It starts as a domestic joke. He snores. She elbows him. Somebody moves to the spare room “just for a while”, and a while turns into eleven years. Nobody calls a GP about snoring, because snoring is not an illness, it is a personality trait.
Except that for a substantial number of people over 65 in Ireland, it is the loudest symptom of a treatable condition that is fragmenting their sleep, making them dangerous on the N11 at four in the afternoon, and being written off, by them and sometimes by their doctor, as ageing.
TL;DR
- Obstructive sleep apnoea affects an estimated 20% to 40% of older adults, at least double the rate in younger age groups.
- In older adults it is often not about weight: the airway becomes measurably more collapsible with age, independent of body mass index.
- Standard risk scores are built around high BMI, thick necks and male sex, and are inaccurate in women, in people who are not overweight, and in older adults.
- Night-time peeing gets blamed on the prostate, daytime sleepiness on age, and brain fog on early dementia. All three can be sleep apnoea.
- If you have moderate or severe sleep apnoea causing daytime sleepiness, you must not drive until it is controlled, and you must notify the NDLS using form D501. A letter from your doctor is not accepted.
- The PREDICT trial, run specifically in people aged 65 and over, found CPAP works about as well as it does in middle age. Age is not a reason to be offered less.
What obstructive sleep apnoea actually is
In obstructive sleep apnoea the walls of the throat relax far enough to narrow or fully block the airway, so breathing stops and starts through the night. A complete stop is an apnoea; a partial one is a hypopnoea. Each event usually ends with a brief arousal: the brain surfaces just enough to reopen the airway, then sinks again. This can happen dozens of times an hour, all night, for years, without the person ever knowing they woke up.
Severity is measured by the apnoea-hypopnoea index, the number of these events per hour of sleep. The HSE sets the bands at mild for 5 to 14, moderate for 15 to 30, and severe for over 30. Someone with severe sleep apnoea is being pulled out of proper sleep more than once every two minutes.
Why the airway changes with age, and why weight is not the whole story
The familiar picture, the overweight middle-aged man with an 18-inch collar, describes a different patient. The ageing upper airway changes physically: the pharyngeal airway lengthens in both men and women, the hyoid bone descends, and the cross-sectional area of the airway narrows. The genioglossus, the muscle that holds the tongue forward and the airway open, also responds less briskly. The airway simply collapses more easily. One measure of this, the critical closing pressure, averages roughly -8.3 cmH2O in older adults compared with about -16.0 cmH2O in younger ones, and crucially that difference holds independent of body mass index.
In a classic study using an index above 10 events per hour plus daytime sleepiness, the condition was present in 3.2% of people aged 20 to 44, 11.3% of those aged 45 to 64, and 18.1% of those aged 61 to 100. Broader estimates for older adults in the general population run from 20% to 40%. In nursing home populations, figures as high as 70% have been reported. The male-to-female gap, which is stark in midlife, narrows considerably after menopause.
The risk scores were not designed for you
This matters, because the screening tools in routine use were validated on middle-aged populations and weight their scoring towards high BMI, large neck circumference and male sex. Research is clear that these clinical prediction models “have been shown to be inaccurate” in exactly three groups: women, people who are not obese, and older adults.
Older patients with sleep apnoea typically have a lower BMI and a smaller neck circumference than younger patients with the same disease severity, so they score fewer points on the very form designed to detect them. A slim 72-year-old woman with moderate sleep apnoea can sit through a screening questionnaire and come out looking low-risk.
There is a second, more ordinary blind spot. Most detection advice, including the HSE’s own, assumes someone is watching you sleep: ask a partner whether you snore, gasp or stop breathing. A great many people over 70 in Ireland sleep alone. The most reliable witness to the condition is the one person the guidance quietly assumes you have.
The symptoms that get filed under something else
Sleep apnoea in later life rarely announces itself. It gets absorbed into other explanations, most of them plausible:
- Getting up three times a night to pee. Nocturia has many causes, and in men it is routinely attributed to the prostate. Sleep-disordered breathing is on that list and is almost never the first thing considered.
- Daytime sleepiness. Nodding off after lunch, in front of the television, in the passenger seat. Treated as a normal feature of retirement rather than a symptom.
- Memory and concentration problems. Among people with cognitive impairment, sleep-disordered breathing prevalence may be as high as 50%. In one study of patients with diagnosed dementia and night-time agitation, 49% had an index above 15 events per hour. Sleep apnoea is not a cause of every cognitive symptom, but it is a treatable contributor that is worth ruling out before conclusions harden.
Complicating all of it, sleep genuinely does fragment with age on its own. The number of spontaneous arousals per hour in people over 60 can be nearly double that of younger adults, entirely independent of sleep apnoea. So “I sleep badly, but I’m 74” is a reasonable thing to think. It is just not a reason to stop asking.
What Ireland knows, and what it doesn’t
Honestly: not enough. There is no accurate national prevalence figure for obstructive sleep apnoea in Ireland. Estimates extrapolated from international studies put the number between 50,000 and 100,000 adults, and the Road Safety Authority’s driver leaflet states it is “believed to affect at least 100,000 people in Ireland”. Both are inferences, not measurements.
Your GP will ask about symptoms and daytime sleepiness, take your blood pressure, and may take bloods to rule out other causes such as an underactive thyroid. From there, referral is to a sleep clinic. Overnight polysomnography in hospital remains the reference test, but home-based respiratory polygraphy, a small device recording airflow, breathing effort, oxygen levels and snoring in your own bed, is now widely used and agrees with the hospital test around 79% of the time, rising above 90% in more severe disease. For anyone frail, or unwilling to spend a night wired up in a strange room, that matters.
The driving conversation you cannot skip
Sleepiness and fatigue account for an estimated 15% to 20% of all road traffic crashes. Drivers with untreated obstructive sleep apnoea syndrome are roughly three times more likely to be in a collision than the general population, and that excess risk disappears with effective treatment.
Under the Sláinte agus Tiomáint medical fitness to drive guidelines, if you have moderate or severe sleep apnoea causing excessive daytime sleepiness, you must not drive until your symptoms are under control and confirmed as such by a medical professional, and you must notify the National Driver Licence Service. Car, motorcycle and tractor drivers may then be granted a one to three year licence with regular reviews; bus and truck drivers face annual review. Notification means bringing a completed driver licence application form, a Medical Report Form D501 completed by your doctor, proof of your PPS number and your current licence to an NDLS centre. A letter from your doctor is explicitly not accepted in place of the D501.
One caution worth flagging: the RSA leaflet on this topic still directs readers to the Irish Sleep Apnoea Trust at isat.ie. As of today that web address resolves to an unrelated commercial hotel supplier. If you are following the printed advice, go to your GP or the NDLS site rather than that link.
“I’d never stick with a machine at my age”
Probably the most common objection, and the evidence does not support it.
PREDICT was designed precisely because CPAP had been proven in middle age and never properly tested in older patients. It randomised 278 patients aged 65 and over with newly diagnosed sleep apnoea syndrome across 14 hospital sleep services to CPAP plus best supportive care or best supportive care alone, and followed them for 12 months. CPAP reduced daytime sleepiness on the Epworth scale by 2.1 points (95% CI -3.0 to -1.3), improved quality of life, and was marginally cost-effective. The authors’ conclusion was unambiguous: CPAP should be offered routinely to older patients. A second large trial in this age group found the same, with added gains in cognitive measures.
On sticking with it, age has not been identified as a risk factor for poorer CPAP adherence. Studies in patients averaging 66 and 73 years found compliance comparable to middle-aged groups, and a cohort with mild-to-moderate Alzheimer’s disease tolerated it well. Where CPAP is not workable, a mandibular advancement device fitted by a dentist experienced in sleep medicine is a real alternative.
Where the evidence is genuinely softer is cardiovascular benefit specifically in older adults. Some large cohorts found the risk more clearly elevated in people under 65 than over. Against that, a cohort of 939 patients aged 65 and over followed for 69 months found those with severe untreated disease had the highest all-cause and cardiovascular mortality, while those treated with CPAP had mortality similar to people with only mild disease. The sleepiness benefit is well established; the cardiac case is suggestive rather than settled.
What it costs in Ireland
Sleep apnoea is not covered by the Long-Term Illness Scheme, whose list of qualifying conditions has not been added to since the 1970s. CPAP rental is, however, an approved appliance under the Drugs Payment Scheme, which caps household spending on approved drugs, medicines and appliances at €80 a month. Medical card holders can have CPAP equipment covered by the HSE, with the supplier handling the paperwork.
Three things worth doing this week
- Keep a seven-night sleep diary. Hours slept, night wakings, trips to the bathroom, how rested you feel in the morning, how sleepy you get during the day. Bring it to your GP: it converts a vague complaint into something a referral can be built on.
- Ask specifically, not generally. “Could my night-time waking and daytime tiredness be sleep apnoea?” is a different conversation from “I’m not sleeping well.” Name the condition.
- Be honest about driving. Heavy eyes, continual yawning, or no memory of the last few miles: that is the conversation to have first, and to have before someone else makes it for you.
Growing older changes how you sleep. That much is true and unavoidable. But an airway that closes sixty times an hour is not ageing, it is a diagnosis, and it is one of the more reliably treatable things in geriatric medicine. The difficulty is not the treatment. It is getting anyone, including yourself, to take the snoring seriously enough to ask.
Críonna Health publishes evidence-informed guidance on ageing well in Ireland, including how HSE schemes and referral pathways actually work.
📷 Photo by Ahya Agawis on Unsplash
