Elsevier

Sleep Medicine

Volume 2, Issue 3, May 2001, Pages 225-232
Sleep Medicine

Original article
The age and other factors in the evaluation of compliance with nasal continuous positive airway pressure for obstructive sleep apnea syndrome. A Cox's proportional hazard analysis

https://doi.org/10.1016/S1389-9457(00)00063-0Get rights and content

Abstract

Objective: To elucidate the predictive role of age and other pre-treatment, putative confounding factors on compliance with nasal continuous positive airway pressure (nCPAP) therapy.

Patients and methods: This study was designed as a prospective cohort study in the setting of a sleep laboratory in a teaching hospital at Saint Antoine, Paris. One hundred and sixty-three patients referred to the sleep laboratory with complaints of snoring and excessive daytime sleepiness for whom nCPAP had been prescribed for obstructive sleep apnea syndrome (OSAS; defined as an apnea–hypopnea index (AHI) of >15/h of sleep during a polysomnographic recording) were followed for a median period of 887 days. The main outcome measure was the risk ratio for elderly patients associated with nCPAP compliance.

Results: Four patients, who remained under treatment, died before the end of the study, and 50 patients stopped their nCPAP therapy for reasons other than death (insomnia, equipment too noisy, etc.). When compliance curves were compared by univariate analysis (log-rank test), the oldest group (57/163 patients, >60 years old) was significantly less compliant with nCPAP than the youngest (P=0.01). However, in the Cox's proportional hazards model, age did not exert any independent effect on compliance with nCPAP after controlling for confounding factors (adjusted relative risk, 1.09, 0.5–2; P=0.70). On the other hand, female sex (adjusted relative risk, 2.8, 1.4–5.4; P=0.002), a body mass index (BMI) of ≤30 kg/m2 (adjusted relative risk, 2.2, 1.2–4; P=0.006), an Epworth sleepiness scale (ESS) score of ≤15 (adjusted relative risk, 3.2, 1.1–8.9; P=0.025), an AHI of ≤30/h (adjusted relative risk, 2.2, 1.2–4; P=0.01) and a nCPAP of ≥12 cmH2O (adjusted relative risk, 2.3, 1.2–4.4; P=0.011) were predictive factors for non-compliance.

Conclusion: This study suggests that there is no independent effect of age on compliance with nCPAP therapy.

Introduction

Sleep–wake patterns in older adults are modified and a difficulty in sleep maintenance is commonly reported with increasing age [1]. The number and duration of nocturnal awakenings increase in the elderly, and the duration of rapid eye movement (REM) episodes declines. New data, however, have shown that daytime complaints, such as excessive daytime napping, which are very incapacitating in the daily life of the elderly, may be secondary to specific sleep disorders, i.e. sleep apnea [2]. Obstructive sleep apnea syndrome (OSAS) is highly prevalent in the elderly population [3], [4], [5], [6]. Mant et al. [7] reported a prevalence rate of 15%, when a criterion as severe as 15 apneas or more/h of sleep was used. Among elderly subjects, almost 3% suffer from a symptomatic sleep apnea syndrome [8]. Nasal continuous positive airway pressure (nCPAP) therapy is the treatment of first choice for OSAS [9]. While its role in improving survival is still being debated [10], clear-cut objective benefits, in terms of reduced daytime sleepiness and improved cognitive functions, have been demonstrated [11], [12]. However, this is a palliative treatment, which is both constraining for the patient and expensive. Presently, the social security funds in France reimburse such treatment at the rate of FF9000 (Euro1500)/patient per year [13]. More than 20 000 patients were on nCPAP in 1996, and a recent French study reported that of 547 patients treated, 30% were aged 60–69 years old, and 13% were more than 70 [14].

Many reasons might negatively influence the compliance with nCPAP in the elderly: social discomfort due to excessive daytime somnolence, physical problems to adapting the mask, e.g. loss of vision, greater physical impairment, associated chronic diseases and treatments.

At the same time, some authors do not consider OSAS to be a mortality risk factor in the elderly, and several retrospective case series imply that sleep apnea in this population does not warrant treatment [15], [16]. Actually, under the present financial constraints affecting health care, age is increasingly put forward as a criterion for access to care, considering that aged people consume more healthcare resources, but less benefit, than younger patients [17], [18], [19].

All these considerations make an objective evaluation of the long-term compliance with nCPAP therapy in the elderly population pertinent. Using Cox’ proportional hazards model, our prospective study, lasting about 4 years, was conducted to elucidate the predictive role of age and other putative, pre-treatment, confounding factors on compliance with nCPAP therapy, in a cohort of 163 OSAS patients.

Section snippets

Patients

The study population was based on all 199 patients for whom nCPAP had been prescribed for OSAS (defined as an apnea–hypopnea index (AHI) of greater than 15/h of sleep over a 26-month period. These patients had been referred to the sleep laboratory with complaints of snoring and excessive daytime sleepiness. We excluded 36 patients; five had an AHI<15 before nCPAP therapy, 13 only had their respiratory measures recorded during the diagnostic study (i.e. sleep characteristics were not available),

The 163 OSAS patients

We followed up the 163 patients for a median of 887 (range, 14–1549) days. There were 27 females (17%) and 136 males (83%), on average they were 55 years old (11.5), 35% being more than 60, and 8% more than 70, with a BMI equal to 30.80 (5.5) kg/m2 and an AHI equal to 52 (27). The effective nCPAP was 10.36 cmH2O (2.1). A positive correlation was found between the AHI and the nCPAP level (r=0.21; P=0.008), and also between the BMI and the effective level of pressure (r=0.20; P=0.01).

No patients

Discussion

The development of new technologies will keep driving healthcare costs up, and it is likely that a next step will be some form of systematic rationing of healthcare [19], [25]. Berry et al. [26], Ancoli-Israel et al. [6], and more recently, Bixler et al. [8] stated that sleep apnea syndromes in any age group, if severe and accompanied by symptoms, should be adequately treated on a long-term basis. In our opinion, compliance with nCPAP should constitute one of the major criteria for allocating

Acknowledgements

The authors would like to thank Mrs Olga Razanadramasy-Chapelle for her support in extracting the data from the sleep laboratory register.

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