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CPAP may not be effective in very old patients with OSA

Sleep Medicine
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Reuters Health - 24/12/2021 - Continuous positive air pressure (CPAP) may not be effective in very old patients with moderate to severe obstructive sleep apnea (OSA), according to an exploratory analysis of data from clinical trials.

"The present study findings suggest that CPAP treatment is not effective in patients over 80 years of age with OSA," Dr. Miguel Angel Martinez-Garcia of Hospital Universitario y Politecnico La Fe in Valencia, Spain, and colleagues write in Sleep Medicine.

Dr. Martinez-Garcia and his colleagues conducted a post-hoc pooled analysis of two open-label, multicenter trials aimed to determine the effect of CPAP in 369 patients 70 years of age or above with an apnea-hypopnea index (AHI) of at least 15 events per hour. The patients were randomly assigned to receive CPAP or no CPAP for three months.

The researchers analyzed data from the 97 participants who were 80 years of age or older. The mean age in this group was 81.5 years; 47 received CPAP and 50 did not.

Participants who used CPAP did so for an average of 4.3 hours per night, and 53% of patients used the device at least four hours per night, which the researchers considered to be good adherence.

Patients in the CPAP group significantly improved snoring (-58%) and witnessed apneas (-35%), as well as AHI (from 41.9 to 4.9 events per hour). However, there was no clinical improvement in Epworth Sleepiness scale (ESS, -1.2 points), any domain of the Quebec Sleep Questionnaire, any neurocognitive test, depression or anxiety, OSA-related symptoms, or blood pressure.

"The frequency of very elderly patients with OSA suspicion has been increasing in the last years. We tend to treat them as we treat younger people, and this probably is not correct," Dr. Martinez-Garcia told Reuters Health by email. "When a very elderly patient goes to the sleep lab with suspicion of OSA, the treatment should be individualized and cautious."

Dr. Martinez-Garcia and his team would like to learn the clinical phenotype of very elderly patients who will benefit from CPAP. "To answer this important question, we are planning to conduct a large randomized controlled trial with more than 700 individuals over 80 years of age with OSA in over 40 centers."

Dr. Beth A. Malow, director of the Sleep Disorders Division at Vanderbilt University Medical Center in Nashville, Tennessee, cautioned, "People who may benefit from CPAP in terms of their health may not be offered CPAP because of these results. This is concerning."

"It is important to keep in mind that, even though sleepiness did not improve in this group, the mean Epworth Sleepiness Scale score was below 10 (in the non-sleepy, normal range)," Dr. Malow, who was not involved in the study, told Reuters Health by email. "Had the sample shown a higher ESS score in the sleepiness range, it is possible that an improvement in sleepiness would have been detected. Similarly, if blood pressure measurements include those without hypertension, an improvement in blood pressure measurements may not be observed."

"I would like to see more data on CPAP efficacy (in other words, the AHI during treatment, not only during the titration study)," she said. "Is it possible that patients had mask leak or other challenges that affected how well CPAP worked in their homes, that might have affected outcomes? With only 53% of patients using the device for more than 4 hours a night, it is not a surprise that stronger results were not seen."

Dr. Atul Malhotra, a sleep medicine specialist and professor of medicine at the UC San Diego Health, in La Jolla, echoed the cautious note, saying, "It would be premature to overreact to one study."

"In this study, treatment did not have benefits, but that does not mean the disease should be ignored," he told Reuters Health by email. "Ideally, sleep apnea should be diagnosed earlier. Some patients benefit from alternative therapies for sleep apnea or need intensive support to tolerate CPAP well."

"Sleep apnea is an important disease. In older adults, sleep apnea may affect memory, and its treatment may improve memory," Dr. Malhotra added. "We need more data about the importance of sleep apnea in general and the ideal treatment for various age groups."

"If you treat patients, consider asking them about diet, exercise, and sleep as the three pillars of health," he advised.

SOURCE: https://bit.ly/3IHXGrR Sleep Medicine, online November 24, 2021.

By Lorraine L. Janeczko

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