchildren. (Patient 1: 65 years, female)

To live until now, health status is the most important thing. I am so proud of me about my successful job and my children. They graduated from college and one of them works as a governor. (Patient 2: 69 years, male)

The most valuable thing in my life at this age is to live with children and grandchildren, and to take care of them. (Patient 3: 65 years, male)

I want to live peacefully and do not want to work, though I received a lot of offers. (Patient 4: 62 years, female)

The most important thing in my life now is to live with family. I want my family to be happy. I want my children and grandchildren to success in their lives and be independent. I am worried about some of them who may struggle in their lives. I am trying to be a role model for them. (Patient 5: 72 years, male)

When I was tested for sleep study and diagnosed as sleep apnea, this was critical. I was stressed out, and worried about it. It may cause sudden death during sleep, fatigue, and unrefreshed sleep. Sleep apnea may worsen more and more. If I used CPAP, symptoms may be improved. (Patient 6, 65 years, male with diabetes and hypertension more than 10 years)

I am a stressful person. I am worried about my youngest son and my poor sleep quality. My blood pressure was high at 190 mmHg, so I should be treated with an auto CPAP. It may help me with my sleep quality and my high blood pressure. If I get a good sleep quality, I may feel better and less irritable (Patient 7: 68 years, male)

I stop breathing 21 times/hour with diabetes, high blood pressure, and high cholesterol. I am trying to keep myself healthy by exercising regularly and eating healthy food. I want to treat my sleep apnea as well to be healthy. (Patient 8, 64 years, male)

Family Support

Family members support the older adults with OSA to be treated with CPAP. They did research on how to treat sleep apnea with CPAP and showed their support on CPAP use as well.

My daughters who lived in another province bought the machine for me and my husband. They always give me a call frequently to remind me and my husband to use CPAP every night. They said that they want me to live long and support them. (Patient 9: 62 years, female, merchant, three daughters)

I take care of my wife as I did not take care of her well in the past. I worked too hard previously and spent time with friends too much. I do not have any financial issues about buying CPAP. So, I bought for her. (Patient 2: 69 years, male)

My sons and daughters bought the machine for me. This makes me so glad that they take care of me. (Patient 7: 68 years, male; Patient 10: 69 years, male with renal disease)

I have sleep apnea, and it makes me tired. I am scared and afraid of dying. My son told me to treat with the best machine. (Patient 11: 70 years, female)

My wife is so worried about me. She saw I stop breathing during the night and had difficulty breathing while sleeping. She always woke me up during the night as she was afraid of sudden death during the night. She told me to purchase CPAP as my snoring was better while trying the CPAP. The machine makes my wife feeling released about my apnea and my symptoms (Patient 8, 64 years, male)

Worries About Their Family Members

Older adults with OSA worry about their family members as they want to live as long as possible to take care of their young family members, particularly nieces and nephews. These older adults do not work, so they have a role as a babysitter.

I decided to purchase CPAP as I am afraid of sudden death. I want to take care of my son. (Patient 4: 62 years, female)

When I first tried with the machine, I could not breathe due to high pressure. But I am afraid of dying as I live alone. I want to live long to take care of my nieces and nephews. (Patient 12: 72 years, female, widowed)

Actually, I do not want to live long. But I want to raise my niece and see her grow up. I also want to live and be a good role model for my niece. (Patient 5: 72 years, male)

Factors Associated with CPAP Purchasing

There are two main factors regarding a decision of CPAP purchasing in older adults with OSA: affordability and benefits of CPAP. The affordability for CPAP is from pocket money or health insurance coverage, while benefits of CPAP include symptom improvement and sleep quality improvement.

Affordability

My sons and daughters bought CPAP for me as I was unable to buy it. (Patient 5: 72 years, male)

When my doctor told me that I stopped breathing, and he asked me if I wanted to use it or not. I have enough budget to buy it. I spent a lot of money on other unnecessary things, this machine is good for my health. I should get it. (Patient 13: 67 years, male)

I think most people may not hear about sleep apnea and do not know how to treat it. My wife also does not know about it. The machine is covered by her health insurance. We decided to buy it and hope that it is good for her health. (Patient 2: 69 years, male)

As an older adult, I do three things: keep healthy, be calm, and be easy in life without worries. I have enough money with health insurance to cover the machine cost. (Patient 11: 70 years, female)

Benefits of CPAP

Older adults with OSA stated that they had a new life after CPAP trial and good sleep.

After CPAP trial, I felt a lot better, felt refreshed, and had no fatigue as previously. I felt like I had a new life. (Patient 7: 68 years, male)

When my doctor told me to have a CPAP trial, I did not want to try as some patients told me that it was discomfort. But I could use it and felt so refreshed. (Patient 4: 62 years, female)

The machine makes my breathing smooth. Without it, I could not breathe while sleeping and I was worried about my breathing. (Patient 10: 69 years, male with renal disease)

Some patients told me that the machine is a foreign body on us. But it makes me confident that I will not have a sudden death while sleeping. (Patient 14: 62 years, female)

I was scared about my sleep apnea. I stopped breathing 21 times/ hour. I thought it was just snoring. When I used the machine, I did not snore at all. (Patient 8, 64 years, male)

I have had a problem of poor sleep and insomnia for years. When I tried the machine, it helped me with my sleep. I sleep deeply and peacefully with the machine. (Patient 13: 67 years, male)

I could not breathe while sleeping and I had to wake up to have a deep breath. I am also worried about sudden death. This machine makes me confident that I will not have sudden death. My family members also feel relaxed if I have the machine. (Patient 9: 62 years, female, merchant, three daughters)

The machine makes me breathe better and I am satisfied with my sleep. I am feeling better and do not have fatigue with it. (Patient 15: 70 years, female)

My husband always checks on me during my sleep as I stop breathing during the night. But I do not have those events after using the machine. (Patient 1: 65 years, female)

Discussion

Older adults with OSA who decided to purchase CPAP wanted to be healthy and live longer (Patient 1: 65 years, female). Their perspectives on OSA are that OSA is a critical condition that may lead to cardiovascular diseases and nocturnal death (Patient 6, 65 years, male with diabetes and hypertension more than 10 years).² As previously reported, a systematic review of older adults (mean age of 62 years) found that OSA was independently related to sudden death by 1.74 times; 95% confidence interval of 1.44, 2.10.²⁴ Nocturnal death was occurred more in patients with OSA than in those without OSA (46% vs 21%; p = 0.01).²⁵

Additionally, older adults showed fear of death from OSA; I want to live with my family (Patient 5: 72 years, male). A previous study in older adults confirmed that poor health condition increased risk of fear of death from known cause significantly (beta = −0.11; p < 0.01).²⁶ Additionally, previous studies in older adults found that meaning in life significantly associated with self-esteem and death anxiety (p < 0.01) and low parental self-efficacy was significantly related to loneliness and death anxiety.^27,28 Older adults in this study showed that they have meaning in life: being proud of themselves (Patient 2: 69 years, male) and parental self-efficacy: correlation with family (Patient 2: 69 years, male; Patient 3: 65 years, male). The good correlation with family was also an indicator of low loneliness in older adults. Once again, these older adults received good support from their families, resulting in low loneliness: my daughters bought the machine for me, and they always reminded me to use it (Patient 9: 62 years, female, merchant, three daughters). Several studies showed that family can improve loneliness of older adults.^29–32 Both children’s emotional support and children's caregiving support significantly lower the loneliness of older adults (β = 3.920, p < 0.05 and β = 3.801, p < 0.001, respectively).³¹ Even though CPAP was shown to be beneficial in terms of cardiovascular protection such as stroke or cognitive impairment,^33,34 there are several limitations or challenges in older adults with OSA to accept and purchase CPAP.³⁵ Older adults may face problems with cognition or understanding how to use the CPAP. Support from family members may recognize and realize the benefits of CPAP in prevention of cardiovascular diseases leading to a decision to purchase CPAP for older adults. Additionally, family members may be a caregiver to assist older adults with OSA to comply with CPAP. A previous study in women with OSA found that relationship conflict with spouse was leading to low CPAP compliance (r = −0.60; p < 0.05).³⁶

The other two themes that associated with a purchasing decision: affordability and benefits of CPAP. A previous study found that patients with high economic status had higher chance of purchasing CPAP with adjusted odds ratio of 1.23 (95% confidence interval of 1.02, 1.40; p = 0.03).³⁷ The same study also showed that those with OSA symptoms, such as daytime sleepiness, were also likely to purchase CPAP by 35% (p = 0.002). This qualitative study confirmed these findings from the quantitative study: I have enough budget to buy it (Patient 13: 67 years, male); I feel so refreshed after the CPAP trial (Patient 4: 62 years, female). Fatigue was previously reported to be associated with future CPAP adherence 5.380 times.³⁸ In this study, older adults with fatigue symptom were associated with purchasing CPAP: I am feeling better and do not have fatigue (Patient 15: 70 years, female).

Unlike the quantitative study,⁷ results of this study may be important factors associated with CPAP purchasing in older adults with OSA. Both affordability and benefits of CPAP were the top factors ranked by the participants from an in-depth interview until data saturation. Factors associated with CPAP purchasing by the quantitative study may be several and cannot be ranked. Physicians may use the results of this study to facilitate CPAP purchasing in older adults with OSA. There are some limitations in this study. First, the results of this study may not be generalized for older adults particularly in terms of affordability. Those with full insurance coverage may not have this issue, while those with financial constraint may have similar results with this study. Second, this study did not evaluate the effects of CPAP use such as symptom improvement. Finally, other aspects of CPAP such as adherence or compliance with CPAP machine were not studied. Further studies are required to examine these aspects, particularly in older adults.

In conclusion, perspectives of OSA on health, family support, affordability, and benefits of CPAP were factors associated with CPAP purchasing in older adults with OSA by the in-depth interview. Generalizability of the results may be limited to those with insurance or financial constraints. Further studies with CPAP adherence or compliance in older adults may be required.