Clinical Review
Continuous positive airway pressure treatment for sleep apnea in older adults

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Summary

Daytime sleepiness and sleep disordered breathing are increased in older compared to middle-aged adults. The cognitive and cardiovascular sequelae associated with obstructive sleep apnea (OSA) have significant implications for the older adult who may already be suffering from chronic illness. Most of the evidence supporting the utilization of continuous positive airway pressure (CPAP) for the treatment of OSA has been generated from studies employing samples consisting predominately of middle-aged adults. To examine the efficacy of CPAP for the treatment of obstructive sleep apnea in older adults with an emphasis on adherence and related treatment outcomes, this paper reviews findings from clinical trials including older individuals as well as those specifically targeting this population. These studies have demonstrated that following CPAP therapy, older adults have increased alertness, improved neurobehavioral outcomes in cognitive processing, memory, and executive function, decreased sleep disruption from nocturia and a positive effect on factors affecting cardiac function, including vascular resistance, platelet coagulability and other aspects of cardiovascular health. Physiological differences in respiratory structure and function between younger and older adults of similar disease severity are believed to result in older individuals requiring titration at lower CPAP levels. Once initiated, CPAP treatment is tolerated by older adults, including those with Alzheimer's disease. Patterns of adherence in older individuals are consistent with that of middle-aged adults.

Introduction

Obstructive sleep apnea (OSA) is as common as diabetes mellitus and typically associated with middle-age. However, while an estimated 20% of middle-aged men have OSA,1 the prevalence of this sleep-related breathing disorder in older adults is greater, ranging from 24% to 42%.1, 2 Older adults have almost a three-fold increased risk of having sleep apnea.1 OSA is associated with significant neurocognitive3 and cardiovascular sequelae, 3problems commonly experienced by the general elderly population. Daytime sleepiness, the primary manifestation of OSA, occurs in approximately 9% of adults4 and results in decreased daily functioning in older adults.5 Indeed, daytime sleepiness occurs twice as often in individuals older than 75 years compared to middle-aged adults.4

Given the prevalence and functional impact of OSA in the elderly, treatment for sleep apnea holds considerable promise. In addition to conservative management, approaches to the treatment of OSA include nasal continuous positive airway pressure (CPAP), oral appliances and surgery. Continuous positive airway therapy is more commonly used as adequate dentition is required for oral appliances and the risk of surgery is increased in those over 50 years of age. The purpose of this review is to examine efficacy of CPAP treatment in the older adult with an emphasis on adherence and related treatment outcomes.

Section snippets

Prescription of CPAP treatment

Essential to the treatment of OSA is the accurate determination of the apnea-hypopnea index (AHI), the number of apneas and hypopneas that occur per hour of sleep. Night-to-night variability in disturbed breathing has previously been described.6 Findings from the Sleep Heart Health Study7 suggest that at lower levels of respiratory disturbances, night-to-night variability is a function of increasing respiratory events and age. In exploring night-to-night variability in disturbed breathing in

Efficacy of CPAP treatment

A recent review of the literature evaluating the efficacy of CPAP treatment demonstrated the positive impact of CPAP on the AHI, sleep architecture, daytime sleepiness, quality of life, neurobehavioral performance and psychological effects, and cardiovascular morbidity (see Table 1).18 The majority of the clinical trials reviewed for the practice parameters were conducted primarily in the middle-aged population.18

Given the number of clinical trials now available for review, with the exception

Conclusion

Documented by this review, there is a paucity of data regarding CPAP treatment in older sleep apnea patients. There have been few investigations of CPAP patterns of use in this population as well as whether outcomes achieved with younger individuals are also true in older patients who may be less sleepy, have a higher apnea and hypopnea index, and suffer from more co-morbidities. Whether reductions in daytime sleepiness demonstrated for older CPAP-treated patients will result in increased

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