CPAP for excessive sleepiness in elderly patients

Abstract

Expansion of the ageing population has led to questions about the rationalisation of health-care support and the cost-effectiveness ratio of all treatment approaches for elderly patients. Sleep-related breathing disorders are highly prevalent after age 65 years,1Sforza E Gauthier M Crawford-Achour E et al.A 3-year longitudinal study of sleep disordered breathing in the elderly.Eur Respir J. 2012; 40: 665-672Crossref PubMed Scopus (21) Google Scholar and their treatment is a major reason for the increase in health-care spending. Obstructive sleep apnoea (OSA) syndrome is a well established risk factor for cardiovascular diseases in adults, but the deleterious effect of OSA syndrome in elderly people remains controversial,2Lavie P Lavie L Unexpected survival advantage in elderly people with moderate sleep apnoea.J Sleep Res. 2009; 18: 397-403Crossref PubMed Scopus (128) Google Scholar and some authors have discussed the concept of so-called preconditioning with chronic intermittent hypoxia, meaning elderly apnoeic patients could have less chance of myocardial infarction.3Rosenzweig I Kempton MJ Crum WR et al.Hippocampal hypertrophy and sleep apnea: a role for the ischemic preconditioning?.PLoS One. 2013; 8: e83173Crossref PubMed Scopus (44) Google Scholar The unknown benefits routinely offered by the treatment of OSA syndrome in elderly patients should be taken into account by public authorities when planning resource allocation. However, the main symptom associated with sleep apnoea, diurnal sleepiness, seems to be costly and dangerous in this population4Gooneratne NS Richards KC Joffe M et al.Sleep disordered breathing with excessive daytime sleepiness is a risk factor for mortality in older adults.Sleep. 2011; 34: 435-442PubMed Google Scholar and seems to be a valid target for the efficacy of treatment of OSA syndrome in older people.In the PREDICT study published in The Lancet Respiratory Medicine, Alison McMillan and colleagues5McMillan A Bratton D Faria R et al.Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial.Lancet Respir Med. 2014; (published online Aug 27.)http://dx.doi.org/10.1016/S2213-2600(14)70172-9Google Scholar show in a multicentre, randomised, two-parallel-group study of continuous positive airway pressure (CPAP) that this treatment significantly reduced daytime sleepiness in patients aged 65 years or older at 3-month and 1-year follow-up visits. The quality of work done by the authors should be emphasised. The magnitude of improvement is quite similar to that noted in younger adults, and this amplitude is well correlated with the average night duration use of CPAP.6Marshall NS Barnes M Travier N et al.Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis.Thorax. 2006; 61: 430-434Crossref PubMed Scopus (159) Google Scholar The short median duration of CPAP usage in the PREDICT study (1 h 52 min per night at 3 months and 2 h 22 min per night at 12 months) suggests a greater efficiency of CPAP for patients with longer nightly CPAP use. A minimum duration of 5 h of daily use for patients should be insisted upon if CPAP is to have a substantial effect on neurocognitive function.7Antic NA Catcheside P Buchan C et al.The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA.Sleep. 2011; 34: 111-119Crossref PubMed Google Scholar The authors did not attempt to explain the important question of the beneficial role of CPAP on cardiovascular morbidity and mortality in patients aged 65 years or older. This treatment approach leads to a marginal reduction in health costs. During 1-year follow-up, CPAP does not seem to improve mood, cognitive function, or incidence of accidents. We should emphasise here that the study was not originally designed to address these issues, and thus, firm conclusions could not be derived from these secondary endpoint analyses. In our opinion, the decrease in plasma LDL cholesterol is difficult to explain by the nocturnal CPAP alone.8Roche F Sforza E Pichot V et al.Obstructive sleep apnoea/hypopnea influences high-density lipoprotein cholesterol in the elderly.Sleep Med. 2009; 10: 882-886Summary Full Text Full Text PDF PubMed Scopus (55) Google Scholar Somewhat surprisingly, the lower blood pressure noted in the group who received best supporting care can only encourage us to heavily emphasise advice on lifestyle (reducing physical inactivity, reducing salt intake, and improving medication adherence) when patients are seen in our sleep medicine clinics.9Mendelson M Tamisier R Laplaud D et al.Low physical activity is a determinant for elevated blood pressure in high cardiovascular risk obstructive sleep apnea.Respir Care. 2014; 59: 1218-1227Crossref Scopus (16) Google Scholar The reported decrease of 3–4 mm Hg in blood pressure could be very profitable in terms of health costs at the 10-year follow-up point.Several criticisms can be made of this study. First is the use of the Epworth sleepiness scale to characterise the extent of daytime sleepiness; this questionnaire is sometimes not suitable for elderly patients because most are not able to answer all of the Epworth scale score items, thus this scale might underestimate sleepiness severity in older patients.10Onen F Moreau T Gooneratne NS Petit C Falissard B Onen SH Limits of the Epworth Sleepiness Scale in older adults.Sleep Breath. 2013; 17: 343-350Crossref PubMed Scopus (56) Google Scholar However, significant and consistent improvements in the Oxford Sleep Resistance test reported in the CPAP group confirm an objective improvement in daytime sleepiness from use of CPAP. Additionally, a detailed comparative analysis of the macroarchitecture and microarchitecture of sleep in the two groups of patients is absent. In fact, sleep apnoea syndrome in elderly people is often entangled with other sleep diseases, and it would have been interesting to compare the improvement of the effectiveness and continuity of sleep in both groups. Finally, daytime sleepiness is usually present less often (and if present, is less severe) in elderly patients with OSA syndrome, and elderly patients can cope better with sleepiness symptoms because they are often not in full-time work. Older apnoeic patients screened and recruited in this study were far from representative of the whole panel of older apnoeic patients seen in routine clinical practice. Many elderly apnoeic patients have no daytime sleepiness and consult for other symptoms—eg, nocturia, severe snoring, waking with feelings of choking, or minor memory complaints—or OSA is discovered by chance after onset of stroke or heart attack. It is difficult to determine the benefit of CPAP in the non-sleepy elderly apnoeic patients complaining about non-specific symptoms associated with unrefreshing sleep. In the study, the number of women is low, and thus the underrepresentation of women reduces the generalisation of the results obtained in men. We know that daytime sleepiness, according to an equivalent severity of apnoea or hypopnea, is often less severe in women than in men.1Sforza E Gauthier M Crawford-Achour E et al.A 3-year longitudinal study of sleep disordered breathing in the elderly.Eur Respir J. 2012; 40: 665-672Crossref PubMed Scopus (21) Google Scholar This difference in clinical presentation is important to consider in the detection and treatment of all apnoeic patients.The quality of the work in this study is remarkable and encourages continued high-quality controlled clinical trials in the specialty of sleep-related breathing disorders in elderly people; a disorder that can affect a third of patients aged 68 years or older and that might significantly accelerate cognitive decline in undiagnosed and untreated patients.We declare no competing interests. Expansion of the ageing population has led to questions about the rationalisation of health-care support and the cost-effectiveness ratio of all treatment approaches for elderly patients. Sleep-related breathing disorders are highly prevalent after age 65 years,1Sforza E Gauthier M Crawford-Achour E et al.A 3-year longitudinal study of sleep disordered breathing in the elderly.Eur Respir J. 2012; 40: 665-672Crossref PubMed Scopus (21) Google Scholar and their treatment is a major reason for the increase in health-care spending. Obstructive sleep apnoea (OSA) syndrome is a well established risk factor for cardiovascular diseases in adults, but the deleterious effect of OSA syndrome in elderly people remains controversial,2Lavie P Lavie L Unexpected survival advantage in elderly people with moderate sleep apnoea.J Sleep Res. 2009; 18: 397-403Crossref PubMed Scopus (128) Google Scholar and some authors have discussed the concept of so-called preconditioning with chronic intermittent hypoxia, meaning elderly apnoeic patients could have less chance of myocardial infarction.3Rosenzweig I Kempton MJ Crum WR et al.Hippocampal hypertrophy and sleep apnea: a role for the ischemic preconditioning?.PLoS One. 2013; 8: e83173Crossref PubMed Scopus (44) Google Scholar The unknown benefits routinely offered by the treatment of OSA syndrome in elderly patients should be taken into account by public authorities when planning resource allocation. However, the main symptom associated with sleep apnoea, diurnal sleepiness, seems to be costly and dangerous in this population4Gooneratne NS Richards KC Joffe M et al.Sleep disordered breathing with excessive daytime sleepiness is a risk factor for mortality in older adults.Sleep. 2011; 34: 435-442PubMed Google Scholar and seems to be a valid target for the efficacy of treatment of OSA syndrome in older people. In the PREDICT study published in The Lancet Respiratory Medicine, Alison McMillan and colleagues5McMillan A Bratton D Faria R et al.Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trial.Lancet Respir Med. 2014; (published online Aug 27.)http://dx.doi.org/10.1016/S2213-2600(14)70172-9Google Scholar show in a multicentre, randomised, two-parallel-group study of continuous positive airway pressure (CPAP) that this treatment significantly reduced daytime sleepiness in patients aged 65 years or older at 3-month and 1-year follow-up visits. The quality of work done by the authors should be emphasised. The magnitude of improvement is quite similar to that noted in younger adults, and this amplitude is well correlated with the average night duration use of CPAP.6Marshall NS Barnes M Travier N et al.Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnoea: a meta-analysis.Thorax. 2006; 61: 430-434Crossref PubMed Scopus (159) Google Scholar The short median duration of CPAP usage in the PREDICT study (1 h 52 min per night at 3 months and 2 h 22 min per night at 12 months) suggests a greater efficiency of CPAP for patients with longer nightly CPAP use. A minimum duration of 5 h of daily use for patients should be insisted upon if CPAP is to have a substantial effect on neurocognitive function.7Antic NA Catcheside P Buchan C et al.The effect of CPAP in normalizing daytime sleepiness, quality of life, and neurocognitive function in patients with moderate to severe OSA.Sleep. 2011; 34: 111-119Crossref PubMed Google Scholar The authors did not attempt to explain the important question of the beneficial role of CPAP on cardiovascular morbidity and mortality in patients aged 65 years or older. This treatment approach leads to a marginal reduction in health costs. During 1-year follow-up, CPAP does not seem to improve mood, cognitive function, or incidence of accidents. We should emphasise here that the study was not originally designed to address these issues, and thus, firm conclusions could not be derived from these secondary endpoint analyses. In our opinion, the decrease in plasma LDL cholesterol is difficult to explain by the nocturnal CPAP alone.8Roche F Sforza E Pichot V et al.Obstructive sleep apnoea/hypopnea influences high-density lipoprotein cholesterol in the elderly.Sleep Med. 2009; 10: 882-886Summary Full Text Full Text PDF PubMed Scopus (55) Google Scholar Somewhat surprisingly, the lower blood pressure noted in the group who received best supporting care can only encourage us to heavily emphasise advice on lifestyle (reducing physical inactivity, reducing salt intake, and improving medication adherence) when patients are seen in our sleep medicine clinics.9Mendelson M Tamisier R Laplaud D et al.Low physical activity is a determinant for elevated blood pressure in high cardiovascular risk obstructive sleep apnea.Respir Care. 2014; 59: 1218-1227Crossref Scopus (16) Google Scholar The reported decrease of 3–4 mm Hg in blood pressure could be very profitable in terms of health costs at the 10-year follow-up point. Several criticisms can be made of this study. First is the use of the Epworth sleepiness scale to characterise the extent of daytime sleepiness; this questionnaire is sometimes not suitable for elderly patients because most are not able to answer all of the Epworth scale score items, thus this scale might underestimate sleepiness severity in older patients.10Onen F Moreau T Gooneratne NS Petit C Falissard B Onen SH Limits of the Epworth Sleepiness Scale in older adults.Sleep Breath. 2013; 17: 343-350Crossref PubMed Scopus (56) Google Scholar However, significant and consistent improvements in the Oxford Sleep Resistance test reported in the CPAP group confirm an objective improvement in daytime sleepiness from use of CPAP. Additionally, a detailed comparative analysis of the macroarchitecture and microarchitecture of sleep in the two groups of patients is absent. In fact, sleep apnoea syndrome in elderly people is often entangled with other sleep diseases, and it would have been interesting to compare the improvement of the effectiveness and continuity of sleep in both groups. Finally, daytime sleepiness is usually present less often (and if present, is less severe) in elderly patients with OSA syndrome, and elderly patients can cope better with sleepiness symptoms because they are often not in full-time work. Older apnoeic patients screened and recruited in this study were far from representative of the whole panel of older apnoeic patients seen in routine clinical practice. Many elderly apnoeic patients have no daytime sleepiness and consult for other symptoms—eg, nocturia, severe snoring, waking with feelings of choking, or minor memory complaints—or OSA is discovered by chance after onset of stroke or heart attack. It is difficult to determine the benefit of CPAP in the non-sleepy elderly apnoeic patients complaining about non-specific symptoms associated with unrefreshing sleep. In the study, the number of women is low, and thus the underrepresentation of women reduces the generalisation of the results obtained in men. We know that daytime sleepiness, according to an equivalent severity of apnoea or hypopnea, is often less severe in women than in men.1Sforza E Gauthier M Crawford-Achour E et al.A 3-year longitudinal study of sleep disordered breathing in the elderly.Eur Respir J. 2012; 40: 665-672Crossref PubMed Scopus (21) Google Scholar This difference in clinical presentation is important to consider in the detection and treatment of all apnoeic patients. The quality of the work in this study is remarkable and encourages continued high-quality controlled clinical trials in the specialty of sleep-related breathing disorders in elderly people; a disorder that can affect a third of patients aged 68 years or older and that might significantly accelerate cognitive decline in undiagnosed and untreated patients. We declare no competing interests. Continuous positive airway pressure in older people with obstructive sleep apnoea syndrome (PREDICT): a 12-month, multicentre, randomised trialIn older people with OSA syndrome, CPAP reduces sleepiness and is marginally more cost effective over 12 months than is BSC alone. On the basis of these results, we recommend that CPAP treatment should be offered routinely to older patients with OSA syndrome. Full-Text PDF Open Access