copd includes chronic bronchitis and pulmonary emphysema , having as a common feature the blockage of the lung airways , thus reducing significantly the airflow at the end and trapping the air inside .
the obstruction initially causes decline in lung function , leading to decreased breathing , especially after severe fatigue .
moreover , everyday life of elderly is often disturbed by exacerbations of the disease , caused by frequent pulmonary infections ( 1,2 ) .
the main characteristic of copd is a progressive airway obstruction ; however the term copd often refers to a separate group of diseases concerning their pathophysiology , which share common causes , such as smoking and air pollution , leading to a common result of obstruction .
the obstruction in copd is irreversible , but some patients have a low degree of reversibility after administration of bronchodilators and cortisone drugs , that is why often appear common characteristics with chronic asthma , where airway obstruction may be improved ( 3 - 5 ) . the elderly consist a vulnerable age group , with many special needs . several times , those elderly suffering from copd apparently show complications in breathing , during sleep that characterize sleep apnea syndrome .
apnea is defined as the cessation of breathing , of the airflow , in a sleeping person , at least for 10 seconds , causing electrocerebral  awakening  and drop of the saturation of hemoglobin in oxygen .
if the cessation of airflow is accompanied by lack of respiratory movements in the chest and abdomen , and there is no aspiratory effort , then the apnea is characterized as central , where , on the contrary , if there is respiratory activity is the chest or both , and the inhalation effort is growing during apnea , then it is characterized as obstructive .
the term sleep apnea is usually laboratory , in contrast with the term sleep apnea syndrome , which , in addition to apnea , requires the appearance of clinical symptoms . to show the clinical manifestations of the syndrome
usually are required more than 15 apneas per one hour of sleep , and vary depending on the chronic status , the number and severity of apnea . at the beginning ,
clinical symptoms are of low significance or absent , but later on , as copd progresses , apneas increase , leading to more severe symptoms ( 6 - 8 ) .
the main clinical symptoms of the copd include ( 6 , 9 - 11 ) : 
 sleepiness during the day : it is the most important and troublesome symptome seen in an elderly patient with copd .
often patients complain that they have not slept for several hours and that they fall asleep during daily activities .
people who have an increased level of daytime sleepiness should be advised to avoid driving , in order to prevent accidents.snoring : it is a sound generated during sleep by the vibration of the walls of the pharynx and soft palate .
the vibration is caused due to the difficulty of access to air through a clogged throat .
along with sleepiness are the main symptoms of the syndrome and the type of snoring can help in diagnosis , since the instability in frequency and intensity , suggest the presence of the syndrome of obstructive sleep apnea.obesity : the syndrome occurs more often in people with increased body weight , and therefore fat tissue in the neck.frequent night urination : it forces sufferers to interrupt their sleep and occasionally to have involuntary loss of urine .
this is due to release of natriuretic factor from the dilatation of the sinuses and to a pressure of the urinary bladder , caused by increased abdominal pressure during obstructive apnea.night sweats : are often due to the restless sleep and due to the intense respiratory efforts during sleep.morning headaches , irritability and memory decline : patients awake with a feeling of dizziness , headaches and dry mouth . in more severe cases ,
there is a memory degradation , concentration and observation . trying to overcome the drowsiness and the sense of inferiority because of the symptoms , usually leads to depressive symptoms and stress disorders.decreased sexual activity : men often face sexual problems due to loss of libido and sense of helplessness .
sleepiness during the day : it is the most important and troublesome symptome seen in an elderly patient with copd . often patients complain that they have not slept for several hours and that they fall asleep during daily activities .
people who have an increased level of daytime sleepiness should be advised to avoid driving , in order to prevent accidents .
snoring : it is a sound generated during sleep by the vibration of the walls of the pharynx and soft palate . the vibration is caused due to the difficulty of access to air through a clogged throat .
along with sleepiness are the main symptoms of the syndrome and the type of snoring can help in diagnosis , since the instability in frequency and intensity , suggest the presence of the syndrome of obstructive sleep apnea .
obesity : the syndrome occurs more often in people with increased body weight , and therefore fat tissue in the neck .
frequent night urination : it forces sufferers to interrupt their sleep and occasionally to have involuntary loss of urine .
this is due to release of natriuretic factor from the dilatation of the sinuses and to a pressure of the urinary bladder , caused by increased abdominal pressure during obstructive apnea .
night sweats : are often due to the restless sleep and due to the intense respiratory efforts during sleep . morning headaches , irritability and memory decline : patients awake with a feeling of dizziness , headaches and dry mouth . in more severe cases , there is a memory degradation , concentration and observation . trying to overcome the drowsiness and the sense of inferiority because of the symptoms , usually leads to depressive symptoms and stress disorders . decreased sexual activity : men often face sexual problems due to loss of libido and sense of helplessness .
the diagnosis of obstructive sleep apnea syndrome takes place by studying the elderly patients in a special workshop during sleep , while recording parameters of sleep and the respiratory function . for the staging of sleep ,
eeg is recorded , along with the eye movements , with an electrocardiogram , the movements of chest and abdominal wall , the airflow in the nose and mouth , the saturation of hemoglobin and the body position during sleep .
other methods that help assess the functioning of the position and the degree of airway obstruction during sleep are the imaging methods of computing and magnetic resonance imaging ( mri ) , fluoroscopy and ultrasound . the only non - imaging method , but also the only one that directly assesses the functional competence in multiple sites of upper airways , is the measurement of the differential pressure across the palate until the rinofarynx ( 12 - 14 ) . in order to choose the appropriate way of disease management , the severity of the clinical picture , the study s findings in sleep centers , as well as patients severity of copd must be taken into account .
treatment of sleep apnea syndrome targets to increase the pharynx s lumen diameter during sleep .
these treatments may be generic , non - invasive , and in many difficult cases , surgical .
reduction of body weight , because obesity is an aggravating factor in the obstruction of the upper airway , during sleep.avoidance of alcohol consumption by patients with copd and syndrome of obstructive sleep apnea , especially before bedtime.education of the patient to take a side position rather than a supine position during sleep.continuous positive airway pressure ( cpap ) : it consists the continuous provision of positive air pressure in the upper airway through the nose , by a special device .
the cpap device assists the normal function of the entire airway , using bigger pressure than the atmospheric one , so that at no stage and point becomes negative , creating thus a respiratory  splint  that keeps the upper airway free.nasopharyngeal tube : it can help directly , simply , safely and effectively all patients , bypassing the airway obstruction during sleep.surgical interventions often take place , including the permanent tracheotomy , and nose , jaws and throat surgery , aiming to keep free the upper airway .
reduction of body weight , because obesity is an aggravating factor in the obstruction of the upper airway , during sleep .
avoidance of alcohol consumption by patients with copd and syndrome of obstructive sleep apnea , especially before bedtime .
education of the patient to take a side position rather than a supine position during sleep .
continuous positive airway pressure ( cpap ) : it consists the continuous provision of positive air pressure in the upper airway through the nose , by a special device .
the cpap device assists the normal function of the entire airway , using bigger pressure than the atmospheric one , so that at no stage and point becomes negative , creating thus a respiratory  splint  that keeps the upper airway free .
nasopharyngeal tube : it can help directly , simply , safely and effectively all patients , bypassing the airway obstruction during sleep .
surgical interventions often take place , including the permanent tracheotomy , and nose , jaws and throat surgery , aiming to keep free the upper airway .
quality of life is an important factor of assessing recovery of patients suffering from copd .
the recovery can take place either in specialized medical units , whose primary purpose is to address the problem , such as sleep centers , or through properly designed programs implemented at home by a group of health professionals , whose main concern is the identification , diagnosis and treatment of the problem , alongside with the application of appropriate techniques .
also are required efficient teaching methods for patients and their carers , towards an active participation in the selection and application of a suitable therapeutic approach
the sample of this study was composed of 500 elderly individuals ( 274 men and 226 women ) , aged from 70 years old and above .
open centers for the elderly  , which are located in various municipalities of greater athens .
all patients completed a specialized anonymous questionnaire , with a personal interview with the investigator , after a clear explanation of the purpose of this study . during the investigation ,
spirometry was carried out by using a portable spirometer , mir spirobank , while the parameters examined were fev1 , fevc , and particularly the ratio fev1/fevc .
this ratio was also used for the classification of the disease . to investigate the occurrence of apnea in people suffering from copd
were also used , specialized and standardized questionnaires , such as the  berlin questionnaire  and  epworth sleepiness scale  .
contingency tables were used for the relationship between categorical variables , using fishers exact test ( for tables 2x2 ) and person s chi square test ( for all other dimensions of contingency tables ) , as appropriate .
data processing , along with statistical analysis and visualization was performed by using the statistical package spss 17 .
table 1 presents the classification of the copd , regarding the sex , by using gold scale . according to table 1 ,
there was found a statistically significant difference in the stratification of mild copd . in specific
the results differ in the case of moderate copd , where men developed higher rates ( 61% versus 39% ) .
there is no statistically significant difference between the genders among severe cases of copd ( table 1 ) .
almost all elderly people of the sample ( 98% ) , have reported to not suffer from any sleepiness during the day ( table 2 ) . according to the berlin questionnaire , which was used to assess the existence of apnea among the population , the 28.6% of the elderly appear to suffer fro a high risk level of apnea , at a rate of 36.0% they suffer from a lower risk of apnea , while the 35.4% suffer from no apnea at all ( table 3 ) . according to table 4
, a large proportion of respondents ( 66.4% ) , stated that they had not received home care for their treatment , but they believe that such an option would help them manage their health problem . on the other hand , at a rate of 12.0% , participants believe that even homecare services could not have helped them .
finally , 21.6% of the sample , received home help , and found out that they have been provided with a satisfactory help .
there was found statistically significant relationship between the existence of severe copd among elderly people who have low risk of apnea .
as far as the daily sleepiness by gender is concerned , there was found no statistically significant difference between the two genders , both in normal and in high - risk sleepiness of the elderly during the day ( table 6 ) .
it was also found that men are more likely to suffer from apnea , in comparison to women .
according to the findings of the study , elderly participants consist a vulnerable group with significant health problems and with difficulties in their daily lives .
no significant statistical difference between the two genders is observed , as far as the prevalence of the under investigation disease is concerned .
one possible explanation have a longer life expectancy rate than men ( 18 ) . as far as the classification of copd is concerned , by gender
, it was found that women suffer from copd more frequently than men , and even more often they suffer from mild copd , while men show more often symptoms of moderate copd , than women .
there is not any statistically significant difference in the case of severe copd between the two genders . in a similar survey , conducted in beijing by zhou ym et al ( 19 ) , among 9.434 elderly people , coming from 7 provinces of china
, it was found that 30% of the sample were patients diagnosed with copd , while from the total sample , at a rate of 12.8% copd was diagnosed in men , with only 5.4% in women .
another study conducted in poland ( 20 ) in 2007 , it is shown that among 603 elderly people , 22.1% suffered from mild copd , with 10.9% of them suffering of moderate to severe type of copd .
based on the results of the above studies , it is evident that the gender plays an important role in the prevalence of copd , and along with smoking , exposure to inappropriate weather conditions and age , they form an unhealthy configuration that leads to a large extent to the existence of copd among the elderly .
it is also observed that the vast majority of the sample ( 98% ) does not have any symptoms of sleep apnea , as daytime sleepiness .
this does not mean that they do not have sleep apnea , as 36.0% of older people suffer from sleep apnea of low risk , 28.6% of them have high risk apnea , while one out of three seniors do not suffer from sleep apnea at all .
there was found statistically significant relationship between the existence of severe copd among elderly people who have low risk of apnea .
two similar surveys carried out by bixler et al , in 1998 and 2001 , in pennsylvania , found out that among 1741 adults , aged up to 99 years , obstructive sleep apnea syndrome occur at a rate of 24% among men and 9% among women ( 21,22 ) .
another study conducted in spain , showed sleep apnea syndrome occurs at a rate of 26.0% among men , and 28.0% among women ( 23 ) . according to what has been previously been reported
, it can be proved that there is no limiting factor in the occurrence of apnea between the two genders .
the obstructive sleep apnea syndrome may occur with the same frequency in both elderly men and women , and occurs more frequently in people who suffer from copd and other obstructive respiratory diseases .
regarding the rehabilitation and participation in a program of home care , the majority of the sample ( 66.4% ) , stated that they do not take part in a specialized program , but they do believe a program like this would help considerably . only at a rate of 21.6%
did the respondents participate in a program and had already seen improvement to their health problems .
it is striking though , that 12.0% of the elderly , state that they were unwilling to participate in a rehabilitation program , while they did not believe that a specialized program would be of any benefit regarding the amelioration of their symptoms . in a canadian survey comprised of a sample of two patient groups
( home care rehabilitation group and inpatient rehabilitation group ) , admissions into hospitals and emergency care departments were decreased significantly among the home care rehabilitation group , in a time span of three months ( 24 ) .
this group was also found to be more satisfied with the choice of a home care program .
similar are the results of another investigation that took place in australia , 2005 , among 60 persons ( age>60 years ) .
the sample attended a specialized 12 week home assistance program , which included specific exercises and patients / carers education .
in conclusion , it is understood that as the number of the elderly people , and their proportion in the general population increases , it is important to understand that specific changes must be made to support their efforts for well being and their active social life .
furthermore , most of the elderly people need to be independent to sufficiently take care of their daily problems . on the other hand
, they do ask for quality services provided by the state ( 26 - 30 ) .
an important step is the development of supportive social structures to monitor the elderly , in order to detect , prevent and facilitate their daily problems .
it is important that the elderly can be provided with a supportive human environment , which can help them discuss about their problems and assist them in communicating their inner needs ( 31 - 33 ) .
institutions such as the specialized sleep centers , open care centers for the elderly and specialized pulmonary rehabilitation home care programs are vital for people with disabilities with limited access to primary health care services ( 32 , 34 - 36 ) .
imperative is considered the staffing of these special social support organizations , who should have specialized and appropriate , up to date knowledge and skills .
the above skills are required so that the health professionals can be able to plan , organize and implement strategies for the emotional and social rehabilitation of patients .
it is also important the social policy of the state to move towards new directions .
specialized health professionals assisted by qualified volunteers can offer their services after attending special health promotion programs .
these programs are provided by community nurses , social workers and other health professionals , with expertise in the dynamics of family and social environment of the elderly ( 37 , 38 ) .
since aging is directly related to physical illness , loss of independence and self - care , entering the golden age is an important area of study in the current health system .
living conditions , social and emotional status of the elderly and their participation in society , are issues that should be further studied .
therefore further research is required , not only to add extra years in the lifespan of older people , but also to improve the quality of life during their remaining years .
 introduction : chronic obstructive pulmonary disease ( copd ) and obstructive sleep apnea syndrome are two diseases , which often coexist in one person . 
 the sleep apnea is often caused by an interruption to breath when sleeping , due to an obstruction of the upper airway during inhalation , causing chronic snoring , morning headaches , increased body weight , blood pressure and sleepiness during the day.aim:the purpose of this study is to investigate the extend of this problem among a large group of elderly people living in the attica basin.material and methods : material of the study was 500 people aged 70 and above years old , including 274 men and 226 women . 
 data collection was facilitated with the use of an anonymous questionnaire with the purpose to identify patients with apnea , after a personal interview with the researcher . 
 data analysis was performed with the use of the statistical package spss 17.results:based on their responses to the questionnaires , it was found that 98.0% of the participants have abnormal sleepiness during the day . 
 the 35.4% of them show no apnea , while 36.0% of the sample suffer from mild sleep apnea . 
 it is important though , the fact that about one out of three seniors , 28.6% , shows sleep apnea in a high risk level.conclusions:copd is a complex disease that occurs in a large proportion of the elderly . 
 emphasis should be given on early diagnosis and treatment of sleep apnea syndrome , in order to improve the quality of the elderly life . 
INTRODUCTION
MATERIAL AND METHODS
RESULTS
DISCUSSION
CONCLUSIONS
Conflict of interest