Obstructive sleep apnea (OSA) is the most common type of breathing-related sleep disorder (BRSD) in the elderly population. Rate of depression is higher in patients with OSA than in the general population.1,2 However, treatment for OSA depression is often overlooked by psychiatric care providers due to lack of screening. Screening for OSA should be performed routinely in the elderly as it becomes more common with increased age.
A 67-year-old man with a medical history of hypertension, diabetes, and atrial fibrillation (AFib) presented to an outpatient psychiatry clinic accompanied by his wife. His chief complaint included feeling depressed every day for 2 months. Other complaints included fatigue, excessive daytime sleepiness (EDS), difficulty staying asleep, lapses in memory, and poor concentration. His wife told the psychiatrist that her husband had gained more than 30 pounds over the last year. His Patient Health Questionnaire-9 (PHQ-9) score was 26 (>10 is indicative of depression). His physical examination was remarkable for obesity with a body mass index (BMI) of 37 kg/m2 and a neck circumference of 23 inches. The psychiatrist diagnosed him with major depressive disorder and prescribed sertraline.
At the 3-month follow-up visit, he reported an improvement in his depression, and his PHQ-9 score decreased to 18. However, he continued to experience EDS and difficulty concentrating when working on his projects. Further questioning revealed a history of loud snoring that “wakes up his wife,” and led to her sleeping in the next room. His Epworth Sleepiness Scale score was 17 (normal is <10), and an in-laboratory polysomnogram (PSG)3 confirmed the diagnosis of severe OSA with apnea-hypopnea index (AHI) (Table 1) of 50 per hour. He was treated with continuous positive airway pressure (CPAP). Nightly use of CPAP led to a significant improvement in the quality of sleep as well as mood. His second follow-up visit showed a significant increase in energy level, improved sleep, and concentration.
Terminology Used in Sleep-Related Breathing Disorders
What Is Obstructive Sleep Apnea?
OSA is a condition in which patients have frequent episodes of apnea (they stop breathing for 10 seconds or more) or hypopnea (they have shallow breathing—reduced airflow by 30% or more) for 10 seconds, accompanied by oxygen desaturation of 4% or more.4,5 Apneas and hypopneas are caused by the obstruction or partial obstruction of the upper (oropharyngeal) airway during sleep—when there is a reduction of the motor tone of the pharyngeal muscles.5 Although patients' respiratory drive is intact, they are not able to take in adequate air because of airway collapse.
A definitive diagnosis of OSA is made by a PSG. Diagnostic criteria require polysomnographic evidence of ≥5 obstructive apneas or hypopneas per hour of sleep accompanied by EDS, fatigue, and/or unrefreshing sleep.5 Alternatively, the diagnosis can be made if there are ≥15 episodes of apneas or hypopneas, regardless of the presence of symptoms (Table 1).5
Contrary to OSA, in central sleep apnea (CSA) there is a decrease in the central nervous system mediated respiratory effort. Diagnostic criteria commonly used for CSA are a central apnea index (CAI) of ≥5 events per hour with ≥50% of overall AHI accounted for by purely central events (ie, in the absence of airway obstruction).3
Signs, Symptoms, and Screening
There are several signs and symptoms of OSA.3 Several questionnaires are useful in screening for OSA (Table 2). Cardinal features of OSA are snoring, nocturnal choking, gasping, and EDS.6 A report of witnessed apneas by a bed partner or a caregiver is an important clue and increases the probability of a sleep apnea disorder.
Scales for Obstructive Sleep Apnea Screening and Daytime Sleepiness
Other risk factors for OSA include obesity, poor dentition, cognitive dysfunction, and an increase in neck size (men with a neck size of 17 inches or 43 cm or women with a neck size of 16 inches or 41 cm). Smoking is an intervenable risk factor for sleep-disordered breathing (SDB).7
Pathophysiology of Obstructive and Central Sleep Apnea in the Elderly
During the wakeful hours, the muscles of the upper airway maintain patency of the airway. Breathing is under voluntary control during wakefulness. However, when a person falls asleep, there is decreased neuronal input to these muscles, which predisposes the airway to collapse.8 Additionally, people with OSA have anatomical abnormalities that lead to a crowded oropharynx and predispose them to have an intermittent collapse of the airway during sleep. These anatomical abnormalities may be both intrinsic (enlarged tonsils, micrognathia, large tongue) and extrinsic (fat around the neck muscles).8
In the elderly, other risk factors, such as a decrease in muscle tone that promotes airway collapse, become more significant. BMI is a less significant risk factor in older adults.9
This is an oversimplification of the pathophysiology of OSA, and there are many other factors involved. The authors encourage the readers to read the review by White and Younes.8
For CSA, there is a decreased respiratory drive, which could be secondary to medical disorders or medications.10
Prevalence of Sleep-Disordered Breathing in Older Adults
Twenty percent of older adults meet the criteria for sleep apnea syndromes.1 Some studies report the prevalence as high as 45% to 62% for those older than age 60 years.2 Men of all ages are at a higher risk of developing OSA (27% in men versus 9% in women).11,12
A study of healthy older adults showed a stepwise increase in the prevalence of OSA with each decade, such that 3% of 60-year-old adults, 33.3% of 70-year-old adults, and 39.5% of 80-year-old adults had an AHI of 5 or more.13
Prevalence of CSA is also higher among men age 65 years and older.14 According to one study, 1.1% of men older than age 65 years had CSA as compared to 0.4% of younger adults.14 As with OSA, the prevalence of CSA is underestimated. Another study found 24% of adults age 65 years and older had a CAI ≥5.15
Comorbid Sleep Apnea and Psychiatric Diagnoses
There is a high prevalence of OSA in people with mental illness.16 OSA often presents with signs and symptoms of depression.7 Various studies have reported the prevalence of OSA in patients with depression to be between 17% and 41%.17 The prevalence of OSA in mental illnesses such as bipolar disorder and schizophrenia has been found to be as high as 24.5% and 15.4%, respectively.18
Also, there is increasing evidence of sleep apnea and insomnia comorbidity. Insomnia is often present in elderly patients and is often a residual symptom of depression.19
Psychiatrists are trained to review medical disorders (like hypothyroidism) as possible causes of depression. Similarly, OSA and other sleep disorders should be considered as medical disorders potentially causing depression, and mental health providers should routinely screen for them. Clinicians should inquire about sleep history, including symptoms of snoring and witnessed apneas during the initial visit, and about neck circumference (collar size), which is one of the criteria on the commonly used STOP-BANG20 screening for OSA.
In the illustrative case, the patient presented with depression without psychotic features. Sleep history was not obtained until the second visit, which delayed treatment of OSA. In this case, patient obesity, oral cavity examination, and neck circumference would have pointed toward the increased risk of OSA.
Sleep Apnea and Other Disease Associations
There is a strong association between OSA and type 2 diabetes mellitus, which further increases the risk for cardiovascular events.21 Obesity is a risk factor for OSA; however, the rates of obesity decrease with age. OSA increases the risk for cardiovascular events such as stroke, myocardial infarction, congestive heart failure, and hypertension.22 However, these associations are not as clearly seen in elderly patients as in younger patients.23
There is a strong correlation between sleep apnea and congestive heart failure because recurrent episodes of apnea/hypopnea have a negative effect on heart function. Furthermore, as more as a 4-fold increase in AFib prevalence has been reported in OSA patients with AHI ≥30, as well as a high recurrence of AFib in untreated OSA patients.24
A recent, large meta-analysis of 14 studies (4,288,418 patients) showed that patients with SDB were 26% more likely to develop cognitive impairment (relative risk, 1.26; 95% confidence interval, 1.05–1.50).25 Particularly, patients with SDB had more impairment in executive functioning. SDB was not associated with memory or global cognition.
Risk factors for CSA in older adults include heart failure, AFib, and stroke. An additional risk factor for CSA is chronic opiate use. A systematic review found that the mean prevalence of CSA in chronic prescription opioid users of all ages was 24%.26 High-morphine equivalent daily doses of opioids were associated with more severe CSA. The national opioid epidemic has had a significant effect on adults older than age 65 years; this patient population accounts for most opiate-related hospital visits in many states.27 Although illegal opiate use and prescription misuse are of growing concern among older adults, it should be noted that most opioid use leading to adverse effects is per prescription.27 Adults older than age 65 years are frequently prescribed opioid medications.27
OSA is suspected based on clinical history and physical examination. If clinical suspicion is high, then the patient can be referred for home sleep apnea testing (HSAT). However, HSAT is not appropriate for elderly patients with specific medical comorbidities including congestive heart failure, chronic obstructive pulmonary disease, and cognitive disorders or if they have trouble following instructions.
An in-laboratory PSG is recommended for elderly patients with medical comorbidities or with cognitive problems. For some patients, split-night PSG is used (ie, during the first part of the night, PSG confirms the diagnosis of OSA, CPAP titration is performed in the second part of the night). The CPAP titration portion of the study allows the sleep provider to evaluate the therapeutic effects of the CPAP therapy.
Treatment Options in the Elderly
Conservative measures include weight loss, smoking cessation, and alcohol cessation. Mental health providers can educate their patients about the benefits of weight loss and smoking cessation.
Standard treatment includes nasal CPAP. The CPAP apparatus is composed of a motorized unit that moves air through oronasal passages, acting as a pneumatic splint. The goal of treatment is normalization of blood oxygenation (SpO2) and increased sleep continuity. The rates of CPAP adherence are low in the elderly, which can make it more challenging to treat SDB in this population. Another treatment option is a mandibular advancement device (dental appliance). The device is placed in the mouth and pulls the lower jaw forward, which opens the space behind the tongue by pulling the mandible forward. However, this treatment can only be used if a patient has healthy teeth, which precludes many elderly patients. If these treatments do not work, often elderly patients are instructed to sleep with the head of the bed elevated or to sleep on their side, as OSA is less severe in lateral sleeping position.
CSA is harder to treat than OSA, with CPAP often being ineffective. First-line treatment options include a reduction in opiate pain medication.
Breathing-related sleep disorder, particularly OSA, are common in the elderly population. OSA is commonly associated with cardiovascular, endocrine, and mental health disorders, with an increase in morbidity if left untreated. Mental health providers should have a low threshold for an initial sleep apnea symptom screening and referral for treatment to minimize the risk of complications. PSG is considered the gold standard for the diagnosis of sleep apnea syndromes. CPAP and avoidance of opiate medication are considered first-line treatment for OSA and CSA.
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- American Academy of Sleep Medicine. International Classification of Sleep Disorders: Diagnostic and Coding Manual. 3rd ed. Westchester, IL: American Academy of Sleep Medicine; 2014.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Wolkove N, Elkholy O, Baltzan M, Palayew M. Sleep and aging: 2. Management of sleep disorders in older people. CMAJ. 2007;176(10):1449–1454. doi:. doi:10.1503/cmaj.070335 [CrossRef]
- Ejaz SM, Khawaja IS, Bhatia S, Hurwitz TD. Obstructive sleep apnea and depression: a review. Innov Clin Neurosci. 2011;8(8):17–25.
- White DP, Younes MK. Obstructive sleep apnea. Compr Physiol. 2012;2(4):2541–2594. doi:10.1002/cphy.c110064 [CrossRef].
- Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med. 1993;328(17):1230–1235. doi:. doi:10.1056/NEJM199304293281704 [CrossRef]
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- Zhao YY, Blackwell T, Ensrud KE, et al. Sleep apnea and obstructive airway disease in older men: outcomes of Sleep Disorders in Older Men study. Sleep. 2016;39(7):1343–1351. doi:. doi:10.5665/sleep.5960 [CrossRef]
- Hoch CC, Reynolds CF 3rd, Monk TH, et al. Comparison of sleep-disordered breathing among healthy elderly in the seventh, eighth, and ninth decades of life. Sleep. 1990;13(6):502–511. doi:10.1093/sleep/13.6.502 [CrossRef]
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Terminology Used in Sleep-Related Breathing Disorders
||Episode of airflow cessation lasting 10 seconds or more
||Episode of airflow reduction of 30% or more resulting in oxygen desaturation of 4% or more
||The average number of hypopnea and apnea episodes per hour of sleep
|Central Apnea Index
||The average number of central apnea episodes (apneas occurring without inspiratory effort) per hour of sleep
|Obstructive sleep apnea
||Frequent episodes of apnea and/or hypopnea in the presence of obstructive respiratory distress
Diagnostic criteria include: an AHI ≥5 accompanied by symptoms (snoring, daytime sleepiness, mood disorders, impaired cognition, comorbid medical illness such as hypertension, heart disease) or an AHI ≥15 (regardless of symptoms reported)
|Central sleep apnea
||AHI ≥5 with many events happening without an inspiratory effort; associated with daytime sleepiness or sleep disturbance
Scales for Obstructive Sleep Apnea Screening and Daytime Sleepiness
||Predictive of moderate to severe sleep disordered breathing with higher sensitivity
||Consists of 8 dichotomous questions; a sum of 3 or more is considered positive
||Determines the risk of obstructive sleep apnea as low or high risk
||Consists of 10 items in addition to body mass index and history of hypertension; considered positive in ≥2 categories
|Epworth Sleepiness Scale11
||Measures average daytime sleepiness compared to excessive daytime sleepiness
||Consists of self-rating in 8 items with scores from 0–3; a sum of 11 or more is considered positive