Obstructive Sleep Apnea and Obesity in Older Adults: What Patients and Clinicians Should Know

By Glenye Cain Oakford

Obstructive sleep apnea (OSA) and obesity are two of the most prevalent and consequential health conditions affecting older adults in the United States. Both are common. Both are frequently underdiagnosed. And increasingly, research shows they are biologically interconnected.

During a recent webinar hosted by the Gerontological Society of America (GSA) in partnership with the Alliance of Sleep Apnea Partners (ASAP), three leading experts examined how obstructive sleep apnea changes with age, how obesity and sleep apnea influence one another, and important factors in treating older adults.

The panel featured ASAP President and CEO Monica Mallampalli, PhD; Jennifer L. Martin, PhD, Professor in the College of Medicine at Florida International University; and Christopher Schmickl, MD, PhD, Associate Professor at the University of California San Diego.

Their message was clear: sleep apnea in older adults is common, often missed, and treatable, but treatment must be individualized.

Key Takeaways

• Obstructive sleep apnea is believed to affect at least 54 million U.S. adults, and likely more.

• OSA prevalence increases with age, especially in women after menopause.

• Obesity and sleep apnea have a bidirectional relationship, meaning they contribute to each other.

• Untreated OSA increases risk for cardiovascular disease, type 2 diabetes, atrial fibrillation, and cognitive decline.

• Women are more likely to be underdiagnosed due to different symptom presentation from the classic symptoms in men.

• CPAP remains first-line therapy, but patients can find it challenging to stick with CPAP.

• New weight-loss medications have shown promise in reducing OSA severity.

• Consumer wearables cannot rule out or definitively diagnose sleep apnea.

• Interdisciplinary screening and patient self-advocacy are essential.

How Common Is Obstructive Sleep Apnea in Older Adults?

"We believe there are over 54 million adults living with obstructive sleep apnea," Dr. Mallampalli said. "But I think the numbers may even be higher, because we really don't know the true numbers."

Prevalence increases with age. After age 60, rates appear to plateau, but this might reflect underdiagnosis rather than decreased risk.

Sleep Apnea and Menopause

Obstructive sleep apnea is more common in men during midlife. But after menopause, women's risk rises significantly.

"We see it's much higher in men," Dr. Mallampalli explained. "But when women reach menopause, their risk for obstructive sleep apnea is equal to men."

Despite this shift, women remain less likely to be diagnosed, Florida International University’s Dr. Martin noted. Women often report fatigue, low energy, or insomnia-like symptoms rather than the classic loud snoring or excessive daytime sleepiness commonly associated with sleep apnea in men.

“So sometimes we have to be thoughtful, because even with mild sleep apnea, women can have more severe symptoms during the day,” Dr. Martin explained. “The other thing to consider … is because women tend to have milder sleep apnea, they may have a larger range of treatment options available, including oral appliances. Because men tend to have more severe sleep apnea, some of those treatments might not alleviate the severity of their sleep apnea or their symptoms as much.”

Women also are more likely to have both sleep apnea and insomnia disorder than men, Dr. Martin added. “So sometimes, even if we treat a woman's sleep apnea, their sleep doesn't get better, because they have another sleep disorder layered on top of it. I think we have to also be mindful that just because a person has sleep apnea, that doesn't mean it's the only sleep issue that they have.”

The Bidirectional Relationship Between Obesity and Sleep Apnea

Obesity is one of the strongest risk factors for obstructive sleep apnea. Fat deposition around the upper airway increases airway narrowing and collapsibility. 

"We know about 69% of adults with obesity have some form of obstructive sleep apnea," Dr. Mallampalli said, noting that “an individual has a six times higher chance of developing obstructive sleep apnea with a 10% weight gain.

“I do want to mention something for the audience to understand,” she added. “Not all people with obstructive sleep apnea have obesity, so that means there are certain factors that are at play here that can lead to obesity in patients with obstructive sleep apnea.”

The relationship goes both ways, creating a vicious cycle for patients that can negatively affect their health. UC San Diego’s Dr. Schmickl said that, while the relationship between sleep apnea and obesity is “complicated,” some data suggests that obstructive sleep apnea can disrupt hormones that regulate hunger and satiety, contributing to weight gain. It may also contribute to insulin resistance and metabolic dysfunction. 

Importantly, treating OSA with CPAP does not guarantee weight loss, Dr. Schmickl said. Similarly, losing weight does not guarantee sleep apnea will resolve, Dr. Mallampalli pointed out.

“I want to make sure when someone living with obesity does try to lose weight or manage their condition,they cannot assume that their obstructive sleep apnea may go away,” she said. “This is something they always have to be on the lookout for, and this is sort of something we always bring up and discuss with people.”

Health Risks of Untreated Sleep Apnea in Older Adults

Untreated obstructive sleep apnea is associated with increased risk for:

• Hypertension

• Cardiovascular disease

• Atrial fibrillation

• Heart failure

• Type 2 diabetes

• Cognitive decline

• Alzheimer's disease

  
  

These same conditions are comorbid with obesity. "When you have both OSA and obesity, I believe there will be a synergistic effect and much more increased risk towards these conditions," Dr. Mallampalli said. “We also need more research and understanding of these connections and links.”

“Even in patients or people without overweight or obesity, the prevalence starts going up as we age, and that's probably related to age-related changes of upright airway anatomy, neuromuscular control, ventilatory control, for example,” Dr. Schmickl said. “Other comorbidities also become more prevalent, like heart failure, atrial fibrillation, which can lead to some ventilatory instability, which can contribute to sleep apnea pathogenesis. There are also potential changes like in fat distribution—not every BMI is equal. If the fat is maybe more in the tongue, that might be more significant for the sleep apnea pathogenesis. And there are changes to sleep architecture: there are more light sleepers who might be more vulnerable to having sleep apnea.”

"Having any untreated sleep disorder is not good for your brain health," Dr. Martin observed. “There's some data that when you treat sleep apnea in patients who have mild or moderate cognitive impairment, that their cognition does improve. It doesn’t cure their underlying dementia, but it does improve their cognition and reduce sleepiness during the day.

Treating sleep apnea in individuals with mild cognitive impairment may improve cognition and daytime alertness. “It's not going to make the dementia go away," Dr. Schmickl noted, "but it may help improve cognition on a day-to-day level."

Treatment Considerations in Older Adults

Treatment decisions for obstructive sleep apnea in older adults should be individualized and grounded in shared decision-making.

"The focus in my older patients is often a little bit more on quality of life, but it's really, really important to individualize that," Dr. Schmickl said. 

Clinicians must consider symptom burden, cardiovascular risk, cognitive status, fall risk, muscle loss, treatment burden, and caregiver involvement.

"With my older patients, I do emphasize the potential risks even more so, trying to focus on the safety and also considering the treatment burden,” Dr. Schmickl explained. “CPAP for some people may work really well, but some people may not have the dexterity to kind of put on that mask. So then the question is, ‘Do you have someone to help you with that?’ Or with tirzepatide [Zepbound^®]—this weight loss medication now which is very effective—some of the risks might be more pronounced now. Like if you have some dehydration, you get dizzy, and you may have a fall or something. … At the end of the day, it's what matters to you, what is important to you, what are you trying to achieve here? It's usually a very long discussion that I have with my patients."

Dr. Martin noted that patients also have to navigate the misinformation they encounter.

“There's a lot of bad information out there,” she said. “I haven't heard it for a while, but putting duct tape over your mouth does not cure your sleep apnea. And there's a lot of ineffective and a few unsafe treatments out there, so [we encourage] patients to go to organizations like ASAP or the American Academy of Sleep Medicine or the American Thoracic Society and make sure that the information that they're getting about sleep apnea is accurate and safe.”

CPAP and Adherence

CPAP remains the most effective therapy for moderate to severe OSA. However, adherence—sticking to treatment—can be challenging for many patients.

“It's very important that patients are realistic about their ability to use the treatments that they choose,” Dr. Martin said. “And I think on the provider side, we should be more supportive and encouraging of people who use their treatment sometimes. This is a big challenge with CPAP treatments, because Medicare has a threshold that they require patients to use their CPAP machine in order to keep it and continue to get supplies. I also work in the VA system; we have no such rule. And a big reason why that's important is that we have a lot of folks with mental health conditions like post-traumatic stress disorder, where their sleep time is actually quite short. 

“I think we always want patients using their treatment all the time, but I hear a lot of patients who come to me for help with CPAP adherence, because their perception is that if they're not using it all the time, they're failing. They're not failing, they're just not fully succeeding. So I think from a patient education perspective, treating your sleep apnea sometimes is better than not treating it at all.”

Weight Loss and Emerging Medications

“Just in the last 10 years, so much has changed” in the treatment landscape, Dr. Schmickl said. “We have CPAP, oral appliances, hypoglossal nerve stimulation. There are two other hypoglossal nerve stimulators that are getting approved soon.”

Perhaps the biggest recent change is the emergence of new medications, such as the weight-loss medication tirzepatide, the first medication approved by the Food & Drug Administration to treat sleep apnea in patients with obesity.

"On average, people lose about 20% of weight, which, on average improves sleep apnea severity by 55%," Dr. Schmickl said of tirzepatide. “I think in the next few years, we’ll see a whole range of new medications in that space coming out that will be a lot of value for our patients with sleep apnea.”

Wearables and Sleep Tracking Devices

Consumer devices such as smart watches and sleep apps can be useful for accountability, Dr. Mallampalli noted. But it’s important to understand that they cannot diagnose or rule out obstructive sleep apnea.

"If your wearable tells you don't have sleep apnea, we have no evidence that that is an accurate assessment," Dr. Martin said. 

So instead of trusting what your smart watch or ring says, “definitely have that conversation with your doctor,” Dr. Mallampalli agreed. 

The Role of Interdisciplinary Care

Sleep apnea screening should occur across healthcare disciplines.

"Every healthcare provider has the ability to identify a patient at risk for sleep apnea and get them on the right path," Dr. Martin emphasized.

A simple question, “How are you sleeping?” can initiate meaningful intervention.

“If people living with obesity are seeing cardiologists, they may be good at diagnosing sleep apnea, so it's worth having the conversation with doctors from other disciplines,” Dr. Mallampalli said. “Neurologists, cardiovascular disease specialists, dentists have become an important part of diagnosing people with obstructive sleep apnea.”

Ideally, look for a doctor certified in sleep medicine. And ask questions.

"At ASAP, we encourage self-advocacy," Dr. Mallampalli said. “We want patients to understand what the symptoms are, what the risks are, and how to talk to your providers.”

Dr. Mallampalli also noted that because patients are asleep during apneic events, bed partners are often the first to recognize symptoms. Bringing a partner to appointments can improve diagnosis and communication.

Frequently Asked Questions

Does sleep apnea increase with age?

Yes. Obstructive sleep apnea becomes more common with age, particularly after menopause in women.

Can weight loss cure obstructive sleep apnea?

Weight loss can reduce severity but does not guarantee resolution. Patients should continue medical follow-up.

Why is sleep apnea underdiagnosed in women?

Women often present with fatigue or insomnia rather than classic snoring or daytime sleepiness, leading to misdiagnosis.

Can wearable devices detect sleep apnea?

No. Consumer sleep trackers cannot reliably diagnose or rule out obstructive sleep apnea. If you suspect you have sleep apnea, it’s important to consult with a doctor, who can help arrange a sleep test as part of the diagnostic process.

Should older adults with dementia be treated for sleep apnea?

Possibly. Treatment may improve cognition and alertness, but decisions must be individualized based on factors such as overall health. 

Glenye Cain Oakford is a freelance science writer and communications strategist covering public health, patient advocacy, environmental issues, and veterinary science, translating complex research and policy topics for the public and nonprofit audiences.