sl sleep eep di disorders sorders in the elderly Geriatrics - - PowerPoint PPT Presentation

Dr.Mohammad Bodaghabadi M.D

Ma Managing aging

sl sleep eep di disorders sorders

Geriatrics Center Tehran University of Medical Sciences. Zeiain Hospital

in the elderly

 HAZZARD – 2017, CHAPTER 49 , SLEEP DISORDERS

 Sleep and Aging Well , 2009 ,

National Sleep Foundation ; www.sleepfoundation.org  Kamel NS, Gammack JK. Insomnia in the elderly: cause, approach, and treatment. Am J Med. 2006 Jun;119(6):463-9. Review  Townsend-Roccichelli J, Sanford JT, VandeWaa E; Managing sleep disorders in the elderly. Nurse Pract. 2010 May;35(5):30-7  Schroeck JL, Ford J, Conway EL, Kurtzhalts KE, Gee ME, Vollmer KA, Mergenhagen KA.; Review of Safety and Efficacy of Sleep Medicines in Older Adults.Clin Ther. 2016 Nov;38(11):2340-2372. doi: 10.1016/j.clinthera.2016.09.010. Epub 2016 Oct 15. Review.  Markota M, Rummans TA, Bostwick JM, Lapid MI. ;Benzodiazepine Use in Older Adults: Dangers, Management, and Alternative Therapies. ; Mayo Clin

• Proc. 2016 Nov;91(11):1632-1639. doi: 10.1016/j.mayocp.2016.07.024.

Review.  Rawtaer I, Mahendran R, Chan HY, Lei F, Kua EH . A nonpharmacological approach to improve sleep quality in older adults.Asia Pac Psychiatry. 2017 Oct 10. doi: 10.1111/appy.12301  Tsapanou A, Gu Y, O'Shea D, Manly J, Schupf N, Scarmeas N, Stern Y. Self- Reported Sleep Disordered Breathing as Risk Factor for Mortality in the

• Elderly. J Stroke Cerebrovasc Dis. 2016 Jun;25(6):1524-31.

Sleep and aging

Sleep is Essential to Our Overall Health and Well-Being

Key to our health, performance, safety and quality

• f life

As essential a component as good nutrition and exercise to optimal health Essential to our ability to perform both

cognitive and physical tasks, engage fully in life, function in an effective safe and productive way

Normal Sleep and Normal Aging : Our Internal Clock

The biological clock resides in the brain It helps regulate when we feel sleepy and when we are alert It works in tandem with light and dark, and our body temperature and hormones

Awake

Stages

The Sleep Cycle in Adults

REM REM REM REM REM

1 2 3 4 1 2 3 4 5 6 7 8

Hours in Sleep

The progression of sleep across the night is called sleep

• architecture. It is displayed as a sleep histogram or hypnogram.

Sleep architecture is composed of 3 segments.

• NON REM

I. First segment light sleep (stages 1 and 2), II. Second segment deep sleep (stages 3 and 4).

• Taken together, stages 3 and 4 are referred to as delta sleep or slow wave

sleep (SWS). SWS is believed to be the most restorative part of sleep. Stages 1 to 4 constitute non rapid eye movement (non-REM).

• REM
• III. The third sleep segment includes the period of REM sleep.

 Stages 3 and 4 are generally observed during the first half of

the sleep period, and REM sleep occurs most frequently during the second half. Typically, subjects cycle through non-REM and REM sleep stages with a periodicity of 90 to 120 minutes.

SLEEP ARCHITECTURE

Sleep Stages

Awake Stage 1 and REM Stage 2 Stage 3 Delta 4

Electroencephalography Recordings Typical Nighttime Sleep Pattern in a Young Adult

Awake Stage 1 Stage 2 Stage 3 Stage 4

1 2 3 4 5 6 7 Time (hours)

aRapid eye movement

The sleep architecture changes significantly in the healthy elderly individual

a) Sleep initiation is more difficult; b) total sleep time and sleep efficiency are reduced; c) delta wave or SWS decreases; d) sleep fragmentation increases; e) and more time is spent in bed awake after retiring.

Natural physiologic changes in circadian rhythm influence many

• lder people to go to bed earlier and to wake up earlier. These

factors can contribute to deterioration in sleep quality and less total sleep. With aging, the duration of REM sleep tends to be more preserved, but sleep latency is significantly decreased, suggesting the elderly are more somnolent than the younger population.

Sleep Architecture in the Elderly

Change in sleep stages with age

Normal Sleep and Normal Aging: Less Deep Sleep

chronological age itself may not be the greatest predictor of sleep quality

 age-related changes in sleep are due to a decreased ability to sleep rather than a decreased need to sleep.  When older poor sleepers and good sleepers are compared, poor sleepers have worse

• health-related quality of life,
• increased medication use,
• greater health care utilization

 Many of the illnesses associated with aging can disrupt sleep, which may inhibit the normal progression through sleep stages.  lower sleep efficiency and higher amount of wake after sleep onset are associated with more cognitive decline compared to those in whom sleep is well preserved.  Since N3 sleep is associated with growth hormone secretion, the reduction in N3 sleep with aging may be partly responsible for the decrease in growth hormone in older men.

Normal Sleep and Normal Aging: Sleep Efficiency

Men Women

Age Sleep Efficiency

(% Time in Bed Sleeping)

Changes with age

The ability to get continuous and consolidated sleep may become more difficult as we age

Adults often require less sleep as they get older, and adults in their late 70s need 30 to 60 minutes less than people in their early 20s. Harbison5 notes that the proportion of REM sleep to non-REM sleep is preserved throughout life. Older adults spend less time in the later stages of non-REM sleep, which results in a lighter sleep and easy arousal. Consequently, even though elders need a shorter duration of sleep, they may need to spend longer in bed to get it.

END OF PART 1

PART 2:

Sleep Problems/Disorders Among Older Persons

SLEEP-DISORDERED BREATHING RESTLESS LEGS SYNDROME AND PERIODIC LIMB MOVEMENT DISORDER OTHER PARASOMNIAS CIRCADIAN RHYTHM DISORDERS INSOMNIA SLEEP IN INSTITUTIONALIZED OLDER ADULTS AND NEURODEGENERATIVE DISORDERS

SLEEP-DISORDERED BREATHING

Sleep-disordered breathing (SDB) : disturbed respiration during sleep arising from repetitive events of complete (ie, apnea) or partial (ie, hypopnea) cessation of airflow lasting at least 10 seconds.

• A. OSA : due to an obstructed airway, which is determined by the persistence of respiratory effort.

B. CSA: concomitant cessation of breathing effort, because there is a momentary defect in the central control of breathing.

OSA is by far the most common sleep-related breathing disorder; however, there is

• ften overlap between the two clinical syndromes.

Common cause:

• Heart failure is the most commonly recognized cause of CSA and is often

characterized by Cheyne-Stokes respiration, which is periodic cycling between ypoventilation and hyperventilation.

• cerebrovascular accidents, opioid use, hypoventilation syndromes.

CSA (central sleep apnea)

It is generally determined by the apnea hypopnea index (AHI), which is the number

• f apneas and hypopneas per hour of sleep.

SDB can be diagnosed :

• AHI is greater than 15, or
• when it is greater than 5 with significant symptoms or related comorbidities.
• An AHI greater than 30 is generally considered to indicate severe SDB.

The consequences of respiratory events during sleep include arousals from sleep, intrathoracic pressure swings, and cyclical drops in the blood oxygen level & leads to sleep fragmentation and nocturnal hypoxemia. Sever SDB is increase in young population due to obesity from 4 F & 9M to 6F &13M in 2010 in 30 to 60 years old.

The severity of SDB

Association of obstructive sleep apnea (OSA) with age.

OSA is underdiagnosed in the general population, particularly in women he risk of OSA increases with increasing age until the age of 70 at which time there is a plateau premenopausal status appears to protect against OSA meaning that the gender discrepancy between men and women narrows in the older population. OSA may be more severe in African-American and Asian populations compared to the Caucasian population. It is estimated that upwards of 50% of patients with stable heart failure have some form

• f SDB.

patients with end-stage renal disease have a very high prevalence of SDB Other conditions associated with CSA include stroke, neurodegenerative diseases, respiratory disorders leading to hypoventilation, and chronic pain requiring opiates.

Epidemiology

There are three types of SDB events: central, obstructive, and mixed.

1. Central events result from a failure of the respiratory control center to send a signal to breathe.  abnormal sensitivity of the respiratory controller, which can lead to oscillations between hyperventilation and hypoventilation. 2. Obstructive events occur from anatomic obstruction of the upper airway despite respiratory effort.  Features that govern the size of the upper airway include excess adiposity, craniofacial structure, excessive tonsilar and peritonsilar soft tissue, and lower lung volumes. 3. Mixed events are a combination of central and obstructive components.

The most significant immediate consequence of OSA is excessive daytime sleepiness and the risk of motor vehicle accidents. Significant epidemiologic associations of OSA with adverse cardiovascular and metabolic consequences have been reported.

Pathophysiology

SDB :a standardized measure such as the Epworth Sleepiness Scale

1) information from a bed partner regarding snoring 2) indicative of a partially collapsed airway and is a useful predictor of the presence of OSA or future development of the condition.

increased risk of OSA:

I. elevated body mass index (BMI), II. a large neck circumference(greater than 17 inches in men and 16 inches in women), III. a crowded upper airway In clinic the airway can be assessed using a modified Mallampati score known as the Friedman classification, with positions III and IV conferring a high risk for OSA. In general, the less posterior oropharynx that can be visualized confers a greater risk of SDB.

measurement

Patients suspected of having SDB should be referred for sleep testing. An attended in-laboratory polysomnography (PSG) is considered the gold standard test for SDB. The test involves the use of EEG, electromyogram (EMG), and electrooculogram (EOG) leads to determine presence and stage of

• sleep. There is measurement of

airflow with a nasal pressure transducer as well as an oronasal thermistor. Respiratory effort is measured using chest and abdominal belts; and

• ccasionally with an esophageal

pressure monitor

• r

accessory muscle EMG.

Evaluation

An alternative approach to the diagnosis

• f SDB uses out-of-center testing. The

patient takes the sleep testing equipment home and puts it on before bed. These tests are not generally able to measure sleep directly. Most of these tests measure airflow, effort, and pulse

• ximetry. Out-of-center sleep testing is
• nly recommended for patients
• with a high pretest probability of having SDB
• who do not have significant cardiopulmonary

comorbidities.

In populations at high risk for OSA, studies have shown that out-of-center sleep testing leads to similar patient

• utcomes compared to in-laboratory
• PSG. Due to cost issues third-party

payers are increasingly pressuring practitioners to move toward out-of- center sleep testing.

 The first-line treatment for SDB is positive airway pressure therapy.  CPAP is a device that delivers a constant positive pressure in

• rder to splint the airway open preventing collapse.

 the amount of air pressure (usually between 5 and 20 cm H2O) is manually determined in the sleep laboratory  There is evidence that patients who have mild to moderate dementia are able to tolerate CPAP therapy and such a condition is not a contraindication to CPAP initiation.  Auto titrating CPAP (APAP) is now available, in which the machine adjusts the pressure based on events and flow characteristics using internal algorithms that are proprietary to the device manufacturers. APAP can be used to determine a fixed CPAP pressure or can be used as the primary modality of therapy.

Management

CPAP is usually 100% effective in eliminating

• bstructive apneas and hypopneas.

Estimates are that at the end of a year only 50% of patients are adherent to CPAP therapy. Bilevel airway pressure has sometimes been used for patients who have difficulty tolerating therapy due to difficulty exhaling against pressure.

Positive airway pressure therapy has to be individualized in patients who have CSA. Many patients who have Cheyne-Stokes respiration will respond to a combination of CPAP and/or supplemental oxygen. Likewise, the majority of patients with obesity- hypoventilation syndrome respond to CPAP alone. these advanced devices involve applying bilevel pressure with a back-up respiratory rate. The amount of pressure support given during a certain breath by algorithms in order to achieve specific desired clinical effects. Dental devices that move the jaw forward (mandibular advancement or mandibular repositioning devices) are a treatment alternative to positive airway pressure in OSA. The principal behind such therapy is that when the lower jaw moves forward the tongue is also pulled forward, thus opening up the airway. These devices are generally thought to be more effective in mild to moderate OSA rather than severe OSA. recent comparative effectiveness studies suggest equivalence for major

• utcomes.

One of the major limiting factors to mandibular advancement therapy, particularly in

• lder adults, is that teeth are generally required to anchor the device in place.

Other …

mandibular repositioning devices

Tongue repositioning/retaining devices can be used in patients who lack their native

• teeth. However, these devices have been less extensively studied and are less likely to

be effective. expiratory positive airway pressure (EPAP) provided through nasal valves. This therapy consists of nasal valves that adhere to the nares via adhesive, which makes it more difficult to breathe out than breathe in. This causes pressure build up that helps stent the airway open, as well as causing an increase in lung volume that may prevent obstructive respiratory events. This therapy is less well validated but may be used as a salvage therapy or in mild cases.

hypoglossal nerve stimulation. This involves an implanted box with a lead that goes to the respiratory muscles to sense the onset of inspiration and a lead that goes to the hypoglossal nerve that causes tongue contraction to open the airway with inspiration.

• A recent randomized trial found promising results in a highly selected group of

patients with a BMI less than 32 kg/m2 who could not tolerate CPAP therapy. In this group there was a significant reduction in AHI.

Surgery is also an alternative therapy for SDB. There are multiple surgical techniques that are available to otolaryngologists for the treatment of SDB. The most common of which is the uvulopalatopharyngoplasty (UPPP). This procedure has variable success rates depending on anatomic factors and the degree of obesity. other behavioral changes that the patients with SDB can implement to help treat the syndrome include weight loss, sleeping on the side, and the avoidance of alcohol and other sedatives.

Modafinil and armodafinil, central nervous system stimulants, have Food and Drug Administration (FDA) approval for the treatment of residual excessive daytime sleepiness in treated OSA. Acetazolamide has an unclear role in some CSA syndromes. Ventilatory stimulants such has progesterone have been tried unsuccessfully in obesity hypoventilation syndrome.

Pharmacologic therapy

Have a good sleep

Tsapanou A1, Gu Y2, O'Shea D2, Manly J3, Schupf N4, Scarmeas N5, SternY6.

J Stroke Cerebrovasc Dis. Author manuscript; available in PMC 2017 Jun 1.

Cognitive Neuroscience Division, Department of Neurology and The Taub Institute for Research on Alzheimer's disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, NY, USA

Background/Aims

To examine the association between self-reported sleep disordered breathing (‘awaken short of breath or with a headache’) and mortality in a large and ethnically diverse group of community-dwelling elderly people.

Methods

1288 participants, 65 years and older, were examined longitudinally. Sleep problems were estimated using the Medical Outcomes Study Sleep Scale examining Cox regression analysis was used to examine the association between sleep problems and

• mortality. Age, gender, education, ethnicity, and body mass index were included as
• covariates. In further analyses we included hypertension, diabetes, heart disease, and stroke

as additional covariates.

Results

The participants were followed for up to 6 years (mean 2.9, SD: 1.1), and 239 (18.6%) participants died during the follow-up. In unadjusted models, SDB at the initial visit was associated with mortality HR=1.37; 95% CI 1.21-1.55; p<0.0001. After adjusting for all the covariates, the relationship between SDB and mortality remained significant HR=1.48; 95% CI 1.29-1.70; p<0.0001. Participants with Caribbean-Hispanic ancestry have higher risk for mortality.

Conclusion

Our results suggest that SDB is a risk factor for mortality in a large and ethnically diverse group of older adults, independent of demographic and clinical factors. Further research is needed in order to examine the underlying mechanisms of this association.

sleep disordered breathing (SDB) – including difficulties breathing during sleep- has a high prevalence among older adults, and often occurs even with atypical symptoms. Obstructive sleep apnea (OSA) is the most salient symptom of SDB, and has a prevalence rate of 30-80% in the elderly SDB has been associated with increased risk of both cardiovascular disorders and dementia , understanding whether SDB can be linked to mortality in older adults is of a paramount importance. A number of studies have shown ,

• Sleep duration has been linked to mortality in older, but not middle aged adults.
• Longer durations of sleep in older adults have been shown to increase the risk of dementia

mortality .

• daytime napping, associated with an elevated risk of cardiovascular disease mortality .
• Similarly, excessive daytime sleepiness seems to be an independent risk indicator for

cardiovascular mortality in older adults

In contrast, much less is known about the association between SDB and mortality.

• One recent 10-year-follow-up study suggests that OSA with a higher risk of mortality
• A different study reported that OSA is specifically associated with cancer mortality
• However, even though untreated SDB IS a strong risk factor for mortality

There are some significant limitations in the present literature exploring the association between SDB and mortality.

• First, the sample size of some of the existing studies is relatively small.
• most of the studies have not specifically focused on the impact of SDB in older adults.
• Furthermore, do not adequately represent an ethnically diverse population sample .

Thus, we aimed to examine the association between SDB and mortality, in a large and ethnically diverse sample of older adults.

Study participants

Participants were selected from the Washington Heights-Inwood Community Aging Project (WHICAP) at Columbia University Medical Center . WHICAP is a longitudinal community based research study aimed at identifying risk factors and biomarkers for aging and Alzheimer's disease in a multi-ethnic cohort that includes Caucasian, African-American and Hispanic participants. The age range was 65 years and older. Each participant underwent a structured in-person Participants were followed at intervals of approximately 1.5 years, repeating the baseline examination and consensus diagnosis at these time points. From 2007 onwards, sleep information was gathered from the participants. In the current study, we define the baseline visit as the visit when the sleep questionnaire was first administered to the participants. The initial sample was consisted of 2358 participants. By the time when sleep questionnaire was first introduced to the cohort, 1838 participants remained alive. Among these, we excluded 550 participants who had no sleep information or follow- up data. Thus, the final sample consisted of 1288 participants.

Sleep measures

Sleep quality was assessed using the Sleep Scale from the Medical Outcomes Study. This scale is a self-report 12-item questionnaire which asks the following questions : Sleep Scale from the Medical Outcomes Study Each of the questions has a possible rating of 0-6, based on the frequency of the sleep problem (See Appendix), with a higher score indicating greater sleep dysfunction. We used response to the question ‘awaken short of breath or with a headache’ as a marker for self-reported SDB.

Sleep Scale from the Medical Outcomes Study

• 1. How long did it usually take for you to fall asleep during the past 4 weeks?(Circle One)

0-15 minutes…………..…1 16-30 minutes……………..2 31-45 minutes……………..3 46-60 minutes……………..4 More than 60 minutes …….5

• 2. On the average, how many hours did you sleep each night during the past 4 weeks? Write in

number of hours per night: How often during the past 4 weeks did you…

• 3. Feel that your sleep was not quiet (moving restlessly, feeling tense, speaking, etc., while

sleeping)?

• 4. Get enough sleep to feel rested upon waking in the morning?
• 5. Awaken short of breath or with a headache?
• 6. Feel drowsy or sleepy during the day?
• 7. Have trouble falling asleep?
• 8. Awaken during your sleep time and have trouble falling asleep again?
• 9. Have trouble staying awake during the day?
• 10. Snore during your sleep?
• 11. Take naps (5 minutes or longer) during the day?
• 12. Get the amount of sleep you needed?

Possible answers: 1= All of the time, 2= Most of the time, 3= A good bit of the time, 4= Some of the time, 5= A little of the time, 6= None of the time, -1= Not asked, -2= Too impaired to respond, -3= Refused

Covariates

Age (years), education (years), and body mass index (BMI) were used as continuous variables. Ethnicity was ascertained based on self-report using the format of the 1990 census . Participants were then assigned to one of four ethnic groups: African-American (non-Hispanic), Hispanic, White (non-Hispanic), and Other. Ethnicity was used as a dummy variable with White (non-Hispanic) as the reference. In further analyses, we added hypertension, diabetes, heart disease, and stroke as covariates.

Statistical analysis

Analyses were performed using SPSS 22 (SPSS, Chicago, Illinois). Baseline characteristics of subjects were compared using

• t-test or ANOVA models for continuous variables (i.e., age, education), and with
• chi-square test for categorical baseline characteristics (i.e., gender, ethnicity).

In order to examine the association between SDB and mortality we used Cox proportional hazards model, with death as the dichotomous outcome. The time-to-event variable was the time from recording of baseline sleep quality reports to death for those who died, and from baseline to the last follow-up for those who survived. The sleep question: ‘awaken short of breath or with a headache’, as a continuous variable was used as the predictor. Adjustments were made initially for age (years), gender, education (years), ethnicity, and BMI, and then for hypertension, diabetes, heart disease, and stroke, in order to estimate the association between sleep problems and mortality. The predictor of interest was the sleep question score as a continuous variable.

In the sample, there were more females than males, and more participants with an Hispanic ancestry (see Table 1). From the total of 1288 participants, 239 (18.6%) died, over a mean of 2.9 (SD= 1.1; range: 0.2-6) years of follow-up. The average age at death was 87.4 (SD: 7.0) (see Table 1). In the unadjusted models, self-reported SDB, was associated with mortality (HR=1.37; 95% CI 1.21-1.55; p<0.0001). After controlling for age, gender, education, ethnicity, and BMI, the association between self-reported SDB and mortality remained highly significant (HR=1.47; 95% CI 1.29-1.69; p<0.0001).

Demographic and clinical characteristics of the participants

Characteristics Death Total No Yes p value Total (n) (%) 1049 (81.4) 239 (18.6) 1288 Age at evaluation, (SD) 79.5 (6.5) 85.5 (7.0) <0.0001 80.6 (7.0) Age at death, M (SD) 82.2 (6.6)(last visit) 87.4 (7.0) <0.0001 83.1 (7.0) Gender, N (% Female) 745 (71.0) 152 (63.6) 0.024 897 (69.6) Education, M (SD) 10.0 (5.1) 10.0 (5.1) 0.915 10.0 (5.1) Ethnicity, N (%) 0.026 Whites 234 (22.3) 68 (28.5) 302 (23.4) Hispanics 568 (54.1) 109 (45.6) 677 (52.6) African-Americans 236 (22.5) 58 (24.3) 294 (22.8) Other 11 (1.0) 4 (1.7) 15 (1.2) BMI, M (SD) 29.1 (5.7) 27.2 (5.8) <0.0001 28.8 (5.7) Hypertension 826 (79.3) 173 (73.3) 0.042 999 (78.2) Diabetes mellitus 293 (28.1) 79 (33.5) 0.104 372 (29.1) Heart disease 282 (27.1) 96 (40.7) <0.0001 378 (29.6) Stroke 97 (9.3) 47 (19.7) <0.0001 144 (11.2)

We then added hypertension, diabetes, heart disease, and stroke as covariates to our

• model. The association between SDB and mortality remained significant (HR=1.48; 95%

CI 1.29-1.70; p<0.0001) (see Table 2 and Figure 1). We ran further analysis in order to examine whether the association would remain significant in a model that included all 12 sleep questions. After adding all of the questions and controlling for all covariates, SDB remained significantly associated with mortality (HR=1.39; 95% CI 1.20-1.61; p<0.0001). None of the other sleep problems was associated with mortality (see Table 2). Finally, after stratifying the adjusted analyses by ethnicity, and adding the above covariates, our results suggest that participants with Caribbean-Hispanic ancestry have higher risk for mortality (HR=1.51; 95% CI 1.26-1.82; p<0.0001), followed by Caucasians (HR=1.61; 95% CI 1.19-2.17; p=0.002).

• 1. How long did it usually take for you to fall asleep during the past 4 weeks?
• 2. On average, how long did you sleep each night during the past 4 weeks? How often

during the past 4 weeks did you:

• 3. Feel that your sleep was not quite (moving restlessly, feeling tense, speaking, etc.)

while sleeping?

• 4. Get enough sleep to feel rested upon waking in the morning?
• 5. Awaken short of breath or with a headache?
• 6. Feel drowsy or sleepy during the day?
• 7. Have trouble falling asleep?
• 8. Awaken during your sleep time and have trouble falling asleep again?
• 9. Have trouble staying awake during the day?
• 10. Snore during your sleep?
• 11. Take naps (5 minutes or longer) during the day.
• 12. Get the amount of sleep you needed?

Sleep Scale from the Medical Outcomes Study

Sleep variable HR (95% CI), p value SDB* HR=1.37; 95% CI 1.21-1.55; p<0.0001 *SDB: sleep disordered breathing: ‘Awaken short of breath or with a headache’. Association between SDB and mortality. Model used SDB as a separate question adjusted for: age, gender, education, ethnicity, BMI. Sleep variable HR (95% CI) p value SDB HR=1.47; 95% CI 1.29-1.69; p<0.0001 Association between SDB and mortality. Model used SDB as a separate question adjusted for: age, gender, education, ethnicity, BMI, hypertension, diabetes, heart disease, and stroke. Sleep variable HR (95% CI) p value SDB HR=1.48; 95% CI 1.29-1.70; p<0.0001 Association between SDB and mortality. Model included all 12 sleep questions, age, gender, education, ethnicity, BMI, hypertension, diabetes, heart disease, and stroke. Sleep variable HR (95% CI), p value

• 1. Duration to fall asleep

a

HR=1.11; 95% CI .970-1.27; p=0.130

• 2. Duration of sleep (h)

a

HR=.925; 95% CI .838-1.02; p=0.123

• 3. Sleep not quite

a

HR=1.00; 95% CI .892-1.12; p=0.981

• 4. Feel rested in the morning

a

HR=.985; 95% CI .857-1.13; p=0.829

• 5. SDB

a

HR=1.39; 95% CI 1.20-1.61; p<0.0001

• 6. Drowsiness/ sleepiness

a

HR=1.00; 95% CI .877-1.15; p=0.959

• 7. Trouble falling asleep

a

HR=.901; 95% CI .768-1.06; p=0.198

• 8. Awakening and trouble falling asleep again

a HR=.976; 95% CI .854-1.12; p=0.719

• 9. Daytime sleepiness

a

HR=1.10; 95% CI .942-1.29; p=0.223

• 10. Snoring

a

HR=.973; 95% CI .880-1.07; p=0.587

• 11. Taking naps

a

HR=1.09; 95% CI .985-1.21; p=0.095

• 12. Sleep adequacy

a

HR=1.08; 95% CI .925-1.26; p=0.325

Survival plot for mortality, with SDB as the predictor

In the present study, we examined the association between SDB and mortality, in a large and ethnically diverse sample of older adults. Although some previous studies have found a significant association between SDB and mortality, most of these studies included varied age groups, focused only one gender, or had relatively small sample size. According to our results, SDB was significantly linked to mortality in our large group of elderly men and women. The present study has some limitations.

• First, we did not use an objective measure of sleep problems, such as actigraphy/

polysomnography.

• Moreover, the answers in the sleep questionnaire refer to the previous four weeks,

and may not accurately represent a participant's chronic sleep pattern.

• Finally, the study had a relatively short follow-up period.

However, the present study has strengths that are noteworthy. This is a large study examining the association between SDB and mortality in the elderly including both men and women, thus, having a great ecological validity. Furthermore, to the best of our knowledge, this study is the first to include a large number of ethnically diverse participants, counting African- Americans and Hispanics. In conclusion, our results suggest that SDB is significantly associated with incident mortality, in older adults, over and above numerous demographic and clinical factors. The meaning of the study is great as early detection and treatment of the SDB symptoms may reduce the risk of mortality in

• lder adults.

Further research is needed in order to understand the exact underlying mechanisms involved in this association.

Have a good sleep