Picture someone with sleep apnea.
Did you see a big guy with a thick neck and a soft, heavy face? A guy who carries quite a lot of extra weight? At night, his bedroom fills with the rumble and roar of snoring, punctuated every so often by a choke or gasp that makes his partner nudge him to roll over. By day, he fights to keep his eyes open, maybe even nodding off in his cubicle in the middle of entering data or staring at a spreadsheet.
That the person who instantly came to mind?
For decades, most of the studies and screening tools used to diagnose obstructive sleep apnea (OSA) were built largely around male patients who looked a lot like that. But as researchers have taken a closer look at how the condition shows up across different populations, a more complicated reality has come into focus.
A recent projection suggests that by 2050, nearly 77 million adults between the ages of 30 and 69 could be living with OSA. More striking, though, is that the increase is expected to be far steeper for women – about 65%.
And that raises a troubling possibility: What if a good number of those future individuals don’t fit the picture that doctors have been trained to look for?
That’s exactly what some researchers now believe is happening.
Take women, for instance. As Wired recently reported,
The checklists physicians rely on—loud snoring, witnessed breathing pauses, excessive daytime sleepiness—were largely developed and validated in male or mixed cohorts. Many of the most widely used tools for measuring hypersomnia, including the Epworth Sleepiness Scale, were not validated in women across age groups. And the symptom that often triggers CPAP referral, such as excessive daytime sleepiness, may be described or experienced differently by women.
Women’s complaints often lean toward insomnia, mood changes, headaches, or persistent fatigue rather than overt sleepiness. They may report nocturia—“so getting up to use the restroom more often can be a sign,” Aurora says—or fragmented sleep that feels indistinguishable from stress.
Meanwhile, the breathing events themselves can be quieter.
You can’t see what you’re not looking for. How could you possibly diagnose it?
Age can complicate the picture in similar ways, as a new paper in Sleep Medicine Reviews shows. Its authors highlight several physiological changes that come with aging – from shifts in upper airway function to changes in breathing control and sleep structure – that may influence both how sleep apnea develops and how it responds to treatment.
Accordingly, the symptoms of sleep apnea can be different, as well.
Older adults often do not have classic symptoms such as excessive daytime sleepiness. Instead, they tend to experience fatigue, insomnia, cognitive changes, falls or mood disturbances.
The authors also highlight the close relationship between obstructive sleep apnea and frailty. The researchers noted that intermittent low levels of oxygen in the blood, inflammation and hormonal dysregulation may contribute to declining physical and cognitive reserve[s]. While CPAP remains the standard treatment for moderate-to-severe cases, evidence suggests that benefits may be attenuated in patients over 80.
That last point about CPAP is worth noting. While the device can literally save lives, it isn’t always the most practical or comfortable option for every patient, especially seniors. In fact, some research suggests that oral appliance therapy may be a particularly helpful option for certain older adults.
And as we saw in another recent post on our blog, teens, too, can have OSA that presents differently from the classic case of the big, middle-aged guy with the big neck.
Sure, sometimes that stereotype is accurate. But not always.
Sometimes it’s a woman lying awake night after night, wondering why sleep never feels restorative. Sometimes it’s an older man struggling with fatigue or memory changes that seem to have no clear cause. And sometimes it’s someone much younger than anyone would expect.
Sleep apnea doesn’t always announce itself in obvious ways.
And sometimes the hardest part of diagnosing a condition is recognizing that it doesn’t always look the way we were taught to expect.