Fall 2025

Fall 2025 Issue

The Last Word: The Hidden Danger
By Bahar Esmaili, DDS
Today’s Geriatric Medicine
Vol. 18 No. 4 P. 32

How Untreated Sleep Apnea Puts Millions of Older Adults at Risk

Untreated obstructive sleep apnea (OSA) severely affects overall health and quality of life in older adults, increasing the risk of cardiovascular disease, stroke, cognitive decline, and depression, while also exacerbating conditions like diabetes and hypertension, chronic fatigue, and poor sleep quality leading to depression. Fragmented sleep and intermittent hypoxia impair immune responses, increasing susceptibility to infections and slowing recovery from illnesses. Despite its prevalence, awareness and testing remain low due to a lack of routine screening, misinterpretation of symptoms as age-related changes, and limited knowledge among older adults and health care providers.

Age-related muscle tone loss, obesity, and anatomical changes in the airway contribute to the high prevalence of OSA in older adults. Many cases can be traced back to underdeveloped upper and lower jaws, which lead to a restricted airway. Symptoms like fatigue, irritability, and memory difficulties are often attributed to natural aging rather than a treatable sleep disorder. Additionally, conditions like insomnia and fragmented sleep, common in older adults, can mask OSA symptoms.

Many doctors overlook OSA in older adults, prioritizing other chronic conditions. Promoting early recognition and diagnosis is essential to mitigate these adverse health effects. Raising awareness and increasing screening for OSA in the aging population is critical to improving lifespan, cognitive function, and overall quality of life.

Given the aging population, OSA is a public health crisis that needs greater awareness, better screening practices, and more accessible treatment options.

Risks & Impact of Untreated OSA

Cardiovascular Diseases
Untreated OSA causes repeated oxygen deprivation and disrupted sleep, leading to increased sympathetic nervous system activity, inflammation, and oxidative stress. These physiological responses elevate blood pressure, strain the heart, and contribute to the development of heart failure, coronary heart disease, and arrhythmias. Ignoring OSA in geriatric medicine leads to worsened cardiovascular health, cognitive decline, increased fall risk, higher hospitalization rates, and reduced quality of life.

Diabetes
OSA and diabetes are closely linked, particularly among older adults. OSA disrupts normal sleep patterns and reduces oxygen levels, leading to insulin resistance and glucose intolerance. Additionally, poor sleep quality affects hormonal regulation, further exacerbating diabetes management. Effective OSA treatment can enhance insulin sensitivity, lower blood sugar levels, and improve overall metabolic health, making comprehensive care crucial for older adults with both conditions.

Cognitive Decline and Dementia
OSA is associated with cognitive decline and a heightened risk of dementia due to chronic oxygen deprivation and fragmented sleep. Frequent nighttime awakenings due to apneic episodes prevent deep, restorative, slow-wave sleep and rapid eye movement sleep, both crucial for memory consolidation. Disrupted sleep affects the glymphatic system, which removes toxic proteins like beta-amyloid and tau, both associated with Alzheimer’s disease.

These factors can impair memory, attention, and executive function. Early OSA diagnosis and treatment can protect cognitive function and support brain health in older adults.

Challenges
Diagnosing OSA in older adults is challenging, and OSA is frequently overlooked in geriatric medicine due to symptoms overlapping with other age-related conditions like cognitive decline, depression, and cardiovascular disease. Cognitive impairment may further hinder symptom reporting. Older adults may also underreport symptoms like daytime sleepiness. Moreover, health care providers may prioritize treating more immediate health concerns. Unlike cardiology, endocrinology, or neurology, sleep medicine is not a routine part of geriatric checkups. Specialists such as pulmonologists or sleep physicians may not be easily accessible to older adults.

Understanding that the root cause of OSA often lies in anatomical factors, such as underdeveloped jaws, can also guide more accurate diagnosis and treatment using the latest technologies to remodel and restore proper airway form and function in adults of all ages. Collaborative care models involving primary care providers, sleep specialists, specially trained dentists, and other caregivers can facilitate timely diagnosis and intervention. Implementing routine sleep assessments using the latest home sleep testing equipment, especially for patients with chronic conditions, can improve diagnosis rates and lead to better management of OSA in older adults.

Limitations of CPAP Therapy
CPAP therapy can be challenging for older adults due to mask discomfort, noise, and difficulty maintaining consistent use. Many patients give up on CPAP early due to dryness or claustrophobia, and alternative treatments such as the latest kind of restorative oral appliance therapy are not always well-known or offered to older adults.

Benefits
The latest form of oral appliance therapy is noninvasive, comfortable, restorative to the form and function of the airway, of limited treatment duration time, and easy to maintain after treatment, making it an attractive and effective solution for older adults. This type of treatment offers a more user-friendly and portable solution, promoting adherence. These devices are custom-fitted and work to remodel and rehabilitate the tissues that define and support the form and function of a human airway, allowing for limited treatment time and little or no relapse posttreatment. While CPAP has long been considered the gold standard for OSA treatment, next-generation oral appliances are now recognized as a highly effective alternative and are FDA-cleared for all levels of OSA severity. Unlike CPAP, they require no electricity or complex setup, offering greater convenience for those with limited mobility or dexterity. With CPAP no longer being the sole gold standard, this latest generation of oral appliances provides a sustainable, patient-centered treatment option. By addressing the root cause of OSA, such as underdeveloped jaws, oral appliances and devices offer a more comprehensive solution. Addressing the underlying issue of jaw underdevelopment with next-generation oral appliance therapy can provide lasting relief.

Final Thoughts
Regular follow-ups during the estimated nine to 12 months of active treatment time help ensure optimal fit and effectiveness, and eliminate the need for long-term intervention and patient compliance for life. Older adults should be encouraged to take an active role in their care, working with their providers to select the most appropriate therapy for their needs.

To improve awareness and screening, health care providers should incorporate routine sleep assessments in annual wellness visits. Educational campaigns targeting older adults, caregivers, and providers can increase recognition of OSA symptoms. Caregivers play a crucial role in identifying changes in sleep patterns and behavior. Understanding the link between symptoms and jaw underdevelopment can also aid in a more accurate diagnosis. Multidisciplinary collaboration, including sleep specialists and geriatricians, ensures timely diagnosis and comprehensive management. Encouraging open discussions about sleep health can further reduce stigma and promote proactive care, empowering patients to be actively involved in their treatment decisions. Patients should actively participate in their treatment decisions, considering both options—CPAP and all forms of oral appliance therapy—to choose the solution best suited for their overall health and comfort.

— Bahar Esmaili, DDS, is the vice president of clinical integration at Vivos Therapeutics (https://vivos.com). With over five years of experience transitioning from traditional dentistry to a focus on airway health, Esmaili brings a holistic approach to treating breathing disorders and their impact on overall health. Her expertise lies in addressing root causes of chronic health issues, emphasizing the connection between breathing, posture, and well-being.