People ages 65 and older face unique sleep apnea therapy challenges. Experts discuss common CPAP issues among seniors, as well as suggest strategies to promote adherence.

By Emily Halnon

More than half of Medicare beneficiaries are at high risk of obstructive sleep apnea (OSA), according to a study by Michigan Medicine researchers. Its study of a nationally representative sample of 1,052 seniors ages 65 and older found that 56% are at high risk of OSA and nearly all—94%—were  diagnosed with the sleep disorder after testing.1

“We know that OSA is quite common, yet often underdiagnosed, in adults in the US, but most of the data available are from younger or middle-aged patients,” said co-first author Tiffany Braley, MD, MS, assistant professor of neurology at Michigan Medicine, on the M Health Lab Blog.

In that study, CPAP was prescribed for 82% of seniors with an OSA diagnosis. But even after a CPAP prescription is written, patients often struggle to use the therapy. To ensure the highest rate of CPAP adherence in this population, clinicians should be aware of its unique challenges.

Many seniors report trouble using CPAP, especially if they have other health issues like arthritis or vision loss, says Leisha Cuddihy, PhD, a psychologist at the University of Rochester Medical Center and a member of the Society of Behavioral Sleep Medicine. “It’s a huge behavior change and that shift is one of the hardest parts of using CPAP,” she says.

“The older age group presents unique challenges,” Cuddihy adds. “People are having more health problems, they’re having more cognitive problems—all of which are going to interfere with adherence.”

Retired sleep tech Pam Minkley, RRT, RPSGT, CCSH, FAAST, frequently chats with people about their sleep. So she hears plenty of stories from seniors who have CPAP adherence issues.

According to Minkley, some common issues that seniors report with their CPAPs include:

  • Arthritis-related mobility challenges and increased pain from handling a CPAP mask.
  • Skin irritation from the CPAP mask. Skin thins with age so it becomes more sensitive.
  • Frequent sleep disruptions, including bathroom trips and a bed partner’s wakefulness. Some patients find it difficult to get their mask back on and the machine restarted while groggy. It can also be hard for them to fall back asleep with the machine running.
  • Trouble navigating the complexity of the machines, which may be related to physical and/or cognitive impairments from illnesses such as Parkinson’s disease or Alzheimer’s disease.

Unfortunately, these issues sometimes remain unresolved. “The homecare companies have seen their reimbursement drop so much that they often don’t have staff,” Minkley says. “And the medical providers that seniors see for sleep issues often get minimal training and don’t have a deep understanding of what to do or how to work with specific learning preferences or any disabilities that seniors may have.

“It’s not necessarily that CPAP is an issue. It’s just that you’ve got a huge behavior modification that makes your sleep different and if your sleep is already fragile, that’s a problem.”

Overcoming CPAP Challenges for Seniors

There are many different masks and machines available and modifications that can help users out, Minkley says.

Kelly Rudolph, president of CPAP mask maker Hans Rudolph Inc, says masks made from silicone rubber are more comfortable on sensitive skin. He also recommends masks constructed without a hard frame and with a chin cup for seniors, as he says these features help CPAP masks stay in place better and not irritate skin.

One of the best things seniors can do to set themselves up for success with CPAP is practice, Cuddihy says. She advises her patients to practice with their device during waking hours, which gives them an opportunity to make adjustments while they’re alert. People can start small, she says, and wear the interface for 20 to 30 minutes at a time and build up until they find it more comfortable. “You have to give yourself time to acclimate and build tolerance,” she says.

She also encourages people to stick with CPAP use, even if they don’t feel better immediately. “I always encourage people to at least try to use it for a few months consistently because sometimes it does take two or three months before you start seeing benefit,” she says. “It’s actually not super common that you use it one night and feel great the next day.”

She also encourages people with obstructive sleep apnea to remember their motivation for trying it. Adjusting to CPAP can be similar to other behavioral changes, like diet or exercise, she says, where a person needs to commit to a regular practice for it to feel easier.

Emily Halnon is a science and environmental freelance writer. This is her first article for Sleep Review.

What About CPAP Use in the Very Elderly?

There are differing opinions on whether it’s a good idea for seniors over the age of 80 to be prescribed CPAP. A recent study found no clinical improvements in this age group.3 

“We did not see any improvements in OSA-related symptoms, quality-of-life metrics, mood-related symptoms, or blood pressure compared to the group that did not receive CPAP treatment,” said senior author David Gozal, MD, the Marie M. and Harry L. Smith Endowed Chair of Child Health at the University of Missouri School of Medicine, in a release about the study.

But anecdotally, plenty of seniors over 80, and their doctors, have found CPAP to be beneficial.

Cuddihy sees it as an individual decision that varies from patient to patient. “It’s an important conversation between the whole health care team for older adults,” she says. “There’s a cost-benefit analysis that’s important for each patient. How’s CPAP going to make things worse versus what’s the goal and treatment and how is CPAP going to get the patient towards that or further away?”—Emily Halnon

References

1. Braley TJ, Dunietz GL, Chervin RD, et al. Recognition and diagnosis of obstructive sleep apnea in older Americans. J Am Geriatr Soc. 2018 Jul;66(7):1296-1302.

2. Otman H. OSA in older adults: Often present, seldom investigated. 2018 May 10. M Health Lab, Michigan Medicine.

3. Martinez-Garcia MA, Oscullo G, Ponce S, et al. Effect of continuous positive airway pressure in very elderly with moderate-to-severe obstructive sleep apnea pooled results from two multicenter randomized controlled trials. Sleep Med. 2022 Jan;89:71-7.

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