Why is it necessary to recognize Obstructive Sleep Apnea in the Elderly Population?

SDB is an umbrella term for a constellation of sleep-related breathing disorders and abnormalities of respiration during sleep that do not meet the criteria for a disorder These include - Obstructive sleep apnea disorders, Central sleep apnea syndromes, Sleep-related hypoventilation disorders, Sleep-related hypoxemia, primary snoring and catathrenia¹

Prevalence of SDB- Snoring is reported to affect 19-37 % of the general population and more than 50% of middle-aged men.²The prevalence of SDB in older people in the general the population can vary from 20% to 40%; this is a large variation and a more conservative estimate would suggest that the prevalence is at least double that seen in younger age groups.^3,4 In a study that defined SDB as an apnoea–hypopnea index (AHI) >10 events⋅h⁻¹ with the symptom of excessive daytime sleepiness (EDS), SDB was present at 3.2%, 11.3%, and 18.1% in the 20–44, 45–64 and 61–100 year age groups, respectively.⁵ This trend was also seen in women. However, the sex difference is less apparent after menopause. Obstructive sleep apnea (OSA) can affect all age groups. The Wisconsin cohort study reported that 24% of men and 9% of women had abnormal apnea-hypopnea indices.⁶ This was a population-based study in 602 working subjects aged 30-60 years of age and overnight in 26% of middle-aged urban Indian men. Also, the prevalence of SDB was 19.5% and that of obstructive sleep apnea-hypopnea syndrome was 7.5%. Several studies have shown that prevalence of SDB increases with age ranging from 5-15% in middle-aged adults to approximately 24% in community-dwelling elderly.⁸ Martin et al⁹ reported that upper airway size decreases with increasing age in both men and women. Men have greater airway collapsibility in lying down at the oropharyngeal junction than women.

Clinical presentation of OSA in Elderly

Elderly with OSA present differently. Female gender and obesity are less important risk factors. Usually, the presenting symptoms of OSA in adults is snoring and daytime sleepiness/tiredness. In elderly, the prominent symptoms are nocturia and cognitive dysfunction. Both these symptoms are often ignored and equated with aging process.

Snoring- is often mild in the elderly with OSA. There is a reduction of slow-wave sleep with aging which often results in easily arousable sleep. The reduction in growth hormone secretion in sleep contributes to insulin resistance, central obesity, and its consequences. Snoring predicts the onset of diabetes.¹⁰

Daytime sleepiness- Daytime napping is common particularly after lunch. Microsleeps are often observed.

Nocturia- This can be once or several times which awakens the patient and compels the patient to visit the bathroom. Nocturia must be differentiated from passing urine at night in insomniac patients. Nocturia occurs because at the termination of apnea, there is increased venous return to the right atrium stimulating the release of atrial natriuretic peptide leading to natriuresis. Nocturia has been reported to occur in fixed times in patients with OSA simulating alarm clocks.¹¹ANP also inhibits anti-diuretic hormone and aldosterone. Hyponatremia can direct the patient for ICU care. Insomnia can also be a presenting complaint in OSA due to repeated awakenings.

Cognitive decline- A decline in cognition in the elderly with OSA may resemble dementia. Moe et al¹²have demonstrated that more wakefulness during night and longer REM sleep latencies were associated with impaired cognition and function. Conversely, more REM and slow-wave sleep result in better cognition. A disturbed sleep architecture with poor REM sleep in OSA creates a favorable atmosphere for cognitive decline. There is a high prevalence of OSA in Alzheimer's disease. Usage of continuous positive airway pressure (CPAP) in these patients has demonstrated significant improvement.¹³

Other presentations of OSA particularly in the elderly include (a) Cardiac arrythmias¹⁴Patients with lone atrial fibrillation need to be investigated for OSA (b) erectile dysfunction¹⁵ (c) Heart failure.¹⁶ There is a high prevalence of SDB in heart failure and its management is rewarding.

It is well known that SDB is strongly linked to cardiovascular disease including hypertension, congestive heart failure, cardiac arrhythmias, ischemic events, pulmonary artery hypertension, stroke.¹⁷OSA is closely associated with the development of insulin resistance.^18,19. It is also reported that subjects over the age of 65 years constitute more than 40% of cases of diagnosed diabetes.²⁰. Recent reports suggest that OSA is extremely common among patients with hypertrophic cardiomyopathy, with a prevalence ranging from 32% to 71%.²¹ Retina is highly sensitive to hypoxia. Ophthalmic consequences of OSA have also been discussed.²²

The best mode of therapy is by using Continuous Positive Airway Pressure (CPAP) while sleeping.

Geriatric patients desire good quality of life with minimum usage of drugs. Multiple drugs invite more adverse effects and drug interactions. OSA by virtue of cyclical hypoxia and sympathetic stimulation can lead to several consequences discussed above, each demanding pharmacological intervention. It has been reported that the usage of CPAP while sleeping is highly rewarding. There is an overall improvement in general health and a sense of wellbeing is felt. Improvement is expected in the consequences of OSA. This can cut down the number of medications. It is, therefore, necessary to recognize and treat OSA in the elderly population.

References:

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