Treatment of Sleep Disordered Breathing in the Elderly

Treatment of SDB in the elderly is similar to treatment of SDB in younger adults. In general, several factors should be taken into account when considering SDB treatment. Age or assumed nonadherence should never alone stand as reasons to withhold treatment.

Severity and significance of the patient's symptoms should be the main guides in initiating treatment (69). Older patients with severe SDB (i.e., AHI > 20) deserve a trial of treatment while in those with milder levels of SDB (i.e., AHI < 20) treatment should be considered if other conditions are present, such as hypertension, cognitive dysfunction, or EDS.

Patients should be counseled on weight loss and smoking cessation if indicated. For those with positional-related SDB, that is, with more apneic events typically occurring in the supine position, avoidance of this position and attempting to sleep on their side should be indicated and may be effective.

Some medications and substances should be avoided in older patients. In particular the long-acting, older, sedating benzodiazepines should be avoided as they are respiratory depressants and may increase the number and duration of apneas. Alcohol should be avoided because even small amounts can also exacerbate SDB.

Continuous positive airway pressure (CPAP) is the "gold standard" for the treatment of SDB (see also Chapter 6). CPAP is a device that provides continuous positive pressure via the nasal or oral airway passages, which creates an opening in the airway to permit inspiration. CPAP has been shown to be a very effective and safe treatment for SDB if used correctly (70).

Beneficial effects of CPAP in older adults with SDB have been shown in several studies. Guilleminault et al. (71) found improved nocturia, daytime somnolence, depression ratings, and quality of life scores in older males after treatment of SDB with CPAP. Another study reported that treatment of SDB with CPAP resulted in normalization of prethrombotic states in older adults, with a reported lengthening of prothrombin time and increased fibrinogen levels (72). Older adults treated for SDB with CPAP for three months showed improved cognition, particularly in the areas of attention, psychomotor speed, executive functioning, and nonverbal delayed recall (44).

As with middle aged adults, problems with CPAP adherence may occur in the elderly. However, a study that looked at CPAP adherence in demented elderly with SDB, showed that adherence was good, with the majority of patients using CPAP for about five hours a night. Depression was the only factor associated with poor adherence; age, severity of dementia, or severity of SDB did not predict nonadherence (54).

An alternative treatment for SDB patients where CPAP is not tolerated is an oral appliance (see also Chapter 12). Oral appliances should generally be reserved and considered for thinner patients with milder levels of SDB (73). Reported effectiveness ranges from 50% to 100%. However, patients with dentures are generally not candidates for this device although newer models can be fitted with dentures.

Surgical treatments are not commonly recommended in the elderly. Surgical treatments involve correcting the anatomic abnormalities most responsible for the airway obstruction. There are several possible procedures, the most common being an uvulopalatopharyngoplasty. This involves an excision of the soft palate and uvula (74), and requires general anesthesia, and is only successful in approximately 50% of cases (75). Furthermore, being 50 years old or older is associated with poorer surgical outcome (75).

When patients have trouble tolerating both CPAP and oral appliances and are poor surgical candidates, nocturnal oxygen supplementation may be considered. However, studies that have looked at the efficacy of supplemental oxygen treatment for SDB have arrived at disparate findings. It has been reported that oxygen supplementation is not as effective as CPAP in reducing apneas or improving EDS (76). However, studies have shown that providing one night of supplemental oxygen does improve the nadir oxygen saturation, but at the same time may worsen the respiratory acidosis associated with the apneas (77). There is also evidence that oxygen supplementation during sleep in patients with SDB may cause a slight increase in the mean obstructive apnea duration (77). Hence, before being prescribed oxygen for home use, patients should undergo an attended polysomnogram with oxygen supplementation to ensure that there is only a minimal increase in apnea duration if any and no worsening of cardiac arrhythmias.

Sleep Apnea

Sleep Apnea

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