Studies evaluating positive airway pressure (PAP) use in older adults
| First author [ref.] | Participants | Age years | Participant characteristics | Main outcomes | Type of study | Treatment duration | Compliance | Jadad score | Evidence level# | GRADE level | Study conclusions |
| Ancoli-Israel [33] | CPAP, n=19; placebo CPAP, n=20 | Range 55–91; CPAP mean 79; placebo CPAP mean 78 | OSA (AHI >10 events per h) +AD | Cognition | RCT | CPAP, 6 weeks; placebo CPAP, 3 weeks followed by 3 weeks of therapeutic CPAP | 5.8 h | 4 | 1+ | High | Comparison of CPAP versus placebo CPAP at 3 weeks suggested no significant improvements in cognition but was underpowered; comparison pre- and post-treatment after 3 weeks of therapeutic CPAP showed significant improvement in cognition |
| Arzt [34] | CPAP, n=128; control, n=110 CPAP patients divided post hoc into AHI<15 events per h with treatment (CPAP CSA suppressed, n=57; CPAP CSA unsuppressed, n=43 | Range NR; control, mean 64; CPAP CSA suppressed, mean 60; CPAP CSA unsuppressed, mean 65 | CSA (AHI >15 events per h)+heart failure | LVEF, heart transplant-free survival | RCT | 24 months | 3 months, 4.4 h; 12 months, 3.6 h | 3 | 1− | Moderate | CPAP CSA suppressed subjects had greater increase in LVEF at 3 months and significantly better transplant-free survival than controls; CPAP CSA unsuppressed group did not differ from controls |
| Arzt [35] | CPAP, n=10; BiPAP, n=4 | Range 18–80; mean 65 | CHF+CSR-CSA (AHI >15 events per h) (and residual CSA on PAP) | AHI | COS | 3 nights | NR | 0 | 2− | Low | Flow-targeted dynamic BiPAP support effectively suppresses CSR-CSA in patients with CHF and is well tolerated |
| Ayalon [36] | CPAP, n=14; placebo CPAP, n=16 | Range 53–91; mean 78 | OSA (AHI >10 events per h)+AD | Adherence, depression | RCT | 3 weeks | 4.8 h | 4 | 1+ | Moderate | Patients wore CPAP for 4.8 h per night; more depressive symptoms were associated with worse adherence, OSA+AD patients tolerate CPAP; adherence and long-term use may be more difficult mong those patients with more depressive symptoms |
| Bravata [37] | AutoPAP, n=45; untreated control, n=25 | AutoPAP, mean 66 (range 47–88); control, mean 67 (range 45–88) | OSA (AHI >5 events per h)+TIA | Effect of autoPAP on OSA, autoPAP adherence, recurrence of TIAs | RCT | Observation period for 90 days | 5.6 h | 3 | 2− | Moderate | AutoPAP tolerated; trend for recurrent events to be more frequent in controls |
| Bravata [38] | AutoPAP, n=31; untreated control, n=24 | Range 50–94; autoPAP, mean 71; control, mean 72 | OSA (AHI >10 events per h)+acute ischaemic stroke | Effect on OSA, adherence, NIH Stroke Scale | RCT | 30 days | 5.1 h | 3 | 1− | High | OSA reduced, compliance and greater improvement in NIH Stroke Scale in autoPAP users |
| Chong [39] | CPAP, n=19; placebo CPAP, n=20 | Range 55–91; CPAP mean 79; placebo CPAP, mean 78 | OSA (AHI >10 events per h)+AD | Daytime sleepiness (ESS) | RCT | CPAP, 6 weeks; placebo CPAP, 3 weeks followed by 3 weeks of therapeutic CPAP | NR | 4 | 1+ | High | CPAP, compared to placebo, improved daytime sleepiness |
| Cooke [40] | CPAP, n=27; placebo CPAP, n=25 | Range, NR; CPAP, mean 79; placebo CPAP, mean 78 | OSA (AHI>10 events per h) +AD | Sleep macro- and microarchitecture | RCT | CPAP, 6 weeks; placebo CPAP, 3 weeks followed by 3 weeks of therapeutic CPAP | 5.5 h | 4 | 1+ | High | CPAP improves both macro- and microarchitecture |
| Cooke [41] | CPAP, n=5; placebo CPAP, n=5 | Range 64–84; mean 76 | OSA (AHI >10 events per h)+AD | Cognition, mood | COS | CPAP users for 13 months versus CPAP nonusers | Monitored but NR | 1 | 2− | Low | Long-term use of CPAP associated with improved or stable cognition and mood |
| Dohi [42] | CPAP, n=11; BiPAP (unresponsive to CPAP), n=9 | Range, NR; CPAP, mean 65; BiPAP, mean 68 | CSA (AHI >15 events per h)+ LVHF | LVEF; plasma BNP | OS | 6 months | NR | 0 | 2− | Low | BNP levels significantly decreased and LVEF significantly increased in both groups; BiPAP is an effective alternative for patients with LVHF and pure CSR-CSA who are unresponsive to CPAP |
| Hsu [43] | CPAP, n=15; control (conventional treatment), n=15 | Range, NR; CPAP, mean 73; control, mean 74 | OSA (AHI >30 events per h)+stroke | Primary: activities of daily living; secondary: hypertension, daytime sleepiness, cognitive function, anxiety, depression, QOL | RCT | 80 days | 1.4 h | 5 | 1− | High | CPAP use averaged 1.4 h a night; CPAP treatment resulted in no significant improvements in any outcome measures |
| Koyama [44] | ASV, n=27; untreated control, n=16 | Mean 74 | OSA (AHI >15 events per h)+CHF | LVEF; BNP; C-reactive protein; eGFR | COS | 12 months | Recorded but NR | 1 | 2− | Low | ASV associated with improved eGFR and LVEF; ASV therapy could improve renal dysfunction in CHF patients through haemodynamic support |
| Lacedonia [45] | CPAP plus O2 if positive for T30, n=168 | Mean 68, age stratified | Overlap OSA+COPD, mean AHI 42 events per h | PaO2 and PaCO2 | COS | 12 months | Recorded but NR | 1 | 2++ | Moderate | Overlap syndrome was more common in the elderly; PaO2 in compliant elderly patients with overlap syndrome improved significantly with CPAP but not in patients with COPD only |
| Martínez-García [46] | CPAP compliers, n=15; CPAP noncompliers, n=36 | Range 57–82; CPAP, mean 73; CPAP noncompliers, mean 72 | Ischaemic stroke or TIA, OSA (AHI >20 events per h) | Vascular events | COS | 18 months | 5.7 h | 0 | 2− | Low | Compared to CPAP compliers, the incidence of new vascular events was greater in CPAP noncompliers; risk of new vascular event was 5-fold greater in noncompliers |
| Martínez-García [47] | n=939; control (AHI <15 events per h), n=155; AHI 15–29 events per h without CPAP, n=108; AHI >30 events per h without CPAP, n=173; OSA+CPAP, n=503 | Control, mean 71; AHI 15–29 events per h without CPAP, mean 72; AHI >30 events per h without CPAP, mean 72; OSA+CPAP, mean 70 | OSA | Primary: cardiovascular death; secondary: all-cause mortality and mortality from stroke, heart failure and myocardial infarction | COS | 69 months | Measured as >4 h·day−1 | 1 | 2− | Moderate | Severe OSA not treated with CPAP is associated with cardiovascular death in the elderly and adequate CPAP treatment may reduce this risk |
| Neikrug [48] | CPAP, n=19; placebo CPAP, n=19 | Range, NR; CPAP, mean 68; placebo CPAP, mean 67 | OSA (AHI >10 events per h) and OSA (AHI >10 events per h)+PD | PSG: sleep efficiency, % sleep stages (N1, N2, N3, R), arousal index, AHI, and % time O2 saturation <90%; MSLT: mean sleep-onset latency | RCT | CPAP, 6 weeks; placebo CPAP, 3 weeks followed by 3 weeks of therapeutic CPAP | 5.2 h | 5 | 1+ | High | CPAP versus placebo was effective in reducing apnoea events, improving O2 saturation and deepening sleep in patients with PD and OSA; arousal index and daytime sleepiness were reduced |
| Randerath [49] | ASV, n=31; CPAP, n=32 | CPAP, mean 67.4; ASV, mean 65.3 | OSA+CSA (AHI >15 events per h)+CHF | LVEF, BNP | RCT | 12 months | CPAP, 4.3 h; ASV, 5.2 h | 5 | 1++ | High | BNP improved with ASV relative to CPAP |
| Takama [50] | ASV, n=61 | Mean 70 | CHF | LVEF; BNP | COS | 6 months | NR | 1 | 2− | Moderate | Both LVEF and BNP improved |
| Yang [51] | Young (25–40 years), n=35; middle age (41–65 years), n=169); elderly (>65 year), n=111 | NR | OSA (AHI >5 events per h) | CPAP adherence | COS | 2 weeks | See comments | 1 | 2− | Moderate | Lower acceptance in elderly than younger but no difference in hours used for compliers; CPAP acceptance is low in elderly patients in Taiwan; CPAP acceptance, instead of CPAP adherence, is the critical issue with elderly patients with OSA |
| Woehrle [52] | n=4281 | Range, <40– ≥70; mean 58 | OSA (AHI NR) | CPAP adherence | OS | 3.5 years | <40 years: 368±89 min; >40–50 years: 363±88 min; >50–60 years: 368±91 min; >60–70 years: 385±97 min; >70 years: 392±101 min | 0 | 2− | Low | Adherence high |
| Yagihara [53] | OSA, n=30; no OSA, n=27 | Range, 60–75; OSA, mean 66; no OSA, mean 66 | OSA (AHI >20 events per h); no OSA (AHI <10 events per h) | Oxidative stress; QOL | COS | 6 months | NR | 0 | 2− | Low | CPAP in elderly patients reduced oxidative stress and improved QOL |
| Ng [54] | Elderly Hong Kong population, n=819; OSA, n=161 | Mean 73.9 | Elderly average population, subgroup OSA | CPAP acceptance and adherence | COS | 12 months | CPAP acceptance, hourly use NR | 0 | 2− | Low | CPAP acceptance was 21.3%; those who used CPAP had significant improvement in SAQLI and cognitive function; AHI of CPAP accepters and refusers did not differ significantly |
| McMilan [55] | N=278; CPAP, n=140; BSC, n=138 | Mean 71.1 | OSA population >65 years old | Daytime sleepiness (ESS), lipids, mobility, mood, cognitive function, cost-effectiveness | RCT | 3 and 12 months | Median use between 1 h, 52 min and 2 h 22 min; 35% used >4 h per night | 4 | 1+ | High | ESS and lipids significantly lower in CPAP versus BSC; mobility improved significantly in CPAP versus BSC; no difference in mood or cognitive function; CPAP less expensive than or as expensive as BSC |
| Crawford-Achour [56] | N=126 analysed as part of proof cohort study; CPAP, n=33; no CPAP, n=93 | ≥65 | OSA patients | Cognitve function tests | COS | 10 years | >6 h CPAP use, self reported | 1 | 2− | Moderate | Cognitive function improved significantly in CPAP versus no CPAP |
| Galetke [57] | N=35; ASV (ACMV), n=18 versus CPAP, n=17 | 65.5±9.7 | CHF with CSA | AHI, obstructive and central; ejection fraction; ESS | RCT | 4 weeks | NR | 5 | 1+ | High | AHI (obstructive and central) and ejection fraction improved significantly more or only with ASV/ACMV versus CPAP |
| Troussiere [58] | N=23; CPAP, n=14; no treatment, n=9 | ≥65 | AD+OSA | MMSE | OS | 18 months | NR | 1 | 2− | Low | MMSE decline significantly slower in CPAP versus no treatment |
| Knapp [59] | N=35 | 65.4 | Male OSA patients | Testosterone levels, SHIM | OS | 3 months. | NR | 1 | 2− | Low | No change in testosterone levels, significant improvement in SHIM |
| Nishihata [60] | N=130; CPAP, n=64; no CPAP, n=66 | >65 (range 65–86) | Male and female OSA patients with history of CVD | Survival rate and hospitalisation rate | COS | 32.9 months | NR | 0 | 2− | Low | Survival and hospitalisation rates were significantly lower in the CPAP group |
| Martínez-García [61] | CPAP, n=115; no CPAP, n=109 | ≥70 | Male and female OSA patients with AHI ≥30 events per h | QOL, cognition, depression, anxiety, office-based BP | RCT | 3 months | Mean 4.9 h per night, 70% >4 h per night | 3 | 1+ | High | CPAP associated with improvement in QOL, anxiety, depression and measures of cognition; no change in BP |
GRADE: Grading of Recommendations Assessment, Development and Evaluation; CPAP: continuous positive airway pressure; OSA: obstructive sleep apnoea; AHI: apnoea–hypopnoea index; AD: Alzheimer's disease; RCT: randomised controlled trial; CSA: central sleep apnoea; NR: not reported; LVEF: left ventricular ejection fraction; BiPAP: bilevel positive airway pressure; CHF: chronic heart failure; CSR: Cheyne–Stokes respiration; COS: cohort study; TIA: transient ischaemic attack; NIH: National Institutes of Health; ESS: Epworth Sleepiness Scale; LVHF: left ventricular heart failure; BNP: brain natriuretic peptide; ASV: adaptive servoventilation; eGFR: estimated glomerular filtration rate; T30: arterial oxygen saturation <90% for ≥30% of total sleep time; PaO2: arterial oxygen tension; PaCO2: arterial carbon dioxide tension; PD: Parkinson's disease; PSG: polysomnography; N: non-rapid eye movement sleep; R: rapid eye movement sleep; MSLT: multiple sleep latency test; OS: uncontrolled study; SAQLI: Sleep Apnea Quality of Life Index; BSC: best supportive care; ACMV: anticyclic modulated ventilation; MMSE: mini-Mental Status Examination; SHIM: Sexual Health Inventory for Men; CVD: cardiovascular disease; BP: blood pressure; QOL: quality of life. #: see table 1.