Elsevier

Sleep Medicine

Volume 10, Issue 9, October 2009, Pages 1005-1011
Sleep Medicine

Original Article
Sleep disordered breathing in an elderly community-living population: Relationship to cardiac function, insomnia symptoms and daytime sleepiness

https://doi.org/10.1016/j.sleep.2009.01.011Get rights and content

Abstract

Objective

To describe the prevalence of sleep disordered breathing (SDB) and its relationship to systolic function, different insomnia symptoms as well as excessive daytime sleepiness (EDS) in elderly community-living people. This has not been investigated previously.

Method

Three hundred thirty-one subjects (71–87 years) healthy enough to be independently living in their own homes underwent echocardiographic examinations and sleep respiratory recordings. Questionnaires were used to evaluate insomnia symptoms and EDS.

Results

Mild SDB (AHI 5–15) was found in 32%. Moderate SDB (AHI 15–30) occurred in 16%, and 7% had severe SDB (AHI > 30). Median AHI was significantly higher (p < 0.001) in those with mildly impaired systolic function (AHI 11.7) and moderately impaired systolic function (AHI 10.9) compared to those with normal systolic function (AHI 5.0). Impaired systolic function was associated with central sleep apnea (CSA) but not with obstructive sleep apnea. Concerning insomnia symptoms and EDS, only difficulties in initiating sleep correlated significantly (p < 0.05) with AHI.

Conclusion

SDB is common among the elderly. CSA may be related to impaired systolic function/heart failure. However, detection of SDB in this population may be problematic since insomnia symptoms and EDS correlated poorly with SDB.

Introduction

Sleep disordered breathing (SDB), defined as an apnea–hypopnea index (AHI)  15, is estimated to affect about 4% of women and 9% of men aged 30–60 years [1]. The prevalence is assumed to increase with age. In one study, 16% of the women and 24% of the men aged 60–70 had an AHI  15 [2]. In another study, including subjects aged 65–99 years, 39% of the women and 51% of the men were found to have AHI  20 [3]. In the latter age group heart failure (HF) represents a major and increasing health problem, as well as a possible cause for SDB [4]. It has previously been reported that 24–61% of these patients suffer from SDB [5], [6], [7], [8], [9], [10]. The lowest prevalence rates (24% and 25%) were found in outpatients [7], [10], whereas the highest rates (49–61%) were found in hospitalized patients [5], [6], [8], [9]. However, compared with the mean age of about 75 years for HF patients living in the community [11], the mean age of patients in these studies ranged between 56 and 69 years [5], [6], [7], [8], [9], [10]. None of these studies compared the prevalence of SDB with age-matched populations without HF. The community-based Sleep Heart Health Study showed that SDB was associated with HF [4]. However, HF was defined as a positive answer by the participants to the question of whether they had a diagnosis of HF, and not by today’s recommended methods [12]. These data cannot, therefore, be generalized to an elderly HF population, and therefore it is unknown if SDB in elderly community-living people with HF is a sign of age or impaired systolic function.

Insomnia has been defined as difficulties initiating sleep (DIS), difficulties maintaining sleep (DMS), non-restorative sleep (NRS), or early morning awakenings (EMA) [13], [14]. It is a frequent subjective sleep complaint in the general population [14], [15], often associated with excessive daytime sleepiness (EDS), and negatively associated with health related quality of life (Hr-QoL) in elderly subjects with or without chronic diseases such as HF [16], [17], [18]. SDB can be a possible cause, but is hypothesized to be two distinct conditions in older and younger people [19], [20]. In younger people, SDB has been related to subjective complaints of sleep disturbances, such as insomnia [21] or EDS [1]. Insomnia in elderly people has been thought to be less influenced by SDB [22]. It has been reported that the highest AHI and nadir oxygen levels become less severe as age increases [2], [20]. This indicates that SDB may be more severe in younger persons, and therefore the clinical impact of SDB in the elderly may be weaker. However, Ancoli-Israel et al. showed that changes in RDI were only associated with changes in BMI, independent of age, in people 65 years old [23]. To our knowledge only one study has investigated the association between SDB, insomnia and EDS in community-living elderly, where elderly people with insomnia were found to have a lower rate of SDB [24]. However, insomnia in this study was defined as a composite score. Another aspect is that SDB, i.e., obstructive sleep apnea (OSA), has been found to have a different impact on different insomnia symptoms [25]. Investigating the prevalence of SDB, its relationship to impaired systolic function, the different insomnia symptoms, as well as EDS must be seen as an important healthcare action to target areas for interventions aimed to improve elderly peoples daytime functioning.

Section snippets

Aim

The aims of this study were (1) to describe the prevalence of SDB and its relationship to impaired systolic function in an elderly population living in the community and (2) to describe the relationship between SDB and different insomnia symptoms, as well as EDS.

Participants

Data were collected between 2003 and 2005. All subjects were chosen from a cohort which had been investigated in a previous study which took place between 1998 and 2001 [26]. The primary aim of that study was to investigate the prevalence of impaired left ventricular ejection fraction (LVEF)/HF in an aged population. All inhabitants aged 65–82 years who were independently living in their own homes in the rural municipality of Kinda in the southeast of Sweden were included. In total, 1130

Participants

Of the 346 sleep recordings, 15 were lost due to technical failure. Thus the final study population consisted of 331 persons. Population characteristics, co-morbidities and medications across different SDB groups are given in Table 1. The mean age was 78 years, and 49% were males. Sleep recordings were performed in a median of 12 days (IQR 12) after the clinical and echocardiographic examination. Characteristics that significantly correlated with the severity of SDB were male gender, BMI,

Discussion

This is one of the first studies to objectively examine the prevalence of SDB in older people healthy enough to be living in the community. The aim was to find possible associations between SDB and systolic function as measured by echocardiography, as well as to describe the association between SDB, different insomnia symptoms and EDS.

Conclusion

This study, performed in an elderly population living in the community, demonstrates that about one quarter of such a population may have moderate/severe SDB, as defined by an AHI  15. SDB (i.e., AHI  10 and AHI  15) and CSA, especially, were independently associated with impaired systolic function. Our study shows that detection of SDB by means of different insomnia symptoms or EDS might be problematic. On the other hand, DIS were more common in individuals with an AHI  15. The effects of OSA and

Conflict of interest

None.

References (50)

  • A. Vazir et al.

    Variation in severity and type of sleep-disordered breathing throughout 4 nights in patients with heart failure

    Respir Med

    (2008)
  • N. Roure et al.

    Daytime sleepiness and polysomnography in obstructive sleep apnea patients

    Sleep Med

    (2008)
  • T. Young et al.

    The occurrence of sleep-disordered breathing among middle-aged adults

    N Engl J Med

    (1993)
  • J. Duran et al.

    Obstructive sleep apnea–hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr

    Am J Respir Crit Care Med

    (2001)
  • S. Ancoli-Israel et al.

    Sleep-disordered breathing in community-dwelling elderly

    Sleep

    (1991)
  • E. Shahar et al.

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

    Am J Respir Crit Care Med

    (2001)
  • A. Vazir et al.

    A high prevalence of sleep disordered breathing in men with mild symptomatic chronic heart failure due to left ventricular systolic dysfunction

    Eur J Heart Fail

    (2007)
  • O. Oldenburg et al.

    Sleep-disordered breathing in patients with symptomatic heart failure: a contemporary study of prevalence in and characteristics of 700 patients

    Eur J Heart Fail

    (2007)
  • A. Rao et al.

    Sleep-disordered breathing in a general heart failure population: relationships to neurohumoral activation and subjective symptoms

    J Sleep Res

    (2006)
  • D.D. Sin et al.

    Risk factors for central and obstructive sleep apnea in 450 men and women with congestive heart failure

    Am J Respir Crit Care Med

    (1999)
  • E. Quintana-Gallego et al.

    Home respiratory polygraphy for diagnosis of sleep-disordered breathing in heart failure

    Eur Respir J

    (2004)
  • B. Agvall et al.

    Patients in primary health care diagnosed and treated as heart failure, with special reference to gender differences

    Scand J Prim Health Care

    (2001)
  • K. Dickstein et al.

    ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM)

    Eur J Heart Fail

    (2008)
  • American Psychiatric Association

    Diagnostic and statistical manual of mental disorders

    (1994)
  • C.C. Kao et al.

    Insomnia: prevalence and its impact on excessive daytime sleepiness and psychological well-being in the adult Taiwanese population

    Qual Life Res

    (2008)
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