Recognition and Diagnosis of Obstructive Sleep Apnea in Older Americans

Tiffany J. Braley, MD, MS; Galit Levi Dunietz, PhD, MPH; Ronald D. Chervin, MD, MS; Lynda D. Lisabeth, PhD, MPH; Lesli E. Skolarus, MD, MS; James F. Burke, MD, MS


J Am Geriatr Soc. 2018;66(7):1296-1302. 

In This Article

Abstract and Introduction


Objectives: To estimate the proportion of older Americans at risk for obstructive sleep apnea (OSA) who receive OSA evaluations, diagnosis, and treatment.

Design: Cross sectional study.

Setting: National Health and Aging Trends Study (NHATS), Round 3 survey.

Participants: Community–dwelling Medicare beneficiaries age 65 and older (N=1,052).

Measurements: NHATS participants were asked specific questions about sleep disturbances, including items that resembled critical elements of a validated instrument used to assess OSA risk (the STOP–Bang questionnaire). The proportion of older Americans at risk for OSA who received evaluations with home or in–laboratory sleep studies, OSA diagnosis, and OSA treatment was examined, as well as clinical, social, and demographic correlates of OSA.

Results: Of 1,052 participants who completed the sleep module, 56% (95% confidence interval (CI)=53–59%) were estimated to be at high risk of OSA. Only 8% (95% CI=5–11%) of the high–risk individuals had been tested for it. Of those tested, 94% (95% CI=87–100%) were diagnosed with OSA. Treatment with positive airway pressure was prescribed for 82% (95% CI=65–99%) of participants with an OSA diagnosis.

Conclusions: Evidence from this nationally representative sample of community–dwelling Medicare beneficiaries suggests that high OSA risk is common but seldom investigated. When investigated, OSA is almost always confirmed and usually treated. These findings suggest a significant gap in OSA assessment for older Americans that could have public health implications.


Obstructive sleep apnea (OSA) is a disorder characterized by repeated episodes of upper–airway obstruction during sleep. A major public health threat, OSA is associated with far–reaching adverse effects that include cardiovascular disease,[1–3] cognitive dysfunction,[4–7] depression,[8] metabolic syndrome,[9,10] motor vehicle crashes,[11] and poor quality of life.[12] It is likely that healthcare costs of OSA and its associated morbidity are substantial.[13,14]

Adults aged 65 and older constitute 14.9% of the U.S. population.[15] Although older age is a recognized risk factor for OSA, estimates regarding OSA risk and discrepancies in OSA recognition and treatment are primarily based on regional data from middle–aged adults.[16–20] Little is known about the national scope of OSA risk underrecognition, and undertreatment in older adults. These limitations are gaps in knowledge, given that older Americans are more likely to experience many of the costly, preventable health consequences associated with OSA,[21–23] and older adults are expected to constitute 21.7% of the U.S. population by 2040.[24] To better characterize the national health burden of OSA, inform initiatives to reduce this burden, and optimize health outcomes for one of the primary consumers of health services in the United States, greater understanding of the scope and treatment patterns of OSA in older persons is necessary.

The purpose of this study was to determine the proportion of older Americans at risk for OSA in a large, representative sample of Medicare beneficiaries and to characterize the national scope of gaps in OSA evaluation, diagnosis, and treatment in these at–risk individuals. We hypothesized that, in comparison to general population estimates, a higher proportion of older individuals would be at–risk for OSA, but that these individuals would be less likely to receive OSA evaluations. As an exploratory analysis, social, clinical, and demographic factors associated with OSA diagnosis in older Americans were also evaluated.