A 78-year-old complains of snoring and fatigue and has a history of hypertension and of disruptive snoring for 10 years. His wife has witnessed apneas during sleep. The man has mild to moderate daytime sleepiness and the fatigue has progressed over the past 10 years. On polysomnography, he has an apnea-hypopnea index (AHI) of 18. His lowest registered oxygen saturation level is 82%. The test also shows no N3 sleep stage.
Cases like this force otolaryngologists to consider whether disturbances in sleep are the same in elderly patients as they are in younger patients, how to assess elderly sleep disturbances, and whether to recommend surgery. In the panel session “Issues You Cannot Ignore in Elderly Patients,” experts discussed these points and the importance of considering the frailty in this population.
Benefit of Surgical Treatment
Edward Weaver, MD, MPH, chief of sleep surgery at the University of Washington in Seattle, presented data that supports the idea that sleep disturbances in the elderly should be considered largely along the same lines as it is in middle-aged people, and that it presents the same burden of disease in both groups.
In one study, moderate-to-severe sleep apnea was found to independently confer six times the risk of mortality than in those with no sleep apnea (Sleep. 2008;31:1079-1085). Another study, using a cohort of tens of thousands of U.S. veterans, found that those who had sleep apnea treated experienced half the related mortality risk as those who did not have their sleep apnea treated (p<0.001) (Sleep. 2004;27:A208 [Abstract]).
When the veteran cohort was stratified by age, the researchers found that the risk of death related to sleep apnea was the same in the middle-aged cohort of 63,209 patients as in the geriatric cohort of 53,469 patients (p=0.17), and the beneficial effects of treatment on survival were the same in each cohort (Sleep. 2006;29:A215 [Abstract]). The risk of serious complication with surgery was low in both the middle-aged and geriatric cohorts (Laryngoscope. 2004;114:450-453.).
There is little research on the effects of surgery on symptoms and morbidities in the elderly per se, but Dr. Weaver said there is little reason to think it wouldn’t help. “Don’t ignore sleep apnea in the geriatric population,” Dr. Weaver said. “It can be significant and it can be treated.”
Proceed with Caution
Eric Kezirian, MD, MPH, professor of otolaryngology-head and neck surgery at the University of Southern California, suggested that sleep disordered breathing (SDB) might mean something different in the elderly than it does in middle-aged patients.
A major study published in 2000 found that SDB was associated with a 64% increased risk of hypertension in those younger than 65 years of age but had no association for those 65 years of age and older (JAMA. 2000;283:1829-1836).
—Edward Weaver, MD, MPH
In another study, which Dr. Kezirian called the most detailed longitudinal study attempting to determine whether untreated AHI is associated with mortality, 331 men with SDB were compared with controls who did not have SDB. AHI was assessed as a predictor of death, with adjustments for medical comorbidities. For those younger than age 62, the prime risk factors were chronic obstructive pulmonary disease and diabetes, with an interaction between AHI and body-mass index. For those aged 62 and older, AHI did not appear to be an independent risk factor (J Sleep Res. 2007;16:128-134).
Symptoms such as daytime sleepiness may indicate the older adults who have the highest risk for mortality. A 2011 study of older men showed that those with both OSA and daytime sleepiness had more than double the risk of mortality over time when compared with those who had OSA alone, daytime sleepiness alone, or neither (Sleep. 2011;34:435-442).
Dr. Kezirian indicated that the impact of age on surgical outcomes has not been studied carefully. There are only two small studies that have done this, and the very limited evidence suggests that older patients may not do as well, at least in improving the AHI with surgery. He stressed that more work needs to be done to examine outcomes in older adults, as is common to so many medical fields.
“We need to appreciate the individual distinguishing characteristics of our patients,” Dr. Kezirian said. “It’s true in young and middle aged adults, too. We don’t treat mild sleep apnea with the same urgency as we do for severe obstructive sleep apnea. We treat patients who are tired differently from those who are not. We need to understand the consequences of sleep apnea in older adults and the benefits of surgical treatment.”
Robert J. Stachler, MD, clinical associate professor of otolaryngology-head and neck surgery at Henry Ford Medical Group in Detroit, underscored the importance of considering a patient’s degree of frailty in deciding whether to perform surgery.
In a Norwegian study, researchers examined 171 consecutive patients who were at least 70 years old and who had undergone surgery for colorectal cancer. Patients who were considered frail before the surgery had a four-fold risk of post-operative complications than those not considered frail. Frailty also was a significant predictor of surgical complications and medical complications after surgery (Crit Rev Oncol Hematol. 2010;76:208-217).
In his own work, he and his team have found, using data from the National Surgical Quality Improvement Program, that frailty is a predictor of morbidity and mortality in inpatient head and neck surgery (JAMA Otolaryngol Head Neck Surg. 2013;139:783-789).
Researchers used the modified Frailty Index (mFI)—an assessment of 11 parameters, including diabetes, heart failure, hypertension needing medication, and functional status—to determine patients’ degree of frailty.
As the score on the mFI grew from 0 of 11 to 5 of 11, mortality increased from 0.2% to 11.9% and life-threatening complications rose from 1.2% to 26.2%. For all complications, the rate of complications rose from 9.5% at an mFI score of 0 to 40.5% at an mFI score of 0.44. “That is a very large difference,” Dr. Stachler said.
Other research has shown that high frailty scores predict unfavorable discharge and placement in assisted-care facilities. “It’s our duty right now,” Dr. Stachler said, “for everybody out there to disseminate this information to all of our colleagues so we can establish best practices for our elderly patients.”