Clinical Characteristics in Two Subgroups of Obstructive Sleep Apnea Syndrome in the Elderly: Comparison Between Cases With Elderly and Middle-Age Onset

doi:10.1378/chest.09-2251

Chest

Volume 137, Issue 6, June 2010, Pages 1310-1315

https://doi.org/10.1378/chest.09-2251 Get rights and content

Background

Morbidity due to obstructive sleep apnea syndrome (OSAS) is increased in the elderly population. However, the clinical characteristics of OSAS in elderly patients have not been characterized conclusively. The aim of this study was to clarify differences in clinical characteristics of OSAS between patients with middle-age onset and elderly onset of OSAS.

Methods

Patients with OSAS aged ≥ 65 years were classified into groups according to age at first identification of respiratory pauses during sleep: a middle-age onset group (n = 32) where onset was at age < 50 years and an elderly onset group (n = 31) where onset was at age ≥ 60 years. We compared demographic variables; polysomnographic variables; daytime sleepiness measures, including the multiple sleep latency test (MSLT) and the Epworth sleepiness scale (ESS); and adequate level of nasal continuous positive airway pressure (CPAP) between groups.

Results

BMI and frequency of underlying cardiovascular disorder were lower in the elderly onset group than in the middle-age onset group. No significant differences in apnea-hypopnea index or percentage of the period showing O₂ desaturation were seen between groups. However, arousal index, maximal negative esophageal pressure value, and adequate nasal CPAP level were significantly smaller in the elderly onset group. Mean sleep latency on MSLT was longer, and ESS score was lower in the elderly onset group.

Conclusions

Compared with the middle-age onset group, the clinical significance of OSAS in the elderly onset group seemed to remain milder. This finding is possibly because of the smaller physiologic response to respiratory events.

Section snippets

Materials and Methods

The study protocol was approved by the Ethics Committee for Human Research of the Neuropsychiatric Research Institute (Tokyo, Japan). Eligible subjects were 89 consecutive patients with OSAS (AHI > 5 episodes/h) aged ≥ 65 years who were referred to the outpatient clinic of the Japan Somnology Center (Tokyo) from November 1999 to April 2004. All subjects provided informed consent to participate in this study.

After excluding patients in whom age at onset of respiratory disorder while asleep could

Results

Demographic backgrounds of the elderly and middle-age onset groups are shown in Table 1. No significant differences were noted in either group at investigation or in daily alcohol consumption between groups; however, percentage of male patients, BMI, and the proportion of patients with comorbid cardiovascular diseases were smaller in the elderly onset group than in the middle-age onset group (P < .05, P < .01, P < .01, respectively).

With regard to PSG findings, no significant differences in

Discussion

In this study, comparisons of PSG variables revealed some characteristic differences between the elderly and middle-age onset groups. Patients with elderly onset showed a lower arousal index than patients with middle-age onset, despite similar values of both AHI and durations of apnea episodes. This finding suggests that elderly onset OSAS could show a smaller impact on physiologic changes associated with OSAS than with middle-age onset. Interestingly, Pesmax, indicating respiratory effort, was

Acknowledgments

Author contributions: Ms Kobayashi: contributed to the interpretation of data and the drafting of the article.

Mr Namba: contributed to data collection and analysis.

Dr Tsuiki: contributed to the interpretation of data and the statistical analysis.

Dr Matsuo: contributed to the statistical analysis.

Dr Sugiura: contributed to the interpretation of data.

Dr Inoue: contributed to the conception and design of the study and the drafting of the article.

Financial/nonfinancial disclosures: The authors have

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Adherence to CPAP in summer to autumn predicts self-reported common cold symptoms in patients with obstructive sleep apnea in winter: A prospective observational study
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We conducted a prospective observational study to determine the relationship between adherence to continuous positive airway pressure (CPAP) and susceptibility to the common cold in moderate-to-severe obstructive sleep apnea (OSA) patients.
We prospectively investigated the number of days with common cold symptoms from November 2019 to February 2020. The rate of CPAP use for 4 h/night in the preceding four months (July to October 2019) was used as a measure of CPAP adherence. Multiple generalized linear models were used to evaluate the association to days of common cold symptoms after controlling for demographic variables, habitual short sleep duration, and insomnia severity.
We included 123 outpatients (median age 63 years) with moderate-to-severe OSA treated with CPAP. In the multivariate generalized linear model, better CPAP adherence was independently significantly associated with days with fewer common cold symptoms (β = −0.248, P = 0.031); meanwhile, the severity of insomnia and habitual short sleep duration was not significantly associated with it. Subgroup analyses revealed that the association between CPAP adherence and days with common cold symptoms was also significant in young to middle-aged (<65 years) participants (β = −0.407, P = 0.005). In contrast, the association was negligible in older (≥65 years) participants.
CPAP adherence may be protective against viral infections in patients with moderate-to-severe OSA. This effect appears to be more pronounced in young to middle-aged patients with OSA.
Precision Medicine for Obstructive Sleep Apnea
2019, Sleep Medicine Clinics
Citation Excerpt :
In theory, OSA from a particular underlying mechanism may have different disease consequences than OSA caused by a different mechanism. As one example, OSA in the elderly seems to be more a function of upper airway anatomy and less an issue with loop gain as compared with younger patients with OSA.45–47 The authors and other investigators have hypothesized that the mechanisms underlying OSA in the elderly may explain the lack of observed complications in these patients in some large epidemiologic cohorts.48,49
Obstructive sleep apnea: effect of comorbidities and positive airway pressure on all-cause mortality
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– factors known to be influential. Some studies suggest that OSA in elderly patients represents milder forms of the disease [15], and its consequences for mortality have been found to be minor [16], although other studies suggest that OSA after the age of 50 may influence mortality in subjects with, but not in those without, comorbidities [17]. Most studies have used CVD end-points to measure the effect of CPAP, but we have recently shown that pre-diagnostic morbidities involve a range of comorbidities other than CVD diseases [18] and, as such, OSA may have more wide-ranging consequences.
Most studies have used cardiovascular and cerebrovascular disease (CVD) end-points to measure the effect of continuous positive airway pressure (CPAP), but pre-diagnostic morbidities involve a range of comorbidities that may influence the consequences of obstructive sleep apnea (OSA). We therefore aimed to evaluate all-cause total mortality after a diagnosis of OSA, the effect of CPAP in women and men, and the potential effect of major comorbidities.
We used national registry data as a historical cohort and included 22,135 OSA patients aged 20 years or more with comorbidity data three years before diagnosis and follow-up morbidity and mortality over a period of 17 years.
A total of 8129 (37%) accepted CPAP for more than six months; 14,006 (63%) were CPAP non-user/non-compliant. Those treated with CPAP tended to have higher mortality rates. Patients treated with CPAP were more likely to be male, elderly, suffer from diabetes, and present with more cardiovascular diseases than those not treated with CPAP. After a diagnosis of OSA, more patients in the CPAP-treated group developed cardiovascular complications. Female gender was associated with lower mortality, whereas age, diabetes type 2, and hypertension prior to OSA diagnosis were associated with negative effects on outcome. After an OSA diagnosis, male gender, age, diabetes (types 1 and 2), hypertension, and heart failure were all associated with greater mortality. CPAP treatment had a positive effect in middle-aged and elderly people, whereas CPAP in females had no effect on all-cause mortality.
CPAP-treated patients present more comorbidities before and after diagnosis compared with non-treated/non-compliant patients, which explains the higher mortality in this group. CPAP treatment is associated with lower mortality rates in middle-aged and elderly (aged 60+ years) males, but only after adjustment for multiple comorbidities. No effect of CPAP treatment on all-cause mortality in female OSA patients was found. Males with OSA, older than 40 years, with comorbidities and a low educational level presented a particularly high mortality risk.
Ovarian steroids act as respiratory stimulant and antioxidant against the causes and consequences of sleep-apnea in women
2017, Respiratory Physiology and Neurobiology
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In aged rats (22–24months) exposure to IH for 2 weeks has limited effects on the function of peripheral chemoreceptors, does not alter the release of catecholamine (a reflect of the activity of the sympathetic nervous system), does not induce excessive ROS production and oxidative damages, and does not cause hypertension (Quintero et al., 2016). These results are in line with clinical data showing that in aging subjects (>65 years) the severity of the cardiovascular disorders depend on the age of the onset of sleep apnea: less severe disorders occurred if apnea onset was >60 years than <50 years (Kobayashi et al., 2010). Interestingly, in women, the protective effects of hormone replacement therapy on apnea frequency during sleep are no longer apparent above 70 years of age (Shahar et al., 2003).
Evidence supports the importance of ovarian hormones as potential tools against sleep apneas in women. On one hand, progesterone is largely acknowledged as being a respiratory stimulant that reduces the frequency of apneas, but the underlying mechanisms remain poorly understood. Recent studies in mice showed that the respiratory effects of progesterone are mediated by at least two classes of progesterone receptors, including the nuclear (nPR) and membrane receptors (mPR). Some of these receptors (nPR) have sex-specific effects on the frequency of apneas recorded during sleep in mice, while mPRβ acts in males as well as in females. Moreover, sleep apnea is a condition that induces an “oxidative stress” response in several tissues, and this contributes to the deleterious consequences of sleep apneas, including the development of hypertension. While estradiol is recognized as an antioxidant hormone, its potential protective role has remained mostly ignored in the field. We will review recent data supporting an antioxidant role of estradiol in female rats exposed to intermittent hypoxia, a reliable animal model of sleep apnea. Since estradiol has two main receptors (ERα and ERβ) we will discuss their relative implications, and present new data showing a key role for ERα to prevent the hypertension induced by intermittent hypoxia. Overall this review highlights the fact that ovarian hormones could potentially be used as efficient tools against the causes (i.e. instabilities of the respiratory control system) and consequences (oxidative stress) of sleep apnea.
Control of Breathing and Upper Airways During Sleep
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition
Is there a correlation between OSAS duration/severity and carotid intima-media thickness?
2012, Respiratory Medicine
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Roisman et al.26 and Pelletier-Fleury et al.27 underline the need of a clear diagnosis in relation to the heavy social, health and economic burden of OSAS on the community. Surprisingly, a recent study by Kobayashi et al.,28 points out that elderly onset OSAS patients have milder symptoms than patients with middle-age onset. The authors suggest that this result is due to a milder physiological response to respiratory events.
Obstructive Sleep Apnea Syndrome (OSAS) is a common airways disease recognized as an independent cardiovascular risk factor. It is often associated with obesity, diabetes and dyslipidemia. Its pathophysiological consequences (hypoxia, hypercapnia, micro-arousals, sympathetic hyperactivity, oxidative stress, systemic inflammation and hyper-coagulability) are implicated in the development of hypertension, endothelial dysfunction and higher intima-media thickness (IMT) values, all elements known to lead to atherosclerosis. The study aim was to demonstrate a relationship between OSAS duration and IMT values and to confirm how OSAS severity could influence IMT (a marker of atherosclerosis).
We enrolled 156 patients (125 men, mean age: 60 ± 12 years) affected by OSAS of different severity: 111 (71%) were in CPAP therapy; some of the population were also affected by hypertension [102 (65%)], dyslipidemia [52 (33%)] and diabetes [38 (24%)]. Patients underwent evaluation of carotid artery IMT and answered a questionnaire investigating the time of onset (confirmed by a person aware of the patient’s previous sleeping habits) and the duration of the disease.
We found a statistically significant higher IMT value in patients with longer-lasting disease (OSAS duration in IMT < 0.9 mm: 120 (60–192) months versus OSAS duration in IMT ≥ 0.9 mm: 200 (120–310) months; p < 0.001). OSAS severity is positively related to IMT values. We found a positive relationship between IMT and OSAS duration [r = 0.34; p < 0.001] and between AHI and IMT [r = 0.51; p < 0.001].
Our study shows that the duration of OSAS and its severity are important factor related with higher values of IMT and hence with a higher risk of atherosclerosis.

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Funding/Support: Part of the study was supported by Grants-in-Aid for Scientific Research Projects [20592422, 21406033] from the Japan Society for the Promotion of Science.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

ORIGINAL RESEARCHSLEEP MEDICINEClinical Characteristics in Two Subgroups of Obstructive Sleep Apnea Syndrome in the Elderly: Comparison Between Cases With Elderly and Middle-Age Onset

Background

Methods

Results

Conclusions

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Am J Cardiol

Chest

Chest

Am J Cardiol

Chest

Chest

Sleep-disordered breathing in community-dwelling elderly

Sleep

Predictors of sleep-disordered breathing in community-dwelling adults: the Sleep Heart Health Study

Arch Intern Med

Association of sleep-disordered breathing, sleep apnea, and hypertension in a large community-based study. Sleep Heart Health Study

J Am Med Assoc

Association of nocturnal arrhythmias with sleep-disordered breathing: The Sleep Heart Health Study

Am J Crit Care Med

Sleep-disordered breathing and cardiovascular disease: cross-sectional results of the Sleep Heart Health Study

Am J Respir Crit Care Med

All-cause mortality in males with sleep apnoea syndrome: declining mortality rates with age

Eur Respir J

Normal aging

A new method for measuring daytime sleepiness: the Epworth sleepiness scale

Sleep

A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects

EEG arousals: scoring rules and examples: a preliminary report from the Sleep Disorders Atlas Task Force of the American Sleep Disorders Association

Sleep

ORIGINAL RESEARCH
SLEEP MEDICINE
Clinical Characteristics in Two Subgroups of Obstructive Sleep Apnea Syndrome in the Elderly: Comparison Between Cases With Elderly and Middle-Age Onset