Pharmacologic Treatment for Obstructive Sleep Apnea in Older Adults

Older individuals frequently suffer from obstructive sleep apnea yet present with less severe symptoms than younger counterparts. Diagnosing obstructive sleep apnea in older adults poses unexpected challenges owing to poor specificity of screening tools and difficulty attending polysomnography. Continuous positive air pressure remains recommended, although its benefits in this population are not clear and many patients refuse to even attempt the therapy. Emerging research regarding the pathophysiology of obstructive sleep apnea has facilitated greater understanding of potential pharmacologic targets. Pharmacotherapy for obstructive sleep apnea is multifaceted with unique mechanisms, varying efficacy, and considerations for safety and tolerability. Glucagon-like peptide-1 receptor agonists have yielded well-tolerated positive results in obstructive sleep apnea by facilitating reduced upper airway adiposity, with tirzepatide demonstrating improvements in hypoxic burden, apnea-hypopnea index and sleep outcomes. Noradrenergic-antimuscarinic combinations have demonstrated significant reductions in the apnea-hypopnea index and improved oxygen saturations through increased pharyngeal dilator tone, although these agents present high-risk anticholinergic side effects in older patients. Serotonergic and cholinergic agents may promote increased pharyngeal muscle tone, but studies are limited by small samples, methodology, and conflicting results. Sedative-hypnotics may improve sleep quality or arousal threshold but present risks of central nervous system depression in older adults. The carbonic anhydrase inhibitor sulthiame has demonstrated dose-dependent improvements in obstructive sleep apnea severity with well-tolerated outcomes. Ultimately, older patients have unique diagnostic and management considerations, warranting further study of obstructive sleep apnea pharmacotherapy to assess age-specific efficacy and outcomes.