A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance.

Background and Objectives: Although numerous studies have explored various predictors of positive airway pressure (PAP) adherence, the potential impact of objective sleep scoring data obtained during PAP titration on adherence has not been thoroughly investigated. The objective of this study was to evaluate the association between objective sleep parameters obtained from PAP titration, including sleep efficiency (SE), wake after sleep onset (WASO), and sleep latency (SL), and short-term PAP adherence in individuals with obstructive sleep apnea (OSA). Materials and Methods: A total of 227 individuals with a confirmed diagnosis of OSA underwent overnight PAP titration and were subsequently divided into adherence and non-adherence groups. Baseline demographic characteristics, clinical data, diagnostic polysomnography results, and PAP titration data were obtained for all subjects. Paired sample t-tests were utilized to assess differences in sleep parameters between diagnostic polysomnography and PAP titration within each group. Binomial logistic regression was used to evaluate the predictive value of changes in SE, WASO, and SL for PAP adherence and to determine optimal cut-off values. A χ2 analysis was conducted to assess the relationship between categorical improvements in SE and WASO and adherence to PAP therapy. Results: Among the study cohort, 176 (77.5%) participants were classified as adherent, while 51 (22.5%) participants were classified as non-adherent. SE during PAP titration (83.3 ± 12.6%) was significantly higher compared to baseline polysomnography (80.9 ± 12.4%, p = 0.020), and WASO was significantly reduced (63.9 ± 58.9 min vs. 77.7 ± 67.2 min, p = 0.016). No significant difference was observed in SL between the two groups. Logistic regression analysis indicated that increased SE (odds ratio [OR]: 1.025, p = 0.039) and decreased WASO (OR: 0.994, p = 0.027) both served as significant predictors of PAP adherence, but the overall predictive ability of these indicators was modest (area under the curve 0.60 for SE; 0.62 for WASO). The optimal thresholds distinguishing adherence were ΔSE ≥ 2.39% and ΔWASO < −1.5 min. Participants who exhibited improvements in SE (χ2 = 5.296, p = 0.021) and WASO (χ2 = 6.877, p = 0.009) demonstrated a significantly higher likelihood of adhering to PAP therapy. Conclusions: The findings demonstrate that objective increases in sleep quality, specifically elevated SE and decreased WASO during initial PAP titration, are significantly associated with short-term PAP adherence among patients with OSA.

Black individuals are disproportionately affected by diabetes, cardiovascular disease, obesity, and OSA. Adherence to PAP therapy has been reported to be lower among black individuals. This study seeks to examine associations between black race and PAP adherence among veterans with OSA. This was a retrospective study. Veterans newly diagnosed with OSA at a single Department of Veterans Affairs sleep center who were prescribed a modem-enabled PAP device between January 2015 and November 2017 were enrolled. PAP adherence was defined as ≥ 4 hours nightly usage for at least 70% of nights measured at 30 days from PAP setup. We examined the relationship between race and adherence, controlling for sex, marital status, age, socioeconomic status, residual apnea-hypopnea index), and mask leak. Of 3013 patients identified with OSA, 2571 (85%) were newly started on PAP therapy (95% male, aged 59 years ± 14 years, 45% married, 8% with neighborhood socioeconomic disadvantage). Twenty-five percent of participants were black, and 57% were white. PAP adherence at 30 days was 50% overall (42% among blacks, 53% among nonblacks). Black race was associated with reduced 30-day PAP adherence in unadjusted (P < .001) and adjusted logistic regression models (odds ratio = 0.64; 95% CI, 0.53 - 0.78; P < .001). Among veterans with OSA, black race was associated with reduced PAP adherence. These findings suggest health inequality among black individuals in the treatment of OSA.

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use. 125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected. Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05). An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA. ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

Introduction This study examines the effects of treatment sequences using cognitive-behavioral therapy for insomnia (CBT-I) and continuous positive airway pressure (CPAP) therapy on daytime functioning in people with comorbid insomnia and sleep apnea (COMISA). Methods 118 participants with COMISA (Age=49.99±13.12; 53.4% female) were randomized to one of the three study arms: Arm A- CBT-I followed by CPAP, Arm B- CBT-I concurrent with CPAP, and Arm C- CPAP only. Participants were assessed at four time points [baseline/ start of phase 1 (A1), CPAP titration/ start of phase 2 (A2), 30 days (A3) and 90 days (A4) after CPAP initiation]. This study examined secondary outcome measures of daytime functioning, including the Functional Outcomes of Sleep Questionnaire (FOSQ), Epworth Sleepiness Scale, and Flinders Fatigue Scale (FFS). Results Linear mixed model analyses showed a main effect of time on improving functional outcomes in all measurements, with all p&amp;lt; 0.001. There were also arm by time interactions on FOSQ [F(6, 105.36)=4.21, p=0.001] and FFS scores [F(6, 106.95)=3.10, p=0.008]. Pairwise comparisons with Bonferroni adjustment showed improved FOSQ scores in Arm A from A1 to A2 (p=0.011) and A2 to A3 (p=0.005), Arm B from A2 to A3 (p&amp;lt; 0.001), and Arm C from A2 to A3 (p=0.006). For FFS scores, improvements were shown in Arm A from A1 to A2 (p=0.003), and Arm B from A2 to A3 (p &amp;lt; 0.001). Conclusion The results show daytime functioning improvements in patients with COMISA following CPAP and CBT-I. In addition, CBT-I appears to facilitate improvement in sleepiness-related functional status and daytime fatigue. The findings suggest that the combination of CBT-I and CPAP may have a beneficial effect on daytime functioning in patients with COMISA. Support This study was supported by the National Institutes of Health (R01HL114529).

Untangling Treatment Effect From Patient Factors: The Challenge of the Use of Observational Studies to Investigate the Impact of Positive Airway Pressure Therapy on Medical Costs

Introduction Among Veterans with PTSD, approximately 70% have obstructive sleep apnea (OSA) and 90% have insomnia. In patients with PTSD and OSA, positive airway pressure (PAP) use is associated with not only improvements in daytime sleepiness, but also reduction in overall PTSD symptom severity. Unfortunately, patients with PTSD have lower PAP adherence than those without PTSD, and insomnia is associated with lower levels of PAP use. We developed a behavioral sleep treatment called Apnea and Insomnia Relief (AIR) to target comorbid sleep apnea and insomnia (COMISA). This six-session, telehealth-based protocol combines aspects of motivational enhancement, psychoeducation, positive airway pressure (PAP) desensitization, and cognitive behavioral therapy for insomnia. Methods We conducted a pilot randomized controlled trial (RCT) comparing AIR to a Sleep Education (SE) control in Veterans with PTSD and COMISA who were recommended for PAP therapy for OSA. Sleep outcomes included PAP adherence (4+ hours use, at least 70% of past seven days), insomnia symptom severity (Insomnia Severity Index; ISI), and daytime sleepiness (Epworth Sleepiness Scale; ESS). Results The sample (N=34) included 32 men (94%) and two women (6%); mean age was 50 years (SD=12, range 26-76) and 43% of the sample identified as a racial or ethnic minority. One participant (randomized to AIR) dropped out of the trial. At post-treatment, 41% of participants randomized to AIR met criteria for PAP adherence, compared to 13% of participants randomized to SE (x2(1,32)=3.06, p=.08). Participants randomized to AIR demonstrated greater reduction in insomnia symptom severity from pre- to post-treatment, with average reduction on the ISI of 7.12 points (SD=7.52) for AIR, versus 4.07 points (SD=4.81) for SE (t(30)=4.50, p=.0001). Participants randomized to AIR demonstrated greater reduction in daytime sleepiness from pre- to post-treatment, with average reduction on the ESS of 4.00 points (SD=5.98) for AIR, versus 2.80 points (SD=4.07) for SE (t(31)=3.22, p=.003). Conclusion AIR was associated with higher PAP adherence and reduced symptoms of insomnia and daytime sleepiness in Veterans with PTSD and COMISA. Additional trials are needed to establish efficacy in a larger, more diverse sample and evaluate implementation strategies to increase access to this behavioral sleep intervention. Support (if any) U.S. Department of Veterans Affairs (IK2RX002952)

To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia. 121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints. No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure. The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

Telemonitoring has been found to improve the adherence of short-term positive airway pressure (PAP) adherence in random controlled trials (RCT) among patients with obstructive sleep apnea (OSA), however, the RCT results may not fully reflect the real-world situation of PAP management. The objective of this study was to assess the effect of web-based telemonitoring on PAP adherence in patients with moderate to severe OSA on real-world evidence. PAP therapy data for patients with OSA were retrospectively examined and were divided into two groups according to the PAP machines with or without web-based telemonitoring application (TC group or SC group). The adherence data was analyzed at 1 month, 3 months, 6 months, and 12 months after initiation of PAP therapy. A total of 126 patients, including 64 subjects in the TC group and 62 subjects in the SC group, were included for analysis. Compared with those in the SC group, the percent of nights ≥4 hours of PAP use and the mean nightly duration of PAP use were greater in the TC group in the initial 6 months. However, these adherence data were comparable at the end of 12 months. The decreased rate of adherence parameters was greater in the TC group during the 3-6 months compared with the initial 1-3 months. The uptake of telemonitoring function was found to be only associated with good PAP adherence at the initial 3-month therapy. PAP adherence is significantly improved through telemonitoring in the first 3-6 months after PAP initiation. However, the 12-month adherence was comparable between TC and SC groups. The timing and form of interventions based on telemonitoring data that could be most effectively implemented by healthcare providers, warrants further investigation.

Background and Objective Co-morbid insomnia and sleep apnea (COMISA) is a comorbid condition between insomnia and obstructive sleep apnea (OSA) with a prevalence in 2013 to 2018 of 30%–50% in the world. COMISA patients experience greater impairment in daytime function and quality of life compared to patients with insomnia or OSA alone. COMISA treatment tends to focus on OSA disease therapy, hence, it is less effective. Therefore, other treatment methods are needed to improve the success of therapy. This systematic review and meta-analysis evaluate the effects of cognitive behavioral therapy for insomnia (CBT-I) on patients with COMISA compared to control or positive airway pressure (PAP).Methods The selection of studies for this systematic review and meta-analysis used the PRISMA 2020 guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. A systematic search for studies was conducted from Sage, PubMed, Web of Science, Scopus, EBSCO, and Taylor and Francis accessed in March 2024 and selected according to the inclusion and exclusion criteria. Risk of bias was analyzed with the Cochrane Risk of Bias 2.0 Tool, then meta-analysis was performed using Review Manager V5.4.1.Results Overall, significant changes in sleep diary outcomes were found (mean difference [MD]=7.54, 95% confidence interval [CI]=4.07 to 11.00, p&lt;0.001; MD=-19.97, 95% CI=-22.26 to -17.68, p&lt;0.001, respectively) in CBT-I compared to control. In addition, in the CBT-I+PAP intervention compared to PAP, there were significant changes in the descending sleep diary output (MD=-16.92, 95% CI=-27.08 to -6.67, p&lt;0.001) as well as in the sleep questionnaire output (MD=2.13, 95% CI=1.88 to 2.39, p&lt;0.001; MD=-5.91, 95% CI=-10.41 to -1.40, p=0.01, respectively).Conclusions CBT-I showed effectiveness in patients with COMISA. CBT-I was associated with significant improvements in sleep diary, actigraphy, questionnaires, and compliance with PAP use.

BackgroundThe healthy adherer effect (HAE) has gained increasing attention as potential source of bias in observational studies examining the association of positive airway pressure (PAP) adherence with health outcomes in obstructive sleep apnea (OSA). Research questionIs adherence to PAP associated with healthy behaviors and healthcare resource use prior to device prescription? MethodsData from the IRSR Pays de la Loire Sleep Cohort were linked to health administrative data to identify proxies of heathy behaviors (HB) including adherence to cardiovascular (CV) drugs (medication possession ratio, [MPR]), cancer screening tests, influenza vaccination, alcohol and smoking consumption, and drowsiness-related road accidents during the two years preceding PAP onset in OSA patients. Multivariable regression analyses were conducted to evaluate the association of HB with subsequent PAP adherence. Healthcare resource use was evaluated according to subsequent PAP adherence. FindingsWe included 2,836 patients who had started PAP therapy between 2012 and 2018 (65% of whom were PAP adherent with mean daily use ≥4h/night). Being adherent to CV active drugs (MPR≥80%) and non-smoker were associated with a higher likelihood of PAP adherence (odds ratio, OR [95% confidence interval]: 1.43 [1.15; 1.77] and 1.37 [1.10; 1.71] respectively). Patients with no history of drowsiness-related road accidents were more likely to continue PAP (OR: 1.39 [1.04; 1.87]). PAP adherent patients used less healthcare resources 2 years before PAP initiation, than non-adherents (mean number of outpatient consultations: 19.0 vs 17.2, P=.003; hospitalization days: 5.7 vs 5.0, P=.04; emergency room visit: 30.7 vs 24.0% P=.0002). InterpretationPatients who adhere to PAP therapy of OSA were more health seeking and less healthcare users prior to device initiation than non-adherent patients. Until the HAE associated with PAP adherence is better understood, caution is warranted when interpreting the association of PAP adherence with CV health outcomes and healthcare resource use in non-randomized cohorts.

Introduction Patient characteristics like self-efficacy, daytime sleepiness, and obstructive sleep apnea (OSA) severity are associated with positive airway pressure (PAP) treatment adherence. We examined the association of changes in sleep architecture with PAP titration on split-night polysomnography (PSG) with PAP adherence in an urban, racially diverse population. Methods PSG conducted between January and December 2019 were reviewed for sleep architecture data. The main variables were change in sleep efficiency (SE), arousal index (AI), N1, N3, and REM sleep. Changes were assessed as ratios and differences (therapeutic/diagnostic and therapeutic-diagnostic). Demographic data, body mass index (BMI), social vulnerability index (SVI), apnea hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and the initial 90-day adherence data from PAP download were collected. PAP adherence was defined as ≥4 hours/day use for ≥70% days. Stata v17 was used for analysis. Results PSG was conducted in 381 patients, and 239 patients had complete data for PAP use. The baseline characteristics of analyzed patients (N=239) were not significantly different from the missing sample (N=143). The PAP adherent group (N=109) were similar to the non-adherent group (N=130), except for a higher baseline ESS was noted in the adherent group (p=0.01). The logistic regression model showed that increasing age and lower ESS were associated with greater likelihood of PAP adherence (Odds Ratio, OR 1.02,95% confidence interval, CI 1.00-1.05 and OR 0.94, CI 0.89-0.99). Regarding the changes in sleep architecture with PAP titration, increases in SE and N3 sleep during the titration portion of the PSG were associated with higher likelihood of PAP adherence (OR 1.01, CI 1.00-1.03 for each). Changes in AI, N1, and REM sleep were not associated with PAP adherence. Conclusion Improvements in SE and an increase in N3 sleep during PAP titration on split-night PSG are associated with a higher likelihood of PAP adherence. Support (if any)

BACKGROUND Over 20% of patients with primary brain tumors (PBT) report clinically significant insomnia, yet these symptoms are often undertreated. Our team conducted the first trial of Cognitive Behavioral Therapy for Insomnia (CBT-I)—the recommended, first-line treatment—in patients with PBT. Primary findings suggest this intervention was safe, feasible, and acceptable. Moreover, patients demonstrated improvements in self-reported insomnia severity, fatigue, and mood. The aim of this secondary analysis was to assess changes in subjectively- and objectively-derived sleep metrics using data from patients’ sleep diaries and wrist-worn actigraphy. METHODS Patients with PBT and insomnia (N=44) enrolled in a single-arm pilot trial of CBT-I and completed one-week subjective (Consensus Sleep Diary) and objective (wrist-worn actigraphy; Actigraph GT9X) sleep assessments at baseline (T0) and post-intervention (T1). Participants underwent six weekly group CBT-I telehealth sessions. Subjectively- and objectively-derived sleep metrics include total sleep time (TST), time in bed (TIB), sleep efficiency (SE), sleep onset latency (SOL), wake after sleep onset (WASO), number of awakenings (NOA), and perceived sleep quality (PSQ). We evaluated the accelerometer data using the GGIR package and conducted paired-sample t-tests to evaluate change in sleep metrics from T0 to T1. RESULTS Subjectively, data from participants’ sleep diaries revealed improvements in WASO (MΔ=-27.08, p&amp;lt;.001), SOL (MΔ=-27.04, p&amp;lt;.001), SE (MΔ=0.08, p&amp;lt;.001), NOA (MΔ=-5.42, p&amp;lt;.001), and PSQ (MΔ=0.60, p&amp;lt;.001). Both TIB (MΔ=-78.10, p&amp;lt;.001) and TST (MΔ=-36.64, p&amp;lt;.01) significantly decreased. Objectively, data from participants’ wrist-worn actigraphy revealed significant decreases in NOA (MΔ=-2.63, p&amp;lt;.001), SOL (MΔ=-19.46, p=.04), TIB (MΔ=-1.03, p&amp;lt;.001), and TST (MΔ=-0.90, p&amp;lt;.001). The accelerometer data did not reveal significant changes in WASO or SE (ps&amp;gt;.05). CONCLUSION CBT-I may lead to meaningful improvements in both subjective and objective sleep among patients with PBT. Larger, controlled trials are currently underway to confirm these preliminary findings and to further investigate discrepancies between subjective and objective sleep measures.

Objective/BackgroundDiscrepancies between sleep diaries and actigraphy occur among individuals with insomnia. Cognitive behavioural therapy for insomnia (CBT-I) improves insomnia but the impact on discrepancy is unclear. This study examined CBT-I's effects on actigraphy-diary discrepancy and explored sleep-related beliefs and attitudes as a mediator. Patients/MethodsParticipants were 108 (age M±SD = 47.23 ± 12.42, 67.60 % female) adults with insomnia and major depressive disorder from the Treatment of Insomnia and Depression study. They were randomized to 7 sessions of CBT-I or sham Quasi-Desensitization Therapy for Insomnia (DTI), plus 16 weeks of antidepressants. Two weeks of actigraphy and sleep diary were collected at baseline, mid-treatment, end-treatment. Differences between sleep diary and actigraphy total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE) were calculated. Participants completed Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS) at baseline and mid-treatment. ResultsAt baseline, diary (versus actigraphy) TST was shorter (1.1 ± 1.41h), whilst SOL (21.64 ± 41.25min) and WASO (17.45 ± 61.99min) were longer. Mixed effects models using daily data showed that after adjusting for age and sex, participants in the CBT-I group (versus DTI) showed greater reduction in all actigraphy-diary discrepancy domains (all p-values<.01), reductions evident from mid-treatment. Group differences on actigraphy-diary discrepancy reductions in TST, SOL, and SE (not WASO) were mediated by changes in DBAS from baseline to mid-treatment (all p-values<.05). Changes in discrepancy did not mediate insomnia symptom changes (p-values>.39). ConclusionsCBT-I reduced actigraphy-diary discrepancy in individuals with comorbid insomnia and depression; this reduction was associated with improved sleep-related attitudes, a therapeutic target of CBT-I. Clinical trial registrationTRIAD (Treatment of Insomnia and Depression): Improving Depression Outcome by Adding Insomnia Therapy to Antidepressants. Prospectively registered with Clinical Trials (NCT00767624). Support (if any)MH078924, MH078961, MH079256.

Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors

Introduction Nonadherence to positive airway pressure (PAP) therapy is common in comorbid insomnia and obstructive sleep apnea (COMISA). We previously reported a novel behavioral treatment for COMISA which improves both PAP adherence and sleep. Our current goal was to assess whether improvements in PAP self-efficacy, knowledge, and decisional balance (targets of treatment) are associated with improvements in PAP use and sleep quality. We also collected participants’ perceptions of benefits and challenges of PAP during intervention. Methods 125 veterans (96% men, 39% non-Hispanic white, 24% Black, 17% Hispanic/Latino) with COMISA were randomized to a 5-week intervention integrating behavioral insomnia therapy with a PAP adherence program versus general sleep education (control). Objective PAP use data and Pittsburgh Sleep Quality Index (PSQI) were collected over 6 months. Three behavior change subscales (PAP Self-Efficacy [PAP-SE], Decisional Balance Index [DBI], Knowledge [KNOW]) were administered at 6-months. Weekly self-report of participant-perceived benefits and challenges of PAP use were collected among intervention participants. Subscale scores, PAP use and PSQI were compared between intervention and control, and associations were tested. Change in mean number of benefits and challenges of PAP use were also tested (all analyses intent-to-treat). Results At 6-months, compared to controls, intervention participants had higher scores on all three subscales: PAP-SE (4.1 intervention versus 3.5 control, respectively), DBI (8.3, 0.9) and KNOW (10.5, 9.6, all p&amp;lt;.05). Intervention participants had more PAP use and lower (better) PSQI scores at 6-months (all p&amp;lt;.05). In the total sample, PAP use and PSQI correlated with PAP-SE (r=.52 PAP use, r=-.27 PSQI, respectively), DBI (r=.49, -.35) and KNOW (r=.43, -.21; all p&amp;lt;.05). Among intervention participants, perceived benefits of PAP increased over time (4.3 at week 2, 5.8 at week 4, respectively), and challenges decreased (3.7, 2.3; all p&amp;lt;.05). Conclusion Behavioral treatment for COMISA improves behavioral determinants of PAP use, which is associated with improvements in PAP use and sleep quality. In addition, with treatment, perceived benefits of PAP increase and challenges decrease. These findings suggest improvements in self-efficacy, knowledge and perceived benefits of PAP are important mechanisms through which behavioral interventions improve PAP use in older adults with COMISA. Support (If Any) VAHSRD (IIR12–353-Alessi, RCSA20-191-Martin) and NIH (NHLBI K24HL143055-Martin, NIA K23AG049955-Dzierzewski)