Sleep apnea in older adults: signs, CPAP and Medicare testing

Sleep apnea gets more common as people age, and it often looks different in older adults than in the stereotype of a loud-snoring, sleepy middle-aged man. Older people tend to report less snoring and less sleepiness, while signs like getting up at night to urinate, memory trouble or falls get blamed on age. The good news is that CPAP works in this age group, older adults often use it well, and Medicare covers testing for people with symptoms.

How common is sleep apnea in older adults?

Sleep apnea in older adults is common, and it becomes more common with age. Population studies consistently show higher rates in older age groups than in younger ones, in both men and women, though the exact numbers depend on how each study measured and defined it.

The Wisconsin Sleep Cohort gives clear numbers. Researchers estimated that moderate to severe sleep-disordered breathing (an AHI of 15 or more) affected 17% of men aged 50 to 70, compared with 10% of men aged 30 to 49. In women, the figures were 9% at 50 to 70 and 3% at 30 to 49.

A 2017 systematic review of 24 studies found the same pattern. Prevalence increased with age, and at an AHI of 15 or more it reached as high as 49% in advanced ages. At the lower threshold of 5 events per hour, some elderly groups reached 90% of men and 78% of women. The authors note that study methods varied widely, which partly explains how high some figures are. If you're unsure what those AHI numbers mean, our guide to what AHI is explains the scale.

Why is sleep apnea missed in older people?

Sleep apnea is missed in older people because its signs are quieter and easy to put down to age. A 2022 review in the European Respiratory Journal says obstructive sleep apnea is largely under-recognized and under-diagnosed in older adults.

The same review says older patients who do reach sleep clinics look much like middle-aged ones, with some differences. They underreport snoring as a main complaint, tend to be less obese, are less likely to be men and are less objectively sleepy. The review adds that fatigue, nocturia, unintentional napping and cognitive problems may be blamed on aging or other conditions. Retirement or living alone can also make it easier to work around poor sleep without noticing it.

That matters because the usual checklists lean on snoring and sleepiness. Our list of sleep apnea warning signs covers the classic symptoms, and our article on snoring and age explains why the airway changes later in life.

What atypical symptoms should older adults watch for?

Atypical symptoms of sleep apnea in older adults include waking at night to urinate, memory or thinking problems, repeated falls and adult-onset bedwetting. The 2022 European Respiratory Journal review lists these, along with eye conditions, as common atypical presentations in this age group.

Here's how the typical and atypical pictures compare, based on that review.

None of these signs proves sleep apnea on its own. They're reasons to ask about it, especially alongside a bed partner noticing pauses in breathing or gasping. Gasping awake is a symptom worth mentioning on its own.

Can sleep apnea cause night-time urination?

Sleep apnea can contribute to night-time urination, a symptom called nocturia. A review in the American Journal of Lifestyle Medicine defines nocturia as waking two or more times to urinate and says about half of people with obstructive sleep apnea have it. It adds that treating sleep apnea improves nocturia, yet nocturia isn't included in commonly used screening questionnaires.

The evidence on treatment isn't uniform. In the PREDICT trial, described below, CPAP didn't change nocturia in people aged 65 and over, so it's best seen as a clue worth asking about rather than a symptom CPAP will reliably fix.

Nocturia in later life has many causes, including prostate changes, medicines and heart conditions. So frequent night trips to the bathroom are worth raising with your doctor, and asking whether sleep apnea could be part of the reason is reasonable.

Is sleep apnea linked to memory problems and dementia?

Sleep apnea is linked to a higher risk of later memory problems in some studies of older adults. In a prospective study of 298 older women without dementia, with an average age of 82, those with sleep-disordered breathing were more likely to develop mild cognitive impairment or dementia over a median of 4.7 years. After adjustment for other factors, the odds ratio was 1.85.

The picture isn't simple. The 2022 European Respiratory Journal review notes that studies limited to people over 60 generally show weaker links between sleep apnea and current cognitive performance than studies of middle-aged adults. It suggests the link may be clearest in people referred to specialists. It's also hard to separate age-related decline from effects of sleep apnea.

Whether treatment protects memory is still an open question. In the PREDICT trial below, a year of CPAP didn't change cognitive test scores in people aged 65 and over.

Does CPAP help older adults?

CPAP helps older adults with sleep apnea feel less sleepy, according to the largest trial in this age group. The PREDICT trial randomized 278 people aged 65 and over with newly diagnosed sleep apnea syndrome to CPAP plus supportive care or supportive care alone, across 14 UK sleep centers.

CPAP lowered Epworth sleepiness scores by about 2 points at 3 months and again at 12 months. The effect was larger in people who used CPAP more or who were sleepier to begin with. CPAP also improved objective sleepiness and mobility at 3 months, though those gains weren't sustained at 12 months. Mood, nocturia, cognitive function and cardiovascular events didn't change. No significant harm was attributed to CPAP, and the authors recommended that CPAP be offered routinely to older patients with sleep apnea syndrome.

The trial was about symptoms over a year, not long-term heart outcomes. Our article on sleep apnea and the heart covers what's known about the heart in more detail.

Do older adults stick with CPAP?

Older adults often stick with CPAP as well as or better than younger adults. In telemonitoring data from 789,260 US patients, adherence by Medicare criteria was 72.6% overall but ranged from 51.3% in women aged 18 to 30 up to 80.6% in men aged 71 to 80.

The same study found older patients took longer to settle in. They increased their use steadily, taking more than a week to reach their peak, and then their use declined much more slowly over time than younger patients' did. That's useful to know if the first week feels slow.

The very oldest group may find it harder. The 2022 European Respiratory Journal review describes a study of patients over 65 in which average use fell below acceptable levels, particularly in those aged 80 and older. It lists things that can get in the way at older ages, including living alone, chronic pain, cognitive impairment and dental problems.

If you or a parent is starting out, practical support makes a difference. Our guide to getting used to CPAP covers mask fit, ramp settings and humidity. If the pressure feels hard to breathe against, our comparison of CPAP, APAP and BiPAP explains the other machine types.

Does Medicare cover sleep apnea testing?

Medicare covers sleep apnea testing for people who have signs and symptoms of the condition. Medicare.gov says Part B covers Type I, II, III and IV sleep tests if you're eligible. After the Part B deductible, you pay 20% of the Medicare-approved amount, and your doctor must order the test.

The rules for which tests count come from the national coverage determination for sleep testing (NCD 240.4.1). Type I is an attended, full polysomnography study in a sleep lab and is only covered there. Type II and III devices are covered at home or in a lab. Type IV devices are covered if they measure three or more channels, one of which is airflow. Devices measuring three or more channels that include actigraphy, oximetry and peripheral arterial tone are also covered.

That means many people on Medicare can do a home test. Our guide to the home sleep apnea test explains how the home option works.

Does Medicare cover CPAP?

Medicare covers CPAP for people diagnosed with obstructive sleep apnea, starting with a trial. Medicare.gov says Part B may cover a 12-week trial of CPAP therapy, including devices and accessories. After that, coverage can continue if you see your doctor in person and they document that you meet certain conditions and the therapy is helping.

Medicare.gov says that after the Part B deductible you pay 20% of the Medicare-approved amount for the machine rental and supplies like masks and tubing. Medicare pays the supplier to rent the machine for 13 months as long as you use it continuously, and after that you own it. It also suggests asking whether a supplier accepts assignment before you get equipment, since one that doesn't may charge you more.

Medicare's detailed CPAP rules, including the sleep test results that qualify and how much nightly use counts during the trial, are covered in our comparison of CPAP, APAP and BiPAP, along with how they affect which machine you get.

When should an older adult get checked?

An older adult should get checked if a bed partner hears pauses in breathing, gasping or loud snoring, or if they have daytime sleepiness, frequent night-time urination, new memory trouble or unexplained falls. These are worth raising even when they seem like normal parts of aging.

Bring a list of medicines and any heart, lung or neurological conditions to the appointment. The 2022 European Respiratory Journal review notes that central sleep apnea, a different form that isn't caused by a blocked airway, is a bigger factor in older people, partly because heart failure is common at older ages. Our guide to central sleep apnea explains how it differs.

This article is general information, not medical advice. A doctor can help decide whether testing makes sense for you or someone you care for.

Read next

• Snoring and age
• Home sleep apnea test
• CPAP vs APAP vs BiPAP

* This content is for informational and educational purposes only and is not medical advice. It is not intended to diagnose, treat, cure or prevent any disease or health condition. Talk to a qualified healthcare provider about your health.