July 2, 2018/Geriatrics

Age Doesn’t Matter in CPAP Efficacy for Sleep Apnea

Retrospective study fills evidence gap on therapy’s merits in older adults

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Adults older than age 60 receive benefits from continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA) that are similar to those in younger adults. So concludes a retrospective study conducted at Cleveland Clinic and published in the Journal of Clinical Sleep Medicine earlier this year.

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“We found comparable improvements in subjective outcome measures such as sleepiness, fatigue, depressive symptoms and quality of life in older versus younger adults with OSA,” says Nancy Foldvary-Schaefer, DO, MS, Director of Cleveland Clinic’s Sleep Disorders Center. “This is important because there are few reports of OSA and CPAP therapy in older adults, so our research fills a gap in the literature.”

She adds that because OSA will present an increasing medical and financial burden as the U.S. population ages, the demonstration of clear benefits of CPAP in older adults will be needed to justify its cost.

Mining patient-reported outcomes in CPAP-treated patients

Dr. Foldvary-Schaefer and her team used the Knowledge Program, an electronic data-collection platform developed by Cleveland Clinic’s Neurological Institute, and the Sleep Disorders Center’s Nihon Kohden polysomnography database to identify subjects for the study. “The Sleep Disorders Center performs 15,000 sleep tests a year in patients’ homes or our sleep laboratories,” says Dr. Foldvary-Schaefer, “and our sleep study database has over 200,000 observations, so we have a huge data repository to draw from for research.”

In the current study, she and colleagues analyzed data from 532 patients at the initiation of CPAP therapy and at three, six and 12 months of use. They compared outcomes between the 393 patients who were 18 to 60 years old (mean, 47.1 ± 9.5) and the 139 patients who were older than 60 (mean, 68.6 ± 6.3).

Using validated, patient-reported outcome scales, they found that after one year of CPAP therapy, older adults with OSA had similar and significant score improvements on each of the following compared with the study’s younger adults:

  • Epworth Sleepiness Scale
  • Fatigue Severity Scale
  • Patient Health Questionnaire-9
  • Functional Outcomes of Sleep Questionnaire

Overcoming OSA undertreatment in older adults

Approximately one in four American adults has OSA, Dr. Foldvary-Schaefer notes, and the prevalence is two- to threefold higher in the elderly compared with their middle-aged counterparts. Most OSA cases in this population are undiagnosed.

“We believe older adults are particularly likely to have unrecognized OSA,” she says. “Physicians and patients may mistakenly attribute OSA symptoms to the aging process, comorbid conditions or medication side effects.”

The merits of treating OSA in older adults has been questioned by some, Dr. Foldvary-Schaefer observes.

“We know that untreated moderate-to-severe OSA is associated with adverse outcomes, such as diabetes, obesity and cardiovascular disease, over the long term,” she explains. “Therefore, assuming average life expectancy, older patients are less likely than their younger counterparts to realize some of these health benefits. However, the impact of CPAP on daytime symptoms, mood and quality of life can be measured within weeks of starting therapy. We believe that if we can make these older OSA patients less sleepy, fatigued and depressed, they’ll be more productive and happier and use fewer healthcare resources.”

In a previous study, Dr. Foldvary-Schaefer and colleagues found that treating OSA with CPAP led to better seizure control in patients with epilepsy.

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Knowledge Program applications to expand

Through the Knowledge Program, Cleveland Clinic’s Neurological Institute screens all patients for sleep disorders, including OSA.

Dr. Foldvary says this effort is unique to Cleveland Clinic, which has implemented the Knowledge Program while other centers remain in the planning stages for similar technological initiatives. As a result, the team can now refine screening tools to focus on questions specific to OSA in older patients to improve diagnosis and management.

She says her team plans to embed an OSA care pathway into the electronic medical record system by the end of 2018, to prompt physicians to perform follow-up at designated times for patients who screen positive for OSA. Once the care pathway is available in the Sleep Disorders Center, it will be rolled out across the Cleveland Clinic health system.

“This will allow us to manage a large population of patients and make sure they’re receiving continuing treatment and adhering to therapy,” she explains.

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