Continuous positive airway pressure and survival of very elderly persons with moderate to severe obstructive sleep apnea

doi:10.1016/j.sleep.2015.10.015

Sleep Medicine

Volume 19, March 2016, Pages 23-29

https://doi.org/10.1016/j.sleep.2015.10.015 Get rights and content

Highlights

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No studies have considered, as the study population, very elderly persons diagnosed with obstructive sleep apnea (OSA).
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Acceptable rates of adherence to continuous positive airway pressure (CPAP) are achievable in very elderly persons with OSA.
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CPAP might be associated with higher survival rates in very elderly persons with moderate to severe OSA.

Abstract

Objective

There is evidence of a beneficial effect of long-term continuous positive airway pressure (CPAP) on survival in elderly persons with obstructive sleep apnea (OSA), although the usual age cut off is between 60 and 70 years of age. Our objective was to determine this effect in very elderly patients (ie, those ≥80 years of age).

Methods

An observational study of a historic cohort of very elderly persons with moderate to severe OSA (apnea–hypopnea index ≥20) and the effect of long-term CPAP on their survival was performed. Two groups were formed: one prescribed CPAP treatment (≥4 hours per night), and one without CPAP treatment. Survival analyses, including Kaplan–Meier curves and Cox models, were carried out to determine the association of long-term CPAP with longer survival,

Results

A total of 155 very elderly persons (84 men and 71 women, mean age 81.5 ± 1.5 years) were followed up for 53 months (interquartile range, 41–77 months); 83 deaths occurred. CPAP was prescribed to 132 patients, and adherence was observed in 79 (60%). Kaplan–Meier curves showed longer survival in the treated OSA group (91 months, 95% confidence interval [CI] = 76–106) than in the untreated OSA group (52 months, 95% CI 41–64), which was statistically significant (log-rank 16.9, p < 0.0001). Although history of stroke was significantly associated with higher mortality (hazard ratio [HR] = 2.18, 95% CI = 1.14–4.17, p = 0.02), CPAP treatment was associated with higher survival rates (HR = 0.46, 95% CI = 0.27–0.78, p = 0.004) in an adjusted Cox analysis.

Conclusions

CPAP treatment might be associated with a longer survival in very elderly persons with moderate to severe OSA.

Introduction

Life expectancy has improved because of medical advances, resulting in the need for a thorough knowledge of disease in the elderly population. An increasing incidence of obstructive sleep apnea (OSA) with age has been described [1], [2], although current guidelines do not address special considerations in relation to its diagnosis or treatment in elderly persons [3]. Continuous positive airway pressure (CPAP) is by far the recommended treatment for symptomatic or severe OSA; however, the existing evidence of the beneficial effect of CPAP has been obtained from middle-aged populations. Consequently, whether a CPAP device should be prescribed to very elderly persons often raises a reasonable doubt, as its role has not been adequately determined, and as lack of symptoms or an already impaired quality of life due to other comorbidities may bias the decision of a physician treating these patients.

Previous studies have concluded that long-term CPAP can reduce cardiovascular events and mortality rates in elderly persons [4], [5], [6], along with recent improvements in quality of life and neurocognitive features [7]; yet, consistent evidence of its benefit in very elderly persons is still to be determined, as the CPAP effect may differ from that in younger groups [8]. The main objective of this study was to analyze the effect of long-term CPAP on mortality of any cause in very elderly persons diagnosed with moderate to severe OSA, hypothesizing that longer survival might be a consequence of their adherence to treatment.

Section snippets

Methods

An observational study of a historic cohort of very elderly persons (≥80 years of age at OSA diagnosis) was performed. Between January 1996 and December 2010, patients attending the Sleep Unit (SU) of the 12 de Octubre University Hospital (Madrid, Spain) for suspected OSA were considered for inclusion. Exclusion criteria were an apnea–hypopnea index (AHI) of <20, previous treatment with CPAP or bi-level positive pressure, and diagnosis of central sleep apnea, obesity hypoventilation syndrome,

Results

During the 15-year study period, a total of 10,081 sleep studies were performed, and among these, 331 patients (3.3%) were very elderly persons. Of these 331 cases, 129 were excluded because of chronic respiratory failure (39%), 43 for an AHI <20 (13%), and four for central sleep apnea (1.2%). Hence, 155 patients were included in the study. The flow chart for the patients is presented in Fig. 1. Seven patients were lost to follow-up. There was an increasing number of sleep studies (Fig. 2), as

Discussion

The main finding in our study was that long-term CPAP treatment is associated with a higher rate of survival in very elderly persons with moderate to severe OSA. Although previous stroke persisted as a factor associated with mortality, adherence to treatment had a beneficial effect on survival. The evidence of untreated OSA as a risk factor of mortality is consistent, leading to the conclusion that severe OSA treated with CPAP results in lower cumulative mortality specifically related to

Conflict of interest

No authors have conflicts of interest to disclose.

The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: http://dx.doi.org/10.1016/j.sleep.2015.10.015.

. ICMJE Form for Disclosure of Potential Conflicts of Interest form.

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Cited by (28)

Obstructive Sleep Apnea: Treatment with Positive Airway Pressure
2021, Clinics in Geriatric Medicine
Citation Excerpt :
In a study restricted to patients 65 or older, increased mortality was seen for those untreated with severe OSA (hazard ratio [HR] 2.25, confidence interval [CI] 1.41–3.61), as well as those with mild to moderate OSA (HR 1.38, CI 0.73–2.64).62 Even in very elderly individuals (80 or older), CPAP treatment for those with AHI 20 or higher reduced mortality.63 CPAP remains the most successful treatment for sleep-disordered breathing despite challenges with patient comfort and compliance.
Efficacy of CPAP for Improvements in Sleepiness, Cognition, Mood, and Quality of Life in Elderly Patients With OSA: Systematic Review and Meta-analysis of Randomized Controlled Trials
2020, Chest
Citation Excerpt :
From a total of 2963 references that were identified from different sources, 1390 studies were identified for screening, and the full texts of 28 were assessed for eligibility. Ultimately, a total of 24 studies were excluded based on the preestablished criteria,18-28 and 4 RCTs were included in the qualitative and quantitative analyses (meta-analysis).29-32 Concordance between reviewers showed substantial agreement (kappa = 0.76).
OSA is found commonly in the elderly population (≥65 years old), and CPAP improves sleepiness and health-related quality of life (HRQoL) in the middle-aged population; however, data about its efficacy in elderly patients are unclear. The purpose of this study was to evaluate the efficacy of CPAP for sleepiness, HRQoL, mood, and cognition in elderly patients with OSA.
In elderly patients (≥65 years old) with OSA, is CPAP, compared with usual care or sham CPAP, effective at improving sleepiness, HRQoL, mood, and neurocognitive function?
We conducted a systematic review and meta-analysis of randomized controlled trials that included trials performed in elderly patients with OSA. As an intervention, we compared CPAP vs a control group. Two independent reviewers explored several databases; risk of bias (RoB) was evaluated with the Cochrane tool. Changes in sleepiness (Epworth Sleepiness Scale), HRQoL (Quebec Sleep Questionnaire), mood (Hospital Anxiety-Depression Scale), and neurocognitive tests after treatment were the outcomes. The meta-analysis was conducted according to the DerSimonian-Laird method, and the quality of evidence was rated according to the GRADE guidelines.
A total of 4 randomized controlled trials (680 participants) were included. RoB was high for performance and detection bias. CPAP was associated with a 2.62-point improvement in the Epworth Sleepiness Scale (1.93 to 3.30; I² = 52%). All domains of the Quebec Sleep Questionnaire were improved: hypersomnolence, 0.67 points (0.31 to 1.03; I² = 75%); diurnal symptoms, −0.71 points (−0.98 to −0.44; I² = 58%); nocturnal symptoms, 1.09 points (0.9 to 1.27; I² = 9%); emotions, 0.45 points (0.30 to 0.61; I² = 11%); and social interaction, 0.55 points (0.1 to 0.99; I² = 82%). CPAP also improved the Hospital Anxiety-Depression Scale depression domain, and there were reports of a slight improvement in neurocognitive tests. The quality of evidence was low and very low for all outcomes.
Although CPAP therapy reportedly results in important clinical differences in sleepiness, HRQoL, and mood and a slight improvement in neurocognitive tests, concerns regarding the RoB and quality of the evidence do not support the benefit in all patients.
PROSPERO ID CRD42019146947
Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome
2018, Sleep Medicine
Citation Excerpt :
Obstructive sleep apnea (OSAS) is a disorder characterized by daytime sleepiness and repeated breathing cessations during sleep, which can result in cycles of hypoxia, negative intrathoracic pressure, and arousals with potentially serious cardiovascular consequences [1–5]. Continuous positive airway pressure therapy (CPAP) is a highly effective treatment for OSAS and should be considered both first-line and gold-standard treatment for patients with all stages of OSAS [6–8]. CPAP improves quality of life and excessive daytime sleepiness and decreases sympathetic neural activity and blood pressure.
Continuous positive airway pressure (CPAP) therapy is a highly effective treatment for obstructive sleep apnea syndrome (OSAS). However, poor adherence is a limiting factor, and a significant proportion of patients are unable to tolerate CPAP. The aim of this study was to determine predictors of long-term non-compliance with CPAP.
CPAP treatment was prescribed to all consecutive patients with moderate or severe OSAS (AHI ≥15 events/h) (n = 295) who underwent a full-night CPAP titration study at home between February 1, 2002 and December 1, 2016. Adherence was defined as CPAP use for at least 4 h per night and five days per week. Subjects had periodical follow-up visits including clinical and biochemical evaluation and assessment of adherence to CPAP.
Median follow-up observation was 74.8 (24.2/110.9) months. The percentage of OSAS patients adhering to CPAP was 41.4% (42.3% in males and 37.0% in females), and prevalence was significantly higher in severe OSAS than in moderate (51.8% vs. 22.1%; p < 0.001; respectively). At multivariate analysis, lower severity of OSAS (HR = 0.66; CI 95 0.46–0.94) p < 0.023), cigarette smoking (HR = 1.72; CI 95 1.13–2.61); p = 0.011), and previous cardiovascular events (HR = 1.95; CI 95 1.03–3.70; p = 0.04) were the only independent predictors of long-term non-adherence to CPAP after controlling for age, gender, and metabolic syndrome.
In our cohort of patients with moderate/severe OSAS who were prescribed CPAP therapy, long-term compliance to treatment was present in less than half of the patients. Adherence was positively associated with OSAS severity and negatively associated with cigarette smoking and previous cardiovascular events at baseline.
Apnea in Older Adults
2018, Sleep Medicine Clinics
Citation Excerpt :
Moreover, adherence to PAP was independently associated with a lower risk of CV mortality. A reduction of CV mortality risk or longer survival with CPAP was also observed in patients aged 75 years or older.53,93 CPAP may improve sleepiness but only partly reverse cognitive impairment.
An Evaluation of Obstructive Sleep Apnea Patient’s Quality of life Following Continuous Positive Airway Pressure and Uvulopalatopharyngoplasty
2024, Indian Journal of Otolaryngology and Head and Neck Surgery
Positive airway pressure therapy adherence and outcomes in obstructive sleep apnea: An exploratory longitudinal retrospective randomized chart review
2024, Canadian Journal of Respiratory Therapy

View all citing articles on Scopus

: Part of this study was presented at the European Respiratory Society Congress in Amsterdam, Netherlands, on September 27, 2011.

View full text

Original ArticleContinuous positive airway pressure and survival of very elderly persons with moderate to severe obstructive sleep apnea

Highlights

Abstract

Objective

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest

Arch Bronconeumol

Arch Bronconeumol

Chest

Atherosclerosis

Int J Cardiol

Int J Cardiol

Sleep Med Rev

Med Hypotheses

Chest

Int J Cardiol

Roles of gender, age, race/ethnicity, and residential socioeconomics in obstructive sleep apnea syndromes

Curr Opin Pulm Med

Age- and gender-related characteristics of obstructive sleep apnea

Sleep Breath

Severe sleep apnea and risk of ischemic stroke in the elderly

Stroke

Cardiovascular mortality in obstructive sleep apnea in the elderly: role of long-term continuous positive airway pressure treatment: a prospective observational study

Am J Respir Crit Care Med

Continuous positive airway pressure treatment reduces mortality in elderly patients with moderate to severe obstructive severe sleep apnea: a cohort study

PLoS ONE

Original Article
Continuous positive airway pressure and survival of very elderly persons with moderate to severe obstructive sleep apnea