Sleep, 17(1):77-83 © 1994 American Sleep Disorders Association and Sleep Research Society Review Are Breathing Disturbances in Elderly Equivalent to Sleep Apnea Syndrome? *Sonia Ancoli-Israel and tTimothy Coy * Department of Psychiatry, University of California, San Diego and Veterans Affairs Medical Center, San Diego, California, U.S.A. tSan Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology, San Diego, California, U.S.A. The prevalence of sleep apnea syndrome (SAS) in middle-aged populations is unknown but is currently estimated to be 4% in women and 9% in men (1). In the elderly, however, the prevalence of repetitive ep- isodes of upper airway obstruction has been estimated to be substantially higher, between 24 and 75% (2). Because of this high prevalence, questions arise as to the significance of sleep-disordered breathing (SDB) in the elderly. Is SDB in the elderly the same phenomena, i.e. SAS, that presents in younger adults? Sleep apnea syndrome is defined as repetitive epi- sodes of upper airway obstruction that occur during sleep, usually associated with a reduction in blood ox- ygen saturation (3). Some ofthe more common symp- toms of SAS include loud snoring, feeling unrefreshed in the morning and excessive sleepiness, particularly when in a relaxed position. Cardiovascular disease is also commonly associated with SAS. SAS can result in profound functional impairment, with life threat- ening complications and, ultimately, can lead to pre- mature death (3). Although these are the same symp- toms found in the elderly, the question is still, what constitutes disease in the elderly, i.e. do these symp- toms constitute SAS or SDB? Sleep-disordered breathing is defined as the presence of apneas (complete cessation of respiration) or hy- popneas (partial decrease of respiration), but has no added definition of accompanying symptoms. There is no question that SDB is found in the elderly. We will review the literature to determine whether the symp- Accepted for publication August 1993. Address correspondence and reprint requests to Sonia Ancoli- Israel, Ph.D., Department of Psychiatry, Il6A, Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92163, U.S.A .. toms associated with SAS are also found in elderly with SDB. PREVALENCE OF SLEEP APNEA IN THE ELDERLY Studies all confirm that the prevalence of sleep apnea is higher in the elderly than in younger adults, higher in older men than in older women, and higher in older (postmenopausal) women than younger (premeno- pausal) women (2,4,5). In a review of the epidemi- ology of sleep in apnea in the elderly, Ancoli-Israel reported that the prevalence rates for older men ranged from 28 to 62%, whereas for older women the rates ranged from 19.5 to 60% (2). The different prevalence rates found in different studies resulted from investi- gators using different criteria for apnea indices (AI, the number of apneas per hour of sleep) and for respiratory disturbance indices (RDI, the number of apneas plus hypopneas per hour of sleep), small sample sizes and nonrepresentative populations. Most studies used a criterion level of AI 5, a level thought by many to be too low (6-8). Ancoli-Israel et al. found that 24% of randomly selected elderly had five or more apneas per hour of sleep and 81 % had five or more respiratory disturbances per hour of sleep (4). When more stringent criteria levels were used, the prevalence rates were 10% for AI 10, 4% for AI 20, 44% for RDI 20 and 24% for RDI 40 (2,4,9). 77 Gould and colleagues proposed that the criteria for diagnosing SAS be an RDI greater than 15, with two of the following symptoms: excessive daytime sleepi- ness, loud snoring, poor sleep and/or disrupted sleep (10,11). As will be seen, most elderly with SDB, par- ticularly those with an RDI 15, would present with these symptoms. Downloaded from https://academic.oup.com/sleep/article-abstract/17/1/77/2755039 by guest on 18 June 2020