Sleep Disorders in the Elderly

21 Sep Sleep Disorders in the Elderly

Epidemiology

A survey from the National Sleep Foundation showed that among adults between 55 and 84 years of age, 52% reported a sleep problem.

Common problems:

• difficulty falling asleep,
• frequent awakenings,
• early awakening,
• awakening unrefreshed,
• daytime sleepiness,
• pauses in breathing, snoring,
• unpleasant feeling in the legs,
• or less than 6 hours of nightly sleep.

Population-based studies have shown that symptomatic OSA affects approximately 3% to 7% of adult men and 2% to 5% of adult women. Other studies have shown that the prevalence of OSA, both symptomatic and asymptomatic, is 20% and 56% in women, and 28% and 70% in men between the ages of 65 and 99 years defined by AHI and respiratory disturbance index (RDI) of at least 10 events per hour, respectively.

Other population based studies showed that in adults older than 65, the prevalence of OSA is as high as 90% in men and 78% in women. However, most age-related increases in the prevalence of OSA occur before the age of 65 years. Indeed, the Sleep Heart Health Study found that the increase in prevalence of OSA appeared to plateau after the age of 65 years.

Pathophysiology

Collapse of the pharyngeal and retro-lingual airway is the primary cause of obstruction in OSA.

Factors that contribute to this collapse in elderly:

1. The genioglossus is considered to be most important muscle in maintaining airway patency. Studies have shown that older adults have a decreased genioglossus response and lower neuromuscular tone, which may contribute to their increased rate of OSA.
2. Menopause with the estrogen depletion.
3. Obesity and changes in BMI
4. Snoring and symptoms of daytime sleepiness are not very often reported, the reason: might be the fact that bed partners who typically report on snoring are no longer alive or, because of age-related factors, do not hear the snoring.
5. Older adults also are more likely to have components of central apnoea.
6. Regardless of the cause, sleep-disordered breathing is a more complex entity in older adults and should be recognized through detailed history taking and physical examination. Because it can be overlapped for another condition.

Oftentimes, older adults have various comorbid conditions that interfere with sleep, including depression, prostate hypertrophy, gastroesophageal reflux, arthritis, and pulmonary disorders. Many medications can also cause nocturia, such as diuretics, and are taken commonly in this patient population.

Changes in Sleep

On average, total sleep time decreases by 10 minutes per decade of life.  Sleep onset latency also increases with age. Moreover, slow-wave sleep and rapid eye movement (REM) sleep also decrease in the elderly. (Box 1). When the sleep is affected it brings negative outcomes, such us, decreased cognitive function, and attention, executive function and memory is affected negatively. Additionally, it has negative impact in quality of life, including general health perception, physical and social functioning and vitality.

Treatment

Management of OSA often requires a multidisciplinary approach.

1. The initial treatment of choice for OSA is positive airway pressure (PAP), which can be delivered as CPAP, bilevel PAP, or autotitrating PAP.
2. Behavioural treatment options should be addressed with the patient. The treatment may include weight loss, positional therapy, and avoidance of alcohol and sedatives before bedtime.
3. Oral appliances can be used as an adjunct or alternative to CPAP therapy options. A mandibular advancement device has been shown to improve OSA symptoms, although CPAP generally provided more benefit.
4. Various surgical treatment options are available for the management of OSA and sleep-disordered breathing. Because of higher associated morbidity, surgical treatment is usually considered for patients for whom PAP therapy and oral appliances do not provide adequate treatment. Therapy is usually directed at the site of obstruction and is often staged. Nasal surgeries include septoplasty, inferior turbinate reduction, adenoidectomy, and nasal valve reconstruction. Procedures for palatal obstruction include tonsillectomy and uvulopalatopharyngoplasty and its modifications.
5. Hypopharyngeal surgeries include lingual tonsillectomy, partial midline glossectomy, mandibular osteotomy, genioglossal advancement, hyoid myotomy and suspension, as well as maxillomandibular osteotomy and advancement.
6. Newer technologies such as hypoglossal nerve stimulation implant are becoming more appealing as alternatives to the CPAP treatment option because of lower associated surgical morbidity, good clinical outcomes, and the multilevel effect on airway obstruction.

However, surgical treatments of OSA and sleep-disordered breathing in the elderly are not well studied, in part because of the higher prevalence of comorbid conditions and increased risks associated with general anaesthesia in this patient population. In healthy, older individuals with significant sleep-disordered breathing or OSA with CPAP intolerance, individualized surgical treatment options should be considered.

References:

Jiahui Lin, MD;  Maria Suurna, MD. Sleep Apnea and Sleep Disordered Breathing. Otolaryngologic Clinics of North America. Volume 51, Issue 4, August 2018, Pages 827-833. https://doi.org/10.1016/j.otc.2018.03.009