He was excited about starting CPAP therapy.  He had a great experience in the sleep laboratory.  It was the best night’s sleep he’d had in years.  However, a week after starting on CPAP, he felt discouraged and frustrated that it wasn’t the magic solution he had anticipated. He returned to the sleep clinic to meet with his physician to determine the reason for his difficulty with adapting to CPAP.  He was reporting difficulty falling asleep and staying asleep with the mask on.  As far as he was concerned, CPAP was making his already atrocious sleep worse!  What Mr. Jones failed to appreciate was that the coffee and alcohol were sabotaging his efforts to acclimate to PAP therapy.

There is more to being successful with PAP therapy than putting on the mask and going to sleep.  Since a good portion of what we do during the day affects how we sleep at night, a healthy lifestyle and attention to issues that might affect sleep will make for an easier transition to PAP therapy.  It is not uncommon to develop some bad sleep habits in an attempt to compensate for the poor quality of sleep caused by months or even years of untreated OSA.  Daytime napping, irregular sleeping schedules, spending too much time in bed, as well as excessive caffeine use, are common behaviors people with OSA try to get some relief.  People can recognize and take measures to address those behaviors by following some sleep hygiene principles.

 
· PRIORITY - make sleep a priority.   Look at this experience as an opportunity to make some major lifestyle changes.  There is a lot of evidence showing that getting enough sleep and getting good quality sleep are key ingredients to overall health.  In addition, inadequate or poor sleep has been linked to mood disturbance, cognitive and memory impairment, an increased risk for accident and injury, and a poor quality of life.  Too often sleep is relegated to the back-burner.  Work, family, and community responsibilities have a way of consuming our daily schedule.  Sleep seems a likely place to cut corners.  Change your attitude about sleep.  Most adults need 7 to 7 ½ hours of sleep a night. Allow enough time for an optimal sleep opportunity.  Consider your need for sleep as you plan your daily activities.

·  SLEEP ENVIRONMENT - create an environment that is conducive to sleep.  Make sure the bedroom is dark, quiet, and well-ventilated.  The temperature should be cool with appropriately warm bed covers.  The mattress should be of good quality.  Sleep wear should be loose and comfortable.  Avoid watching television, and engaging in activities other than sleep and intimacy in the bedroom.  You want to create a clear connection in your mind between the bedroom and sleep.

· ROUTINE - establish a pre-bedtime routine that marks the end of the day and beginning of the sleep period and avoid too much variability in your routine.  Too often we work right up until the time we fall into bed.  This doesn’t give our minds or bodies time to unwind from the events of the day.  Create a routine that is relaxing and predictable.  Reading, listening to music, taking a warm bath or shower, and quiet time with family are examples of activities that may help your body to recognize that the day is over. 

Keep a regular sleep/wake schedule.  We are biologic beings and, as such, our bodies crave repeated rhythms.  Going to bed and waking up at the same time each day helps to set our biologic clock and cues us for the transitions in our daily routine.

· CAFFEINE - limit or give up caffeine completely, especially after noon.  People regularly point to their previous experiences with caffeine as a justification for their current use.  They say, “I’ve been drinking five cups of coffee for years”, and expect that to justify their current consumption pattern.  Just as you probably can’t stay out all night anymore, it is unreasonable to expect that you should be able to drink the same amount of coffee you did when you were younger.  Caffeine is a stimulant and can be responsible for increasing the time it takes to fall asleep as well as decreasing deep sleep.  In addition, it is a diuretic, making the likelihood of middle-of-the-night awakening for a trip to the bathroom higher.

· SMOKING – consider giving up entirely.  Fluctuating nicotine levels can be responsible for middle-of-the-night awakenings with difficulty returning to sleep without a cigarette.  Nicotine is a stimulant that causes increased blood pressure, heart rate, and brain wave activity, none of which are conducive to a good night’s sleep.  In addition, smokers frequently find it more difficult to acclimate to PAP therapy as a result of nasal congestion and irritation.

· ALCOHOL – limit your alcohol intake in the evening and consider a trial period with no alcohol use at all.  Alcohol is the great soporific.  For centuries people have been using it as a sleep aid.  Unfortunately alcohol is also responsible for middle-of-the-night awakenings and fractured and restless sleep.  While alcohol can decrease the time it takes to fall asleep, it also decreases deep sleep and REM sleep.  If you routinely have an alcoholic beverage in the evening and are wondering if it is impacting your sleep, try avoiding alcohol for a period of time.  If it is affecting your sleep you will quickly recognize a pattern of improved sleep once you stop using alcohol in the evening. 

· EXERCISE - avoid exercise late in your day.  Exercise has been shown to improve sleep quality by decreasing the amount of time it takes to fall asleep, increasing the amount of slow wave or deep sleep, and decreasing middle of the night awakenings.  However, exercising too late in your day can make it more difficult to fall asleep.  Try to finish exercising at least two hours before your planned bedtime.

· FLUIDS - Limit fluids in the evening.  As we age, middle-of-the-night awakenings for bathroom trips are normal and they are not really a problem per se unless there is difficulty returning to sleep.  In the early stages of PAP therapy, it is probably best to try and limit factors that might wake you up and cause you to remove your mask.

· NAPPING - avoid the urge to nap.  You may have fallen into some habits such as sleeping in the afternoon to make up for a poor quality sleep the night before.  Or perhaps you fall asleep on the couch for several hours before actually getting into bed.  Naps can thwart efforts at sleep by decreasing the drive for nighttime sleep and disrupting the body’s normal sleep/wake rhythms.  If you absolutely feel that you can’t make it through the day without napping, limit it to 30 minutes and use your PAP.

· EXPECTATIONS - set reasonable goals and expectations about your CPAP therapy.  Adjusting to it takes time.  Too often people expect dramatic results and an overnight success.  While some people adjust quickly, others may take as long as three to four months to fully acclimate to PAP therapy.  Keep trying.  Work closely with your respiratory therapist and sleep specialist to address any issues of comfort with your mask and other equipment.  Begin each night with PAP therapy with the ultimate goal of keeping it on each night, the whole night.

During the first follow-up appointment in the sleep clinic, Mr. Jones had a full consultation with the sleep specialist.  They reviewed his progress and he was instructed to reduce his caffeine intake by 50% and avoid alcohol altogether for a period of time.  He was discouraged from napping in the afternoon. At first it was quite difficult for him to adhere to the recommendations.  He frequently felt like an afternoon nap and missed his afternoon cup of coffee.  Over time however, he began to notice less afternoon sleepiness and was surprised to find that he could stay up until 11:00 pm.  He progressed to the point where he could fall asleep quite easily with the CPAP in place.  If he did wake in the middle of the night, it was usually for a quick mask adjustment and he was able to fall right back to sleep.  He reported at his one month follow-up visit that the caffeine and alcohol weren’t worth the toll they took on his sleep patterns.  He’d much rather have a good night’s sleep!