March/April 2015

Obstructive Sleep Apnea Disrupts Elders' Sleep
By Teofilo L. Lee-Chiong, Jr, MD
Today's Geriatric Medicine
Vol. 8 No. 2 P. 26

We've all heard the old adage, "older and wiser," but perhaps a sleep doctor should coin the phrase "older and sleepier." Many older adults report that getting a good night's sleep becomes increasingly difficult with age. A certain level of sleep disruption can be attributed to the aging process itself. Good sleep is further impeded by older adults' increased sensitivity to environmental disturbances such as noise that can make them more prone to multiple awakenings during a single sleep session. Some prescribed medications can also hinder sleep. Older women appear to be better able than older men to maintain satisfactory sleep as they age, but both genders feel the effects that insufficient sleep has on their health and overall quality of life. It is up to clinicians to determine exactly why their older patients are struggling to sleep well and how to most effectively treat the problem.

More frequently than aging, noise, or medication side effects, sleep disruption is an indication of an underlying medical condition such as menopause or nocturia, a neurological condition such as dementia, a psychiatric condition such as depression, or a primary sleep disorder. Among older adults, several sleep disorders, including insomnia, restless legs syndrome (RLS), rapid eye movement sleep behavior disorder, and obstructive sleep apnea (OSA), are more common.

Insomnia is the most common sleep complaint among elderly individuals. People with insomnia may complain of difficulty falling asleep or staying asleep, and may suffer considerable daytime impairment as a result of nonrestorative sleep. RLS is a neurological disorder characterized by unpleasant sensations involving the legs, and less commonly the arms, that begins or worsens during periods of inactivity at night. If severe, RLS can give rise to sleep-onset insomnia. Rapid eye movement sleep behavior disorder involves abnormal motor activity during dreaming that can lead to injury to the patient or bed partner.

OSA
This article focuses on OSA, the repetitive reduction (hypopnea) or cessation (apnea) of breathing due to the collapse of the upper airway during sleep. The apnea hypopnea index (AHI), which is the sum of all apneas and hypopneas per hour of sleep, is used to classify disease severity. An AHI between five and 15 per hour is generally considered mild, whereas 16 to 30 and greater than 30 events per hour are classified as moderate or severe, respectively.

People with narrower upper airways, which are anatomically more vulnerable to collapse during sleep, tend to be more susceptible to OSA. Episodic upper airway obstruction is associated with snoring and oxygen desaturation, and terminates with an arousal. Heart rates often change during apneic episodes, with relative bradycardia occurring during airway obstruction followed by tachycardia during arousals.

Specific cranio-facial and oropharyngeal features also predispose a person to develop OSA. Individuals with large neck circumference (ie, >17 inches in men and >16 inches in women), retro/micrognathia, large tongue, low-lying soft palate, or enlarged tonsils and adenoids are more likely to have OSA. An estimated 25% or more of overweight adults have OSA, and the likelihood of having OSA increases with greater obesity. In addition to weight, age and a positive family history are also OSA risk factors. The disorder is more prevalent in men than in women at all ages, but the risk of sleep apnea increases in women both during and after menopause. Investigators have examined the physiological traits that are responsible for the development of OSA in 10 young (20 to 40 years old) and old (over the age of 60) patients with OSA matched by body mass index and sex. Compared with younger patients, upper airway anatomy and collapsibility play relatively greater pathogenic roles in older adults.1

Other contributing factors for OSA are ingestion of alcohol and certain medications, such as muscle relaxants, sedatives, and anesthetics, which affect upper airway muscle tone and can thus give rise to obstructive apneas and hypopneas.

Patients with OSA may present with complaints of daytime sleepiness, fatigue, or changes in mood. Snoring, repeated awakenings with gasping or choking, or apneas witnessed by a bed partner may prompt a patient to seek medical consultation.

There is a documented prevalence of OSA among the elderly. The Wisconsin Sleep Cohort Study (2007-2010), which included 1,520 participants, estimated the prevalence of moderate-severe sleep disordered breathing at 17% among men ages 50 to 70 and 9% among women of the same age range. This represents a significant increase in prevalence of OSA in the United States over the past two decades.2 In another study, the Berlin Questionnaire and the Epworth Sleepiness Scale were used to screen for OSA-related symptoms in 490 older adults with a mean age of 77.5 in central Greece. Prevalence rates of frequent snoring, breathing pauses, and excessive daytime sleepiness were 28.1%, 12.9%, and 11.6%, respectively. Frequent snoring was more common in males than females.3

OSA Concerns
Consequences of OSA at all ages include sleep disturbance, hypertension, coronary artery disease, heart failure, cardiac arrhythmias, stroke, insulin resistance, and metabolic syndrome. Impaired cognition, memory, and concentration, as well as declines in school or work performance can affect all age groups. OSA has also been linked to insomnia. In one report involving 331 people between the ages of 71 and 87 with cardiovascular disease and OSA, insomnia was associated with the presence of nightly hypoxia (oxygen saturation < 90%; P < 0.001). The critical threshold for causing insomnia was hypoxia that occurred more than 1.5% of sleep time.4

Left untreated, a sleep breathing disorder is believed to contribute to the age-related decline in cognitive function. The PROOF study, an eight-year cohort study enrolled 559 elderly patients without neurological disorders. A slight but significant decline in the attentional domain was noted in persons with abnormal breathing events (AHI >15; P = 0.01) even after controlling for comorbidities, such as sleepiness, hypertension, diabetes, anxiety, and depression. This decline was more pronounced in those with more severe disease (AHI >30; P = 0.004). At least part of the decrease in attention could be attributed to chronic hypoxemia. In contrast, there were no significant changes in executive and memory functions.5

Many older adults with OSA or other sleep disorders develop excessive daytime sleepiness and can grow dependent on frequent daytime naps. Along with impaired attention, memory, response time, and performance, this population is also at an increased risk of falls. The lack of sleep and some of the hypnotic agents used to enable better sleep can impair coordination and mobility. Older adults who experience one or several of these effects as a result of disturbed sleep could be at risk for an accident. For this reason, many are placed in an assisted living or nursing home setting preemptively where they can be more closely monitored and helped in the event of a fall or other medical emergency. Some are placed after an incident occurs.

Diagnosis and Treatment
Unfortunately, neither clinical history nor symptoms are sufficiently sensitive or a specific enough means of diagnosis. Laboratory-based polysomnography or home sleep apnea testing is required to accurately diagnose OSA.

There are many lifestyle and prescription treatments for OSA. Clinicians should encourage obese patients to lose weight. OSA patients should also be advised to avoid alcohol and muscle relaxants that can decrease upper airway dilator muscle activity.

Positive airway pressure (PAP) is the most effective prescription therapy for OSA and remains the treatment of choice for patients with moderate to severe OSA.6 It functions as a pneumatic splint that maintains the patency of the upper airway during sleep. Modalities to deliver PAP include the following ABC devices:

• Auto-titrating PAP: Automatically and continuously provides variable pressures in response to changes in upper airway resistance or airflow.

• Bilevel PAP: Provides two independent pressure levels during the respiratory cycle, specifically a higher level during inspiration and a lower pressure during expiration.

• Continuous PAP (CPAP): Provides a single constant pressure throughout the respiratory cycle.

Some patients with OSA, particularly those with comorbid heart failure or chronic obstructive pulmonary disease, may require more advanced PAP technology, such as adaptive servo ventilation or volume assured pressure support. In a 12-month multicenter randomized trial designed to determine whether CPAP therapy results in any beneficial effects for older adults aged 65 or older with moderate to severe OSA, subjects were randomized to either CPAP plus best supportive care or best supportive care alone. Compared with best supportive care only, CPAP significantly reduced sleepiness (measured by the Epworth Sleepiness Scale) at three and 12 months (both P < 0.0001), and the effect was greater among those with greater CPAP use or who were sleepier at the start of the study. In addition, therapy with CPAP marginally decreased health care costs at 12 months.6

For elderly OSA patients who are unwilling or unable to use a PAP therapy, mandibular advancement devices worn during sleep may also be considered. These devices have been shown to be equally effective in younger and older (aged 65 and older) patients with OSA. Upper airway surgery might be indicated for patients with definitive craniofacial or upper airway abnormalities responsible for OSA, but its role in older adults is generally limited.

The prevalence of OSA increases with aging, and the adverse effects can take a toll on older adults' quality of life and independence. To best enable and empower older patients to live full and active lives, swift and efficient diagnosis is critical. Clinicians who treat this at-risk population should evaluate patients for OSA or other sleep disorders when warranted by symptoms and medical histories, so that the most effective therapy can be prescribed and the consequences mitigated. Age should not prohibit a good night's sleep and with proper care, it doesn't have to.

— Teofilo L. Lee-Chiong, Jr, MD, is a professor of medicine at National Jewish Health in Denver and the University of Colorado Denver School of Medicine. The recipient of the 2012 American Academy of Sleep Medicine Excellence in Education Award, he has authored or edited 16 textbooks in sleep medicine and pulmonary medicine, and has served as the chair of the Nosology Committee of the American Academy of Sleep Medicine and vice-chair of the Associated Professional Sleep Societies Program Committee since 2009. He is the chief medical liaison for Philips Respironics.

References
1. Edwards BA, Wellman A, Sands SA, et al. Obstructive sleep apnea in older adults is a distinctly different physiological phenotype. Sleep. 2014;37(7):1227-1236.

2. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177(9)1006-1014.

3. Kleisiaris CF, Kritsotakis EI, Daniil Z, Tzanakis N, Papaioannou A, Gourgoulianis KI. The prevalence of obstructive sleep apnea-hypopnea syndrome-related symptoms and their relation to airflow limitation in an elderly population receiving home care. Int J Chron Obstruct Pulmon Dis. 2014;9:1111-1117.

4. Johansson P, Svensson E, Alehagen U, Jaarsma T, Broström A. The contribution of hypoxia to the association between sleep apnoea, insomnia, and cardiovascular mortality in community-dwelling elderly with and without cardiovascular disease [published online February 7, 2014]. Eur J Cardiovasc Nurs. doi: 10.1177/1474515114524072.

5. Martin MS, Sforza E, Roche F, Barthélémy JC, Thomas-Anterion C; on behalf of the PROOF study group. Sleep breathing disorders and cognitive function in the elderly: an 8-year follow-up study. The proof-synapse cohort. Sleep. 2015;38(2):179-187.

6. McMillan A, Bratton DJ, Faria R, et al. Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial. Lancet Respir Med. 2014;2(10):804-812.