AirwayZ Invertory

Older Adult Screening Questionnaire

AirwayZ Airway Health Inventory — Older Adult (Ages 65+)
A irway Z
Instrument 5 · Older Adult · Ages 65+
A irway Z
Airway Health Inventory
Older Adult
Ages 65+ · Self-Report
TreatOrigin Productions, LLC
Name
Age
Date
Referring provider
Primary physician
Completed by
How to complete
Answer based on your experience over the past three months. If a family member or caregiver is helping you complete this form, please note that in the "Completed by" field above. All sections that apply should be filled in. There are no right or wrong answers.
Severity scale
0 Not present   1 Mild   2 Mild-moderate   3 Moderate
4 Moderate-pronounced   5 Pronounced

Initial column = today  ·  F/U = after 3 months of care
An important note before you begin: In older adults, sleep-disordered breathing often presents quite differently than it does in younger people. The classic picture of a loud snorer who is sleepy during the day is frequently absent. Instead, the most common features in older adults are nocturia, memory changes, fatigue that does not improve with rest, insomnia, and falls. These symptoms are frequently attributed to aging alone, but they are also well-documented consequences of untreated airway disruption. Because so many symptoms of sleep apnea in this age group overlap with the normal experience of aging, this condition is substantially underdiagnosed in people over 65. You do not need to be a loud snorer to have sleep-disordered breathing. Answer each item honestly based on your actual experience.
Section A · Daytime Sleepiness & Dozing Tendency
How likely are you to doze off or fall asleep in the following situations? Answer honestly, based on your usual life. · 0 = Would never doze · 1 = Slight chance · 2 = Moderate chance · 3 = High chance · Note: in older adults, sleep apnea often produces less obvious daytime sleepiness than in younger patients. A low score on this section does not rule out a significant breathing disorder.
Situation 0
Never 		1
Slight 		2
Moderate 		3
High
Reading or doing a quiet activity on your own
0
1
2
3
Watching a show, film, or the news in the evening
0
1
2
3
Sitting through a presentation, talk, or religious service
0
1
2
3
Riding as a passenger for 30 to 60 minutes
0
1
2
3
Resting quietly in the afternoon when you have the chance
0
1
2
3
Sitting quietly after a meal
0
1
2
3
Waiting in a waiting room, lobby, or office without a specific task
0
1
2
3
Sitting in a comfortable chair or sofa without the intention of sleeping
0
1
2
3
Section B · Nighttime & Sleep
Snoring frequency
Never Rarely Sometimes Most nights Every night
Do you snore? Note: snoring often decreases or disappears with age, even when sleep-disordered breathing is still present. Absence of snoring does not rule out OSA in older adults.
During sleep · Severity: 0–5
0 1 2 3 4 5 F/U
Have difficulty falling asleep, even when tired? Insomnia is more common than excessive daytime sleepiness as a presenting feature of OSA in older adults.
0
1
2
3
4
5
Wake in the early hours of the morning and struggle to return to sleep?
0
1
2
3
4
5
Feel that your sleep is light, fragmented, or unrestorative most nights?
0
1
2
3
4
5
Wake with a gasping sensation, choking feeling, or sudden sense of not being able to breathe?
0
1
2
3
4
5
Sleep with mouth open?
0
1
2
3
4
5
Sweat heavily during sleep, beyond what room temperature would explain?
0
1
2
3
4
5
Have restless legs, leg cramping, or leg kicking during sleep?
0
1
2
3
4
5
Grind or clench your teeth during sleep?
0
1
2
3
4
5
Have very vivid dreams, nightmares, or act out dreams physically (talk, shout, move limbs)? REM behavior disorder is associated with OSA and certain neurological conditions including Parkinson's disease.
0
1
2
3
4
5
Wake unrefreshed despite what feels like adequate sleep?
0
1
2
3
4
5
Wake with a dry mouth?
0
1
2
3
4
5
Wake with headaches before getting out of bed?
0
1
2
3
4
5
Feel confused, disoriented, or briefly uncertain of where you are when you first wake up? Nocturnal disorientation upon waking is a recognized feature of sleep-disordered breathing in older adults and distinct from daytime confusion.
0
1
2
3
4
5
Wake with a sour taste, burning sensation in the throat, or chronic nighttime cough?
0
1
2
3
4
5
Nocturia · Waking to use the bathroom
0 times 1 time 2 times 3 or more
How many times do you typically wake to use the bathroom per night? Nocturia is one of the most common presenting features of OSA in older adults. It is caused by pressure changes in the chest during airway obstruction that trigger the release of a hormone signaling the kidneys to produce urine. Treating OSA often resolves nocturia.
Observed or reported by yourself or a bed partner Yes No Not sure
Has anyone told you that you snore loudly, or have you been told you make choking or gasping sounds during sleep?
Has anyone observed you stop breathing, or have your breathing appear to pause, during sleep?
Do your symptoms seem worse when sleeping on your back?
If yes to any witnessed breathing event, please describe:
Section C · Daytime Symptoms
During waking hours · Severity: 0–5
0 1 2 3 4 5 F/U
Feel persistently fatigued or physically drained, even on days when you rested well?
0
1
2
3
4
5
Take naps during the day, either intentionally or by falling asleep unexpectedly? Frequent or unplanned daytime napping can indicate disrupted overnight sleep architecture from OSA, even when nighttime sleepiness is not prominent.
0
1
2
3
4
5
Have chronic nasal congestion or difficulty breathing through your nose?
0
1
2
3
4
5
Have recurring headaches, apart from those that occur upon waking?
0
1
2
3
4
5
Have low mood, loss of interest in activities, or a persistent flatness that does not fully respond to circumstances?
0
1
2
3
4
5
Have anxiety, excessive worry, or tension that has increased compared to how you felt several years ago?
0
1
2
3
4
5
Have withdrawn from social activities, hobbies, or relationships compared to a few years ago? Social withdrawal in older adults is associated with both sleep-disordered breathing and cognitive decline, both of which may be contributing factors.
0
1
2
3
4
5
Have acid reflux, heartburn, or a chronic need to clear your throat?
0
1
2
3
4
5
Yes No Not sure
Do you feel sleepy or fatigued at least three times per week regardless of how long you slept?
Section D · Falls, Balance & Physical Function
OSA is an independently modifiable risk factor for falls in older adults · Severity: 0–5
0 1 2 3 4 5 F/U
Have difficulty with balance, feeling unsteady, or a sense that you might fall?
0
1
2
3
4
5
Feel dizzy, lightheaded, or unsteady when you first stand up from sitting or lying down?
0
1
2
3
4
5
Have difficulty getting up from a low chair or sofa without using your arms?
0
1
2
3
4
5
Feel generally weaker in your legs or arms than you did several years ago?
0
1
2
3
4
5
Limit your activities or outings because you are concerned about falling?
0
1
2
3
4
5
Yes No Not sure
Have you had one or more falls in the past twelve months?
Have you had a near-fall or felt you nearly lost your balance in the past twelve months?
Have you been woken by the need to use the bathroom and felt unsteady, dizzy, or disoriented while getting up? Nocturia-related falls are a significant cause of injury in older adults and a direct safety consequence of untreated OSA.
Do you use a cane, walker, or other aid for stability when walking?
Section E · Cognitive & Neurological
Memory concerns and cognitive changes · Severity: 0–5
0 1 2 3 4 5 F/U
Notice memory lapses: forgetting names, appointments, or recent conversations more than you used to? OSA is independently associated with accelerated cognitive decline in older adults. CPAP treatment delays the onset of mild cognitive impairment by an estimated 10 years in treated versus untreated patients.
0
1
2
3
4
5
Have difficulty finding words mid-sentence, or notice the word is "on the tip of your tongue" more frequently?
0
1
2
3
4
5
Have difficulty concentrating, following a complex conversation, or staying mentally sharp during familiar tasks?
0
1
2
3
4
5
Feel that your thinking, memory, or mental clarity has noticeably changed over the past few years?
0
1
2
3
4
5
Yes No Not sure
Has a family member or close friend expressed concern about changes in your memory or thinking?
Have you been evaluated for mild cognitive impairment (MCI) or dementia?
Have you been diagnosed with or evaluated for Parkinson's disease or a related movement disorder? OSA is associated with increased risk of Parkinson's disease and worsens its progression. REM behavior disorder, a parasomnia common in OSA, is also a recognized early marker of Parkinson's.
Have you had a stroke or TIA (transient ischemic attack)?
Section F · Oral, Jaw & Structural
Severity: 0–5
0 1 2 3 4 5 F/U
Rest with mouth open, lips apart, or tongue resting low when relaxed?
0
1
2
3
4
5
Breathe through your mouth habitually during the day?
0
1
2
3
4
5
Have jaw pain, clicking, locking, or significant difficulty opening your mouth wide?
0
1
2
3
4
5
Clench or grind your teeth during the day?
0
1
2
3
4
5
Have chronic neck pain, tension headaches, or significant forward head posture?
0
1
2
3
4
5
Have difficulty swallowing, a sense of food getting stuck, or chronic hoarseness?
0
1
2
3
4
5
Experience excessive dry mouth throughout the day, beyond what medications might explain?
0
1
2
3
4
5
Yes No Not sure
Do you have full or partial dentures? Edentulism and denture use affect both orofacial muscle tone and candidacy for oral appliance therapy. Denture-wearers who remove appliances at night lose lower jaw support, which can increase airway collapse.
Do you remove your dentures at night?
Have you been told you have a small jaw, recessed chin, narrow palate, or thick/short neck?
Has anyone ever told you that your face developed in a longer or narrower pattern, or that you have a more vertical facial structure? A long, narrow face with increased vertical growth is associated with reduced upper airway dimensions and higher OSA risk. This structural pattern is often visible from the facial profile alone.
Do you notice scalloping or indentations along the edges of your tongue? Tongue scalloping indicates macroglossia relative to the dental arch, a recognized structural risk factor for OSA.
Section G · STOP-Bang and Berlin Risk Flags
These items correspond directly to the validated STOP-Bang and Berlin questionnaire criteria · Note: in adults over 65, STOP-Bang has high sensitivity but lower specificity than in younger adults. A high score remains meaningful; a low score should be interpreted alongside the full clinical picture.
Yes No Not sure
Snoring: do you snore loudly? [STOP-Bang · Berlin C1]
Tiredness: do you often feel tired, fatigued, or sleepy during the daytime? [STOP-Bang · Berlin C2]
Observed apnea: has anyone observed you stop breathing during sleep? [STOP-Bang · Berlin C1]
Blood Pressure: do you have, or are you being treated for, high blood pressure? [STOP-Bang · Berlin C3]
BMI: is your BMI above 35, or has a physician described you as significantly overweight? [STOP-Bang · Berlin C3]
Age: are you 50 years of age or older? [STOP-Bang]
Neck: has a provider noted a large or thick neck, or do you wear a collar larger than 17 inches (men) or 16 inches (women)? [STOP-Bang]
Gender: are you male, or were you assigned male at birth? [STOP-Bang]
Section H · Medical History & Medications
Please check all diagnoses you have received or are currently being treated for
Check all that apply:
✓
Sleep apnea (diagnosed)
✓
UARS (upper airway resistance)
✓
Insomnia
✓
TMJ disorder
✓
Anxiety disorder
✓
Depression
✓
Acid reflux / GERD
✓
Atrial fibrillation
✓
Hypothyroidism
✓
Type 2 diabetes
✓
Prediabetes
✓
High cholesterol / triglycerides
✓
Chronic kidney disease
✓
Heart attack / coronary artery disease
✓
Heart failure
✓
Stroke or TIA
✓
Mild cognitive impairment (MCI)
✓
Alzheimer's / dementia
✓
Parkinson's disease
✓
Ehlers-Danlos / joint hypermobility
✓
Asthma
✓
COPD
✓
Pulmonary hypertension
✓
Urinary incontinence
✓
Osteoporosis
✓
Gout
Medications · Polypharmacy and sleep-disrupting drugs
Approximately how many prescription medications do you take daily?
Do you currently or regularly take any of the following? Yes No Not sure
Sleeping pills, sedatives, or benzodiazepines (such as Ativan, Xanax, Valium, Ambien, or similar)? These medications reduce upper airway muscle tone and respiratory drive, significantly worsening OSA severity. They are listed in the AGS Beers Criteria as potentially inappropriate for older adults with sleep disorders.
Opioid pain medications (such as oxycodone, hydrocodone, morphine, tramadol, or similar)? Opioids suppress respiratory drive and are independently associated with central and obstructive sleep apnea. Users are approximately five times more likely to develop sleep disorders.
Antihistamines regularly for allergies or sleep (such as Benadryl, diphenhydramine, or similar)? Antihistamines affect sleep architecture and contribute to daytime drowsiness in older adults, complicating symptom assessment.
Diuretics (water pills) taken in the evening or at bedtime? Diuretics taken late in the day are a common and modifiable contributor to nocturia, which in older adults is also driven by OSA.
Muscle relaxants (such as cyclobenzaprine, baclofen, or similar)?
Alcohol regularly in the evening? Alcohol reduces upper airway muscle tone, particularly in the first half of the night, increasing both the frequency and duration of obstructive events.
Treatment and living situation
Are you currently using CPAP or an oral appliance?
Do you live alone or with others?
Yes No Not sure
Have your tonsils or adenoids been removed?
Have you had a formal sleep study (polysomnography or home sleep test)?
Do you smoke, or have you smoked regularly in the past?
Is there a family history of snoring, sleep apnea, or heart disease?
Do you have unusually flexible or "double-jointed" joints, or have been told you are hypermobile?
Section I · Women's Health
Complete if applicable · OSA prevalence in postmenopausal women approaches that of men of the same age
Yes No N/A
Are you postmenopausal?
If postmenopausal, was your menopause:
Yes No N/A
Are you currently on hormone replacement therapy (HRT)? HRT is associated with a 40 to 50% reduction in OSA prevalence in postmenopausal women in large cohort studies.
Did you experience preeclampsia, gestational hypertension, or gestational diabetes during any pregnancy?
Have you been diagnosed with PCOS?
Section J · Quality of Life & Self-Concern
Based on the OSA-18 quality-of-life framework · 0 = No concern or impact · 10 = Severe concern or impact
0 1 2 3 4 5 6 7 8 9 10
How concerned are you that your breathing or sleep is affecting your health, memory, or long-term independence?
0
1
2
3
4
5
6
7
8
9
10
How much does your sleep or breathing affect your daily energy, enjoyment of life, or ability to do what you want to do?
0
1
2
3
4
5
6
7
8
9
10
How would you rate your ability to manage your daily activities and maintain your independence? 0 = Significantly impaired  ·  5 = Moderate ability  ·  10 = Full independence
0
1
2
3
4
5
6
7
8
9
10
How would you rate your overall quality of life right now, with sleep and breathing factored in? 0 = Very poor  ·  5 = Moderate  ·  10 = Excellent
0
1
2
3
4
5
6
7
8
9
10
For the Clinician
This instrument is part of the AirwayZ Airway Health Inventory , a six-instrument comprehensive screening tool spanning birth through older adulthood, developed by Elizabeth Walker, DMD, MSD. The older adult instrument incorporates an original AirwayZ daytime sleepiness and dozing profile in place of the proprietary Epworth Sleepiness Scale, and is otherwise purpose-built around the well-documented atypical presentation of OSA in patients aged 65 and older, drawing on the following literature base: the aging-specific OSA phenotype (Braley et al., JAGS, 2018; Monti et al., Sleep Med, 2021; D'Angelo et al., Sleep Med, 2023); the insomnia-dominant versus EDS-dominant presentation shift after age 65; nocturia as a primary OSA signal in this population (naturiuretic peptide mechanism); the OSA-cognitive decline association (Marchi et al., Eur Respir J, 2023; CPAP delaying MCI onset by approximately 10 years, Alzheimer's Disease Neuroimaging Initiative); OSA as a modifiable fall risk (randomized trial protocol, Sleep Med, 2024); REM behavior disorder as a Parkinson's biomarker; and the polypharmacy-OSA interaction, particularly for benzodiazepines, opioids, antihistamines, and diuretics (AGS Beers Criteria 2023; Journal of Nurse Practitioners, 2024). Section D (Falls and Physical Function) and Section E (Cognitive and Neurological) do not exist in any standard OSA screening instrument and are original contributions of this inventory. STOP-Bang items are labeled for direct clinical extraction. The note in Section A regarding attenuated daytime sleepiness scores in older adults is clinically important: a low score should not be used to exclude OSA in this population. Composite scoring is intentionally absent.
A Note for Patients and Families
What this inventory is
A starting point for a clinical conversation, not a diagnosis. Many of the patterns this form captures (fatigue, nocturia, memory changes, poor sleep, falls) are treatable when their root causes are identified. Bringing this form to your provider is a meaningful and actionable step.
For family members and caregivers
If you are helping an older loved one complete this form, your observations matter. Witnessed breathing pauses, confusion upon waking, recent memory changes, and changes in balance or energy are all clinically relevant. Note your observations in any of the describe fields.
About nocturia
Many older adults accept frequent nighttime bathroom trips as normal aging. They are frequently not. Nocturia driven by untreated airway obstruction often resolves when the underlying breathing disorder is treated. It is worth raising with a provider.
About memory and cognition
Sleep-disordered breathing is one of the few modifiable contributors to cognitive decline. Treating it does not guarantee reversal, but identifying it early gives the best chance of preserving function. Cognitive concerns noted here should be discussed with your physician, ideally alongside sleep evaluation.
A irway Z
Elizabeth Walker, DMD, MSD  ·  TreatOrigin Productions, LLC
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