Higher Subjective Sleepiness Tied to Greater Early CPAP Adherence in Obstructive Sleep Apnea

In a new retrospective observational study, researchers reported that higher baseline scores on the Epworth Sleepiness Scale (ESS) were significantly associated with higher early adherence to continuous positive airway pressure (CPAP) therapy in patients with obstructive sleep apnea (OSA). Published in Respiratory Medicine, these findings suggest that incorporating the ESS into routine clinical evaluation may help identify early CPAP engagement and could inform more personalized strategies to improve long-term adherence.¹

Published in Respiratory Medicine, the analysis included 400 adults with OSA prescribed CPAP therapy between 2021 and 2023. Adherence data were collected over the first 30 days of therapy and categorized into 5 ordinal groups, ranging from very low to very high adherence. Led by senior author Sushil K. Singhi, MD, findings showed that demonstrated a significant association between higher baseline ESS scores and greater adherence (χ2 = 28.7; P = .026; gamma = .199).

“The clinical relevance of these findings lies in the timing of the observed association. Short-term CPAP adherence has been shown to be a strong predictor of long-term treatment persistence, as adherence behaviors and patient expectations are often established during the initial weeks to months following therapy initiation,” Singhi, an associate clinical professor of medicine at Edward Via College of Osteopathic Medicine, and colleagues wrote.¹ “From this perspective, identifying factors associated with early adherence is particularly valuable, as this period represents a critical window during which disengagement may still be preventable and long-term adherence trajectories can be modified.”

The current study investigated the association between baseline subjective sleepiness, measured by ESS,² and subsequent CPAP adherence.³ The patient cohort had a mean age of 53.7 years (SD, 9.9), and 63.0% were men. Mean body mass index (BMI) was 36.6 kg/m² (SD, 7.6), and mean baseline apnea-hypopnea index was 28.3 events per hour (SD, 26.7) e. The mean baseline ESS score was 8.9 (SD 4.8), reflecting, on average, normal daytime sleepiness. Mean adherence over 30 days was 83.2% (SD, 24.1%). Notably, hypertension was the most common comorbidity, reported in 51.3% of participants.

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In an ordinal logistic regression analysis, each 1-point increase in ESS score was associated with 7.4% higher odds of being in a greater adherence category (OR, 1.072; 95% CI, 1.027-1.117; P <.001). Age was a modest predictor, with each additional year associated with a 1.0% increase in the odds of higher adherence (OR, 1.010; 95% CI, 1.004-1.044; P = .019). BMI (P = .306) and sex (P = .470) were not significant predictors. In linear regression analysis, ESS (β = 0.80; P = .001) and age (β = 0.28; P = .021) were both significantly associated with adherence, with higher ESS scores and older age predicting greater adherence.

All told, patients with more severe daytime sleepiness demonstrated higher proportions of excellent adherence. Specifically, those with severe sleepiness comprised 1.6% of the poor adherence group (0%–60%) compared with 15.6% of the excellent adherence group (90%–100%). In contrast, patients with lower-normal sleepiness represented 34.4% of the poor adherence group and 21.7% of the highly adherent group.

“Within this context, ESS may serve as a practical tool to inform early clinical decision-making rather than a predictor of ultimate treatment success. Patients with lower baseline sleepiness, who may perceive less immediate symptomatic benefit, could be prioritized for enhanced education regarding expected benefits, closer early follow-up, or additional support such as mask/interface optimization, telemonitoring, or behavioral interventions,” Singhi noted.¹ “Conversely, patients with higher ESS who demonstrate early adherence may still benefit from proactive counseling to sustain engagement once symptomatic improvement occurs. By enabling targeted interventions during the initiation phase of therapy, the use of ESS at baseline may help clinicians individualize care and potentially improve long-term CPAP adherence outcomes.”

REFERENCES
1. Baki ZT, Alameri MA, Singhi SK. Association between Epworth Sleepiness Scores and CPAP compliance in patients with obstructive sleep apnea. Respir Med. 2026;253:108673. doi:10.1016/j.rmed.2026.108673
2. Gonçalves MT, Malafaia S, Moutinho Dos Santos J, Roth T, Marques DR. Epworth sleepiness scale: A meta-analytic study on the internal consistency. Sleep Med. 2023;109:261-269. doi:10.1016/j.sleep.2023.07.008
3. Sánchez-de-la-Torre M, Gracia-Lavedan E, Benitez ID, et al. Adherence to CPAP Treatment and the Risk of Recurrent Cardiovascular Events: A Meta-Analysis. JAMA. 2023;330(13):1255-1265. doi:10.1001/jama.2023.17465