Westermeyer, Eliza Thompson

Abstract Introduction Emerging evidence suggests that positive airway pressure (PAP) treatment for moderate-to-severe obstructive sleep apnea (OSA) in elderly patients does not improve daytime sleepiness, or quality of life outcomes, despite improving apnea-hypopnea index (AHI). While oral appliance therapy (OAT) is known to be an effective treatment for mild-to-moderate OSA, its efficacy in treatment of elderly patients with severe OSA is unknown. Methods Retrospective chart review of patients ≥ 65 years old with diagnosis of OSA, treated with OAT, who underwent subsequent follow-up sleep testing and clinical assessments, including Epworth Sleepiness Scale (ESS), a measure of daytime sleepiness. Results We studied 66 elderly patients with OSA (31 women, 35 men), including 58 with mild-to-moderate OSA (AHI < 30) and 8 with severe OSA (AHI ≥ 30) treated with OAT. At baseline, patients with mild-to-moderate OSA had a median AHI of 11.6 compared to 41.3 in patients with severe OSA (p < 0.0001). There was no difference in ESS score between patients with mild-to-moderate OSA (median ESS = 8; IQR = 4-12) and severe OSA (median ESS = 6; IQR = 3-9). Following their OSA diagnosis, OAT was offered due to PAP intolerance (n = 32), patient preference (n = 28), or as an alternative treatment option (n = 4). After initiation of OAT, 42 patients with mild-to-moderate and 7 with severe OSA underwent follow-up assessment with home sleep testing (n = 32), oximetry (n = 15), or polysomnography (n = 2). At follow-up assessment, ESS was decreased in patients with mild-to-moderate OSA (median ESS = 5; IQR = 3-8) and severe OSA (median ESS = 5; IQR = 3-7), indicating reduction in daytime sleepiness in response to OAT in both groups. Moreover, 50% of patients with mild-to-moderate OSA and 50% of severe OSA patients saw ≥ 50% reduction in AHI. Conclusion Our study findings suggest that treatment with OAT in mild-to-moderate and severe OSA is tolerable and effective in elderly patients who do not have contraindication for this treatment. OAT should be considered as an alternative treatment specifically for elderly adults with severe OSA not tolerating or improving with PAP therapy. Support (if any)

Abstract Introduction: Dyspnea is a common and debilitating symptom in chronic obstructive pulmonary disease (COPD) that significantly impacts quality of life. While often attributed to cardiopulmonary causes, other factors such as neuromuscular, psychogenic, or medication-related issues should also be considered. In older adults, polypharmacy, comorbid conditions, and age-related physiological changes can complicate evaluation. A comprehensive geriatric approach, which includes medication review and functional status assessment, is helpful in evaluating persistent dyspnea. Here, we present a case of an older adult with dyspnea thought to be due to extrapyramidal symptoms (EPS) related to antipsychotic use. Case Description: A 75-year-old male with a history of bipolar disorder, diastolic heart failure, 15-pack-year smoking history, and recently diagnosed with COPD presented with persistent dyspnea on exertion. His symptoms began after initiating lurasidone for bipolar disorder. Along with dyspnea, he developed involuntary movements, including sniffing, facial grimacing, cheek sucking, and tremors. Discontinuation of lurasidone resolved the tremors and cheek sucking, but sniffing and grimacing persisted. Pulmonary workup, including high-resolution chest CT and pulmonary function testing, showed mild emphysematous changes, borderline obstruction with significant bronchodilator response, and normal diffusion capacity. A comprehensive cardiac evaluation, including myocardial perfusion stress testing and echocardiogram, revealed no cardiac cause. Despite pulmonary rehabilitation and inhaler therapy, symptoms persisted. Ultimately, he was evaluated by a neurologist and geriatrician. He reported significant decline in engagement in previously enjoyable activities due to his symptoms. During examination, frequent sniffing tics were observed. His dyspnea was thought to be caused by involuntary respiratory muscle movements resulting from extrapyramidal symptoms (EPS) induced by lurasidone, which can persist even after the medication discontinuation. Tetrabenazine, commonly used to manage EPS in antipsychotic-treated patients, was considered but ruled out due to its potential side effects in older adults, including orthostasis, sedation, and depression. Given the patient's previous adverse medication reactions, he was particularly concerned about avoiding further side effects. Therefore, he was prescribed low-dose guanfacine, a medication used to treat tic disorders with a lower risk of side effects. After one month, he reported improvement in his sensation of dyspnea. Discussion: This case highlights the importance of a geriatric approach when evaluating unexplained dyspnea in older adults. Polypharmacy and medication side effects, such as EPS, can mimic or exacerbate respiratory symptoms. The American Geriatrics Society's “5 M's” framework—mind, mobility, medications, multi-complexity, and matters most—helps guide management in this complex patient population.