Sleep Apnoea in Older Adults: Signs and Next Steps

What happens in sleep apnoea

In obstructive sleep apnoea (OSA), the muscles of the throat relax during sleep and the airway narrows or closes. Breathing stops or becomes shallow for ten seconds or more, oxygen levels fall, the brain briefly wakes the person to reopen the airway, and the cycle repeats, sometimes dozens of times an hour. The person usually does not remember waking, but sleep is poor.

Central sleep apnoea is less common and occurs when the brain does not send the right signals to breathe; it is linked to heart failure, stroke and some medicines, and has different treatment. A doctor tells them apart.

Who is at risk

• Being overweight or having a thick neck, though thin people can be affected.
• Age: the risk rises with age, as throat muscles and tissues change.
• Male sex, and for women, after menopause.
• Large tonsils, a small jaw or a blocked nose.
• Alcohol, sleeping tablets and sedatives, which relax the throat muscles.
• Smoking.
• High blood pressure, heart failure, atrial fibrillation, stroke, type 2 diabetes and some other conditions.
• Family history.
• Sleeping on the back.

Signs families may notice

At night:

• Loud, habitual snoring.
• Pauses in breathing, gasping, choking or snorting.
• Restless sleep, frequent waking and moving.
• Waking to pass urine several times (nocturia).
• Sweating at night.
• Sleeping upright or in a chair.

By day:

• Unrefreshing sleep and morning headache.
• Dry mouth or sore throat on waking.
• Daytime sleepiness, napping often, dozing during conversations, television or meals.
• Poor concentration, memory lapses and irritability or low mood.
• Falls or near accidents from drowsiness.
• Difficulty controlling blood pressure despite treatment.

In older adults, tiredness and memory problems are easily put down to age or dementia, so sleep apnoea can hide behind them. See mild cognitive impairment: what it is and what families can do and insomnia in older adults: sleep hygiene and when to get help.

Why it matters

Untreated sleep apnoea is linked with:

• High blood pressure that is hard to treat.
• Irregular heart rhythm such as atrial fibrillation, heart failure and heart attack.
• Stroke.
• Type 2 diabetes and weight gain.
• Poor concentration and mood, and possibly worse thinking and memory.
• Accidents and falls, including drowsy driving.
• Complications around surgery and sedation.

The associations are well documented, though not every person with apnoea develops these problems. Treatment often improves sleep, alertness and blood pressure.

How it is diagnosed

A doctor takes a history, often with input from a bed partner or family member, examines the throat, neck and weight, and may use a questionnaire to estimate risk. The key test is a sleep study:

• Home sleep apnoea test: a portable device worn overnight that records breathing, oxygen and heart rate. Suitable for many people with a high likelihood of OSA and no major heart or lung disease.
• In-lab polysomnography: an overnight stay in a sleep laboratory with more detailed monitoring, used for complex cases, including heart failure, lung disease or suspected central apnoea.

The result is expressed as the number of breathing events per hour (the apnoea-hypopnoea index), which indicates severity as mild, moderate or severe. Sleep facilities vary across India, so ask the doctor where tests are available.

Pulse oximeter: what it can and cannot tell you

An overnight fingertip oximeter may show repeated dips in oxygen, which supports suspicion of sleep apnoea, but it cannot diagnose it. A normal overnight trace does not rule it out, and a dip can come from poor finger contact. Do not interpret an oximeter graph yourself. Show it to the doctor if the device records data. See pulse oximeters: how they work and how to use one and pulse oximeter accuracy. If your parent is on oxygen at night, the prescribed flow stays unchanged; see oxygen flow rates and prescriptions: what families should know.

Treatments

The doctor chooses based on severity, symptoms, other conditions and what the person will accept.

CPAP (continuous positive airway pressure). A small machine blows air at a steady pressure through a mask, keeping the airway open. It is the standard treatment for moderate and severe OSA and works well when used regularly. Pressure is set after the sleep study, and some machines adjust automatically. Practical points:

• Mask fit is vital. Nasal, nasal pillow and full-face masks exist; a technician should fit it and adjust as needed.
• Getting used to it takes days to weeks. Start with short periods during the day, then gradually increase. Many people give up in the first weeks without support.
• Common problems: dry mouth or nose (a humidifier helps), air leaks, skin irritation, nasal congestion, claustrophobia and noise.
• Do not change the pressure settings yourself. Ask the sleep clinic.
• Cleaning: wash the mask, tubing and humidifier chamber regularly, as the maker says, with mild soap, and dry them. Replace filters and masks as advised.
• Power cuts: CPAP needs electricity. A battery or inverter may be needed; ask the supplier. See power cuts and older adults.
• Oxygen with CPAP: only as the doctor prescribes; follow fire safety rules. See using an oxygen concentrator safely at home.

Oral appliances. Mouth devices that move the lower jaw forward may help in mild to moderate cases; a dentist trained in sleep medicine fits them.

Weight loss. For people who are overweight, even modest loss can reduce severity. Plan with a dietician and doctor; in older adults, avoid unplanned or rapid loss; see weighing scales and unplanned weight loss in older adults.

Positional therapy. Avoiding sleeping on the back may help in some; ask about aids.

Surgery or nerve stimulation in selected cases, specialist decision.

Treating nasal blockage and allergy.

What families can do at home

• Encourage a medical review rather than accepting loud snoring or tiredness as normal.
• Avoid alcohol in the evening and, unless the doctor has prescribed them, avoid sleeping tablets and sedatives. Tell the doctor about all medicines; see polypharmacy and deprescribing. Do not stop any medicine yourself.
• Help your parent sleep on the side, with a pillow behind the back, and raise the head of the bed slightly if advised.
• Keep a regular sleep schedule and a calm bedroom.
• Manage allergies and a blocked nose, and keep the bedroom dust-free; see indoor air quality for older lungs.
• Stop smoking and keep the home smoke-free.
• Record what you see: note snoring, pauses, daytime sleepiness and blood pressure; bring it to the doctor. See how to measure blood pressure at home accurately.
• Be careful about driving: a drowsy person should not drive, and the doctor will advise.
• Support CPAP use: encourage, help with cleaning, and report problems to the clinic.

When it may not be sleep apnoea

Other causes of poor sleep and breathlessness at night include heart failure, COPD, reflux, restless legs, pain, nocturia from prostate or diabetes, depression and anxiety, medicines and dementia-related sleep disturbance. A doctor should sort these out. Waking at night breathless, needing to sit up, or ankle swelling points to heart failure and needs prompt review; see heart failure at home: daily checks and warning signs.

Warning signs

Call the doctor soon if:

• Snoring with witnessed pauses, gasping or choking.
• Marked daytime sleepiness, or sleepiness while eating or talking.
• Morning headaches, new confusion or memory lapses.
• Blood pressure hard to control, new irregular pulse or leg swelling.
• Falls or near-misses from tiredness.

Call 112 if:

• Your parent cannot be woken, or is blue, gasping or stops breathing for long periods.
• There is chest pain, severe breathlessness or collapse.
• Sudden weakness, face drooping or speech difficulty occurs.

When to ask a professional

Ask the family doctor about a referral to a sleep specialist, a chest physician or an ENT surgeon. Ask about a sleep study and which type suits your parent. Ask a sleep technician to fit the CPAP mask and teach cleaning. Ask a pharmacist to review medicines that affect sleep and breathing. Report CPAP problems early; they are often fixable. Call 112 for emergencies.