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Sleep Apnea In The Elderly
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura Faculty of Medicine
Causes of Disturbed
Sleep in Aging
Poor Sleep
Behaviors
Primary Sleep
Disorders
Psychiatric &
Neurologic
Sleep Problem
Medical Illness
& Medications
Circadian
Changes
Prevalence of Primary
Sleep Disorders
Condition
All Adults
Elderly
• Insomnia
10-20%
40-50%
• Sleep Apnea
1%-25%
24%-40%
• Periodic Limb Movements 2-5%
30%-45%
• Restless Leg Syndrome
2%-15%
12%-30%
• REM Sleep Behavior
0.5%
0.5%-2%
Definition of sleep apnea
• Sleep disordered breathing includes
1- Obstructive sleep apnea syndrome (OSAS)
2-Central sleep apnea syndrome (CSAS) and
3- Sleep hypoventilation syndrome .
• Obstructive sleep apnea is defined as 5 or more
obstructive respiratory events per hour of sleep
accompanied by nocturnal or daytime symptoms, or by
15 or more obstructive respiratory events per hour of
sleep without accompanying symptoms.
• Central sleep apnea is defined as 5 or more central
respiratory events per hour of sleep.
Respiratory events
• Respiratory events may be apneas (cessation of airflow for at least 10
seconds) or hypopneas (at least 30% or 50% reduction of airflow lasting 10
seconds, associated with a drop in oxyhemoglobin saturation of 4%, 3 % or
arousal respectively ). Respiratory effort related arousal exist when there is
a sequence of breaths that lasts at least 10 seconds, is characterized by
increasing respiratory effort and leads to an arousal from sleep but does
not meet the criteria of an apnea or hypopnea
• The apnea–hypopnea index (AHI) is the number of apneas and hypopneas
per hour of sleep.
• The respiratory disturbance index (RDI) refers to the number of apneas,
hypopneas, and respiratory effort-related arousals per hour of sleep.
• The severity of sleep apnea is generally classified by the AHI.
AHI of < 5 is considered to be normal,
AHI 5–15 is mild sleep apnea,
AHI 16–30 is moderate sleep apnea, and
AHI >30 is severe sleep apnea
Obstructive apnea
Central apnea
Mixed apnea
Cheyne Stokes breathing-central sleep apnea
Cheyne Stokes breathing-central sleep apnea:
Significance of involuntary sleepiness
• Daytime sleepiness can be assessed subjectively by
questionnaires such as the Epworth Sleepiness Scale
(ESS) and objectively by investigation in the sleep
laboratory such as the Multiple Sleep Latency Test
(MSLT).
• Elderly patients with sleep apnea report more
sleepiness than elderly subjects without sleep apnea
and they report a similar degree of sleepiness as young
apneic subjects .
• A complaint of daytime sleepiness in the elderly should
not be attributed to normal aging, and should prompt
further evaluation for an underlying cause including
sleep apnea.
Prevalence of sleep apnea
• Although the prevalence of OSA is over 4%, only 1.6% had
such a diagnosis by their physician, and only 0.6% were
actually treated for OSA, indicating under-diagnosis and underrecognition of this important disorder .
• In the pediatric population, OSA is estimated to occur in 1–3%
of children with a peak age of 2–5 years
• The prevalence of OSA is higher in certain groups, such as
those with male gender, genetic factors, hormonal disorders
(e.g. hypothyroidism), acromegaly, polycystic ovary syndrome,
and specific diseases such as renal failure or diabetes.
• The prevalence of OSA among obese individuals has been
reported to exceed 30% and may reach as high as 50–98% in
the morbidly obese population .
• The overall prevalence of OSA in the elderly is estimated at
roughly 30%
Prevalence of sleep apnea
• In a community-based study of subjects aged 30–60 years, 24%
of men and 9% of women had sleep apnea, defined as an AHI
≥5;
• 2% of women and 4% of men had sleep apnea syndrome,
defined as an AHI ≥5 accompanied by complaints of daytime
sleepiness.
• Elderly have sleep apnea prevalence ranging from 18% to 62%.
• The prevalence of sleep apnea increased with advancing age .
• The apparent increased prevalence of sleep apnea in the elderly
may be largely due to an increased prevalence of central sleep
apnea associated with normal aging ,
Prevalence of sleep apnea
•
•
•
•
The severity of associated hypoxemia decreased with
advancing age.
Sleep apnea syndrome (defined as an AHI ≥10
accompanied by daytime symptoms) was highest in the
middle-aged group.
This suggests that although sleep apnea is more
prevalent in the elderly, it is less likely to be symptomatic
and to have physiological consequences such as
significant hypoxemia.
This raises the issue of its clinical relevance and whether
the criteria for diagnosis of sleep apnea should be
different in the elderly than in middle-aged adults.
Pathogenesis of sleep apnea
• The underlying mechanisms that promote the
development of sleep apnea in the elderly can be
classified into:
(1) Replication of the patho-physiology of sleep
apnea in middle-aged adults
(2) Physiological changes that are uniquely
associated with aging; and
(3) Consequences of chronic medical disorders
and/or medications.
Pathophysiology of sleep apnea
in middle-aged adults
• The predominant cause of obstructive sleep apnea in
middle-aged adults is obesity, either through its effects
on the pharynx and to a lesser extent on lung volume.
• In the Sleep Heart Health Study the strength of the
association between sleep apnea and body weight
decreased as age increased.
• Male gender is a strong risk factor for sleep apnea,
with males having approximately twice the prevalence
of sleep apnea as females. This increased prevalence
in males is still seen in the elderly , despite the fact that
after menopause the prevalence of sleep apnea
increases significantly in women.
Physiological changes
that are unique to aging
• The physiological consequences of obstructive apnea are a rise in
PaCO2, a fall in PaO2, and an increased ventilatory effort against
an occluded airway.
• Ultimately, transient arousals from sleep generally occur, which
re-establish airway patency and ventilation.
• The individual subsequently returns to sleep and the cycle
repeats throughout the night.
• The principal abnormality in the individual with OSA is an
anatomically small pharyngeal airway.
• During wakefulness, the individual compensates for the deficient
anatomy via reflexive increases in the activity of upper airway
muscles that maintain airway patency.
• With sleep onset, these protective compensatory reflexes are lost
and airway collapse occurs.
• Both pharyngeal anatomy and physiology may change with age,
resulting in the observed age-related increases in the prevalence
of OSA.
Physiological changes
that are unique to aging
• There are conflicting data on how aging affects the
upper airway, the diameter of which has been
reported to be larger or smaller in older adults
compared to control subjects.
• Advancing age is associated with increased
pharyngeal collapsibility and increased pharyngeal
resistance during sleep , both of which may
predispose to the pathogenesis of obstructive sleep
apnea and contribute to an increased prevalence of
obstructive sleep apnea in the elderly.
Physiological changes
that are unique to aging
• There are a number of underlying pathophysiological
variables (anatomy ,upper airway muscle function, and
central ventilatory instability) that may be important in
determining apnea status.
• In some patients, they may have primarily an anatomical
problem, whereas other OSA patients may have primarily a
problem with upper airway muscle dysfunction.
• Variety of sleep apnea phenotypes exist whereby a
particular variable (or group of variables) increases the risk
of (or protects from) the development of OSA.
• These phenotypic clusters are potentially important since
therapies targeting the underlying pathogenesis of the
condition are likely to be different for each of these
subgroups
UAW anatomy
• The upper airway requires stiffness of the soft tissue
walls around it and activity of the dilator muscles to
maintain patency.
• Any reduction in UAW cross sectional area, change in its
length, muscle activity, or a combination of these
variables, may lead to vulnerability of the UAW to
collapse.
• Many of these characteristics may be affected by aging.
• Upper airway dilator muscle and increased lung volume
tend to maintain pharyngeal patency.
• A small pharyngeal airway in apnea patients is found
compared to controls, with the smallest airway luminal
size generally occurring at the level of the velopharynx in
both patients and controls .
UAW anatomy
• Through upper airway receptor mechanisms during
wakefulness, there is an increase in the activity of the
pharyngeal dilator muscles. However, during sleep, these
protective mechanisms fail leading to a fall in activity of the
pharyngeal dilator muscles and an increased propensity for
loss of upper airway patency.
• Aging may compromise upper airway anatomy, and/or
neural control of upper airway muscles either through the
CNS or through peripheral upper airway receptor
mechanisms.
• Finally increased end expiratory lung volume can promote
upper airway patency, although this mechanism could also
be compromised with aging.
UAW anatomy
• Sleep apnea patients have increased thickness of the
lateral pharyngeal walls .
• This finding is helpful in explaining the reduced lateral
diameter of the airway lumen in OSA patients as compared
to controls.
• Using acoustic reflection in 60 men and 54 women with an
age range of 16–74 years. All upper airway dimensions,
except at the oropharyngeal junction, decreased with
increasing age in both healthy men and women.
• Another researcher ,Older patients (>63 years) had larger
upper airways at all pharyngeal levels than the youngest
group of patients (<52 years), using a CT assessment of
airway size.
• The studies assessing the effects of age on airway
anatomy are too sparse and disparate to draw firm
conclusions.
Acoustic reflection
Acoustic Rhinometer
Acoustic Pharyngometer
UAW length
• Since cross-sectional UAW is generally greater in men
than women, intrinsic pharyngeal size is an unlikely
explanation for the male predisposition to pharyngeal
collapse.
• Men had a significantly longer UAW than women,
independent of body size, so major independent effect of
pharyngeal airway length on upper airway collapsibility.
• As non-rigid tubes become longer they are increasingly
prone to collapse (assuming similar tethering); So airway
length is a potentially important mechanism responsible
for the increased UAW collapsibility.
• A significant positive correlation between RDI and UAW
length, which persisted when UAW length was normalized
to body height .
UAW length
• Airway length may also partially explain the agerelated change in the gender predisposition of
OSA in children. While in pre-pubertal children the
prevalence of OSA is similar between genders,
there is a known male predominance in the postpubertal population and in adults.
• Pre-pubertal children UAW length was similar
between boys and girls, and even shorter in boys
when normalized to body height
• The pharyngeal airway became significantly longer
in post-pubertal males compared to females (both
absolute length and length normalized to body
height)
UAW muscle function
• Airway patency depends on both UAW anatomy and
function,
• Many diseases such as muscular dystrophy and myopathy
result in increased risk of OSA, probably secondary to the
loss of protecting effect of the UAW dilators.
• Three groups of muscles have been investigated in the
context of the pathogenesis of OSA:
(1) the muscles influencing hyoid bone position (geniohyoid,
sternohyoid, etc.);
(2) the muscle of the tongue (genioglossus); and
(3) the muscles of the palate (tensor palatini, levator palatini).
The activity of many of these muscles is increased inspiration
(“phasic muscles”) thus stiffening and dilating the upper
airway thereby counteracting during the collapsing
influence of negative airway pressure
Central ventilatory instability
• The term loop gain is used to refer to the intrinsic stability or
instability in the ventilatory control system.
• A system with high loop gain would be relatively unstable
requiring only a minor perturbation to yielding periodic
breathing.
• A system with low loop gain would be intrinsically stable with a
regular breathing pattern persisting despite a major
perturbation.
• Cyclical oscillations from the central pattern generator in the
brainstem could therefore yield upper airway collapse when
output to the pharyngeal dilator muscles was at its nadir in an
individual who was anatomically predisposed.
• Most studies failed to demonstrate a relationship between the
higher susceptibility to OSA seen in men or with aging to this
ventilatory control instability .
Central ventilatory instability
• Since the prevalence of central sleep apnea appears to be
increased in the elderly, it is possible that factors which promote
the development of central apnea may be enhanced by aging.
For example, an increased ventilatory response to hypercapnia
can promote the development of sleep apnea by destabilizing
the chemical control of breathing.
• However, it appears that the ventilatory response to hypercapnia
during euoxic wakefulness is not altered by aging. In fact, the
sensitivity of the hypercapnic ventilatory response may be
reduced during hypoxia in the elderly .
• The change in the ventilatory response to hypercapnia during
transition from wakefulness to sleep also influences the
development of central sleep apnea.
Central ventilatory instability
• Normally, the hypercapnic ventilatory response is reduced
during this transition, which helps to stabilize breathing
during sleep. Loss of this stabilizing response during aging
could promote the development of central apnea.
• Comparison of loop gain in healthy young and elderly
subjects found no significant difference between them .
Consequently there is no convincing evidence that aging per
se destabilizes the control of breathing and that age-related
changes in the control of breathing are responsible for the
increased prevalence of sleep apnea in the elderly.
Central ventilatory instability
• Termination of the apnea generally requires a transient
arousal from sleep thus activating the upper airway muscles
and re-establishing airway patency.
• Without such an arousal, profound hypoxemia and
hypercapnia would likely ensue.
• The possible mechanisms leading to arousal, include direct
stimulation of peripheral and central chemoreceptors by rising
PaCO2 and falling PaO2, afferent CNS input from the lung,
chest wall, or upper airway receptors resulting from the
increasing ventilatory effort that develops over the course of
an apnea, or direct stimulation of the reticular activating
system by respiratory neurons activated by the apnea process
• Arousal remains an important mechanism by which apneas
are terminated, but at the same time arousals may increase
the severity of the sleep disordered breathing by promoting
greater ventilatory instability
Chronic medical disorders that are
associated with sleep apnea
• The prevalence of chronic medical disorders increases with
advancing age and many of them, such as heart failure, stroke
and renal failure, are associated with the development of sleep
apnea.
• Congestive heart failure over 65 years, 71% of those whose left
ventricular ejection fraction was < 40% had sleep apnea, defined
as an AHI greater than 10. Forty-three percent of patients had
OSA and 28% had Cheyne-Stokes respiration.
• The prevalence of sleep apnea is high in patients who have
suffered a stroke; 53% of patients with an acute stroke had sleep
apnea, reflected by an AHI >10.
• The prevalence of sleep apnea in end-stage renal disease has
been reported to be at least 60% in middle-aged patients.
Clinical presentation
of sleep apnea
Clinical presentation
of sleep apnea
• Significant proportion of elderly patients may have
asymptomatic sleep apnea,
• Elderly patients with sleep apnea can present with typical
clinical features such as:
1- Daytime sleepiness.
2-Snoring,
3-Choking or gasping respirations,
4-Witnessed apneas,
5-Morning headaches,
6-Hypertension
Clinical presentation
of sleep apnea
• it is important to recognize that sleep apnea may also be
heralded by atypical symptoms that are unique to this age
group.
1- Enuresis may be a consequence of sleep disordered
breathing in the elderly , and can be improved with effective
treatment of sleep apnea.
2- Nocturnal wandering or confusion may be associated with
sleep apnea .
3- Cognitive impairment, measured by Mini-Mental State
Examination, delayed verbal recall, and impaired
constructional abilities, and even dementia, have all been
described in the elderly with sleep apnea.
4- Falls during the day or night-time are associated with sleep
disordered breathing ,
5- Ocular conditions associated with OSA eg. glaucoma and
non arteritic anterior ischemic optic neuropathy (NAION).
Clinical presentation
of sleep apnea
• In the middle-aged population, anthropomorphic
features, such as BMI, neck and waist
circumference , history of snoring and nocturnal
choking, are significantly associated with the
AHI and, hence, are considered predictive of
sleep apnea .
• One study has demonstrated that these typical
anthropomorphic features and symptoms are
also predictive of sleep apnea in the elderly.
Clinical presentation
of sleep apnea
• At age 40 the odds ratio for a positive association
between BMI and AHI was 2.0 , but by age 80 it was
1.3. Neck circumference was no longer a significant
predictor of AHI by age 80 and waist-to-hip ratio was
no longer significant by age 70.
• This suggests that anthropomorphic features used to
predict sleep apnea in middle aged subjects may not
be as robust in the elderly.
• In addition, a history of snoring was noted to decrease
1.8-fold from age 50–60 to age 70 and beyond,
indicating that typical symptoms of sleep apnea may
not be reported as frequently in the elderly.
Diagnosis of
sleep apnea
• Comprehensive overnight polysomnography in the sleep
laboratory is the gold standard for the diagnosis of sleep
disordered breathing .
• Alternative diagnostic testing includes nocturnal
cardiopulmonary monitoring (i.e. without sleep monitoring)
and polysomnography at home.
• Studies that have evaluated these diagnostic modalities
have not included elderly subjects, and consequently we
are left to extrapolate from studies on younger subjects.
• Cardiopulmonary monitoring in middle-aged subjects has
been found to be as effective as polysomnography in
predicting which patients will benefit from continuous
positive airway pressure therapy .
Diagnosis of
sleep apnea
• Comparing cardiopulmonary monitoring with
polysomnography in selected patients with a
high probability of OSA found no difference in
their outcome measurements, which included
AHI on CPAP, daytime sleepiness, quality of life,
and CPAP requirement .
• Although these data suggest that
cardiopulmonary monitoring may be adequate
to diagnose sleep apnea in selected elderly
subjects, this needs to be confirmed
Diagnosis of
sleep apnea
• This suggestion is supported by the fact that the elderly
have some unique factors that may confound the accurate
interpretation of limited diagnostic testing. For example, the
high proportion of central apnea and increased prevalence
of periodic limb movements in the elderly may require
monitoring of respiratory effort and leg movements,
respectively.
• Some elderly subjects are not capable of setting up a
monitoring system at home either because of infirmity
and/or lack of family support; in such cases, attended
monitoring in a sleep laboratory may be the best option.
Impact of sleep apnea
on clinical outcomes
Sleepiness
• Sleep apnea is associated with increased daytime
sleepiness in the elderly.
• Severe sleep apnea (AHI ≥30) was associated with
daytime sleepiness as measured by the Epworth
Sleepiness Scale. Even mild sleep apnea in the
elderly, as defined by an AHI ≥5, has been associated
with increased daytime sleepiness compared to
elderly patients with an AHI <5.
• Treatment of OSA with CPAP can reduce daytime
sleepiness as measured by ESS and improve daytime
vigilance as measured by driving simulation
performance
Neuro-cognitive function
• Neurocognitive function in the elderly may be
influenced by multiple factors including age itself.
• Although sleep apnea may contribute to changes in
neurocognitive function in the elderly, studies to
date have shown conflicting evidence.
• Randomly selected elderly patients showed no
difference in neuropsychiatric or medical outcomes
in subjects with mild or moderate OSA compared to
healthy controls .
• Vigilance testing on community-dwelling elderly
volunteers has shown that decreased vigilance is
associated with increasing age.
Neuro-cognitive function
• Other studies have demonstrated decreased
performance on the Mini-Mental Status Examination
associated with increased daytime sleepiness and the
severity of sleep apnea reflected by the RDI.
• Diminished neurocognitive performance associated with
sleep apnea in the elderly may be due to intermittent
nocturnal hypoxia (executive and psychomotor
function) or excessive daytime sleepiness and reduced
vigilance as a result of sleep fragmentation (attention
and memory) or both
• The impact of sleep apnea on daytime function can be
amplified by co-existing sleep disorders such as
insomnia .
Neuro-cognitive function
• Treatment of sleep apnea with CPAP has been
shown to improve cognition in the elderly.
• Treatment of sleep apnea with CPAP for 3 months
showed greater improvement in attention,
psychomotor speed, executive functioning, and
non-verbal delayed recall in those who were
compliant with CPAP . Therapeutic CPAP also
improved steering performance and reaction time
to target stimuli in patients with OSA.
Mood
• There is a dose–response relationship in
the elderly between OSA and the risk of
developing depression
• Whether treatment of sleep apnea improves
symptoms of depression in the elderly is
unclear.
Hypertension
• Obstructive sleep apnea is associated
with hypertension in the elderly.
• In a 1-year follow-up of elderly patients,
those with sleep apnea (apnea index ≥5)
had higher systolic blood pressure than those
without sleep apnea .
• Although CPAP therapy has been found in a
recent meta-analysis to significantly improve
blood pressure, randomized controlled trials of
CPAP therapy to date have not included elderly
subjects .
Coronary artery disease
• Sleep apnea has been shown to be
modestly associated with cardiovascular
disease in the Sleep Heart Health Study .
• Because of its association with
hypertension, sleep apnea is felt to play a
role in cardiovascular disease risk.
Congestive heart failure
• In the Sleep Heart Health Study, which included
elderly subjects, OSA was also associated with
an increased risk of congestive heart failure with
an odds ratio of 2.38 independent of other known
risk factors .
• Congestive heart failure is a significant risk factor
for the development of central sleep apnea, and
sleep apnea is present in about 30–40% of
patients with congestive heart failure .
Stroke
• Severe sleep apnea (AHI ≥30) is associated with
an increased risk of stroke in the elderly with an
adjusted hazard ratio of 2.52 .
• Intolerance of CPAP in a group of elderly
patients with OSA following stroke increased
the probability of a new vascular event five-fold
(odds ratio 5.09) even after adjusting for other
vascular and neurological risk factors .
Mortality
• There is conflicting evidence as to whether sleep apnea
increases mortality in the elderly.
• In a 10-year follow up of community-dwelling elderly, subjects
with a respiratory disturbance index ≥30 had a shorter
survival but sleep apnea was not an independent predictor of
death (age and cardiovascular and pulmonary disease were
identified as independent predictors) .
• Elderly women with an AHI ≥5 had significantly increased
mortality This effect may be amplified by co-morbid disease
as suggested by the findings of a long-term follow-up study in
which the presence of central sleep apnea was associated
with a shortened lifespan in elderly subjects with congestive
heart failure
Treatment of sleep apnea
Obstructive sleep apnea
• Conservative measures that are used to treat sleep apnea
in younger adults should also be considered in the elderly
patient.
• Identification and treatment of any underlying medical
disorders that contribute to sleep apnea, such as
hypothyroidism and acromegaly, weight reduction, the
avoidance of alcohol and sedative/hypnotic medication
close to bedtime ,and postural therapy.
• CPAP is the gold standard therapy for OSA and it has been
shown to be effective in the elderly .
• Elderly patients generally require lower CPAP levels than
weight-matched younger subjects, which probably reflects
differences in the compliance of the elderly pharynx.
Obstructive sleep apnea
• Compliance with CPAP therapy in the elderly is
correlated with attendance at a CPAP education class
and improvement of daytime symptoms. Compliance is
negatively correlated with nocturia and benign prostatic
hypertrophy.
• Treatment of sleep apnea with CPAP is feasible in the
elderly with mild to moderate dementia.
• Continuous positive airway pressure adherence in
community dwelling patients with Alzheimer’s disease
averaged 4.8 hours/night.
• Depressive symptoms predict lack of compliance in this
group
Change in the upper airway of a normal individual after application
of CPAP of 0 cm H2O (A) and CPAP of 15 cm H2O (B).
Obstructive sleep apnea
• Oral appliances can be used as an alternative to CPAP in
middle-aged patients with mild OSA , although the use of
these appliances may be limited in older patients by poor
dentition.
• In the absence of correcting a specific upper airway
abnormality, such as enlarged tonsils, uvulo-palatopharyngo-plasty and laser-assisted uvuloplasty , surgical
therapy has a very limited role for the management of sleep
apnea in adults. This role is even more limited in the elderly
where abnormalities such as enlarged tonsils are a rarity
and co-existing medical disorders increase the risk of
surgical procedures.
• Pharmacological management of residual daytime
sleepiness following CPAP therapy with modafinil has been
shown to be beneficial .
Mandibular advancement device
Central sleep apnea
Central sleep apnea
• The specific therapy chosen needs to be individualized for
each patient and depends partly upon the underlying cause
of sleep apnea.
• Cheyne-Stokes respiration (CSR) can be corrected by
improvement of ventricular function in patients with
congestive heart failure .
• Alternative therapeutic interventions for central sleep
apnea, including CSR, include supplemental oxygen ,
which is not universally effective, and inhaled carbon
dioxide , which has been demonstrated to be effective in
the sleep laboratory but is not a feasible long-term option
at the present time.
• Short-term use of respiratory stimulants, such as
theophylline and acetazolamide, has also been
demonstrated to improve CSR in patients with heart failure
Central sleep apnea
• A prospective randomized controlled trial of CPAP in
patients under 65 years of age with congestive heart failure
and CSR found that CPAP reduced apnea, improved
nocturnal oxygenation, the 6-minute walk test, and ejection
fraction but did not confer a survival benefit.
• For elderly patients with CSR and heart failure, adaptive
servoventilation (ASV) improves AHI and daytime
sleepiness .
• In a study of middle-aged and elderly patients with complex
sleep apnea (persistent CSA despite CPAP treatment of
OSA), Bi-level positive airway pressure with backup rate and
ASV improved AHI.
Summary
• Sleep apnea is common in the elderly.
• Its multi-factorial etiology results in a more
heterogeneous clinical and polysomnographic
presentation than what is characteristically seen
in younger adults.
• The elderly present some unique challenges for
the diagnosis and treatment of sleep apnea,
which may require modification of the diagnostic
algorithms that have been established in middleaged patients.
Summary
• Although there is evidence that untreated sleep
apnea has clinical consequences, more research
that is specifically directed at this patient
population is required to determine its impact on
important clinical outcomes and co-morbid
disease.
• The need for this direction is likely to grow as the
population ages and the associated prevalence
of sleep apnea increases.