Among older persons, sleep complaints in the form of insomnia and daytime drowsiness are highly prevalent and associated with adverse outcomes. The underlying mechanisms are linked to agerelated declines in physiology, i.e., normal aging, and age-related increases in disease prevalence, i.e., usual aging. In this monograph, we describe how normal aging leads to less restorative sleep, characterized by reductions in homeostatic and circadian sleep, and to phase advancement of the sleep-wake cycle, characterized by older persons being more alert in the early morning but drowsier in the early evening. We also describe how usual aging leads to sleep complaints through reductions in health status, loss of physical function, and primary sleep disorders. Psychosocial influences are likewise described and their relevance to sleep complaints is discussed. We subsequently incorporate these aging-related changes into a conceptual model that describes sleep complaints as a consequence of multiple and interdependent predisposing, precipitating, and perpetuating factors, akin to a geriatric syndrome. We conclude our discussion by applying our conceptual model to the sleeprelated care of an older person with insomnia and daytime drowsiness, and suggest that the diagnostic assessment consider, in addition to primary sleep disorders, multiple domains including medical, physical, cognitive, psychological, and social issues with the intent of developing an overall therapeutic plan and establishing long-term follow-up.

Aging is associated with an increased risk of developing respiratory impairment, which is best defined by spirometric Z-scores. Alternatively, in selected cases, respiratory impairment may be defined by peak expiratory flow, also expressed as a Z-score.

Background Among older persons, the association between frailty and spirometry-confirmed respiratory impairment has not yet been evaluated. Methods Using data on white participants aged 65–80 years (Cardiovascular Health Study, N=3,578), we evaluated cross-sectional and longitudinal associations between frailty and respiratory impairment, including their combined effect on mortality. Baseline assessments included frailty status (Fried-phenotype; non-frail, pre-frail, and frail) and spirometry. Outcomes included development of frailty features (pre-frail or frail) at Year-3 and respiratory impairment (airflow limitation or restrictive-pattern) at Year-4, and death (median follow-up, 13.2 years). Results At baseline, 48.3% were pre-frail, 5.8% were frail, 13.8% had airflow limitation, and 9.3% had restrictive-pattern; 46.1% subsequently died. At baseline, pre-frail and frail were cross-sectionally associated with airflow limitation—adjusted odds ratio (OR) (95% confidence interval): 1.62 (1.29, 2.04) and 1.88 (1.15, 3.09), and restrictive-pattern—adjusted OR: 1.80 (1.37, 2.36) and 3.05 (1.91, 4.88), respectively. Longitudinally, participants with baseline frailty features had an increased likelihood of developing respiratory impairment―adjusted OR: 1.42 (1.11, 1.82). Conversely, participants with baseline respiratory impairment had an increased likelihood of developing frailty features—adjusted OR: 1.58 (1.17, 2.13). Mortality was highest among participants who were frail and had respiratory impairment—adjusted hazard ratio: 3.91 (2.93, 5.22), relative to those who were non-frail and had no respiratory impairment. Conclusion Frailty and respiratory impairment are strongly associated with one another and substantially increase the risk of death when both are present. Establishing these associations may inform interventions designed to reverse or prevent the progression of either condition and to reduce adverse outcomes.

The Global Lung Function Initiative (GLI) Network has become the largest resource for reference values for routine lung function testing ever assembled. This article addresses how the GLI Network came about, why it is important, and its current challenges and future directions. It is an extension of an article published in Breathe in 2013 [1], and summarises recent developments and the future of the GLI Network.Key pointsThe Global Lung Function Initiative (GLI) Network was established as a result of international collaboration, and altruism between researchers, clinicians and industry partners. The ongoing success of the GLI relies on network members continuing to work together to further improve how lung function is reported and interpreted across all age groups around the world.The GLI Network has produced standardised lung function reference values for spirometry and gas transfer tests.GLI reference equations should be adopted immediately for spirometry and gas transfer by clinicians and physiologists worldwide.The recently established GLI data repository will allow ongoing development and evaluation of reference values, and will offer opportunities for novel research.Educational aimsTo highlight the advances made by the GLI Network during the past 5 years.To highlight the importance of using GLI reference values for routine lung function testing (e.g. spirometry and gas transfer tests).To discuss the challenges that remain for developing and improving reference values for lung function tests.

Rationale: The lambda-mu-sigma (LMS) method is a novel approach that defines the lower limit of normal (LLN) for the ratio of FEV 1 /FVC as the fifth percentile of the distribution of Z scores. The clinical validity of this threshold as a basis for establishing chronic obstructive pulmonary disease is unknown. Objective: To evaluate the association between the LMS method of determining the LLN for the FEV 1 /FVC, set at successively higher thresholds, and clinically meaningful outcomes. Methods: Using data from a nationally representative sample of 3,502 white Americans aged 40-80 years, we stratified the FEV 1 /FVC according to the LMS-LLN, with thresholds set at the 5th, 10th, 15th, 20th, and 25th percentiles (i.e., LMS-LLN 5 , LMS-LLN 10 , etc.). We then evaluated whether these thresholds were associated with an increased risk of death or prevalence of respiratory symptoms. Spirometry was not specifically completed after a bronchodilator. Measurements and Main Results: Relative to an FEV 1 /FVC greater than or equal to LMS-LLN 25 (reference group), the risk of death and the odds of having respiratory symptoms were elevated only in participants who had an FEV 1 /FVC less than LMS-LLN 5 , with an adjusted hazard ratio of 1.68 (95% confidence interval, 1.34-2.12) and an adjusted odds ratio of 2.46 (95% confidence interval, 2.01-3.02), respectively, representing 13.8% of the cohort. Results were similar for persons aged 40-64 years and those aged 65-80 years. Conclusions: In white persons aged 40-80 years, an FEV 1 /FVC less than LMS-LLN 5 identifies persons with an increased risk of death and prevalence of respiratory symptoms. These results support the use of the LMS-LLN 5 threshold for establishing chronic obstructive pulmonary disease.

GLI-defined spirometric impairment establishes clinically meaningful respiratory disease, as validated by graded associations with respiratory-related phenotypes.

Objectives To evaluate the association between sleep–wake disturbances and frailty. Design Cross-sectional. Setting New Haven, Connecticut. Participants Three hundred seventy-four community-living persons aged 78 and older. Measurements Frailty was based on the Fried phenotype, and sleep–wake disturbances were defined as daytime drowsiness, based on an Epworth Sleepiness Scale (ESS) score of 10 or greater, and as subthreshold and clinical insomnia, based on Insomnia Severity Index (ISI) scores of 8 to 14 and greater than 14, respectively. Results Mean age was 84.3; 87 (23.8%) participants were drowsy, 122 (32.8%) had subthreshold insomnia, 38 (10.2%) had clinical insomnia, and 154 (41.2%) were frail. There was a significant association between drowsiness and frailty, with unadjusted and adjusted odds ratios (ORs) of 3.79 (95% confidence interval (CI) = 2.29–6.29) and 3.67 (95% CI = 2.03–6.61), respectively. In contrast, clinical insomnia was significantly associated with frailty in the unadjusted analysis (OR = 2.77, 95% CI = 1.36–5.67) but not the adjusted analysis (OR = 1.93, 95% CI = 0.81–4.61)), and subthreshold insomnia was not associated with frailty in the unadjusted or adjusted analysis. Conclusion In older persons, sleep–wake disturbances that present with daytime drowsiness, but not insomnia, are independently associated with frailty. Because drowsiness is potentially remediable, future studies should determine whether there is a temporal relationship between drowsiness and frailty, with the ultimate goal of informing interventions to reverse or prevent the progression of frailty.

Objective To evaluate, among older persons, the association between respiratory impairment and hospitalization for chronic obstructive pulmonary disease (COPD), based on spirometric Z-scores (Lambda-Mu-Sigma [LMS]) and a competing risk approach. Methods Using data on 3,563 white participants aged 65–80 years (Cardiovascular Health Study), we evaluated the association of LMS-defined respiratory impairment with incident COPD hospitalization and the competing outcome of death without COPD hospitalization, over a 5-year period. Respiratory impairment included airflow limitation (mild, moderate, and severe) and restrictive-pattern. Results Over a 5-year period, 276 (7.7%) participants had incident COPD hospitalization, whereas 296 (8.3%) died without COPD hospitalization. The risk of COPD hospitalization was elevated more than 2-fold in LMS-defined mild and moderate airflow limitation and restrictive-pattern (adjusted hazard ratio [HR]: 2.25 [1.25, 4.05], 2.54 [1.53, 4.22], and 2.65 [1.82, 3.86], respectively), and more than 8-fold in LMS-defined severe airflow limitation (adjusted HR: 8.33 [6.24, 11.12]). Conversely, only LMS-defined restrictive-pattern was associated with the competing outcome of death without COPD hospitalization (adjusted HR: 1.68 [1.22, 2.32]). Conclusion In white older persons, LMS-defined respiratory impairment is strongly associated with an increased risk of COPD hospitalization. These results support the LMS method as a basis for defining respiratory impairment in older persons.