Older Adults at Risk for Sleep Apnea

An Expert Interview With Marquetta Flaugher, DSN, ARNP-BC, RN-BC

Elizabeth McGann, DNSc, RN

September 23, 2011

September 23, 2011 — Editor's note: The risk of developing obstructive sleep apnea increases with age. Comorbidities and medications can exacerbate the problem and contribute to life-threatening episodes. Early detection is critical to ameliorate potential serious health problems that can occur without proper treatment. "Sleep Apnea: A Potentially Deadly Sleep Disorder Among Older Adults" was featured as a podium presentation at the Gerontological Advanced Practice Nurses Association (GAPNA) 30th Annual Conference, held September 14 to 17 in Washington, DC.

To find out more about sleep apnea among older adults, Medscape Medical News interviewed Marquetta Flaugher, DSN, ARNP-BC, RN-BC, an advanced nurse practitioner who currently works at the Bay Pines VA Healthcare System in Florida. She is an American Nurses Credentialing Center (ANCC)-certified family nurse practitioner who practices in the area of sleep medicine. She has conducted clinical research and given numerous presentations on sleep disorders at local, regional, and national conferences.

Medscape: What is the incidence and prevalence of obstructive sleep apnea in older adults?

Dr. Flaugher: The National Commission on Sleep Disorders Research estimates that 7 to 18 million people in the United States are affected with sleep-disordered breathing. The risk of obstructive sleep apnea (OSA) increases 2- to 3-fold with increasing age, up to 65 years. Over the age of 65, there is little difference in risk, most likely due to increased overall mortality in this older age group.

Medscape: What are the common signs and symptoms of obstructive sleep apnea?

Dr. Flaugher: The most common signs and symptoms of OSA include snoring, daytime sleepiness, and sleep apnea. Additional symptoms include choking, restlessness, nocturia, diaphoresis, reflux, dry mouth, nasal congestion, poor concentration, short-term memory deficits, weight gain, changes in mood and personality, diminished productivity, increased auto accidents, school failures or dropouts, mistakes and accidents, daytime fatigue, hypersomnolence, sleep interruptions, and early morning headaches.

Medscape: What are the best assessment approaches and common treatments?

Dr. Flaugher: The best assessment starts with a thorough sleep history and clinical examination. The Epworth Sleepiness Scale is commonly utilized to determine the severity of daytime sleepiness a person is experiencing. If the healthcare provider feels that OSA may be affecting sleep, a polysomnography should be performed to determine the presence and severity of the sleep disorder.

Common treatments include behavioral interventions such as weight loss, side-lying positions, alcohol and tobacco cessation, and good sleep hygiene. The best practice in the treatment of OSA is positive airway pressure therapy, which includes various mechanisms of air pressure delivery commonly referred to as continuous positive airway pressure (or CPAP). The amount of air pressure is dependent on the anatomy of the individual, not necessarily the severity of the OSA.

For people with mild or positional OSA, an oral appliance may be constructed to move the jaw and tongue forward and assist with holding the soft palate in place. While surgical procedures are accepted treatment options for OSA, they are very painful and not always 100% successful.

Surgical interventions can include laser-assisted uvulopalatopharyngoplasty; radiofrequency ablation of excessive oral/pharyngeal tissue; correction of jaw deformities; removal of nasal polyps or excessive tissue; lacing stents in the palate to "stiffen" the area to prevent a relaxation drop; and the Genial Bone Advancement Trephine System, which involves a gingivobuccal incision and a circular osteotomy that pulls forward the outer cortex and medullary bone. A portion of this bone is removed, which subsequently advances the tongue muscles and opens the posterior airway.

Medscape: Are older adults affected differently than younger adults?

Dr. Flaugher: Older people tend to achieve less total nighttime sleep. The deepest stages of non-REM sleep are usually reduced in the older patient, while REM sleep remains preserved. Also, as the person ages and retires, they become less sensitive to sleep cues, and the sleep–wake cycle may become delayed, altering their normal sleep cycle and resulting in less consistent periods of sleep–wake across a 24-hour time period. Other factors to consider for assessing OSA and sleep-disordered breathing in the older patient include the presence of obesity (which predisposes to upper airway narrowing), age-related decreases in muscle tone due to lack of collagen and elastin (which enhances upper airway collapsibility), and impaired pharyngeal sensory discrimination.

While vocalized signs and symptoms may be the same, there are some unique findings with sleep apnea in older adults. Comorbidities often create difficulties for restful sleep in the older patient. Having 5 or more apneas or hypopneas per hour of sleep occurs in approximately 70% to 80% of patients with dementia. Recent data suggest that 50% of older patients with heart failure experience sleep-disordered breathing. Medications may also affect sleep, such as antidepressants, some antihypertensives, bronchodilators, diuretics, and decongestants. When considering treatment options for the older patient with OSA, a good fit with the interface may be difficult when considering edentulism.

Medscape: How would you describe the state of the science with regard to sleep apnea in older adults? What are your predictions for the future?

Dr. Flaugher: The science of sleep apnea continues to evolve. Studies are currently being conducted on the feasibility of a hypoglossal nerve stimulator for the treatment of OSA. The stimulator activates the hypoglossal nerve, which mobilizes the genioglossus muscle, which will lead to tongue protrusion with increased pharyngeal diameter and air flow. The initial costs, most likely, will be prohibitive for older patients, although when comparing the cost of this treatment to potentially decreasing the risk of associated healthcare diagnoses, such as atrial fibrillation, congestive heart failure, and stroke, it may prove to be a cost-effective measure.

There is a pharmacological agent in development for individuals with moderate to severe OSA. This drug has been shown to be effective in reversing depressed breathing by opioids. Additionally, the drug has been shown to stimulate an additional brain region that regulates muscle tone in the upper airways.

Medscape: What resources are available to healthcare providers who treat older adults relative to sleep apnea?

Dr. Flaugher: A Systematic Review of the Literature Regarding the Diagnosis of Sleep Apnea is available from the Agency for Healthcare Research and Quality Web site.

Other excellent sources of online information are the Web sites of the National Institute of Neurological Disorders and Stroke, the American Sleep Medicine Foundation, the National Sleep Foundation, the American Academy of Sleep Medicine, and the Sleep Research Society.

Medscape: What major challenges do providers and families face when dealing with older adults with sleep apnea?

Dr. Flaugher: Early assessment and treatment of sleep disorders is one of the most challenging obstacles when working with the older adult. Often older patients don't realize problems with their sleep and are compensating by taking daily naps. Many prescribed medications also affect normal sleep patterns, and the presence of comorbidities makes them at high risk for additional health problems and possible death.

Medscape: What were the most significant aspects of your presentation?

Dr. Flaugher: Two points I would like stress from my presentation are that early recognition of OSA is critical, and that potential serious health problems can occur without proper treatment modalities. If more people are identified as having OSA and receive early treatment, the life-threatening comorbidities that have been associated with this particular sleep disorder can be limited.

Dr. Flaugher has disclosed no relevant financial relationships.

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